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

Cautions

 Allows us to put warnings

immediately adjacent to medication or procedure to assure key points are remembered Stops

 On page reminder to keep

certain actions from

• ccurring without lengthy

explanation in key points that will likely be forgotten, missed, or misunderstood.

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

 Old CONTACT MEDICAL

CONTROL red box confusing, makes it seem like every patient contact required call to Medical Control Revised Box

 Spells out events as they are

actually performed

WHO TO CONTACT?

 YOUR MEDICAL CONTROL

IS HILLCREST HOSPITAL.

 THE PATIENT WANTS TO

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.

 WHO DO YOU CALL TO

GIVE A REPORT?

 HILLCREST OR CCF MAIN?

FIRST PATIENT CONTACT TO 12 LEAD

 First patient contact to 12 lead

acquisition and transmission interval added where ACS may be causative factor

Affected Protocols

 ACS  CHF  Abdominal Pain  Respiratory Distress  Altered LOC

Stroke

SCOPE OF PRACTICE CHANGES

 Effective date 10.16.2013  Mainly affect EMT and AEMT

VERBIAGE CHANGES

 All protocol pages updated to

be consistent with Ohio EMS Scope of Practice / OAC

 Titles changed throughout

protocol to new standards

EMT

(Formerly EMT-B)

AEMT

(Formerly Intermediate)

Paramedic

(Formerly EMT-P)

EMT SCOPE CHANGES

 Intubation for EMT removed

Jan 1, 2013

 Still only permitted to use

advanced supraglottic (King / 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 responders and EMT’s

 AEMT / Paramedic allowed

to use IM / IV as well

 Used to reverse the

respiratory effects of narcotics

NALOXONE (NARCAN) PHARMACOLOGY

Class and Mechanism of Action

 Narcotic antagonist  Competes for and binds to

narcotic receptors in the brain

 Reverses respiratory

depression associated with narcotic overdose Works on narcotics only

 Heroin  Morphine  Fentanyl  Dilaudid  Codeine  Methadone  Percocet  Demerol  Not a complete list

NALOXONE (NARCAN) PHARMACOLOGY

Contraindications

 None if patient not breathing

• r breathing insufficiently

Precautions

 May cause withdrawal effects

in opiate dependent patients (Hypertension, tachycardia, N&V, etc) Indications

 Altered mental status AND;  Patient breathing

insufficiently (Low resp rate high Co2)

 Patient not breathing at all

(Resp rate 0, no Co2 or 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

to INTUBATE APNEIC as well as PULSELESS and APNEIC patients

 Advanced EMT now allowed

to use supraglottic airway (King / LMA) on APNEIC as well as PULSELESS and APNEIC patients

VAD 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 New Protocol !

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

 Added at request of

departments that utilize the device – not required by protocol

 Automated CPR device  Use in medical arrest

situation only

 Patients > 12 years old  Contraindications – Trauma

Arrest / Patient will not fit device

 Manual CPR must continue

while device is being prepared and placed

NEW!

NEW POLICY

New Department Supplied Equipment

 Allows individual

departments to purchase devices not specifically

• utlined in protocol and have

their respective Medical Directors authorize its use

 Departments required to

have written policy on its use Updated Restocking Policy

 CCF updated EMS

Medication and Equipment Policy will be added

MEDICATION CONSOLIDATION LORAZEPAM (ATIVAN)

 Lorazepam (Ativan) replaces

1 - Midazolam (Versed) 2 / 2 2 - Midazolam (Versed) 5 / 1 3 - Diazepam (10 / 2) as the Benzodiazepine of choice all protocols Lorazpam (Ativan) storage

 90 days unrefrigerated  Till expiration date

refrigerated Affected Protocols

 Adult Airway  ACS  Adult Bradycardia  Adult Narrow Complex Tachycardia  Adult Wide Complex Tachycardia  Adult Extremity Trauma  Adult Seizure  Peds Bradycardia  Peds Narrow Complex Tachycardia  Peds Seizure

 OB Emergencies

MEDICATION CONSOLIDATION LORAZEPAM (ATIVAN)

Comparison

 1 mg Lorazepam (Ativan) =

approx 10 mg Diazepam (Valium)

 Half Life 10 Hours

Routes Intravascular (IV) Intraosseous (IO) Intramuscular (IM) Intranasal (IN) 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

Patient protocol to remind Paramedics agents are available for specific situations where prehospital intervention of hypertension may be indicated

 Routine management of

hypertension is not recommended – for specific situations

 Medical Control contact

required

 Follows similar BP measures

found in Stroke / CVA protocol ( SBP 220 or DBP 120 )

 Patient is symptomatic

pre/post dialysis HTN PT ( dizzy, HA, Diaphoresis, blurred vision)

 Labetalol 10 mg IV with Med

Control Consult

 Labetalol 20 mg IV with Med

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

 D50 – Adult Only  D25 – Peds Only  D10 – Neonate, Peds, and

Adults

 Need to carry for neonates

anyway, can be used in any population

 Simplifies administration if

department chooses D10

 Safer

Affected Protocols

 Altered LOC  Diabetic Emergencies  Peds Altered LOC  Peds Asystole / PEA  Peds Diabetic Emergencies  Peds Head Trauma  Peds Seizure  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 MONTHS OF AGE.

 D25 AGE 1-15  D50 ADULT  D10= 5CC/KG  D25=2CC/KG  D50=1CC/KG

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 abnormalities in ventilation, perfusion, or metabolism

 Already required by AHA for

intubation

 Added where sedation or

multiple doses of respiratory depressants medications are used

 Lorazepam (Ativan) for

procedural sedation and seziures

 Second doses of Morphine or

Hydromorphone

Affected Protocols

 Adult Medical  Adult Trauma  Peds Medical  Peds Trauma  OB Emergencies

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

ACS

 First Patient Contact to

EKG timeframe added

 Stops added for NTG  Pathway added for;

Clean 12 lead with suspicion of MI, perform right sided 12 lead

 Lorazepam (Ativan)

replaces Midazolam / Diazepam for cocaine induced STEMI

CHF

 First Patient Contact to

EKG timeframe added

 Stops for NTG, CPAP,

and ResQGARD added

 Captopril blue boxed,

assuming no stops prevent administration

 Lasix remains red

boxed per best practices

 Cardiogenic shock

highlighted (gray box) to remind providers its not “hypotensive CHF”

ANAPHYLACTIC SHOCK

 Stops added for 1:1000

vs: 1:10000 IV, Solu-Medrol, and Albuterol for EMT use

 EPI – PEN added in

protocol for EMT use

 Anaphylactic shock

highlighted (gray box) to remind provider that the patient needs IV medications rather than IM

CASE: ANAPHYLAXIS AFTER EATING TRAIL MIX BAR

 PATIENT COLLAPSE  POX=70%  B/P 60/40 P=120 R=30  TREATMENT?

RESPIRATORY DISTRESS

 Albuterol / Atrovent

yellow boxed with STOP for EMT use without direct Medical Control

 First Patient Contact to

EKG timeframe added

 Stops added in CPAP

and Solu-Medrol

CPAP REMINDERS

 CPAP DOES NOT

VENTILATE.

 CPAP IS USED FOR

OXYGENATION AND TO OPEN UP AVEOLI.

 COPD AND ASTHMA

PATIENTS HAVE DISTENDED AVEOLI AND CPAP MAY CAUSE BAROTRAUMA TO THESE PATIENTS. LAST DITCH USE FOR EXTREME HYPOXIA.

 WE DO USE BIPAP FOR

THESE PATIENTS

 MAJOR USE IN PRE

HOSPITAL IS CHF.

 CAN’T USE IN

HYPOTENSION.

 CAN’T USE WITH FACIAL

TRAUMA.

 CAN’T USE WITH VOMITING

OR AIRWAY ISSUES, INCLUDING ALTERED MENTAL STATUS.

 CAN’T USE WITH PNTX TILL

TREATED.

STROKE

 Improved Cincinnati

stroke scale to help catch posterior circulation problems

 CincinnatiPlus  Added Visual Fields,

Following, and Acuity

 Labetalol blue boxed

with cautions and stops

 First Patient Contact

to EKG timeframe added

 ADD FINGER NOSE

FINGER FOR CEREBELLAR TESTING.

 ADD FIELD OF VISION

TESTING AND EXTRA OCCULAR MOVEMENTS TO TEST OCCIPITAL AREA AND BRAINSTEM.

PSYCH EMERGENCIES

 Lorazepam (Ativan)

added as sedative in addition to Haloperidol / Diphenhydramine

PEDS HEAD TRAUMA

 Capnography targets

added to mirror adult head trauma