Transcript Revision Review Region X SOP`s March 1, 2007

Revision Review
Region X SOP’s
March 1, 2007
Condell Medical Center
EMS System
May, 2007
Site Code #10-7200E-1207
Prepared by:
Sharon Hopkins, RN, BSN, EMT-P
Objectives
• To familiarize the EMS provider with the
changes to the March 1, 2007 Region X SOP’s
in preparation for examination
• Assess patients to be stable or unstable to
determine if a conservative intervention is
appropriate (ie: medications) or more
aggressive intervention is needed
• Clarify interpretation of the SOP’s
• Review Lead II rhythm strips
Region X March 1, 2007 SOP’s
• Some pages have been reformatted
– reading left to right
– moving from less critical to more critical
conditions/situations reading left to right
– attempted consistency of language through
out the document (ie: low acceptable B/P 100)
• Most changes in the SOP’s were made to
reflect the updates in the 2005 AHA
guideline revisions
• SOP’s must be followed by the EMS provider;
Medical Control can choose to deviate
Table of Contents
• Reorganized into sections
• Introduction
• Cardiac
• Respiratory
• Medical
• Trauma
• Obstetrics
• Pediatric
• Pediatric Considerations
• Appendices
• Alphabetized within each section
Introduction to Use of SOP’s - pg 1
• Added statement to allow judgement in
decision making
– “An alternate order of listed interventions may
be appropriate based upon patient
assessment”
• If EMS is unable to establish
communication with Medical Control,
follow interventions approved in the SOP’s
• Clarification of pediatric age
– under the age of 16
– this means 15 and under
Routine Medical Care - pg 2
• Combined with “General Patient Care”
• Pain scale is part of vital signs
• If following the Acute Coronary Syndrome
protocol, a 12-lead EKG is indicated
• If a 12-lead is obtained, it needs to be
transmitted
• Not every patient that needs to be
monitored needs to have a 12-lead
obtained
Adult IV Conscious Sedation for
Intubation - pg 7
• Age contraindication raised to 16
(consistency)
• Initial Versed dosage raised to 5 mg IVP
• If not sedated within 60 seconds (1 min)
give Versed 2 mg IVP every minute until
sedated
• Following sedation, if needed for agitation,
can give Versed 1 mg every 5 minutes
• Total dose of Versed is 15 mg IVP
Adult IV Conscious Sedation for
Intubation cont’d
• Morphine is given following the start of the
Versed dose
• Versed & Morphine together potentate
effects of the drugs enhancing results
greater than either drug alone
• Versed relaxes and sedates the patient;
Versed does not affect the level of pain
“Secure Airway”
• Term used on all protocol pages when
responding to the arrested patient
• Term used to indicate to secure the airway in
whatever way possible and whatever means
available at the time
• You are to accomplish this with minimal
interruption to CPR
• Initially using a BVM with or without an
oropharyngeal or nasopharyngeal airway
would accomplish the task of securing an
airway with minimal interruption
Asystole/PEA - pg 8
• 2 algorithms combined into one
• A 6th “H” added to possible causes hypoglycemia
• Intubation to be accomplished when time is
appropriate, not necessarily immediately,
and with minimal interruption to CPR
• Atropine administered for asystole and when
the PEA rate is <60
• No transcutaneous pacing for Asystole
Withdrawing Resuscitation
Efforts - pg 9
• Language changed for consistency
“confirmation of intubation”
replaced with
“advanced airway secured”
Bradycardia and AV Blocks - pg 11
• Repeat dosage of Atropine is 0.5 mg
“when they’re alive, give them 0.5”
• Wide complex bradycardias
(Type II second degree heart block and
third degree AV block)
– begin with TCP first
– consider sedation (Valium)
Acute Coronary Syndrome - pg 12
• Note added regarding prior Aspirin intake
“Aspirin may be withheld if patient reliable
and states has taken within 24 hours”
• Document what time and what dosage was
taken by the patient
• If pain persists after a 2nd dose of
Nitroglycerin, proceed to Morphine
• Once you have moved onto Morphine,
continue Nitroglycerin after consultation
with Medical Control
Transition of Care From AED
Trained Personnel To ALS - pg 14
• AED users need to follow whatever prompts
are given by the particular AED unit
• Older AED’s will prompt for 3 shocks and 1
minute of CPR
• Newly reprogrammed AED’s will prompt for
1 shock followed immediately by 2 minutes
of CPR before reanalysis
Supraventricular Tachycardia
(Narrow Complex Tachycardia) pg 15
• Diltiazem moved to this page to follow
Adenosine failures
• When the stock of Diltiazem is exhausted,
to be replaced with Verapamil
• Verapamil to be given 5 mg IVP slowly (over
2 minutes)
• If no response in 15 minutes, repeat
Verapamil 5 mg slow IVP
Rapid Atrial Flutter/Fibrillation
(Narrow Complex Tachycardia) pg 16
• Added note to use Verapamil when
Diltiazem is no longer available
• Verapamil can cause hypotension
– give slowly (over 2 minutes plus)
– treat hypotension with IV fluid challenge of
200 ml Normal Saline
Ventricular Fibrillation or
Pulseless Ventricular
Tachycardia - pg 17
• All defibrillation attempts are singular
• All defibrillation immediately followed by 2
minutes of CPR prior to rhythm check
• Antidysrhythmic drugs (choose one)
– Amiodarone 1st dose 300 mg IVP (diluted)
– Repeat dosage in 5 minutes Amiodarone 150
mg IVP (diluted)
– Lidocaine 1st dose 1.5 mg / kg IVP
– Repeat dosage in 5 min Lidocaine 0.75 mg/kg
AHA Guideline Revision
• If arrest is witnessed, begin and perform
CPR until defibrillator is charged and ready
– If arrest time < 4-5 minutes, perform CPR
just until defibrillator ready
• If arrest unwitnessed (or time >4-5 minutes
since arrest), perform 2 minutes of CPR
before stopping to defibrillate
• Immediately after each defibrillation
attempt resume 2 minutes of CPR
• After 2 minutes of CPR stop for <10 seconds
for rhythm check
Ventricular Tachycardia or Wide
Complex Tachycardia (Patient
with a Pulse) - pg 18
• Amiodarone added as a choice of
antidysrhythmic
– if chosen, dosage of Amiodarone is 150 mg
diluted in 100 ml D5W IVPB over 10 minutes
• Mix IV bag, gently rotate bag to mix
medication, spike IV bag with mini-drip
tubing and prime tubing, plug in IV tubing to
primary line, run drip so you can see drops
Acute Pulmonary Edema - pg 19
• CPAP procedure steps moved to Appendix
• If the patient is unstable, CPAP provided
only on orders of Medical Control
• Remember:
– All interventions (Nitroglycerin, Lasix,
Morphine, and CPAP) can cause
hypotension
Transcutaneous Pacing Protocol
- pg 20
• TCP suggested for symptomatic
bradycardia
– back-up to Atropine failure for narrow
complex
– primary intervention if QRS is wide
• Second degree type II - Classical
• Third degree heart block - Complete
• Valium used for patient comfort
Acute Abdominal Pain/Flank Pain
- pg 21
• Added flank pain to title
• On this SOP, Medical Control must be
contacted for any pain medication order
• Pain management orders often based on
your radio report
– be an effective patient liaison
– if you feel pain management is appropriate
and you don’t receive the order, you need to ask
for one
Airway Obstruction - Adult - pg 22
• Follows AHA standards
– If the obstruction is unrelieved, perform CPR
– An extra step is taken each time you open the
airway
• look in the mouth to visualize for an
obstruction
• if one is noted, attempt removal
• if no obstruction is noted, continue with 2
breaths and move onto 30 compressions
Adult Allergic Reaction
Anaphylactic Shock - pg 23
• Defined stable and unstable patients
– Stable: hives, itching, rash, GI distress, alert,
warm & dry, B/P >100
– Stable with airway involvement: alert, warm &
dry, B/P >100
– Unstable: altered mental status; B/P < 100
• Defined slow IVP for Benadryl dose - over 2
minutes
• To anaphylaxis added Benadryl 50 mg slow IVP
and if wheezing, albuterol nebulizer
Allergic Reactions & Anaphylaxis
• For simple reactions without airway
involvement, Benadryl used (stops release
of histamines)
• For allergic reactions with airway
involvement or anaphylaxis, start with
Epinephrine followed by Benadryl
– Epinephrine is life saving
– Effects are immediate to vasoconstrict blood
vessels to support circulation
– Benadryl slowly stops progression of the
allergic response - stops release of histamines
Altered Mental Status - pg 24
• Title condensed
• Added to consider etiology as you are
caring for the patient
– may help lead the decision making for
treatment & interventions
Asthma/COPD with Wheezing pg 25
• Added
– “Contact Medical Control to consider use of
CPAP in a patient has symptoms of COPD”
Stroke / Brain Attack - pg 26
• Added
– “Determine time of onset of symptoms”
• Opportunity to definitively treat a patient
with an occlusive stroke is a very narrow
window of time - 3 hours from time of onset
• To expedite patient intervention, notify
Medical Control as soon as general
impression of a stroke is made
Seizures & Status Epilepticus pg 30
• Changed the order of medications
– Valium attempted first
– Dextrose listed 2nd
• This is a good example of the statement in
the Introductory to allow for the EMS
provider, after patient assessment, to use
judgement to follow an alternate order of
listed interventions
Severe Respiratory Febrile
Illness - pg 31
• New SOP
• Promoting the use of PPE and limiting
contamination are the goals of this SOP
• If a patient must wear a
mask, they are to be given
a surgical mask
• The N95 mask is reserved
for use by the medical team
and never to be given to the
patient
N95 mask
Region X Field Triage Criteria for
Assessing Trauma Patients pg 33
• Gives guidelines for transporting patient
based on:
hemodynamic values (ie: serial B/P)
stability of vital signs
anatomy of injuries
mechanism of injury
existence of co-morbid factors
special circumstances: traumatic arrest;
burns >20%; inability to open airway
Transporting The Trauma Patient
• Unstable trauma patient (adult B/P <90 x2
or peds B/P <80 x2 or Category I trauma
patient (based on unstable vital signs &/or
mechanism or injury)
– transport to highest level Trauma Center
within 25 minutes
• you need to be aware of this especially if
responding mutual aid where this applies
– CMC departments will go to a Level II trauma
hospital as no Level I exists within a
guaranteed response time 24/7 of 25 minutes
Trauma Transports
• Traumatic arrest
– Closest Trauma Hospital
• Unable to secure an airway
– Closest Emergency Department
regardless of Trauma status
Amputated and Avulsed Parts pg 35
• Care of stump added
– covered with damp sterile dressing and
elastic wrap with uniform pressure
Chest Injuries - pg 38
• New SOP - long standing interventions
• Authorizes EMS responder to perform
bilateral chest decompression for a patient
with traumatic arrest
– the mechanism of injury should indicate
potential or actual traumatic injury to the
chest
Heat Emergencies, Adult
• Defined heat stroke as hot and dry or hot
and moist skin
– classic heat stroke is hot and dry
– exertional heat stroke is hot and moist
Routine Pediatric Care - pg 52
• New SOP - generic care for all peds patients
• Reminder that pediatric age is <16
• Pediatric assessment triangle (PAT)
– used to quickly establish level of severity &
identify key physiologic problems
– assesses appearance, work of breathing,
circulation to skin
– obtain this information as you cross the room
and are approaching the patient
Pediatric Care Guidelines
Note:
Any pediatric drug calculation should never
exceed the adult drug maximum
Pediatric Respiratory Failure - pg
53
• Expanded signs & symptoms of respiratory
distress & failure
• Distress
–  work of breathing,  respiratory rate, use of
accessory muscles, nasal flaring, effectively
compensating
• Failure - needs to be bagged!!!
– exhausted energy reserves, cannot maintain
adequate oxygenation & ventilation, low resp
rate, effort, bradycardia, agitation, lethargy,
cyanosis
Pediatric Altered Level of
Consciousness - pg 54
• Added reference to fluid challenge
– “Administer IV fluid challenge 20 ml/kg”
Pediatric Acute Asthma - pg 55
• Phased approach of care added
– mild to moderate distress (increased work of
breathing)
– severe distress (inadequate oxygenation,
ventilation, or both)
• The patient in severe distress (and
especially the pediatric patient with
bradycardia & respiratory failure) may
need to be ventilated via a BVM with 100%
O2
Pediatric Airway Obstruction pg 56
• AHA guideline changes
– “back blow” terminology changed to “back
slaps”
– 5 back slaps and 5 chest thrusts repeated in
sequence for patients < 1 year old
• Unrelieved obstructions handled alike for
all patients
– Perform steps of CPR
– Pause before the 2 ventilations to look directly
into airway & attempt removal if object noted
Pediatric Ventricular Fibrillation
or Pulseless Ventricular
Tachycardia - pg 57
• Title change
• Follows 2005 AHA guidelines
• CPR- compression rate 100/minute
– 30:2 for 1 person CPR all victims
– 15:2 CPR for child and infant if 2 person CPR
• Airway
– Once intubated, ventilation rate one breath
every 6-8 seconds asynchronous with
compressions
Pediatric VF/Pulseless VT cont’d
• Amiodarone is alternative antidysrhythmic
to Lidocaine
– 5 mg/kg IVP/IO
– Repeat dosage thru Medical Control order
– needs to be diluted due to irritation to vein
• ETT route discouraged (absorption
unreliable) but not eliminated
– IV and IO are preferred routes
Pediatric Asystole, PEA, Pulselsss
Idoventricular Rhythms - pg 58
• Follows AHA guidelines
– 6th “H” to possible causes- hypoglycemia
– Revised CPR guidelines
• CPR 30:2 for 1 and 2 person CPR
• CPR 15:2 for 2 person CPR for children and
infants
• Once intubated, patient is ventilated once
every 6-8 seconds
• ETT drug route de-emphasized
Pediatric Bradyarrhythmias pg 59
• Expanded signs and symptoms of
compromise
• Epinephrine 1:10,000 - 0.01 mg/kg IVP/IO
repeated every 3-5 minutes for the
duration
• For persistent bradycardia, contact
Medical Control for possible order for
Atropine
• Medical Control needs to be contacted for
Pediatric Tachycardia with Poor
Perfusion - pg 61
• Under probable ventricular tachycardia
column, contact Medical Control for
possible antidysrhythmic order
(Amiodarone or Lidocaine)
Pediatric Tachycardia with
Adequate Perfusion - pg 62
• Under probable ventricular tachycardia
column, if Amiodarone is chosen, must be
diluted and administered over 20 minutes
–
–
–
–
Dilute dosage in 100 ml D5W
Prime mini-drip tubing
Plug piggyback into primary line
Run Amiodarone drip to count
30 minidrips / 10 seconds
Croup/Epiglottitis - pg 64
• Position of comfort encouraged but
transportation must be done safely and
following current traffic laws
• Transport in parent/caregiver arms no
longer allowable
SIDS - pg 66
• Expanded external appearance of SIDS
victim
cold skin
frothy blood tinged fluids around mouth &
nostrils
vomit may be present
lividity or dark reddish blue mottling on
dependent side of the body
unusual position due to muscle spasms at time
of death
Burns, Pediatric - pg 67
• New SOP
• Formatted following adult Burn SOP
• Contact Medical Control for pain
management orders
• Rule of Nines moved to Appendix
Pediatric Toxic Exposures - pg 68
• Title change
• For toxic exposures, follow Hazardous
Materials SOP
Pediatric Heat Emergencies pg 69
• New SOP
• Follows format of adult heat emergencies
• During cooling process, if pediatric patient
begins to shiver, administer Valium to stop
the shivering (shivering generates energy
and heat - counterproductive to efforts to
lower body temperature)
• Heat stroke can present hot and dry or hot
and moist (classic or exertional)
Pediatric Allergic
Reaction/Anaphylaxis - pg 70
• Columns headed like adult SOP
– Allergic Reaction Stable
– Allergic Reaction Stable with Airway Involvement
– Anaphylactic Shock
• Benadryl added to 3 columns
– Benadryl 1 mg/kg
– Max at the adult dosage
• stable - 25 mg maximum
• stable with airway involvement &
anaphylaxis - 50 mg maximum
Glasgow Coma Scale/Revised
Trauma Score - pg 76
• Moved to back of SOP’s
• GCS to be obtained on every EMS call
Calculating Body Surface Burn
Percentages - pg 77
• Includes schematic for adult, child, and
infant
• Includes breakdown of body areas
– superior and inferior (ie: chest & abdomen)
– anterior versus posterior
• Note: Different resources may vary the
percentage slightly; not all award any
percentage to perineum
CPR for Infants and Children pg 78
• Follows revised 2005 AHA guidelines
• 1 person CPR
– 30:2 for all persons
• 2 person CPR for adults
– 30:2
• 2 person CPR for infants and children
– 15:2
• Compression rate 100/minute
Pediatric Resuscitation
Medication - Cardiac and
Medical - pgs 80, 81
• Expansion of pediatric weights
• Provides information of ml (helpful for
bedside care) and mg (helpful for
documentation)
• Epinephrine 1:1000
– On Cardiac page, ETT dosage is shown for
arrested and critical level patient
– On Medical page, SQ route is shown for nonarrest and stable patients
IV Fluid Challenge
• Formula for all persons
– 20 ml / kg
• All persons need reassessment
– every 200 ml of fluid administration
while the fluid challenge is being
administered
Region X Approved Drug
Information List - pgs 82-84
Information on individual medications revised
Preferred routes in arrest: IV/IO; ETT
unpredictable (last resort)
• Adenosine
– do not use in setting of WPW history
• Amiodarone
– Adult - initial dose in arrest 300 mg; repeat
dosage 150 mg in 5 minutes
– Adult & pediatric dose in patients with pulse must be diluted in 100 ml D5W and run slowly
Region X Approved Drugs cont’d
• Benzocaine
– limit spray to < 2 seconds
• Lidocaine
– Added to indications for suppression of cough
reflex when used for patient with head injury
(medical or trauma) requiring conscious
sedation intubation
• Nitroglycerin
– Added to avoid use if Viagra or Viagra-type
drug taken within past 24 hours
Region X Approved Drug
• Verapamil
– New addition
– Calcium channel blocker to slow the
ventricular response of stable SVT or rapid
Atrial Fibrillation or Atrial Flutter
– To be used when stock of Diltiazem/Cardizem
is no longer available
– Avoid in any wide complex rhythm, in the
setting of heart block, in severe CHF, in the
presence of hypotension
Region X Approved Drug
• Versed
– Noted increase dosing of Versed used during
Conscious Sedation
• 5 mg to start
• continued at 2 mg every minute til sedated
• 1 mg every 5 minutes to continue sedation
after intubated
Appendix - Needle
Decompression, Chest - pg 89
Insertion site
is 2nd
intercostal
space,
midclavicular line
Combitube , Dual Lumen Airway
Device - pg 91
• Available alternative to secure an airway
for the individual department that places it
into service
• Once trained, the EMS
provider (Basic and
Paramedic) may use
the Combitube
What’s This Rhythm?
What’s This Rhythm?
What’s This Rhythm?
What’s This Rhythm?
What’s This Rhythm (rate 80)?
What’s This Rhythm?
What’s This Rhythm?
What’s This Rhythm?
What’s This Rhythm?
What’s This Rhythm?
NO PULSE
What’s This Rhythm?
What’s This Rhythm?
2 different simultaneous leads
Rhythm Answer Key
#1 - Ventricular fibrillation
#2 - Ventricular tachycardia
#3 - Atrial fibrillation
#4 - Second degree Type II - Classical
#5 - Sinus Rhythm
#6 - Sinus Bradycardia
#7 - Atrial fibrillation
Rhythm Answer Key cont’d
#8 - Paced rhythm
#9 - Second degree Type I - Wenckebach
#10 - PEA
#11 - SVT
#12 - Third degree heart block - complete