PROTOCOL UPDATE ALABAMA EMS PROTOCOLS

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PROTOCOL UPDATEALABAMA EMS PROTOCOLS

• EDITION 5
• JUNE, 2009 UPDATE

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PROTOCOL UPDATE

• IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF
  YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES EMAIL
  John.Campbell_at_adph.state.al.us

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PURPOSE OF PROTOCOLS

• IMPROVE PATIENT CARE
• PROVIDE OFF-LINE MEDICAL DIRECTION
• REPRESENT STANDARD OF CARE
• PROVIDE QI STANDARDS
• PROVIDE EDUCATION STANDARDS

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GENERAL CHANGE

• CHANGED THE WORD DRUG TO MEDICATION
  THROUGHOUT THE PROTOCOLS

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TITLE PAGE TABLE OF CONTENTS

• CHANGED TO 5TH EDITION
• TABLE OF CONTENTS UPDATED WITH CHANGES
• Has been alphabetized and renumbered (except
  General Patient Care and Communications were left
  as 4.1 4.2
• Deleted Coma, 4.15 and combined it with Altered
  Mental Status, 4.5
• No new Patient Care Protocols added
• Two protocols were extensively rewritten
• Added one new medication (Ondansetron)

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PREFACE

• Dr. Campbells email address corrected
• Clarified the EMTs responsibility to refuse to
  accept orders that are not in his/her scope of
  privilege
• Added that a pediatric patient is defined as
  someone aged 15 years or younger unless otherwise
  noted in the protocols
• Noted that anything referring to a pediatric
  patient will be in Tahoma font, in bold, and
  colored green

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SECTION 2PATIENTS RIGHTS

• 6Corrected to explain that families of patients
  do not have the same rights as the patients
  themselves. While as a general rule the EMT
  should take the patient to the hospital the
  patients family wants, if the hospital is
  inappropriate or is on diversion, OLMD must be
  called and his/her orders followed

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SECTION 2PATIENTS RIGHTS

• 7 Added that, while an ambulance service does
  not have to take a patient out of town if it
  leaves the community without ambulance service,
  that is not a license to ignore the trauma system
  and always take the trauma patient to the local
  hospital.
• If the ambulance service is unable to comply with
  the regional trauma plan, the service must
  contact the office of EMS Trauma to develop a
  plan to correct this.

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SECTION 3.3PHYSICIAN MEDICAL DIRECTION

• Clarifies that medication orders may be signed by
  an OLMD physician or by the services medical
  director.

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SECTION 3.4MEDICATION AND PROCEDURE
CLASSIFICATION

• Added list of pediatric Category A and Category B
  medications since they are not the same as the
  adult Category A and Category B medications

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SECTION 3.4MEDICATION AND PROCEDURE
CLASSIFICATION

• Added Hemostatic Agents, CPAP, and Ondansetron to
  the list of required medications and procedures.
• All are Category A

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SECTION 3.5OPTIONAL MEDICATIONS AND PROCEDURES

• Removed CPAP and Hemostatic Agents from the list
  of optional medications and procedures

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SECTION 4

• TREATMENT PROTOCOLS

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GENERAL PATIENT CARE 4.1

• Clarified that when filling out the ePCR, the
  General Patient Care protocol can be listed if
  there is no specific protocol for use in treating
  the patient

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COMMUNITCATIONS 4.2

• For stable patients and patients only requiring
  Cat. A treatment, added that the EMT may notify
  the nurse or paramedic at the receiving hospital
• Some hospitals have paramedics answer the phone

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ALTERED MENTAL STATUS 4.5

• Combined COMA 4.15 with this protocol
• You should review this entire protocol as there
  are so many changes

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BURNS 4.7

• For burn patients with wheezing, changed
  albuterol to Category A for adults

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CARDIAC ARREST 4.8

• Added that if the patient is in cardiac arrest,
  and has a venous port, you may access the port if
  you have been trained and have the proper
  equipment
• This requires your medical director to see what
  type of ports are being used in your area and see
  that you are trained how to access that
  particular port
• Some ports require special needles to access

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QUICK REFERENCE TO CARDIAC MEDICATIONS 4.9

• INFANTS AND CHILDREN (Age one month t 8 years)
• Under Sodium Bicarbonate changed Dilute 50 with
  D5W to Dilute 50 with NS
• Also changed dose from 1 mEq/dose to 1mEq/kg
  initial dose

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CARDIAC SYMPTOMS/ACUTE CORONARY SYNDROME 4.10

• Added note that this protocol is for adults only.
  you should contact OLMD for chest pain in
  pediatric patients (age 15 or less).
• Aspirin to be given to adults unless at least
  324mg has already been given in the last 24 hours
• Aspirin is almost never given to pediatric
  patients (CAT. B) because of danger of Reyes
  syndrome

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PEDIATRIC BRADYCARDIA 4.11

• Added that epinephrine and atropine are CAT A
• Epinephrine may be repeated every 3-5 minutes
  until heart rate is 80 or above
• Atropine may be repeated once in 5 minutes if
  heart rate is not 80 or above (maximum total dose
  of 1 mg)
• Added that external pacing is for age 14 and
  above and is CAT B

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CHILDBIRTH 4.12

• Changed the order of clamping and cutting the
  cord to the correct place in the sequence of care
• It was originally listed after wrapping the baby
  in a blanket and taking the vital signs

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CONGESTIVEHEART FAILURE 4.14

• Added that the patient should be put in the
  upright sitting position
• Made nitroglycerin and CPAP Cat. A
• Kept lasix and morphine as CAT. B
• This was to bring our protocols in line with
  current treatment of CHF

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COMA 4.15

• Deleted this protocol and combined its content
  with ALTERED MENTAL STATUS 4.5

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NEAR DROWNING 4.22

• Added near drowning as a CAT. A indication for
  use of CPAP

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POISONS AND OVERDOSES 4.23

• Since paramedics no longer carry syrup of ipecac,
  deleted the list of conditions in which you
  should not induce vomiting
• The protocol now simply states DO NOT INDUCE
  VOMITING

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RESPIRATORY DISTRESS 4.25

• Added that for pulmonary edema, nitroglycerin and
  CPAP are CAT. A and all other treatments (lasix
  and morphine) are CAT B.
• This reflects current treatment of pulmonary edema

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SEIZURES 4.26

• Protocol has been changed to allow either
  diazepam or lorazepam for treatment of seizures
• Some doctors prefer lorazepam
• The only drawback to lorazepam is that it has
  only a 60-day unrefrigerated shelf-life

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SHOCK 4.27

• Added that if external bleeding from an extremity
  cannot be controlled by pressure, application of
  a tourniquet is the reasonable next step in
  hemorrhage control
• This reflects current treatment and current
  National Registry testing

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SHOCK 4.27

• Added to use a hemostatic agent if unable to stop
  severe bleeding with pressure or a tourniquet
• Added that if the patient is in hypovolemic shock
  and the patient has a venous port, you may access
  the port if you have been trained and have the
  proper equipment

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STROKE 4.28

• Protocol has been rewritten to reflect the
  current national guidelines for diagnosis and
  treatment of the stroke patient
• You should review the entire protocol since so
  many changes have been made

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VOMITING 4.32

• Deleted NAUSEA
• Changed treatment of vomiting from
  diphenhydramine to ondansetron (Zofran)
• The cost of injectable ondansetron is now
  reasonable

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SECTION 5

• MEDICATIONS

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ALBUTEROL 5.3

• Added burns and CHF as adult CAT. A use of
  albuterol
• Still CAT B for pediatric burns with wheezing

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ASPIRIN 5.5

• Added that aspirin is CAT. B for pediatric
  patients because it may be associated with Reyes
  syndrome

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ATROPINE 5.6

• Added that atropine is CAT A for pediatric
  cardiac dysrythmias

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DIPHENHYDRAMINE 5.10

• Changed diphenhydramine to a secondary medication
  for treating vomiting

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EPINEPHRINE 5.12

• Added use for pediatric bradycardia (CAT A)

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FUROSEMIDE 5.13

• Added a pediatric dose (CAT. B)
• 0.5 to 1mg/kg IV given slowly over 2 minutes

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LORAZEPAM 5.17

• Added that lorazepam may be used in place of
  diazepam
• Rather than only if you cant get diazepam
• Lorazepam was originally added to the protocols
  because for a time diazepam was unavailable

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MAGNESIUM SULFATE 5.18

• added pediatric dose for treating torsade (CAT.
  B)
• 25 to 50mg/kg IV or IO Maximum dose is 2 grams

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NITROGLYCERIN 5.21

• Added that nitroglycerin is contraindicated for
  pediatric patients in the EMS setting

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NITROUS OXIDE 5.22

• Added that use of nitrous oxide is CAT. B for
  pediatric patients

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ONDANSETRON 5.24

• Added new medication, ondansetron (Zofran) for
  treatment of vomiting
• Ondansetron is non-sedating but has been too
  expensive to use in the past
• It is now generic and inexpensive

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SODIUM BICARBONATE 5.26

• Added that for children between the ages of one
  month and 8 years of age the sodium bicarbonate
  should be diluted 50 with NS

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THIAMINE 5.27

• Added that there is almost no indication for
  thiamine (CAT. B) use in a child
• Only use is for treatment of Beriberi, a disease
  caused by a lack of thiamine (not an emergency
  condition)

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VASOPRESSIN 5.28

• Added that vasopressin use is contraindicated for
  pediatric cardiac arrest

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SECTION 6

• PROCEDURES

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CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) 6.3

• Added near drowning as an indication for use of
  CPAP
• Added a note that CPAP is not used in children
  under the age of 12 because of lack of complete
  development of their respiratory system

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ENDOTRACHEAL INTUBATION 6.5

• Added that orotracheal intubation is CAT. B for
  children and nasotracheal intubation is
  contraindicated in children

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SECTION 8

• ADMINISTRATIVE PROTOCOLS

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DOCUMENTATON OF CARE 8.2

• Added that ePCRs must be completed and
  transmitted to the office of EMS Trauma within
  168 hours (one week) of the provided medical care

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TRAUMA SYSTEM PROTOCOL 8.5

• Changed the protocol to reflect suggestions made
  by the pediatric workgroup and the State Trauma
  Advisory Council
• Physiologic Criteria
• Added that a BP of lt90mmHg refers to an adult or
  a child 6 years of age or older

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TRAUMA SYSTEM PROTOCOL 8.5

• Physiologic Criteria (cont.)
• Added that respiratory distress rates in children
  are
• lt20 or gt60 in a newborn
• lt 20 or gt 40 in a child three years or younger
• lt12 or gt29 in a child four years or older
• Added that head trauma with any neurologic
  changes in a child 5 years or younger puts the
  child in the trauma system

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SECTION 9

• ACCEPTABLE EMS EQUIPMENT AND DEVICES

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BOUGIE FOR DIFFICULT INTUBATIONS 9.2

• Added this optional equipment to the list of
  acceptable equipment
• Bougie, Endotracheal Tube Introducer
• 15 French by 60-70cm for 6.0 to 11.0 ET tubes

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BOUGIE
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DEVICES TO PERFORM CHEST DECOMPRESSION 9.4

• Added Becton Dickinson Angiocath 14 gauge by
  3.25 inches long

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HEMOSTATIC AGENTS 9.5

• Added QuikClot Combat Gauze
• Kaolin based
• Currently being used by military in combat in
  Iraq
• Added WoundStat
• Granular combination of smectite and polymer

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SECTION 10

• FORMS

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STROKE CHECKLIST 10.3

• Rewrote stroke checklist to reflect the new
  Stroke Protocol

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REQUEST TO BE TAKEN TO A HOSPITAL ON DIVERSION
10.4

• Removed the patients family as being able to
  sign to take the patient to a hospital on
  diversion

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ALERT! BEFORE USING NEW PRTOTOCOLS

• EACH SERVICE MUST NOTIFY AND PROVIDE YOUR SERVICE
  OFF-LINE MEDICAL DIRECTOR A COPY OF THE 5TH
  EDITION PROTOCOLS (June 09 edition) AND A COPY OF
  THIS UPDATE PRESENTATION
• It is OK for the medical director to download the
  material instead
• EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL
  DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS ARE
  AWARE THAT THE PROTOCOLS HAVE BEEN UPDATED AND
  WHERE TO GET THE MATERIAL
• The service is not responsible for furnishing
  copies of the protocols or update slide
  presentation

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NEW PROTOCOLS CAN BE USED

• WHEN EVERYONE IN A SERVICE HAS BEEN UPDATED
• TURNED ON SERVICE BY SERVICE NOT INDIVIDUAL BY
  INDIVIDUAL
• TURN IN ROSTER TO REGIONAL EMS AGENCY NOT TO
  OFFICE OF EMS TRAUMA
• Also acknowledge that you have updated your
  off-line medical director and provided copy of
  protocols
• REGIONAL EMS AGENCY WILL NOTIFY YOU WHEN YOU CAN
  START USING NEW PROTOCOLS
• EVERY SERVICE MUST BE UPDATED BY OCTOBER 1ST, 2009

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QUESTIONS?