Transcript University Hospital 2016 protocols

2016 EMS PROTOCOL
INSTRUCTOR UPDATE
How We Got Here
• Year long project
• Team approach
• Frequent Team meetings 2 times a month since
January 4 to 5 hours per meeting
• Emailed every section to the Medical Director
and Specialists for comment and approval
Protocol Team
• Dominic Silvestro, Paramedic, EMSI
• Todd Kulina, Paramedic, EMSI
• Bill Bernhard, Paramedic, EMSI
• Scott Wildenheim, Paramedic, EMSI
341 Pages
74808 Words
11251 Editing Mins
4.5 MB File
New Protocol Goals
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Fresh new look, unique to UH
Improve ease of use
Add safety features
Format Pediatric section same as adult
Streamline treatment pathways
Match prehospital care with care provided in the ED
Group interventions as they would be actually undertaken in field
Review / Update clinical care to meet current research and studies
Assure inexperienced providers have clear, understandable,
treatment pathways with little room for misunderstanding
• Allow experienced providers the room to practice good prehospital
medicine
Creation and Approval Process
New Order of Protocol Sections
Unique New Look
Sections Color Coded
Blue – Adult
Pink – Peds
Purple – OB
Gray- Reference
Edge Tabs for Easy of Use as Printed Document
Blue tab is current section
Gray tabs are other sections in document
Safety Features Added to Protocol Tree
New Bold Colors & Rounded Boxes
Transport - “CONTACT MECDICAL CONTROL” box reworded to
actual order of events
Legend moved to bottom of page
Hyperlinked Protocol
• Single file adobe .pdf
• Downloadable
• Multi-platform (Anything
that supports adobe .pdf)
• Hyperlinks within the .pdf
(Over 3500 Hyperlinks)
• Internet connection not
required for hyperlinks
• Hyperlinks will be
explained later in this
PowerPoint.
Built In Safety Features
Stops / Cautions
• Stops – Brings critical
contraindications to the
treatment tree
• Cautions – Reminds
provider of pertinent
decision making issues
during treatment
Grouped Interventions
• This new layout “Blocks”
interventions in groups as
they are actually
performed
• However most will usually
be done concurrently by
multiple providers
PROCEDURE CHANGES,
ADDITIONS, AND
UPDATES
EMT Scope of Practice Change
“Patient Assisted” Meds
• In the State EMT Scope of Practice there are Two Meanings
for Patient Assist as it relates to Medication administration
– Can assist with patient’s Prescription upon patient request and with
written protocol - OR
– Can Provide supplied medications with verbal medical direction
• This Protocol will adopt this definition for EMT’s
• Off line Meds – EPI PEN, ASA, Narcan
Working Cardiac Arrest on Scene
• Survival odds decrease when
patients are transported This is a
Suggestion only, each situation
should be judged individually every
situation is unique. Use common
sense.
• The best option for patients who do
not have special resuscitation
circumstances (hypothermia,
electrocution, etc.) is to attempt to
gain ROSC on scene.
• ALS only
• Adult only
• Transport once ROSC is achieved
Sedation in Airway
• Pre Intervention if patient
responds to pain
• Post Intervention if patient
awakens
• Use Midazolam or
Lorazepam as available
• STOP for head injured
patients
• THIS IS NOT RSI
Sedation in Airway
• Expectations with Ativan
and Versed
– These Drugs are NOT
Paralytics
– Your patient will not fall
motionless on your cot
– These meds provide amnestic
effects as well as sedation
(they won’t remember)
• Apnic Oxygenation
– Assures the patients pulse ox
stays up during intubation
attempts
Respiratory Distress - Stridor
• Added column for Severe
Distress with STRIDOR adults
• Nebulized epinephrine for
treatment of upper airway
constriction
• Differentiated from lower airway
with hashed background
• Lower airway issues are treated
per the left column (not pictured
here) and the middle column
“Moderate / Servere Distress” as
shown on this slide
Half Amp Dextrose
• Change recommended by UH endocrine
specialists
• BGL < 40 – Full Amp (25 Grams) of D50
• BGL > 40 up to 70 Treat with Half Amp
(12.5 grams) of D50
(With signs and symptoms as stated in the Key Point of
this protocol)
• Repeat as necessary
• Recent research reveals that treating
acute CVS’s with D50 should only be done
if the glucose level is below 60 as
hyperglycemia may injure the punumbra.
•
• Large Glucose molecules draw fluid. High
and low swings in glucose levels streese
the body systems
Alcohol Related Emergencies
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New Protocol
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Addresses Mild Symptoms, Severely
Combative, Obtunded, and Alcohol
Withdrawal Patients
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This is a protocol that takes several
existing treatments and puts them in
one protocol / location
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When using Oral Zofran remember
that this is a soft tablet that dissolves
rapidly DO NOT try to push it through
the package as it may crumble
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In this case the Benzo’s (Ativan /
Versed) are for sedation and only
given by Medics
CPR Device
• There have been
documented cases across
the country of cardiac arrest
patients waking up during
CPR device chest
compressions ie: LUCUS CPR
ever though they are still in
a non-life sustaining
rhythm.
• If CPR device yields
Consciousness, pain
management with fentanyl
(sublimaze) is indicated.
Bleeding / Hemorrhage Control Procedure
• One general procedure
covers
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Tourniquet
iT Clamp
Hemostatic Gauze
BLS – Gauze Bandage, Direct
Pressure, Pressure Points,
Etc.
• Remember to either keep
product packaging or refer
to the protocol for removal
procedures as some
receiving facilities may not
be familiar with some of
these products (iT Clamp)
Active Shooter / Direct Threat
• Outlines basic scene
care for “warm zone”
casualties of violent
events
• Standard EMS care to
resume after patient
extricated from scene
Double Sequential Defibrillation
• For VFIB / VTACH refractory to 360 J and medications
• 720 J – Requires 2 Defibrillators
– This is a LAST RESORT for refractory VFIB / VTACH patients
– Do not waste time acquiring a second device if device not already on site
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Medical control contact required for DSD consideration (Red Box)
1 set of Pads Anterior / Posterior
1 Set of Pads Apex / Sternum
Charge both monitors to 360 J and press Shock at the same time
Induced Hypothermia
• Passive cooling only
• AHA No longer
recommends Chilled
Saline for induced
hypothermia
• Use Cooling Collar
• Cold Packs
• No target temp, EMS
Induced Hypothermia is
designed to start the
cooling process as soon as
possible
Peds Dosing Charts
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Pre-Calculated
Follows Broslow Colors
Error Reduction
Includes all protocol
medications
• Hyperlinked from med
pages (shown in upcoming slide)
• We are currently working
to standardize the drug
boxes across the system.
Until then, double check
the concentration to
make sure it matches
these charts. (Early 2016)
Dialysis / Renal Patient
• EKG examples provided for
hyperkalemia
• Addresses multiple topics
pertinent to dialysis patients
• Covers Respiratory issues,
Cardiac changes,
Hypertension, Hypotension,
Chest Pain, and Bleeding
catheters
• Albuterol and Calcium for
Peaked T waves
• Calcium and Bicarbonate for
Sine Wave
(see next slide)
Dialysis / Renal Patient
• Peaked T waves should be
narrow and higher than the
QRS in this setting
• Albuterol is easy and fast and
should be done rapidly
• Calcium is safe and should be
given SLOWLY over 2-3
minutes in a good IV /IO line
• Once you see Sine Wave there
is only minutes until cardiac
arrest and you must treat
aggressively with Calcium and
Sodium Bicarbonate
• Flush IV before CALCIUM and
before SODIUM
BICARBOANTE
Narcan
• Everyone seems to have a
different thought process on
how much to give
• Need to standardize for
teaching / simplicity reasons
• We took a middle of the road
approach
• Give at least 1 mg IV / IO
• 2 mg IN
• Now found in the Toxic
Ingestion Protocol
• Also Per AHA Narcan can be
given in Cardiac Arrest when
you suspect Opiate overdose
as the cause.
Severe Pain Management
• The Severe Pain Management has been
reworked as well
• Some dosages have been changed to meet
current standards as well as an update of
indications and contraindication based on
current research and current accepted ED
treatment
• Added Hydromorphone (Dilaudid) to your
pain management options
Severe Pain Management
Hydromorphone (Dilaudid)
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8-10 x Potency Morphine, Longer lasting
Preferred for unremitting / intractable pain
Supplied 1 mg / ml, 1 ml Carpuject
Dose 0.5mg – 1.0mg IV/IO/IM May repeat to a Max 2.0mg (Half
Dose >65 yrs old, Liver or Renal disease)
Fentanyl (Sublimaze)
• Preferred for hemodynamic instability, trauma, procedural pain
management, Can be given IN, Shorter acting
• New Dose 25 – 100mcg IV/IO/IM/IN 100mcg MAX
• Small chance of chest wall ridgity (only happens if pushed to fast
remember to push slowly
Morphine
• Still available, mostly for peds / ACS
• New Dose 2.5 – 5.0mg IV/IO/IM – MAX 10mg
Toradol
• Dosage change due to recent literature that finds more
than 15mg IV /IO does nothing more for pain and
increases risk of bleeding.
• Dose - 15 mg IV / IO, 30 mg IM – 1 DOSE LIMIT
• Has many Contraindications (list below)
Peds Severe Pain Management
Morphine
• For IV / IO / IM
administration
Fentanyl (Sublimaze)
• IN use ONLY
ACS Pain Management
• You now have two options for pain management in the
Acute Coronary Syndrome Patient
• Morphine Sulfate or Fentanyl (Sublimaze)
– Fentanyl will not drop BP and gives you an IN option
– Note Dose Changes
Narrow Complex – Rate Control
• Metoprolol (Lopressor) now red
boxed
• Concerned about incorrect use, many
contraindications
• If Capnography is in normal range
there is no need to change the rate
• Not for physiological tachycardias,
cocaine use
• Cocaine is a sympathetic alpha and
beta stimulant. A beta blocker only
will leave unopposed alpha and the
blood pressure may actually rise
Behavioral / Psych Emergencies
• New Columns
– Agitation – Non Combative
– Combative – Physical
Restraint
– Combative – Chemical
Restraint
• While Benzo’s and Benadryl are
Advanced EMT Drugs (Green Box)
in this protocol it is a Medic only
(Blue box) because they are being
used for sedation with Haldol and
to treat EPS (Benadryl) caused by
the administration of the Haldol
and should only be given by a
Paramedic in this instance.
Hypertensive Emergencies
• New Protocol
• Primarily a direction
finding protocol
– Use Critical Thinking. It is
important to find an
underlying cause if
present.
– This protocol is used to
remind you of the possible
causes and direct you to
the specific protocol.
(Hyperlinked in the electronic
version)
Stroke / MEND
• Addition of MEND to
stroke protocol
• MEND is not done on
scene. Conduct the
MEND while enroute to
the receiving facility.
• May be able to detect
strokes NOT evident
from The Cincinnati
Stroke Scale
Neonatal Resuscitation
• Ventilate with ROOM AIR in the first 30 seconds at 40
– 60 BPM
• Low Pulse Ox is a normal finding as it may take up to
10 minutes for the neonate to be in the 90% range
Med Pages
• Pregnancy Class
– A – No Risk in controlled
human studies
– B – No risk in other studies
– C – Risk not ruled out
– D Positive evidence of risk
– X – Contraindicated in
pregnancy
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Adult Dose
Peds Dose
Color coded for level of care
Peds dosing weights
hyperlinked to dose charts in
.pdf version shown earlier in
this Lecture.
Special Operations
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Procedures
Nitrous Oxide
Administration
Tasered Patient
Active Shooter / Direct
Threat Protocol
Patient Decontamination
Nerve Agent Exposure Kit
Blood Collection for
Evidence
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Medications
Ciprofloxicin (Cipro)
Clopidrogril (Plavix)
Vobramycin (Doxycycline)
Duo-Dote
Etomidate (Amidate)
Hydroxocobalmin (Cyanokit)
Ketamine
Nitrous Oxide
Succinylcholine (Anectine)
Tenecteplase (TNKase)
Altered Level of Consciousness
• There are many causes for
Altered Level of
Consciousness
• Identifying the cause will
ensure rapid care
• This is a Direction finding
protocol each possible
cause will be hyperlinked to
the appropriate protocols
listed in the .pdf version
Croup
• New Peds Protocol
• Upper airway is
separate protocol from
lower
• Stridor at rest –
Aerosolize Epinephrine
1:1000
• Nebulized saline
otherwise
Peds Aerosols
• Lower airway
• Rainbow added Duoneb
this year in Severe
Column
• Albuterol first, then
transition to Duoneb for
Mild / Moderate
Peds Toxic Ingestion / Exposure / OD
• Rainbow approved dosing
for Calcium Chlorine in
Calcium Channel Blocker OD
• 10 mg / kg IV/IO MAX 1
gram
• Narcotic OD moved here
same as adult protocol
What's Hyperlinked?
Section Tabs
What's Hyperlinked?
Table of Contents
What's Hyperlinked?
Procedures
What's Hyperlinked?
Medications
What's Hyperlinked?
Medication Indication
Click on the indication and you will be taken to that protocol
What's Hyperlinked?
Pediatric Dosing
Rollout
• System wide Protocol Rollout Education
throughout the month of December
• Hard Copy Protocols will be given to each
department for each Ambulance in their fleet.
• Electronic .pdf complete with all hyperlinks will
go live on our website on January 1, 2016
• You will be able to download this .pdf to any
computer, tablet, smart phone, etc. that supports
Adobe .pdf.
• We encourage you to put this on every computer
in your station and fleet.
Protocol Email
• Established email for protocol suggestions /
corrections
• [email protected]
• Seen by all team members
Questions
?