IMPORTANT ECRN INFORMATION!!!

1. IMPORTANT ECRN INFORMATION!!! • Region X SOP’s revised • Effective February 1, 2012 for most of Region X EMS • ECRN’s and ED MD’s need to be familiar with the changes • Complete the packet reviewing the changes • Submit the post quiz ASAP • Follow-up packet coming out shortly reinforcing changes • Check date listed on cover page of SOP’s to note new/old version

2. Region X SOP ChangesEquipment, Drugs, Skills ECRN Mod III 2011 CE Condell Medical Center EMS System 2 hours CE Credit - IDPH Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev 1.20.12

3. Objectives Upon successful completion of this module, the ECRN will be able to: • Review changes to the Region X SOP’s beginning 2/1/12 • Discuss the action, indications, contraindications, dosing, and side effects of Atrovent (Ipratropium), Etomidate, Fentanyl, and Zofran (Ondansetron) • Identify indications for use of the humeral site for IO insertion • Identify indications for placement of the King airway • Review case scenario presentations • Complete the 10 question quiz with a score of 80% or better

4. Why Changes to the SOP’s? • Revisions made based on changes in guidelines to practice in several organizations: • AHA – conference every 5 years • Impacts BLS, PALS, ACLS, NALS • ITLS • International Trauma Life Support • Guidelines that impact trauma care • EMSC • Emergency Medial Services for Children

5. How will these changes affect me? • Effective 1st shift of the day 2/1/12 EMS will follow the revised Region X SOP’s • This may mean 0700 or 0800 for departments in Region X • Region 9 EMS providers have already adopted these changes in 2011

6. Region X Members • The Condell EMS System members transport to Condell and Lake Forest Hospitals • Also transport to additional area hospitals • Condell and Lake Forest also receive EMS members from other Region X EMS Systems (ie: Vista, Highland Park) • Condell and Lake Forest also receive members from Region 9 EMS Systems • ie: Lincolnshire, Buffalo Grove, Long Grove, Lake Zurich • Most common Region 9 departments to transport to Condell and Lake Forest Hospitals

7. Condell EMS System Countryside Fire Grayslake Fire Lake Forest Fire Libertyville Fire Mundelein Fire Round Lake Fire Wauconda Fire Lake Bluff Fire Knollwood Fire Murphy Highland Park EMS System Deerfield Fire Glencoe Gurnee Fire Highland Park Fire Highwood Fire Northbrook Fire NIPAS Six Flags Superior Vernon Hills Region X EMS ProvidersWill begin to use new SOP’s 2/1/12

8. Vista EMS System Antioch Fire Beach Park Fire Great Lake Fire Lake Villa Fire Newport Fire North Chicago Fire Waukegan Fire Winthrop Harbor Fire Zion Fire Vista EMS Privates ATEC Murphy Paratech Murphy St. Francis EMS System Providers around the Evanston based hospital area Region X EMS ProvidersWill begin to use new SOP’s 3/1/12

9. Global Changes Made • Oxygen administration • (per AHA) Oxygen should be administered to patients with breathlessness, signs of heart failure, shock or an arterial oxyhemoglobin saturation <94% • Insufficient evidence to support routine administration in uncomplicated AMI or ACS without signs of hypoxemia or heart failure* • Bottom line: less use of routine O2 • *AHA 2010 Guidelines

10. Oxygen Administration • Supplemental oxygen is necessary to prevent hypoxia and for cells to function • During normal cellular metabolism; oxygen changed to a byproduct • A free radial toxic molecule • Damages cell membranes • Normally, enzymes in cells destroy toxic oxygen molecules • Enzymes produced at a fixed rate • Enzymes insufficient in number when metabolism increases

11. Excessive Oxygen • Cells function poorly in low O2 environments • As O2 availability increases, cellular function increases • There is an end point to additional benefits • Over time excessive O2 can become harmful • Measurement in the field • SpO2 levels >94% is the goal • Measurement in the hospital • Blood gases • Cellular damage roughly evident by 24 hours

12. Oxygen Orders • Never withhold O2 from patients in respiratory distress or who are hypoxic • Administer O2 to those with smoke inhalation • To prevent complications, consider the use of nasal cannula before the non-rebreather mask • Apply O2 just long enough to maintain normal saturations

13. Global Changes Made • IV fluid challenge language • Formula for all persons: 20ml/kg • Reassessment performed at every 200 ml increment • Adults: If signs or symptoms of shock or hypoperfusion, administer fluid challenge in 200 ml increments. Titrate to desired response. • ie: adults may require 1-2 L • Peds 1-15: Adjust flow rate based upon condition and weight; administer IV fluid challenge 20 ml/kg; repeat as needed

14. “Desired Response” for Fluid Challenge • Evaluate level of consciousness • Evaluate blood pressure • Goal is to maintain adult B/P >90 systolic • Evaluate skin parameters • Drier? • Warmer? • Less pale? • Auscultate lung sounds • Keep lungs dry

15. Global Changes Made • Standardized adult systolic B/P >90 • Medication route • Any med given IVP can be given IO • IN (intranasally via MADD) may take precedence over IVP/IO routes (active seizure and no IV access) • If IV access established, use IV over IN • IN meds: Narcan, Glucagon, Fentanyl, Versed • Same dose amount as IVP/IO route

16. Global Changes Made • “Securing the airway” • Not a new term • A vague term to indicate to secure the airway (make the patient ventilate/breath and oxygenate) in whatever method works for the situation • Patient positioning – most under used technique • Oro/pharyngeal airways • Supportive bagging via BVM • Advanced airway – King, combitube, endotracheal tube

17. Airway Control • Not all patients need to be intubated in the field • Technique takes time • Could delay transport time to perform • Could increase risk of additional problems (ie: vomiting with aspiration) • If airway is “secured” using an alternate method of intubation, ventilation and oxygenation have been achieved, anticipate placing an advanced airway in the ED, not in the field

18. Global Changes Made • Once intubated, methods to secure the tube • Tape • Commercial tube holder • Cervical collar • Studies conducted prove that immobilizing the neck prevents dislodgment of the distal end of the airway that was placed

19. Global Changes Made • Ventilation rates • Guidelines from 2010 AHA changes • Respiratory rates for patient with a pulse and no advanced airway in place • Supportive BVM for assistive ventilations • Adult (puberty and beyond): 1 breath every 5-6 seconds • 10-12 breaths per minute • Child (1 to puberty): 1 breath every 3-5 seconds • 12-20 breaths per minute • Neonate: 1 breath per second

20. Global Changes Made • CPR changes • Switch compressors every 2 minutes (5 cycles) • Push harder/faster; breathe slower • Compression rate: • Infant/child/adult: at least 100 compressions per minute • Coordination ventilations/compressions • Prior to intubation, compressions paused for 2 ventilations • After intubation, compressions continuous; ventilations interposed during compressions

21. Ventilation Rate Via Advanced Airway • Ventilate once every 6-8 seconds • 8-10 breaths per minute • During CPR, compressor does not pause if advanced airway is in place • Ventilations are interposed during compressions • For compressions – push faster/push harder • For ventilations – SLOW DOWN!!!

22. Global Changes Made • After defibrillation, NO PULSE CHECK • Immediately resume compressions • Perform pulse check after 2 minutes of CPR and only if a rhythm is viewed that should produce a pulse

23. Global Changes Made • Return of Spontaneous Circulation – ROSC • If patient regains a pulse after cardiac arrest, outcome improved if patient is cooled for 12-24 hours • ROSC defined • Pulse maintained for at least 5 minutes • Systolic B/P >90 • EMS to place ice packs in axilla, around groin and neck, and over IV site • ED can continue or change to their internal procedures

24. Global Changes Made • Withdrawing resuscitative efforts • Patient is normothermic adult • Unwitnessed arrest/unknown downtime • Airway secured, IV/IO placed • Patient remains in asystole • No response to at least 20 minutes ALS care • Provide name of ED MD terminating efforts • EMS may need to bring the body to the ED • Extenuating circumstances, EMS may be unable to leave the body at the scene • May need to transport to the ED

25. Advanced Directives • EMS cannot honor Living Wills • EMS CAN honor • Valid DNR – must be with the patient • Durable Power of Attorney for Healthcare • Agent does not speak for patient until patient no longer able to speak for themselves

26. Global Changes Made • Transport to Grayslake and Lindenhurst free standing ED • Acceptable as closest appropriate facility for BLS transports • No IV required in the field • No EKG monitor applied in the field

27. Medication Changes to the Region X SOP’s • Region 9 made these changes in 2011 • Changes follow AHA guidelines • If you have taken a recent ACLS, PALS or BLS class, the changes should not sound new

28. Medications Modified/Changed No Lidocaine in cardiac patients No Atropine in PEA or asystole More reliance on Versed for active seizures stick exposure) Medications added Atrovent (Ipratropium Bromide) Etomidate Fentanyl Zofran (Ondansetron) New indications added Lidocaine for IO needles in non-arrested patient Medication Changes

29. Why Medication Deletions? • Lidocaine in cardiac patient • Not heavily studied • Amiodarone proven to be more effective • Atropine in PEA and asystole • Not proven to be effective • Removed from treatment

30. Control of Seizures • Why Versed over Valium for seizure control with no IV access? • Versed can be given via IN with MADD • Decreases risk of needle exposure and therefore needle stick during active seizure • Versed and Valium only stop the current seizure; do not prevent future seizures • If seizure stops before full dose delivered, EMS should stop administration of medication and “bank” the extra dose

31. Why Adding a Bronchodilator? • Albuterol is a “rescue” bronchodilator • Atrovent is a long acting bronchodilator • One dose sufficient for field treatment • After mixing the 2 bronchodilators for the first dose, can repeat the Albuterol alone as needed • Atrovent has no effect on cardiovascular system

32. Atrovent (Ipratropium Bromide)Actions • Bronchodilation of bronchial smooth muscle • Blocks action of acetycholine at parasympathetic sites in bronchial smooth muscle (an anticholinergic drug) • Will dry up excessive secretions • Onset 5 - 15 minutes • Duration 4 - 6 hours

33. Atrovent (Ipratropium Bromide) Indications • Treatment of bronchospasm due to asthma, COPD, bronchitis, emphysema • Not used for immediate relief but for maintenance of effects from bronchospasm • Therefore helpful when mixed with Albuterol • Albuterol used for the rescue, Atrovent for the longer effects • If taken at home, can be repeated x1 by EMS upon their arrival

34. Atrovent (Ipratropium Bromide)Contraindications • Hypersensitivity to atropine • No age-related precautions • Children and elderly • Unknown if passes through to breast milk • Peanut allergies are related to the metered dose prescription; not the product used in Region X

35. Atrovent (Ipratropium Bromide) Dosing • Adult and peds • 0.5mg / 2.5 mL ampule • To be mixed with Albuterol in nebulizer cup • First dose only; Albuterol alone after first dose

36. Atrovent (Ipratropium Bromide)Side Effects • Coughing • Dizziness • Insomnia, restlessness • Nausea • Dry mouth • Headache

37. Why Changes to Drug Assisted Intubation? • Name change to better reflect care provided • Etomidate replacing Versed, Morphine, Benzocaine for pre-sedation • Continue to use Lidocaine if head insult (medical or trauma) present • Eliminates cough reflex which would spike intracranial pressure (ICP) • Bolus sufficient; no drip required • Versed continues to be used for post sedation

38. What is the Difference to Intubate the Pediatric Patient? • Atropine added as a premedication • Blunts a bradycardic response that may be triggered during the process of intubation • Lidocaine used to blunt the cough reflex if head insult (medical or trauma) • Etomidate used to sedate the patient • Versed used to continue sedation post-procedure

39. Etomidate Actions • Nonbarbiturate hypnotic, sedative • Short acting drug to produce rapid anesthesia • Minimal cardiovascular effects • Onset 1 - 2 minutes • Duration generally 3 - 5 minutes

40. Etomidate Indications • Sedation to relieve apprehension or impair memory during intubation • Effects may be increased when combined with other central nervous system (CNS) depressants

41. Etomidate Contraindications • Hypersensitivity to Etomidate • Labor and delivery • Insufficient data to support its use • EMS to contact Medical Control for clarification if situation presented • ECRN to consult with ED MD for orders

42. Etomidate Dosing • Adult and peds • 0.3 mg/kg slow IVP/IO • Give over 30-60 seconds • Maximum dose 20 mg • Typical 150 pound person meets the max of 20mg • Too rapid an injection may result in hypotension (Treat with fluid challenge) or short term muscle twitch • 0.3 mg/kg is an average dose • Dosing charts for adults and peds available in back of the SOP’s

43. Etomidate Side Effects • Nausea and vomiting • Dysrhythmias • Breathing difficulties • Hypotension – treat with fluids • Hypertension • Transient involuntary muscle movement • Myoclonic activity (coughing, hiccups) • Appears as muscle twitching especially if given too rapidly • Usually resolves spontaneously, does not interfere with ability to finish securing the airway • Pain at injection site • Less when larger, more proximal sites used

44. Why Add Fentanyl? • Morphine dilates blood vessels • Morphine can cause a drop in blood pressure so use may be more limited • Morphine longer lasting than Fentanyl • Patient’s ability to give detail regarding their complaint may be obscured by the Morphine • Morphine can cause nausea/vomiting as a side effect • Less incidence with Fentanyl

45. Fentanyl Actions • Opioid analgesic • Alters pain reception • Increases pain threshold • Also known as • Duragesic • Onset 7-8 minutes • Duration ½ - 1 hour

46. Fentanyl Indications • Sedation • Pain relief • Adjunct to general or regional anesthesia • In cardioversion, Versed (midazolam) used for sedation and as an amnesic • Fentanyl used for pain/discomfort • Cardioversion is a painful procedure!!!

47. Fentanyl Contraindications • Increased intracranial pressure (ICP) • Severe hepatic (liver) or renal impairment • Severe respiratory depression • Cautious use in bradycardia • Readily crosses the placenta • May prolong labor if given in first stage of labor or before cervical dilation of 4-5 cm

48. Fentanyl Dosing • Adult and peds • 0.5 mcg/kg slow IVP/IN/IO • Administer over 1-2 minutes • IN route must be delivered rapidly to create a mist; dispensing syringe can be paused as med is being delivered • Too rapid administration increases risk of skeletal and thoracic muscle rigidity resulting in larygo and broncho spasms and apnea • In 5 minutes may repeat 0.5 mcg/kg slow IVP/IN/IO • Max total dose 200 mcg adult and peds

49. Fentanyl Side Effects • Mixing with benzodiazepines may increase risk of hypotension and respiratory depression • Narcan an effective reversal agent • BVM should be available when medications that can cause respiratory depressant are being administered • Nausea, vomiting, diarrhea, constipation • Less nausea noted than with use of Morphine • Dry mouth • Abdominal pain • Orthostatic hypotension

50. What Is Done for the Patient With Nausea? • Primary concern is protecting the airway • Positioning • Suction available • Possible intubation • Once the nausea is relieved, other issues may not need field treatment (ie: pain) • Think the volume of patients into the ED as walk-ins that just want the nausea relieved • These patients may also need hydration