EMS PROTOCOL ROLL-OUT 2014 Cleveland Clinic Regional Hospitals EMS - PowerPoint PPT Presentation

EMS PROTOCOL ROLL-OUT 2014 Cleveland Clinic Regional Hospitals EMS Don Spaner, MD CCF East Region Medical Director Scott Wildenheim, Paramedic, EMSI

OVERVIEW  New Safety Features  Medication Consolidation  Standardized Terminology  Scope of Practice Updates  First Patient Contact to 12 Lead Parameters Added  Capnography Stressed / Added

SAFETY - CAUTIONS / STOPS Stops  On page reminder to keep Cautions certain actions from  Allows us to put warnings occurring without lengthy immediately adjacent to explanation in key points that medication or procedure to will likely be forgotten, assure key points are missed, or misunderstood. remembered

GROUPED INTERVENTIONS  Actions / interventions grouped in protocol, reflecting the way it would actually be done in field, rather than individual boxes

CONTACT MED CONTROL Current Revised Box  Old CONTACT MEDICAL CONTROL red box  Spells out events as they are confusing, makes it seem like actually performed every patient contact required call to Medical Control

WHO TO CONTACT?  YOUR MEDICAL CONTROL  WHO DO YOU CALL TO IS HILLCREST HOSPITAL. GIVE A REPORT?  THE PATIENT WANTS TO  HILLCREST OR CCF MAIN? BE TRANSPORTED TO CCF MAIN AS THEY HAVE A FEVER AND THE LVAD PLACED 2 MONTHS AGO, HAS AN INFLAMED TENDER SURGICAL SITE.  YOUR FOLLOW YOUR PROTOCOL, START AN IV AND TRANSPORT.

FIRST PATIENT CONTACT TO 12 LEAD Affected Protocols  ACS  First patient contact to 12 lead  CHF acquisition and transmission  Abdominal Pain interval added where ACS  Respiratory Distress may be causative factor  Altered LOC Stroke

SCOPE OF PRACTICE CHANGES  Effective date 10.16.2013  Mainly affect EMT and AEMT

VERBIAGE CHANGES  All protocol pages updated to  EMT be consistent with Ohio EMS (Formerly EMT-B) Scope of Practice / OAC  Titles changed throughout protocol to new standards  AEMT (Formerly Intermediate)  Paramedic (Formerly EMT-P)

EMT SCOPE CHANGES  Still only permitted to use  Intubation for EMT removed advanced supraglottic (King / Jan 1, 2013 LMA) airways on pulseless and apneic patients

EMT SCOPE CHANGES (CONT)  Direct laryngoscopy removed for EMT of FBAO

EMT SCOPE CHANGES (CONT)  NTG, Aerosols still “patient assisted” which includes online Med Control order  Epi Pen added for protocol use

EMT SCOPE CHANGES (CONT)  Intranasal Naloxone (Narcan) permitted for all first  Used to reverse the responders and EMT’s respiratory effects of narcotics  AEMT / Paramedic allowed to use IM / IV as well

NALOXONE (NARCAN) PHARMACOLOGY Works on narcotics only Class and Mechanism of Action  Heroin  Narcotic antagonist  Morphine  Competes for and binds to  Fentanyl narcotic receptors in the brain  Dilaudid  Reverses respiratory  Codeine depression associated with  Methadone narcotic overdose  Percocet  Demerol  Not a complete list

NALOXONE (NARCAN) PHARMACOLOGY Contraindications Indications  None if patient not breathing  Altered mental status AND; or breathing insufficiently  Patient breathing insufficiently (Low resp rate Precautions high Co2)  May cause withdrawal effects  Patient not breathing at all in opiate dependent patients (Resp rate 0, no Co2 or (Hypertension, tachycardia, N&V, etc) waveform)

NALOXONE (NARCAN) ADMINISTRATION  Push hard push fast to atomize  1ml / per nostril limit  Carried 2mg in 2ml  Half of the syringe in each nostril

CASE: 18 Y/O FEMALE UNRESPONSIVE AT A PARTY  GLUCOSE 80  RESPIRATIONS 6, SNORING RESPIRATIONS  B/P= 90/70 P=120  POX=80  TREATMENT?

CASE: 20 Y/0 MALE SLEEPING IN FRONT OF GOODWILL STORE  EASILY AROUSED  POX=96%  R=14,P=90,B/P 120/80  INTACT AIRWAY  KNOWN HEROIN ABUSER  TREATMENT?

AEMT SCOPE CHANGES  Advanced EMT now allowed  Advanced EMT now allowed to INTUBATE APNEIC as to use supraglottic airway well as PULSELESS and (King / LMA) on APNEIC as APNEIC patients well as PULSELESS and APNEIC patients

VAD PROTOCOL New Protocol !  Not specific to LVAD (most common)  Encompasses all types, LVAD, RVAD, BiVAD  Emphasis on correct transport destination (Implantation Center)  Emphasis on keeping power to unit  Emphasis on Contacting specialized VAD team following patient

TRACH PATIENT MANAGEMENT  Verbiage added in Adult Airway and Adult Respiratory Distress in key points regarding managing Trach patients  Emphasis on suctioning and maintaining open airway  Emphasis on replacing uncuffed Trach tubes with ET tube if ventilation required

LUCAS CPR DEVICE NEW!  Added at request of departments that utilize the  Manual CPR must continue device – not required by while device is being protocol prepared and placed  Automated CPR device  Use in medical arrest situation only  Patients > 12 years old  Contraindications – Trauma Arrest / Patient will not fit device

NEW POLICY New Department Supplied Equipment Updated Restocking Policy  Allows individual departments to purchase  CCF updated EMS devices not specifically Medication and Equipment outlined in protocol and have Policy will be added their respective Medical Directors authorize its use  Departments required to have written policy on its use

MEDICATION CONSOLIDATION LORAZEPAM (ATIVAN) Affected Protocols  Lorazepam (Ativan) replaces 1 - Midazolam (Versed) 2 / 2  Adult Airway 2 - Midazolam (Versed) 5 / 1  ACS 3 - Diazepam (10 / 2)  Adult Bradycardia as the Benzodiazepine of  Adult Narrow Complex Tachycardia choice all protocols  Adult Wide Complex Tachycardia  Adult Extremity Trauma Lorazpam (Ativan) storage  Adult Seizure  90 days unrefrigerated  Peds Bradycardia  Till expiration date  Peds Narrow Complex Tachycardia refrigerated  Peds Seizure  OB Emergencies

MEDICATION CONSOLIDATION LORAZEPAM (ATIVAN) Routes Intravascular (IV) Comparison Intraosseous (IO)  1 mg Lorazepam (Ativan) = Intramuscular (IM) approx 10 mg Diazepam (Valium) Intranasal (IN)  Half Life 10 Hours Supplied 2 mg / 1 ml Carpuject

CASE: SOLDIER STARTS SEIZING AT COMPUTER TRAINING CENTER  AFTER INITIAL SEIZURE HE IS POSTICTAL.  BS=130  VS:140/90, P=120,R=20  COMPLEX GENERALIZED SEIZURE REOCCURS.  TREATMENT?

DIALYSIS PATIENT SYMPTOMATIC HYPERTENSION  Added to Dialysis / Renal  Follows similar BP measures Patient protocol to remind found in Stroke / CVA Paramedics agents are protocol ( SBP 220 or DBP available for specific 120 ) situations where prehospital  Patient is symptomatic intervention of hypertension may be indicated pre/post dialysis HTN PT ( dizzy, HA, Diaphoresis,  Routine management of blurred vision) hypertension is not recommended – for specific  Labetalol 10 mg IV with Med situations Control Consult  Medical Control contact  Labetalol 20 mg IV with Med required Control Consult

WHAT IS HTN EMERGENCY?  SIGNS OF END ORGAN DAMAGE DUE TO SEVERE ELEVATED B/P.  NEUROLOGIC SYMPTOMS  CARDIAC SYMPTOMS  RENAL SYMPTOMS  ANY PRE HOSPITAL TREATMENT REQUIRES MEDICAL CONTROL ORDER SOLDIER!

MEDICATION CONSOLIDATION DEXTROSE Affected Protocols  D50 – Adult Only  D25 – Peds Only  Altered LOC  D10 – Neonate, Peds, and  Diabetic Emergencies Adults  Peds Altered LOC  Need to carry for neonates  Peds Asystole / PEA anyway, can be used in any population  Peds Diabetic Emergencies  Simplifies administration if  Peds Head Trauma department chooses D10  Peds Seizure  Safer  Peds Shock  Neonatal Resuscitation

DEXTROSE 10% PHARMACOLOGY  Required use in Neonate  Can be used in all patient populations (Adult, Peds, Neo)  Not required use in Peds / Adult – Department Choice  1 Bag 250 ml D10 = 25 Grams Dextrose (Same as 1 AMP D50)  Not as thick, piggyback on already established IV – Hands free – Can Hand Push from syringe

5-2-1 RULE FOR DEXTROSE  D10 MUST BE USED FOR INFANTS UNDER 12  D10= 5CC/KG MONTHS OF AGE.  D25=2CC/KG  D25 AGE 1-15  D50=1CC/KG  D50 ADULT

STANDARDIZED BP TERMINOLOGY NEW STANDARD TERMINOLGY IV NORMAL SALINE BOLUS To Maintain SBP 90 or Radial Pulses  Changed from specifying bolus amount to what is done in practice

CAPNOGRAPHY  Added wherever there may be potential for gross Affected Protocols abnormalities in ventilation, perfusion, or metabolism  Already required by AHA for  Adult Medical intubation  Adult Trauma  Added where sedation or multiple doses of respiratory  Peds Medical depressants medications are used  Peds Trauma  Lorazepam (Ativan) for  OB Emergencies procedural sedation and seziures  Second doses of Morphine or Hydromorphone

HOSPITAL CAPABILITIES  Updated and enhanced with additional services

AIRWAY  Direct laryngoscopy removed for EMT  Lorazepam replaces midazolam  Apnic oxygenation for intubation  Stops for head injury, medications down supraglottic airway  Advanced airway use rules as cautions for EMT / AEMT