The Greater Miami Valley EMS Council

1. The Greater Miami Valley EMS Council 2014 Standing Orders Changes & Updates

2. All SQ injections are now IM; SQ has less reliable absorption particularly in a shock state. This is consistent with current recommendations particularly for epinephrine in allergic reactions. • EMT can suction tracheostomies; has been determined to be within scope of practice for basics in Ohio. • Sobering Center; still checking on Ohio Division of EMS regs. If transport is permissible, will issue guidelines as a JITSO.

3. Ceasing resuscitation efforts: if you encounter a scene with CPR in progress, regardless of who initiated CPR, and you realize that there are obvious signs of death, efforts may cease. • CPAP is not allowed under DNR-CC; This is considered ventilatory support which is expressly prohibited. • EMS must speak directly with MCP for field termination; this has always been a policy. • Lidocaine dosage changed: To apply the KISS principle, 100 mg is used in all scenarios including nebulizer.

4. Requirements for STI changed to match Optional Manual: To clarify requirement for cric technique. It was always intended for EMS to have an alternative method to obtain an airway if things went bad once a patient was paralyzed. • Patient must be Hemodynamically Unstable or in arrest to access either port on CVADs. • Pain Control Protocol: Simplify and save pages. Not intended to expand use of analgesia especially for chronic pain.

5. Added JITSO Calcium Gluconate to protocol; Due to shortages. • Changed PATH protocol to INTRA-ARREST protocol; Permits this but does not require it. • Have two identifiers on all transmitted EKGs: hospitals need this information to verify EKGs to link it to a patient. • Women were deleted from the list of those having atypical presentations. Anyone can have atypical presentations. • Max Ped Versed dose changed to 2 mg. This may have caused confusion with a Pedi dose exceeding adult doses.

6. Deleted orthostatic vitals, SBP ~ 100 for hemorrhage. Orthostatics not accurate in many patients. Cumbersome in the field. • Changed time limits for stroke symptoms to determine destinations from 3 to 4 hours. More recent guidelines allow administration of TPA up to 4.5 hours in many cases. • Added penetrating trauma to chest and abdomen; “Permissive hypotension” is the principal whereby IV fluids are not administered unless there is loss of radial pulse. This helps prevent hypothermia, coagulopathy secondary to dilution of clotting factors, and may actually decrease internal bleeding.

7. Wording changed pertaining to Combat Gauze. Granular agents should not be used. Packing is permissible if necessary to reach the site of bleeding. • Morphine and Fentanyl were removed from pulmonary edema. No benefit. Possible harm. • If a breathing treatment is given, it is encouraged that the patient be transported. We wish to discourage individuals from calling EMS with no intent to be transported but simply to receive a breathing treatment.

8. If patient arrests, consider bilateral decompression. This is in reference to asthmatic patients. Pneumothorax is a potentially reversible mechanism of arrest. Very difficult to diagnose on physical findings in this setting. The arrest is generally from hypoxemia and acidosis which portends a poor outcome. Should also emphasize limited ventilation in order to allow complete exhalation and recoil of the chest. “Breath stacking” leads to incomplete exhalation, increased intrathoracic pressure with decreased venous return, and barotraumas such as pneumothorax.

9. Deleted constricting bands; Lack of benefit. May be harmful. • Changed doses of Epi for Asthma and Anaphylaxis; National guidelines particularly from allergists are calling for higher dosing. About 0.5 mg for the initial dose in the average adult. The pedi dose will be 0.01 mg/kg to a max of 0.5 mg. • IM route of Midazolam should be a last resort. Intranasal is the better alternative when no IV is available.

10. You are encouraged to transport patients who have been given Narcan. More recent information has lessened the concern for re-sedation after naloxone. With naloxone possibly being available in the community, we will be encountering more patients refusing transport upon arrival of EMS. • Initial doses for chemical restraint in peds is not call for orders, but repeats are. • Deleted Diazepam from combative patients. Not currently necessary with the availability of both Versed and ketamine. Diazepam is very poorly absorbed intramuscularly.

11. Deleted spinal clearance and inserted BB policy. Cover by the new spinal immobilization protocol: Spinal Immobilization Protocol Introduction • Traditionally, EMS has immobilized all patients with potential spinal injury to include backboards and associated adjuncts (B/AA). However, studies indicate that traditional spinal immobilization with B/AA has risk and may even cause harm in select cases. As such, the spinal immobilization protocol is being modified to more accurately reflect appropriate indications and mechanisms for spinal immobilization.

12. Spinal Immobilization Protocol (cont) Blunt trauma (falls, MVC) • The following patients must be immobilized with a C-collar and a spinal immobilization device (e.g. spine board, KED, vacuum splint): • Any clinical indication of a spinal injury, such as focal neurologic deficit including paralysis. • Those patients who are unable to follow commands: • Combative • Confused • Intoxicated

13. Spinal Immobilization Protocol (cont) • 2. The following patients should have a c-collar placed and moved in-line as a unit to the cot: • Patients who are alert, with NONE of the above AND: • Neck pain • Midline neck or spinal tenderness • Pain on motion of the neck • Age > 65, <8 • High risk mechanism (high speed MVC, fall > 10 feet, axial loading injury) • Patients who are non-ambulatory (sitting, lying on ground) are to be moved in-line as a unit. • Patients who are ambulatory may ambulate to the cot, and then be assisted onto the cot in-line as a unit.

14. Spinal Immobilization Protocol (cont) Penetrating trauma • Patients with penetrating trauma to the torso or neck with focal neurological signs or paralysis should be immobilized in a c-collar and with a spinal immobilization device. • Patients without the above need NOT be immobilized. • Delays in transport for immobilization are to be minimized. Airway / Ventilatory Management • Patients who are immobilized and require airway and / or ventilatory intervention (including intubation) may have the collar removed, with in-line stabilization performed during the intervention. The collar should then be reapplied.

15. Spinal Immobilization Protocol (cont) Other • Patients who do not tolerate immobilization (e.g., shortness of breath, anxiety, body habitus) should have immobilization adjusted to the point of removal if necessary based on clinical response. They should be maintained in the manner of immobilization that they can tolerate (e.g., may not tolerate a LSB but may tolerate sitting up with a c-collar) • Spinal immobilization devices may be utilized for movement from a site of injury to the cot. Patients who do not require immobilization as above should be removed from the device prior to transport and kept in-line during transport.

16. HazMat section has been modified: Amyl nitrite is no longer manufactured and sodium thiosulfate is no longer carried in drug bags. • Third Trimester is a contraindication for administration of ASA. Use of aspirin or anti-inflammatories increases bleeding at the time of delivery. Also interferes with fetal circulation which is prostaglandin mediated. May cause premature closure of the ductus arteriosus. • JITSO for Ondansetron is also PO; For use when no IV access is possible and shortage.

17. Hospitals that request to be notified on every patient transported to their facility are: • Children’s Medical Center, Good Samaritan Maternity, Grandview, Greene Memorial, Huber Heights, Jamestown Emergency Department, Kettering Medical Center, McCullough-Hyde, Miami Valley Maternity, Miami Valley South, Soin, Southview, Springfield Regional Medical Center, Sycamore, Upper Valley Medical Center, Veterans Adm. Medical Center, Wayne, and WPAFB Medical Center. • Contact MVH and GSH with all serious patients, e.g., stroke, MI, respiratory distress, shock and major traumas.

18. SAMPLE history is now defined in the book. • Combined Field Termination with no available ALS for simplicity. • Added JITSOs for phenergan, vasopressin, calcium gluconate and oral Zofran. • Cyanokits have been modified • SALT Triage section has modifications for Yellow patients to have significant injuries, and two mnemonics for assess questions which was CRAP and good or bad.