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Protocol Update

Protocol Update Version 6.032 Updated January 20, 2006 Created by Central Mass EMS Corp. (Region II EMS) Visit us! www.cmemsc.org Overview General Changes Specific Protocol Changes New Protocols Appendix Changes

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Protocol Update

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  1. Protocol Update Version 6.032 Updated January 20, 2006 Created by Central Mass EMS Corp. (Region II EMS) Visit us! www.cmemsc.org

  2. Overview • General Changes • Specific Protocol Changes • New Protocols • Appendix Changes • Administrative Requirements and Advisories released since last protocol update • Conclusion

  3. General Changes

  4. General Changes • New Format (redundancy eliminated) • Preamble updated (see #13) • Generic names for all medications; also bold typed • Drug Reference edited to include only those medications on Medications List (see Appendix A)

  5. General Changes, continued • Use of nasal Naloxone wherever Naloxone allowed • Blood glucose threshold changed in all pertinent protocols from 100 to 70

  6. General Changes, continued • Reference to “Follow AED Protocol” replaced in all pertinent protocols with: “Use AED according to the standards of the American Heart Association or as otherwise noted in these protocols and other advisories”.

  7. Specific Protocol Changes

  8. Asystole/Cardiac Arrest (1.1) Paramedic Standing Orders: Administer a250cc bolus of IV Normal Saline if warranted

  9. Atrial Fibrillation (1.2) andAtrial Flutter (1.3) • NOTE: For rate control in adult patients currently prescribed a beta-blocker Paramedic Medical Control: • Administer Metoprolol Bolus 2.5mg-5mg slow IV Push over 2 minutes • Repeat dosing in 5 minute intervals to a max of 15mg

  10. Atrial Fibrillation (1.2) andAtrial Flutter (1.3), continued CAUTION: Do not mix IV Metoprolol with IV Ca blockers

  11. Chest Pain (1.5) • Name changed to Acute Coronary Syndrome • Paramedic Standing Orders: Morphine dose 2.0-4.0 mg • Medical Control: Lidocaine and repeat bolus removed

  12. Post Resuscitation (1.6) Paramedic Standing Orders: Dopamine 10.0mcg/kg per minute if BP is < 80 systolic after fluid bolus

  13. VTach with Pulses (1.11) • Paramedic Standing Orders: Amiodarone 150mg in 10cc normal saline IV over 8-10 minutesadded • Medical Control: Amiodarone 150mg-300mg in 10ml Normal Saline IV over 8-10 minutes (changed from 1-2 minutes)

  14. Hypothermia (2.4) Paramedic Standing orders: Thiamine administration removed

  15. Nerve Agent Exposure (2.6) First Responders may administer nerve agent antidotes (Mark-1 kits) to fellow authorized public employees (This change was initially released as an OEMS Advisory on January 18, 2005)

  16. Abdominal Pain (3.1) Medical Control: Patients with severe pain and a BP > 110 systolic may be considered for pain management under Adult Pain Management Protocol (3.14)

  17. Allergic Reaction/Anaphylaxis (3.2) and Pediatric Anaphylaxis(5.2) • “NOTE” section deleted referring to authorized EPI course. • All EPI training should now be completed within the Initial EMT course. • Further “refresher” training of EPI may be done through continuing education.

  18. CHF/Pulmonary Edema (3.5) Paramedic Standing Orders: Dobutamine infusion deleted

  19. CHF/Pulmonary Edema (3.5) and Hypertensive Emergencies (3.7) Nitrate note changed to: Do not administer Nitroglycerin if patient (male or female) has taken any medication in the phosphodiesterase-type-5 inhibitor category within the last 48 hours.

  20. Obstetrical Emergencies (3.8) • Pitocin (Oxytocin) removed • Eclamptic Seizures: • Lorazepam 2-4mg slow IV Push or IM -OR- • Diazepam 5-10mg slow IV Push or IM

  21. Seizures (3.9) • Paramedic Standing Orders: Lorazepam 2-4mg slow IV Push or IM over 2-3 minutes • CAUTION note added: In patients with head injury or hypotension, the use of Diazepam or Lorazepam may be contraindicated

  22. Shock/Hypotension (3.10) Medical Control Options deleted: • Second IV of NS/LR • Dobutamine Infusion 2-20µg/kg/minute (duplication) • Norepinephrine Infusion

  23. Acute Stroke (3.11) Edited for consistency with current Stroke POE guidelines • Reference to Massachusetts Stroke Scale (MASS) • Reference to Thrombolytic Checklist included in Basic Procedures

  24. Spinal Injury (4.7) Paramedic Medical Control Option deleted: • Methylprednisolone (Solumedrol) IV infusion over 30 minutes

  25. Newborn Resuscitation (5.1) “NOTE” section referring to AED use removed from Basic and Intermediate procedures

  26. Pediatric Seizures (5.7) • Paramedic Standing Orders: • Cardiac Monitor 12 lead ECG-manage dysrhythmias removed • Naloxone HCL removed • Diazepam 0.25mg/kg IV/IO to max 5-10mg or Rectal Diazepam 0.5mg/kg -OR- • Lorazepam 0.05-0.1mg/kg IV/IO (dilute 1:1 NS) or IM to max 2mg

  27. Pediatric Seizures, continued • Medical Control Note: Reference to seizure activity changed from 30 minutes to 10 minutes

  28. Pediatric VFib/Pulseless VTach (5.12) Paramedic Standing Orders: Epinephrine doses reformatted • Initial dose: IV/IO: 0.01mg/kg; ET: 0.1mg/kg(1:10,000, 0.1mL/kg) • Subsequent doses: same • May repeat every 3-5 minutes • IV/IO doses up to 0.02mg/kg of 1:10,000 may be effective

  29. New Protocols

  30. Adult Upper Airway Obstruction (3.15) • Modeled after Pediatric Upper Airway Obstruction (5.11) • Provides guidance for Tracheostomy tube obstruction management in the adult

  31. Diabetic Emergencies (3.16) • Referenced in Altered Mental Status Protocol (3.3) • Hypoglycemia threshold changed from 100 to 70

  32. Appendix Changes

  33. Appendix A: Medication List Additional Nerve Agent Antidotes added to the Optional Medication List

  34. Appendix C: Cessation of Resuscitation • Refer to AR 5-515 (2/1/05) • Current valid DNR • Trauma inconsistent with survival • Body condition clearly indicates biological death

  35. Appendix D: Rescue Airway • Name changed to Emergent Advanced Airway • Paramedic Medical Control Option: Sedative medications may be allowed

  36. Appendix D, continued • If intubation unsuccessful, insert LMA, Combi-Tube, or other approved rescue device • “Grading Airway” figuresadded

  37. Appendix N: Inter-facility Transfers Updated version to be released soon

  38. Appendix Q: MASS • Massachusetts Stroke Scale • Facial Droop • Arm Weakness • Speech Disturbance

  39. Administrative Requirements and OEMS Advisories Review

  40. Administrative Requirements 2005 • AR 5-610 Responding to Scenes Involving Minors Refusing Treatment or Transport • Refers to minors that have an emergency medical condition (or potential for one) • Use reasonable judgment in determining if patient is minor (<18) or emancipated

  41. ARs 2005, continued • AR 5-610 (Minors), continued • Refusal for <18 must be made by parent or legal guardian • Document in detail: findings, actions and reasons • Services should also develop policies with own legal counsel to establish guidelines

  42. ARs 2005, continued • AR 5-520 Requirements for Basic & Intermediate EMT Use of Glucose Monitoring • Optionalskill for EMT-B and I • Requires agreement for medical director oversight • Service must provide appropriate training & associated records

  43. ARs 2005, continued • AR 5-520(Glucometer) continued • QA/QI program in place that includes yearly training review • Glucose results must be documented • Blood borne pathogen policies must be adhered to • Glucose monitoring device must meet department requirements

  44. ARs 2005, continued • AR 5-520(Glucometer) continued • Manufacturer’s instructions for control runs, use, care & cleaning must be followed • CLIA (Clinical Laboratories Improvement Amendments) waiver must be obtained

  45. ARs 2005, continued • AR 5-615 Cancellation of ALS • Affiliate hospital and/or service medical director must establish written guidelines • BLS must complete assessment and treatment according to state protocols • Careful documentation by BLS and ALS

  46. ARs 2005, continued • AR 5-620 ALS Transfer of Calls to BLS • If patient contact established by ALS, must complete assessment & treatment according to state protocols • If ALS intervention initiated, must attend to patient during transport • May transfer care to BLS if ALS intervention is not needed or anticipated • Documentation of encounter required

  47. ARs 2005, continued • AR 2-360 Dept. Assessment of Info Reported by EMS Personnel per 105 CMR 170.937 • EMTs/EFRs must file written report with both DPH/OEMS and own service within 5 days of: • any conviction of misdemeanor or felony • loss or suspension of driver’s license

  48. Advisories 2004 • Administration of Medications by Paramedics to Persons Not Being Transported • Don’t do it • On-Line CPR Training • Not valid unless it also includes practical skills evaluation

  49. Advisories 2005 • Ventricular Assist Devices: • Do not do chest compressions • Use in accordance with manufacturer’s instructions • AED Use for ages 1-8 • Adult AED allowed if pediatric AED is not available

  50. Advisories 2005, continued • Paramedic Medical Control Option: Allows bypass of closest facility to transport to PCI (aka: angioplasty) facility for patients with: • ST elevation AND • Cardiogenic shock or CHF or contraindications to thrombolysis

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