Transcript 2016/2017 PowerPoint Version - Sierra

Sierra –
Sacramento
Valley EMS
Agency
2016/2017
REGIONAL TRAINING
MODULE
S-SV EMS 2016/2017 Regional Training Module
Agenda/Objectives
• Training Module Agenda
▪ Naloxone Utilization
▪ Prehospital Pain Management
▪ Prehospital Documentation
▪ Trauma Triage Criteria
S-SV EMS 2016/2017 Regional Training Module
Agenda/Objectives
• Training Module Objectives
▪ Participants in this course will learn the following:
o Opioid abuse epidemic background and information
o Naloxone administration indications, contraindications,
onset/duration, adverse reactions, warnings, notes and S-SV
EMS protocol requirements
o Background, concerns and trial/retrospective study information
related to prehospital pain management
o S-SV EMS protocol requirements for prehospital pain
management of adult and pediatric patients
o S-SV EMS prehospital documentation policy requirements
S-SV EMS 2016/2017 Regional Training Module
Agenda/Objectives
• Training Module Objectives
▪ Participants in this course will learn the following:
o S-SV EMS prehospital anatomic, physiologic, mechanism of
injury and special considerations trauma triage criteria and
patient destination
o Special considerations related to trauma in older adults
Naloxone
Utilization
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Background
 Opioid abuse is a major public health epidemic
o 16,325 prescription opioid-related deaths in the US in 2013
(4x the number of deaths that occurred in 1999)
o 8,257 deaths in the US from heroin in 2013
o 7,428 prescription opioid-related deaths in California from
2008 to 2012 (16.5% increase from 2006)
o 1,800 opioid-related deaths in California in 2012 alone
(72% involved prescription pain medications)
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Background
▪ Efforts undertaken to combat the crisis
o Calls to improve opioid prescription practices
o Greater access to addiction treatment
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Background
▪ Efforts undertaken to combat the crisis
o Additional tools for the public and first responders

Public naloxone distribution programs –
2015 California State Board of Pharmacy
emergency regulations allow pharmacists
to dispense naloxone without a
prescription

Increased first responder naloxone
utilization – multiple BLS fire and law
enforcement agencies have been
approved to administer IN naloxone
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• S-SV EMS Data (10/1/2015 – 12/31/2015)
▪ Total 911 responses: 29,607
▪ Total transports: 22,102 (74.65%)
▪ Total number of patients receiving naloxone: 223 (1%)
o Adult: 223
o Pediatric: 0
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• S-SV EMS Data (10/1/2015 – 12/31/2015)
Cardiac Arrest Primary Impression – Naloxone Administration
Dose
0.5 mg
1.0 mg
2.0 mg
Patients
2
2
37
Unchanged
2 (100%)
2 (100%)
37 (100%)
Improved
0 (0%)
0 (0%)
0 (0%)
All Other Non-Cardiac Arrest Primary Impressions – Naloxone Administration
Dose
0.4 mg
0.5 mg
0.8 mg
1.0 mg
2.0 mg
Patients
14
18
2
36
112
Unchanged
14 (100%)
18 (100%)
2 (100%)
22 (61%)
30 (27%)
Improved
0 (0%)
0 (0%)
0 (0%)
14 (39%)
82 (73%)
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Naloxone
▪ Description
o Opioid antagonist
▪ Pharmacology
o Competitive narcotic antagonist which reverses all effects of
opioids (morphine, fentanyl, etc.) such as respiratory depression
and central and peripheral nervous system effects
▪ Indications
o To reverse respiratory depression caused by presumed opiate
intoxication
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Naloxone
▪ Contraindications
o Patient hypersensitivity to naloxone
▪ Onset/Duration
o Onset of action is within a few minutes
o Duration of action is approximately 30 – 60 minutes
▪ Adverse reactions
o May include tachycardia, hypertension, dysrhythmias, nausea,
vomiting, and/or diaphoresis
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Naloxone
▪ Warnings
o May introduce opiate
withdrawal in patients
who are physically
dependent
o Certain drugs such as
Darvon may require
much higher doses of
naloxone for reversal
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Naloxone
▪ Notes
o Naloxone should not be given for any reason other than
inadequate ventilatory drive and/or oxygenation associated
with ALOC
o ALOC or cardiac arrest alone, without indication of opioid
use/overdose does not warrant naloxone administration
o Appropriate prehospital documentation indicating suspected
opioid overdose is required for all patients receiving naloxone
o Naloxone administration should be titrated to allow gradual
improvement of respiratory drive and oxygenation
S-SV EMS 2016/2017 Regional Training Module
Naloxone Utilization
• Naloxone
▪ S-SV EMS protocols (R-2, M-5, N-1, P-12, P-22, P-24)
o Administer only if RR < 12 or respiratory efforts are inadequate
o Adult patients (≥ 15 years old)

1 – 2 mg slow IV/IO, may give IM/IN if no IV/IO and/or SBP > 90
o Pediatric patients (≤ 14 years old)

0.1 mg/kg slow IV/IO or IM/IN (maximum dose 2 mg)
o May repeat dose every 2 – 3 minutes x 2 if improvement
inadequate
o Do not administer naloxone if advanced airway is in place and
the patient is being adequately ventilated
Prehospital Pain
Management
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• Background
▪ Pain is a common complaint of EMS patients
o 2.9 million patients are transported by EMS annually with a
complaint of moderate to severe pain (represents 20% of all
EMS transported patients)1
1Mclean,
Maio & Domeier, 2002, pp. 402- 405
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• Concerns
▪ “Pain measurement and relief is complex and should be a priority
for prehospital providers and supervisors. The literature continues
to prove that we are poor pain relievers, despite the high
prevalence of pain in the out-of-hospital patient population.”1
▪ “Significant disparity exists between EMT-P’s
perceptions of acute pain assessment and the
frequency of providing analgesia and their
actual practice. Children and adolescents had
less documentation of pain assessment and
received less analgesic interventions compared
with adults.”2
Emergency Medicine Clinics of North America. 2005 May;23(2):415-31
2 Prehospital Emergency Care. 2005 Jan-Mar;9(1)32-9
1
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• NAEMSP Pain Management Position
▪ “The National Association of EMS Physicians (NAEMSP) believes
that the relief of pain and suffering of patients must be a priority
for every emergency medical services (EMS) system.”
▪ “NAEMSP believes that every EMS system should have a clinical
care protocol to address prehospital pain management. Adequate
training and education of prehospital personnel and EMS
physicians should support this pain management protocol.”
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• EMS Trial & Retrospective Studies
▪ “IV fentanyl can be used safely and effectively in the prehospital
arena without causing significant hypotension, respiratory
depression, hypoxemia, or sedation.”1
▪ “Morphine and fentanyl provide similar degrees of out-of-hospital
analgesia, although this was achieved with a higher dose of
fentanyl. Both medications had low rates of adverse events,
which were easily controlled.”2
1Alameda
EMS Trial Study The Prehospital Use of Fentanyl, March, 2009
County, OR EMS trial study Effectiveness and Safety of Fentanyl Compared with Morphine
for Out-of-Hospital Analgesia, 2007
2Multnomah
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• EMS Trial & Retrospective Studies
▪ 9.9% of patients who received morphine and 6.6% of
patients who received fentanyl experienced an adverse
event in the prehospital setting1
▪ The most common event was
nausea, with a rate of 7.0% for
morphine vs. 3.8% for fentanyl1
1Multnomah
County, OR EMS trial study Effectiveness and Safety of Fentanyl Compared with Morphine
for Out-of-Hospital Analgesia, 2007
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• EMS Trial & Retrospective Studies
▪ Fentanyl is a more rapid acting narcotic than morphine
(2 – 3 minutes vs. 15 minutes) 1
▪ Fentanyl is shorter acting than morphine
(30 minutes versus 3 – 4 hours) 1
▪ Fentanyl does not induce hypotension from histamine
response as does morphine1
▪ Fentanyl is less likely to induce
nausea or vomiting than morphine1
1Alameda
EMS Trial Study The Prehospital Use of Fentanyl, March, 2009
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• Opioid Administration Notes
▪ Both morphine and fentanyl are approved for use by
paramedic personnel in the S-SV EMS region
o Either opioid may be utilized for pain management based on
availability and specific patient factors
o Paramedics may administer one opioid and switch to the other
if necessary based on patient response and other factors
o Maximum total opioid dosing allowed per patient without base
hospital order = 20 mg morphine equivalent (20 mg morphine,
200 mcg fentanyl, or a combination of the two), or four (4) total
doses for pediatric patients (whichever is less)
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ General considerations/requirements (M-8 & P-34)
o Acute injuries:
o Other causes of pain:

Isolated extremity injuries

Non-acute injuries

Multi-system trauma

Abdominal pain

Burns

Back pain

Frostbite

Sickle cell crisis

Bites/envenomations

Cancer
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ General considerations/requirements (M-8 & P-34)
o Asses/document initial pain score, and reassess/document
pain score after each pain management intervention
o Utilize non-pharmacological pain management as appropriate
(psychological coaching, ice packs, immobilization/splinting)
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ General considerations/requirements (M-8 & P-34)
o Continuous cardiac and SpO2 monitoring required for all
patients receiving pain medication
o Titrate pain medication to a tolerable pain level
o Use caution when administering both opioids and midazolam to
the same patient
o Each individual medication dose and patient response
(including pain score) must be documented on the PCR
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ Adult Pain Management (M-8)
o Pain from acute injuries – standing order pharmacological
management may be utilized if all the following are present:

Significant pain

RR > 12

SBP > 100

GCS 15 or baseline mental status and no evidence of a head injury
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ Adult Pain Management (M-8)
o Other causes of pain – base hospital order required for
pharmacological management unless documented
communication failure and all the following are present:

Significant pain

RR > 12

SBP > 100

GCS 15 or baseline mental status and no evidence of a head injury
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ Adult Pain Management (M-8)
o Opioid pharmacological pain management

Morphine: 2 – 10 mg IV/IO or IM/SQ every 5 minutes
OR

Fentanyl: 25 – 100 mcg IV/IO or IM/SQ, or 1.5 mcg/kg IN
(maximum 75 mcg) every 5 minutes

Maximum total opioid dosing for adult patients without base
hospital order = 20 mg morphine equivalent
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ Adult Pain Management (M-8)
o Additional pharmacological pain management for acute
isolated extremity injuries only (if necessary)

Midazolam: 1 – 2 mg IV/IO every 5 minutes

Maximum total midazolam dosing per adult patient without base
hospital order = 4 mg
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ Pediatric Pain Management (P-34)
o Pain from acute injuries – standing order pharmacological
management may be utilized if all the following are present:

Age ≥ 4 years old with significant pain

RR > 12 and SBP age appropriate

GCS 15 or baseline mental status and no evidence of a head injury
o Pharmacological management for other causes of pain in
pediatric patients requires a base hospital order
o Midazolam pharmacological pain management for pediatric
patients requires a base hospital order
S-SV EMS 2016/2017 Regional Training Module
Prehospital Pain Management
• S-SV EMS Pain Management Protocols
▪ Pediatric Pain Management (P-34)
o Opioid pharmacological pain management

Morphine: 0.1 mg/kg IV/IO or 0.2 mg/kg IM/SQ (maximum 5 mg)
every 5 minutes
OR

Fentanyl: 1 mcg/kg IV/IO or IM/SQ (max 50 mcg), or 1.5 mcg/kg IN
(maximum 75 mcg) every 5 minutes

Maximum total opioid dosing for pediatric patients without base
hospital order = 20 mg morphine equivalent or 4 doses (whichever
is less)
Prehospital
Documentation
Note: This module contains minimum S-SV EMS prehospital documentation
requirements – your provider agency may have more stringent documentation
requirements which must be followed if applicable
S-SV EMS 2016/2017 Regional Training Module
Prehospital Documentation
• S-SV EMS Prehospital Documentation Policy (605)
▪ ALS PCR completion requirements
o PCR documentation is not required to be completed under the
following circumstances:

Cancellation prior to arrival at scene

No patient contact is established by a subsequent arriving ALS unit

If an ALS non-transport or transport provider arrives on scene after
another ALS provider and no patient contact is established by the
subsequent provider, only the initial provider that established patient
contact is required to complete PCR documentation
S-SV EMS 2016/2017 Regional Training Module
Prehospital Documentation
• S-SV EMS Prehospital Documentation Policy (605)
▪ ALS PCR completion requirements
o If ALS units arrive at scene and no patient is identified, a single
PCR by one of the ALS providers (as agreed to by on scene
personnel) indicating the following information is required:

Reported incident location

Pertinent incident times

Reason why no patient was identified
S-SV EMS 2016/2017 Regional Training Module
Prehospital Documentation
• S-SV EMS Prehospital Documentation Policy (605)
▪ ALS PCR completion requirements
o If an ALS non-transport provider establishes patient contact prior
to the transport provider, the ALS non-transport provider shall
complete a PCR for each patient

If transfer of care is done within the same agency, a single PCR
documenting the care provided by all personnel on scene is
sufficient
S-SV EMS 2016/2017 Regional Training Module
Prehospital Documentation
• S-SV EMS Prehospital Documentation Policy (605)
▪ ALS PCR completion requirements
o If an ALS non-transport provider establishes patient contact
simultaneously or after the transport provider, a single PCR
documenting the care provided by all personnel on scene is
sufficient
o The ALS transport provider shall complete a PCR for each
patient where patient contact/transport is established. If patient
care is maintained by a non-transport provider and both units
are from the same agency, a single PCR documenting the care
provided by all personnel on scene is sufficient
S-SV EMS 2016/2017 Regional Training Module
Prehospital Documentation
• S-SV EMS Prehospital Documentation Policy (605)
▪ Multiple patient incidents
o The initial ALS provider who establishes patient contact shall
complete a PCR on each patient unless one or more of the
following special circumstances apply:
Patient contact was limited to triage/basic assessment only, and all
pertinent patient assessment and treatment information is
documented by the transporting provider
Patient care was transferred to another provider from the same
agency, and all pertinent patient assessment and treatment
information is documented by the transporting unit
The provider receives approval from S-SV EMS not to complete full
PCR documentation on each patient (i.e. – large MCI)
S-SV EMS 2016/2017 Regional Training Module
Prehospital Documentation
• S-SV EMS Prehospital Documentation Policy (605)
▪ Multiple patient incidents
o If the initial ALS provider is not required to complete a PCR on
each patient, they must complete a minimum of one PCR
containing pertinent incident information (incident nature,
details, patient count/triage categories, etc.)
S-SV EMS 2016/2017 Regional Training Module
Prehospital Documentation
• S-SV EMS Prehospital Documentation Policy (605)
▪ A PCR is a legal medical record, it must be complete
and accurate
▪ Minimum patient care documentation (e.g. an interim
patient care report) must be left at the receiving facility
at time of patient delivery
▪ An approved ePCR must be completed and provided to
the receiving hospital within 24 hours
Trauma Triage
Criteria
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Patients meeting trauma triage criteria should be
transported as soon as possible
▪ On scene procedures should be limited to:
o Triage/assessment
o Airway management
o External hemorrhage control
o Immobilization
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Physiologic Trauma Triage Criteria (one or more):
o Respiratory rate < 10 or > 29 breaths per minute (< 20 in
infants < 1 year of age), or need for ventilatory support
o Glasgow Coma Score (GCS) ≤ 13
o Systolic blood pressure < 90
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Anatomic Trauma Triage Criteria (one or more):
o All penetrating injuries to the head, neck, chest, torso, and/or
extremities proximal to the elbow or knee
o Chest wall instability or deformity (e.g. flail chest)
o Two or more proximal long-bone fractures
o Paralysis
o Pelvic fractures
o Amputation proximal to the wrist or ankle
o Crushed, degloved, mangled, or pulseless extremity
o Open or depressed skull fracture
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Mechanism of Injury Trauma Triage Criteria (any):
o High-risk auto crash (one or more of the following):

Ejections (partial or complete) from automobile

Death in the same passenger compartment

Intrusions, including roof: > 12 inches at occupant site or > 18
inches at any site
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Mechanism of Injury Trauma Triage Criteria (any):
o Non-automotive crash > 20 mph (motorcycle, ATV, go-cart,
bicycle, skateboard, watercraft, aircraft, etc.)
o Auto vs pedestrian/bicycle: thrown, run over, or with significant
impact (> 20 mph)
o Adults who fall > 20 feet
o Children who fall > 10 feet or three (3) times their height
o Other high energy impact
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Special Considerations Trauma Triage Criteria (any):
o Adults ≥ 65 years of age:

Low impact mechanism (e.g. ground level falls) might result in
severe injury

SBP < 110 might represent shock
o Current patient use of anticoagulation or antiplatelet
medication, or history of bleeding disorder
o Pregnancy > 20 weeks
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Special considerations (adults ≥ 65 years of age)
o “Ample evidence demonstrates that injured elderly patients are
less likely to receive care at trauma centers despite ample
evidence that they are at increased risk for adverse outcomes
after injury because of limited cardiovascular reserve,
comorbidities, and general frailty.”1
o “A retrospective analysis of 10 years (1995 – 2004) of the
Maryland Ambulance Information System in 2008 found that
among 26,565 patients, the risk for under-triage was
significantly higher among those older than 65 years (49.9 vs.
17.8%; p G 0.001).”1
1Journal
of Trauma and Acute Care Surgery 2012;73:5:4
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Special considerations (adults ≥ 65 years of age)
o “In general, a lower threshold for trauma activation should be
used for injured patients aged 65 years or older who are
evaluated at trauma centers.”1
o “Preexisting conditions and/or
severe anatomic injuries
dramatically increase the risk of
poor outcome in elderly patients.
Age and anticoagulants and
antiplatelet agents increase the risk
for post injury hemorrhage.”1
1Journal
of Trauma and Acute Care Surgery 2012;73:5:4
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Special considerations (all trauma patients)
o Thorough evaluation/documentation of the scene conditions,
mechanism of injury, patient presentation and other factors are
extremely important on any trauma related incident
o Prehospital personnel should pay special attention to:

Any change in patient’s baseline mentation (especially older adults)

Current patient use of anticoagulation or antiplatelet medication or
history of a bleeding disorder
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• S-SV EMS Trauma Triage Policy (860)
▪ Special considerations (all trauma patients)
o The primary goal is to transport trauma patients to the most
appropriate facility in a timely manner

S-SV EMS regional data indicates that interfacility transfers of
trauma patients from a non-trauma center to a trauma center are
sometimes significantly delayed due to various patient and system
factors

Patients with a high suspicion of serious traumatic injuries should
be transported directly from the field to a designated trauma center
whenever possible
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• EMS Trauma Patient Destination
Unmanageable
Airway?
YES
Transport to closest hospital
NO
Adult
( 15 y/o)
Meets
Anatomic &/or
Physiologic
Criteria?
YES
Pediatric
( 14 y/o)
 If a level I or II trauma center is closest, transport
directly to the level I or II trauma center
 If a level III trauma center is closest, contact the
level III trauma center for destination consultation
 Transport to a pediatric trauma center if transport
time is 45 minutes
 If patient is too critical for transport to a pediatric
trauma center, contact the closest trauma center
for destination consultation
 If transport time to a pediatric trauma center is
> 45 minutes, follow adult destination criteria
Prehospital personnel shall notify the receiving trauma center of the patient s pending
arrival as soon as possible
S-SV EMS 2016/2017 Regional Training Module
Trauma Triage Criteria
• EMS Trauma Patient Destination
Meets
Mechanism of
Injury
Criteria?
YES
 If transport time to a trauma center is 45 minutes, contact the
trauma center for destination consultation
 If transport time to a trauma center is > 45 minutes, contact the
closest base/modified base hospital for destination consultation
NO
Meets
Special
Considerations
Criteria
Only?
YES
 Prehospital personnel shall contact the closest base/modified
base hospital for destination consultation when they believe that
transport to a trauma center may be in the patient s best interest
Prehospital personnel shall notify the receiving trauma center of the patient s pending
arrival as soon as possible