2013 OEMS Prehospital Protocol Update

1. 2013 OEMS Prehospital Protocol Update Amy Gutman MDEMS Medical Directorprehospitalmd@gmail.com / www.teaems.com

2. Objectives • Inform Massachusetts prehospital providers of updates to the OEMS Prehospital Treatment protocols effective as of March 1st, 2013 • Review evidence-based literature rationale behind the changes www.mass.gov/dph/oems

3. Medication Changes • Majority of changes are route-related or provide alternatives during medication shortages • Updated wording reflects national standards, for example removing “trailing zeros” from medication dosing in all protocols, appendixes & drug references www.jointcommission.org Rationale: Joint Commission safety recommendation, consistent with national patient care practices

4. General Principles for Specific Skills • EMS crews should not begin or administer interventions requiring medical assessment if patient brought to environment where intervention will not be provided / monitored • i.e. Giving IV narcotics to patient not being transported to a medical facility • Principle does not apply to giving medications if patient being brought to a facility where personnel available to assess patient, such as a physician’s office or a skilled nursing facility Rationale: Clarification of role of EMS as medical providers

5. General Principles for Specific Skills • Recent advances in resuscitation science have increased potential for survival in out-of-hospital cardiac arrest (OOHCA) • Some MA EMS systems monitor their OOHCA survival rates with excellent results comparable to national norms. Ideally every EMS system should monitor & strive to improve their OOHCA survival rates • For services not currently monitoring & taking steps to improve their OOHCA outcomes the following is recommended: • EMD instructions to provide hands-only CPR if patient unconscious & not breathing normally • Emphasis on continuous compressions to maintain 80% compression fraction • Delay intubation to after 1st 8 mins CPR in primary cardiac arrest to avoid interrupting compressions • Field followed by hospital hypothermia for ROSC • Rapid 12-lead EKG after ROSC to determine if STEMI POE should be used Rationale: Monitoring out-of-hospital cardiac arrest care

6. Ewy GA, Sanders AB. Alternative approach to improving survival of patients with out-of-hospital primary cardiac arrest (OOHCA). J Am Coll Cardiol. 2013. Jan 15;61(2):113-8 • Cardiocerebral resuscitation (CCR) significantly improved survival of OOHCA patients in 2 Wisconsin counties from 15% to 39%, and in 60 Arizona EMS departments to 38% over one year. Using CCR, over a five year period, survival from primary cardiac arrest in Arizona increased from 18% to 33% • Conclusions: Advocating bystander compression only CPR for patients with primary OOHCA, and encouraging EMS CCR vs prior CPR guidelines which included emphasis on ventilations and early airway management

7. Ewy GA, Kern KB. Recent advances in cardiopulmonary resuscitation: cardiocerebral resuscitation. J Am Coll Cardiol. 2009 Jan 13;53(2):149-57 • CCR advocates continuous compressions without mouth-to-mouth ventilations for witnessed cardiac arrest • For bystanders with AED access & EMS arriving in electrical (1st 4-5 mins) phase of VF, prompt defibrillation recommended • For EMS arriving in circulatory phase of VF arrest (>5 mins) when fibrillating myocardium has used up energy stores, compressions mandatory prior to & immediately after defibrillation • Recommendations: delayed endotracheal intubation, avoid excessive ventilations, & utilize early epinephrine

8. Clemmensen P, et al. Diversion of STEMI patients for primary angioplasty (pPCI) based on wireless prehospital 12-lead ECG transmission directly to cardiologist's handheld computer: a progress report. J Electrocardiol. 2005 Oct;38:194-8 • Time to reperfusion critical in STEMI patients. Transfer from receiving hospital to a catheterization center can cause unacceptable delays • Prehospital ECGs transmitted for 408 CP patients (success 93%). Cardiologists receiving ECG recommended 113 patients (28%) diverted for pPCI • Results: EMS scene time increased by 7 mins when ECG transmitted to cardiologist compared to control. Time from ECG to ED arrival 25 mins. Hospital treatment time significantly reduced for diverted patients - ED arrival to pPCI 40 mins vs 94 mins in control group

9. Wenzel V, et al. Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23 • Chest compressions minimum 100/min, 5 cm depth at ratio of 30:2 with ventilation. Avoid interruptions in compressions to ventilate • After every defibrillation attempt (initially biphasic 120-200J, monophasic 360J, subsequently with respective highest energy), compressions immediately reinitiated for 2 min independent of rhythm • ETI performed only by experienced providers during ongoing compressions with a maximum interruption of 10 sec to pass ETT through vocal cords. Supraglottic airways are alternatives to ETI • Active compression-decompression & inspiratory threshold valve are not superior to good standard CPR

10. Wenzel V, et al. Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23 • Pediatric BLS: • Initially 5 rescue breaths, followed by compressions (100-120/min depth 1/3chest diameter), compression-ventilation ratio 15:2 • Foreign body airway obstruction with insufficient cough: alternate back blows & compressions (infants), or abdominal compressions (>1 yo) • Pediatric ALS: • Epinephrine 10 ug/kg IV or IO every 3-5 min. Defibrillation (4 J/kg) followed by 2 min CPR, then ECG & pulse check

11. 1.5 ACS, 1.6 ROSC, 3.11 Acute Stroke • Added: Avoid hyperoxygenation, administer O2 using appropriate delivery device as clinically indicated • If pulse oximetry available, give supplemental oxygen only if oxygen saturation level <94% on room air Rationale: Hyperoxygenation causes coronary & systemic vasoconstriction, resulting in decreased coronary blood flow, increased coronary vascular resistance & free radical formation

12. Ranchord AM, et al. High-concentration versus titrated oxygen therapy in STEMI: a pilot randomized controlled trial. Am Heart J. 2012 Feb;163(2):168-75 • Methods: 136 STEMI patients uncomplicated by cardiogenic shock or hypoxia randomized to receive high-concentration (>6 L/min) or titrated O2 (to achieve O2 saturation 93%-96%) for 6 hrs. Outcomes were 30-day mortality & infarct size assessed by troponin level at 72 hrs. Secondary outcomes: meta-analysis of mortality data from previous trials, & infarct size assessed by MRI at 4 - 6 weeks • Conclusions: No benefit or harm from high-concentration O2 compared with titrated O2 in uncomplicated STEMI. Because meta-analysis data had a large confidence interval (meaning, data uncertainty) larger randomized studies required to resolve any clinical uncertainty

13. Shi J, et al. A new idea about reducing reperfusion injury in ischemic stroke: Gradual reperfusion. Med Hypotheses. 2013 Feb;80(2):134-6 • Occlusion of intracranial arteries leads to direct cell death with cell functional impairment surrounding dead core (ischemic penumbra). Opening the occluded artery to limit ischemic penumbra size is aim of thrombolysis therapy, but reperfusion induced injury counteracts potential benefits of thrombolysis • Conclusions: Gradual reperfusion reduces reperfusion injury by reducing free radical production; free radicals come from reperfusion penumbra & respiration cycle which is upregulated during ischemia. Once reperfusion occurs, respiratory chain enzymes need only normal amount of O2 & glucose to avoid producing free radical intermediates. Gradual reperfusion reduces free radical production by limiting O2 & glucose provided to the respiratory chain

14. 3.4 Bronchospasm/ Respiratory Distress • Added to ALS-P Standing Orders: in patient with known asthma or COPD, without history or findings concerning for CHF give hydrocortisone 100 mg IV, IM, IO or methylprednisolone 125 mg IV, IM or IO • In patients <40 yo epinephrine 0.15-0.3 mg IM* by autoinjector only as 1 time dose, contact medical control for additional dosing • Added to MCO: “BY AUTOINJECTOR ONLY” www.hubpages.com Rationale: Therapy for severe distress by reducing inflammation associated with bronchospasm; Effective treatment to patients <40 yo in treatment of bronchospasm/respiratory distress due to asthma; safety reminder regarding dosing device

15. 4.2 Burns / Inhalation Injuries • Added to ALS-P Standing Orders: In patient with hypotension, AMS, or indications of cyanide toxicity who may have experienced smoke inhalation, consider hydroxocobalamin 5gm IV over 15 mins (adult), or 70 mg/kg (to max 5 gm) IV over 15 mins (pediatric) sanatate.bzi.ro Rationale: Effective treatment for acute cyanide poisoning

16. O’Brien DJ, et al. Empiric management of cyanide toxicity associated with smoke inhalation. Prehosp Disaster Med. 2011. Oct;26(5):374-82 • Closed-space smoke inhalation 5th most common cause of US unintentional injury deaths. Cyanide is a toxin in many cases of smoke inhalation but it’s presence cannot be rapidly confirmed • Findings suggesting cyanide toxicity include: closed-space fire with likely smoke inhalation; oropharyngeal soot or carbonaceous expectorations; altered LOC, otherwise inexplicable hypotension • Prehospital studies demonstrate feasibility & safety of empiric treatment with FDA-approved hydroxocobalamin for patients with suspected smoke inhalation cyanide toxicity. Based on literature review & on-site observation of the Paris Fire Brigade, prehospital protocols to guide empiric & early hydroxocobalamin administration in smoke inhalation victims with high-risk presentations recommended

17. 4.3 Head Trauma & 4.7 Spinal Column / Cord Injuries 4.3 Head Trauma 4.7 Spinal Column / Cord Injuries Removed: “Consider hyperventilation with 100% oxygen with BVM if associated with a significant closed head injury & signs of herniation syndrome” • Removed: “Hyperventilation may help brain injury by reducing intracranial pressure. Hyperventilate patient in suspected cases of herniation syndrome (e.g. decorticate posturing, decerebrate posturing, fixed, dilated pupils, etc.)” • Removed: “Consider hyperventilation if clinically appropriate with a significant closed head injury & signs of herniation syndrome” Rationale: Hyperventilation causes increased ICP & decreased peripheral blood flow, worsening patient outcomes

18. Dumont TM, et al. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma. 2010. Jul;27(7):123-41 • In traumatic brain injury (TBI), hyperventilation to reduce ICP may be life-saving. However, undue use of hyperventilation may increase incidence of secondary brain injury through direct reduction of cerebral blood flow • Methods: TBI patients with GCS <8 (n = 65) sorted into hypocarbic (Pco2 <35 mmHg), normocarbic (Pco2 35-45 mmHg), & hypercarbic (Pco2 >45 mmHg). Survival related to admission Pco2 in TBI patients requiring ETI. Patients with normocarbia had in-hospital mortality of 15%, significantly improved over patients presenting with hypocarbia (77% mortality) or hypercarbia (61% mortality). • Conclusions: Abnormal Pco2 on presentation after TBI correlated with increased in-hospital mortality and advocate prehospital normoventilation

19. 4.6 Soft Tissue / Crush Injury • Removed: under Basic Procedures words “direct pressure”, “pressure points” • Added: “If suspect severe crushing injury / compartment syndrome, if injury permits” Rationale:To avoid contradicting new changes for hemorrhage control (direct pressure followed by tourniquet). Allows use of tourniquet if no other way to stop hemorrhage

20. 4.7 Spinal Column / Cord Injuries • Non-penetrating trauma added when considering immobilization • “Evidence of significant non-penetrating trauma above the clavicles” Rationale: Immobilized patients with penetrating trauma have worse outcomes than non-immobilized patients

21. Paiva WS, et al. Spinal cord injury and its association with blunt head trauma. Int J Gen Med. 2011;4:613-5 • What are risk factors for spine trauma plus traumatic brain injury (TBI)? • Results: 180 pts with moderate or severe TBI had cervical spine x-ray and CT. Most common causes of TBI were pedestrians struck by vehicles (31%), MVC (28%) & falls (25%). Systemic injuries found in 80 (44%) patients. 53% had severe , & 47% had moderate head trauma. 14 patients (8%) had a spinal cord injury (12 cervical, 1 lumbar, 1 thoracic). In the elderly, presence of systemic injuries & GCS <9 were significant risk factors for spine injury • Conclusions: Spinal cord injury related to moderate & severe brain trauma usually affects the cervical spine

22. 4.7 Spinal Column / Cord Injuries • Deleted: “including adult fall from standing” from the high risk factors for determining possible spinal injury • Age <8 years or >65 years still considered “high risk mechanisms” Rationale: Fall from standing only a risk in patients >65 years of age

23. Lomoschitz FM, et al. Cervical spine injuries in patients 65 years old & older: epidemiologic analysis regarding the effects of age & injury mechanism on distribution, type, & stability of injuries. Am J Roentgenol. 2002 Mar;178(3):573-7 • Methods & Results: 225 cervical spine injuries in 149 patients >65 yo retrospectively assessed. Mechanism (falls from standing or seated height vs higher energy mechanisms) & initial neurologic status recorded. 95 (64%) patients had upper cervical injuries. 59 (40%) patients had multilevel injuries. Main causes for cervical injuries were MVCs in "young elderly" (65-75 yo; 61%) & falls from standing or seated height in "old elderly" (>75yo; 40%). Patients >75 yo (independent of mechanism), & patients falling from standing height (independent of age), more likely to injure the upper cervical spine • Conclusions: Elderly patients in general including those falling from standing height are more prone to injuries of the cervical spine

24. 4.10 Traumatic Amputations • Language Added to Basic Procedures: • Control/stop any life threatening hemorrhage • If other methods cannot control bleeding apply appropriate tourniquet • Document exact time of tourniquet application www.thefreedictionary.com Rationale:ITLS recommends use of tourniquets to control life threatening bleeding; pressure points & elevation have been removed

25. Kragh JF, et al. Survey of the indications for use of emergency tourniquets. J Spec Oper Med. 2011 Winter;11(1):30-8 • Optimal tourniquet use in trauma appears to depend on device, doctrine, training, speedy evacuation, & performance improvement. Challenges remain in estimation of blood loss & injury lethality • Methods: Data on emergency tourniquet use analyzed from a clinical study of 728 casualties with 953 tourniqueted limbs. Authors compared known prior datasets to this clinical study • Recommendations: Current indication for emergency tourniquet use is any compressible limb wound that provider assesses as having possibly lethal hemorrhage. This indication has shown good outcomes only when devices, training, doctrine, evacuation & research optimized

26. Appendix D Emergent Airway • Appendix renamed “Difficult Airway Protocol” Rationale: More representative of when process should be utilized

27. Appendix T Nerve Agent Dosing & Reference Table • Added: Duodote to Appendix T • Mark I kits & Duodote not approved for routine pediatric use, however should be used as initial therapy for children with life-threatening nerve agent toxicity (in extremis) when IV therapy not available • “Assumes” 0.8 inch needle insertion depth www.myfirefighternation.com Rationale: Accepted treatment for children with severe life-threatening nerve agent toxicity

28. 1.1 Asystole • Added to ALS-P Standing Orders: if epinephrine 1:10,000 unavailable due to drug shortage, vasopressin 40 units may be substituted & given every 20 minutes IV or IO www.drugline.org Rationale: Handle epinephrine shortages

29. Wenzel V, et al. A comparison of vasopressin & epinephrine for out-of-hospital cardiopulmonary resuscitation. NEJM. 2004 Jan 8;350(2):105-13 • Background: Vasopressin is an alternative to epinephrine for vasopressor therapy during CPR • Study Methods: Adults with OOHCA received 2 injections of either 40 IU of vasopressin or 1 mg of epinephrine, followed by additional treatment with epinephrine if needed. Primary end point was survival to admission; secondary end point was survival to discharge • Study Conclusions: Effects of vasopressin similar to those of epinephrine in management of VF and PEA, but vasopressin superior to epinephrine in patients with asystole. Vasopressin followed by epinephrine may be more effective than epinephrine alone in refractory cardiac arrest

30. Protocols / References Involving Morphine and Fentanyl (1.2, 1.3, 1.4, 1.5, 1.9, 1.11, 3.7, 3.14, 4.2, 5.13) • Standing Orders: • Deleted “This is a one time dose option”; Replaced with “Medication dose may be given in divided doses up to the maximum” • This includes titrating to pain control for ACS (Protocol 1.5) • Added: • Fentanyl linked to drug reference page • IM route added for fentanyl Rationale: Allow pain control titration of under standing orders, technical fix to text, added administration route

31. Protocols & References Involving Epinephrine (1.4,1.6, 3.2, 5.1, 5.2, 5.3, 5.5) • Infusion: • Administer 1 mcg to 10 mcg / min IV or IO • For example: mix 1 mg of 1:1000 Epinephrine in 250 ml NS • 15 micro drops/min = 1 mcg / min commons.wikimedia.org Rationale: Standardized language, administration routes clarified by adding IV & IO routes

32. 1.5 ACS • NTG 0.3mg removed from MCO section www.webmed.com Rationale: Standardized language

33. Protocols Involving Amiodarone (1.6 & 1.11) • Added: “for example” to drip information • Amiodarone 1 mg/min IV drip for example: 100mg/100ml- 1mg/min www.rxprescriptionguide.org Rationale: Standardize dosing option in ALS-P & MCO

34. Allergic Reaction/Anaphylaxis 3.2 Adult 5.2 Pediatric Added: IO route to diphenhydramine Added to ALS-P Standing Orders: Hydrocortisone 2 mg/k. to maximum 100 mg IV, IM, IO or Methylprednisolone 2 mg/kg to maximum125 mg IV, IM or IO • Added: • IO route to diphenhydramine • Added to ALS-P Standing Orders: • Hydrocortisone 100 mg IV, IM, IO or • Methylprednisolone 125 mg IV, IM or IO • Added to MCO Section: • Epinephrine “by autoinjector only” 1:1,000: 0.15-0.3mg IM Rationale: Appropriate administration & therapy route to rapidly reduce inflammation; safety reminder

35. 3.13 Toxicology / Poisoning / SA / OD • Deleted: • EMT-B procedures naloxone 0.4mg • Protocol now reads “Administer naloxone 2.0mg nasal via atomizer” store.airwaycam.com Rationale: Correct dosing as under special project waivers

36. Merlin MA, et al. Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses. Am J EM. 2010. Mar;28(3):296-303 • Proposal that EMS intranasal (IN) naloxone administration preferable to intravenous (IV) naloxone without risk of needle exposure • Methods: retrospective chart review of ALS patients performed on confirmed opioid overdose patients. Initial and final unassisted respiratory rates & GCS used as indicators of naloxone effectiveness • Conclusion: IN naloxone statistically as effective as IV naloxone in reversing effects of opioid overdose with similar average increases in RR and GCS. IN naloxone is a viable alternative to IV naloxone while posing less risk of needle stick injury

37. 3.14 Adult Pain & Nausea Management5.13 Pediatric Pain & Nausea Management • Added: PO and ODT odansetron routes as a standing order & treatment option www.finlandpharmacyonline.com Rationale: Reasonable treatment route & formulation without threat of needlestick injury

38. Seizures 3.9 Adult 5.7 Pediatric Added To ALS-P Standing Orders: Midazolam 0.05 mg/kg IV, IO, IM to max single dose of 4 mg • Added To ALS-P Standing Orders: • Midazolam 2.5-5mg slow IV push or IM Rationale: An option for benzodiazepine therapy shown to work faster in some studies; addresses medication shortages

39. 5.4 Pediatric Bronchospasm / Respiratory Distress • Added to ALS-P Standing Orders : • For >2 yo with known diagnosis of asthma hydrocortisone 2 mg/kg to maximum 100 mg IV, IM, IO or • Methylprednisolone 2 mg/kg to maximum 125 mg IV, IM, IO Rationale: Therapy reduces inflammation associated with bronchospasm

40. Knapp B, Wood C. The prehospital administration of IV methylprednisolone lowers hospital admission rates for moderate to severe asthma. PEC. 2003 Oct-Dec;7(4):423-6 • Compare hospital admission rates for patients with moderate to severe asthma who receive prehospital vs ED methylprednisolone • Results: 31 moderate to severe asthmatics received prehospital methylprednisolone. 33 asthmatics transported by EMS & later received IV methylprednisolone in the ED. Only 13% (4) of patients receiving prehospital solumedrol were admitted to the hospital vs 33% (11) receiving solumedrol in the ED • Conclusions: Patients with moderate to severe asthma receiving prehospital methylprednisolone have 3 times fewer hospital admissions

41. Summary of Medication Changes • Vasopressin 40 units every 20 mins IV or IO if epinephrine 1:10,000 shortage • Morphine & fentanyl may be given in divided doses to the maximum • IM route added for fentanyl • NTG 0.3mg removed from MCO • IO route added for diphenhydramine • Added hydrocortisone 100 mg IV, IM, or IO or methylprednisolone 125 mg IV, IM or IO • “By autoinjector only” added to MCO for epinephrine 1:1,000, 0.15-0.3mg IM • Midazolam 2.5-5mg slow IVP or IM • Midazolam 0.05 mg/kg IV, IO or IM to max single dose of 4 mg (pediatrics) • PO / ODT as odansetron route as a standing order & a treatment option

42. Summaryprehospitalmd@gmail.com • This review serves as notification of the changes to the MA Prehospital Treatment Protocols effective March 1st, 2013 • Provide evidence-based information regarding why changes occurred • Please review the protocol changes yourselves and contact your EMS Education Officer or Medical Director for specific questions or concerns