Note to Instructors

1. Note to Instructors • Please review the comments (notes) below each slide before instructing this session.

2. Monroe-Livingston Regional EMS Protocol Update Basic EMT Version Effective April 1, 2007

3. Hard Copies of the Protocols • http://mlrems.org/forms.php ( http://mlrems.org/MLREMS%202007%20Protocols%20FINAL.pdf )

4. Objective • Review new content and layout of protocols • Identify significant changes to BLS protocols

5. Protocol Development Process • Protocol Subcommittee develops suggested changes • Protocols distributed for 30 day public comment period • Changes are made based on public comment and submitted to REMAC for approval • REMAC approved protocols taken to the SEMAC meeting for state approval

6. Protocol Subcommittee Robert Breese, EMT-P James Capparelli, EMT-P Jeremy Cushman, MD (Chair) Rollin “Terry” Fairbanks, MD Chris Forsyth, EMT-P Dick Garrett, EMT-P Dan Hays, PharmD Marc Lampell, MD Aaron Marks, EMT-P Bryan McKinley, EMT-P Richard Race, EMT-P Erik Rueckmann, MD Rick Russotti, EMT-P Manish Shah, MD Sheri Strollo, EMT-P Terry Taylor, EMT-P

7. Major Changes • Format changes • Educational content decreased • Improved ease of reading • New resources added • In some cases, dramatic changes to existing protocols

8. New Resources Added • BLS Pharmacology • ALS Pharmacology • Appendices • Adult and Pediatric GCS • Adult and Pediatric Trauma Triage Criteria • Pediatric Normal Vital Signs and Airway Equipment • Rule of Nine’s Chart • Emergency Department Contact Information • Dopamine and Epinephrine Infusion Charts

9. Protocol Organization Section 1 Standing orders, radio/phone failure, DNR, termination of resuscitation and obvious death Section 2 Combined patient care protocols (adult and peds) Section 3 Adult Cardiac Life Support Section 4 Pediatric Cardiac Life Support

10. Protocol Organization Section 5 BLS Pharmacology Section 6 ALS Pharmacology Section 7 Regional Policies/Procedures Section 8 SCT Protocols Section 9 HAZMAT Protocols Appendix

11. Pediatrics • No longer a separate section on pediatrics EXCEPT for PALS • Pediatric specific medications and protocols are delineated by the teddy bear:

12. Medical Control Communication Requirements • Medical control may be contacted at any time by any level if there is a question or concern, or if the provider would like additional guidance • New format for indicating medical control contact requirements • The format is as follows

14. 1.0 Routine Standing Orders • Identifies routine care expected on all patients • Determination of decisional capacity • Bringing appropriate equipment to patient side • Documenting vital signs on every patient • Oxygen as needed to maintain saturation ≥ 96% (New) • Blood Glucose determination (BLS if available) (New) • Contacting receiving hospital for unstable or potentially unstable patients • Timely transport and crew safety • Vascular access, airway management and ECG monitoring as appropriate

15. 1.1 Radio/Phone Failure • Radio/Phone failure occurs when • No cellular service, telephones or radios at the scene • No physician is available • Agency is operating outside of region as part of a declared disaster mutual aid plan • All protocols become standing orders with the exception of • EMT-CC: EMT-P and EMT-P Physician consult lines are absolute on-line and cannot be performed unless direct physician order • Absolute On-Line: All providers must obtain direct physician order to perform

16. 1.2 On-Scene Medical Personnel • Personal physician • Must write and sign orders on PCR • Bystander Physician • Must accompany patient to the hospital AND write and sign orders on PCR • RN/PA/LPN, etc • May assist with patient care but only under the direction of the EMS provider and may not assume responsibility for patient care • Other Pre-Hospital Providers • Off-duty personnel may assist with patient care but may not be in charge of or assume responsibility for patient care

17. 1.3 Do Not Resuscitate Orders • Valid DNR includes • NYS approved document, bracelet, or necklace • Properly documented nursing home or hospital DNR form • Properly documented MOLST form • If pulse present – provide oxygen, suction, and comfort measures • If pulse absent – contact police

18. 1.4 Termination of Resuscitation ALL criteria must be met for field termination with ABSOLUTE ON-LINE physician authorization: • Age 18 or older • Non-traumatic, non-hypothermic. • ECG is asystole confirmed in three leads, ventricular standstill, or pulseless idioventricular rhythm with a rate <10 beats per minute. • Cardiac arrest protocols have been followed for at least 25 minutes, including successful intubation or advanced alternate airway, IV/IO access, adequate CPR, and appropriate pharmacologic therapy. • There has been no return of a perfusing cardiac rhythm at any time during at least 25 minutes of resuscitative measures. • Patient is not in a public place. • Appropriate emotional support by family, neighbors, clergy, police, or EMS crewmembers is available at the scene if the family is present.

19. 1.5 Obvious Death • If any ONE of the following conditions are met and the patient is pulseless, CPR need not be begun: • Body decomposition • Rigor mortis with warm air temperature • Dependent lividity • Injury not compatible with life (i.e. decapitation, burned beyond recognition, massive open or penetrating trauma to the head or chest with obvious organ destruction) • If a bystander or first responder has initiated CPR OR if the patient was submerged in water for greater than one hour, you MUST contact medical control

20. 2.0 AIRWAY MANAGEMENT ADULT • All levels • Oxygen therapy is covered under standing orders • Hyperventilation no longer used. • Ventilatory rates 10-12/minute in the adult

21. 2.1 AIRWAY MANAGEMENTPEDIATRIC • All Levels • BVM rate listed at 12-20 • Hyperventilation is strongly discouraged. • Spontaneous respirations supported as needed (up to limits)

22. 2.2 AIRWAY OBSTRUCTION - ADULT • All Levels • Simplified language and matches 2005 AHA Guidelines • No abdominal thrusts for unconscious patient, perform – CPR instead • No blind finger sweeps

23. 2.3 AIRWAY OBSTRUCTION - PEDIATRIC • ALL Levels • Meets 2005 AHA Guidelines • Language simplified and altered to agree with standing orders • Unconscious patients receive CPR • No abdominal thrusts • No blind finger sweeps

24. 2.4 ALTERED MENTAL STATUS • All Levels • Transport guidelines simplified with confusing wording removed • Blood glucose determination has been approved for BLS with referral to appropriate protocol if BG < 80 mg/dL • Remember that BLS cannot cancel ALS for altered mental status or syncopal patients

25. 2.5 ANAPHYLAXIS/ALLERGIC REACTION • All Levels • Combined protocol • Epinephrine in the form of an Epi-Pen should be administered ONLY if evidence of shock, airway swelling or significant respiratory distress • Adult Epi-Pen may be administered by standing order if patient has one previously prescribed; otherwise, must contact medical control prior to administering • Pediatric Epi-Pen should be used for children less than 30 kg (66 pounds)

26. 2.6 APPARENT LIFE THREATENING EVENT (ALTE) ALTE - An episode in an infant or child less than 2 years old which is frightening to the observer and is characterized by one or more of the following: • Apnea (central or obstructive) • Skin color change: cyanosis, erythema (redness), pallor, plethora (fluid overload) • Marked change in muscle tone • Choking or gagging not associated with feeding or a witnessed foreign body aspiration • Seizure-like activity Why a protocol? • Incidence of ALTE is about 7.5% in the pediatric EMS population • Overwhelming (83%) of patients have no apparent illness/distress • But… 48% of these “non-ill” children had significant illnesses upon ED evaluation

27. 2.6 APPARENT LIFE THREATENING EVENT (ALTE) • New protocol • Pediatric only protocol infants or children < 2 years old • All Levels • Routine care • Most children will appear completely normal and healthy • Child should be evaluated by ALS and ALS should not be cancelled upon BLS arrival • Strongly encourage transport (medical control REQUIRED for parent/guardian refusal)

28. 2.7 BEHAVIORAL EMERGENCIES • ALL Levels • Simplified wording and language • Reference to Management of Violent or Potentially Violent Behavior procedures • Consider ALS for sedation if you must physically restrain patients

29. 2.8 BURNS • Combined Adult/Pediatric Protocol • All Levels • Simplified language and combined all aspects • Remove patient from source of burn, and cool/decontaminate appropriately • Pain management should be considered • ALS providers may now give first dose morphine by standing order for burn patients

30. 2.9 CHEST PAIN/THREATENED MYOCARDIAL INFARCTION • ALL Levels • Nitroglycerin warnings regarding Erectile Dysfunction (ED) meds (e.g., Viagra, Levitra, Cialis) added. • Can administer NTG once every 5 minutes up to 3 doses provided patients systolic BP is greater than 120 • Aspirin 75-81 mg x4 by mouth added for EMTs • Contraindicated only in patients who are allergic, actively bleeding, or are having symptoms of a stroke

31. 2.10 CHEST TRAUMA • All Levels • Formatting change with simplification of language to remove redundancy • No specific BLS treatment other than routine trauma care

32. 2.11 Conducted Energy Devices • To standardize treatment of the Taser patient -Patients will be in police custody -Treatment should be a cooperative venture between Police and EMS -Define “High Risk” Patient • BLS may not remove Taser Probes, removal by ALS providers only

33. 2.12 Croup • Treatment of a common Pediatric Respiratory Disorder -Treatment with Humidified High Flow O2 • If patient is unable to ventilate refer to Airway Obstruction Protocol

34. 2.13 Diabetic Emergencies • BLS assessment of Blood Glucose, if agency approved • If Patient is able to speak, offer oral sugar – if they are unable to speak clearly, then no material (glucogel, etc) should be placed in the mouth.

35. 2.14 Fluid Challenge/Replacement • Care within this protocol outside scope of practice of the EMT-B • Should familiarize oneself with indications for fluid challenge/replacement, however, to appropriately request ALS resources

36. 2.15 Head Trauma • Patient’s head should not be lower than body • Maintain cervical spine immobilization • BVM ventilations (if needed) should be at 10/min • Hyperventilation is bad for head injury patients

37. 2.16 Hyperthermia/Heat Exhaustion/Heat Stroke • Defined as a Core Body Temperature of >40.6°C (105°F) • Institute proper cooling of the patient • Do not cool too fast to induce shivering!

38. 2.17 Hypotension/Shock • Shock is inadequate tissue perfusion • Shock may be present even in a normotensive patient • Treat underlying cause of shock

39. 2.18 Hypothermia • Core body temperature of <35°C (95°F) • Avoid rough handling of patient • Assess heart rate for 1 full minute • Passive re-warming • Remove wet clothes • Warm ambulance/blankets

40. 2.19 Nausea/Vomiting • Treatment of Nausea/Vomiting without head injury • Assure scene safety – take universal precautions • No significant changes for BLS providers, ALS may administer phenergan

41. 2.20 Near Drowning • Treatment is routine supportive medical care • Do not use Heimlich to remove water from Lungs • Spinal precautions per protocol

42. 2.21 Neonatal Resuscitation • Care of the Critical Newborn -The primary concerns of newborn resuscitation are adequate oxygenation, airway patency and warmth. All Levels • If respirations < 30 or heart rate < 100 - Ventilate with 100% oxygen using neonatal or small child bag-valve mask at a rate of 40-60 per min. • CPR for Heart Rate < 60 - Begin chest compressions at rate of 120 per minute utilizing a compression/ventilation ratio of 3:1. Begin timely transport.

43. 2.22 Obstetric Emergencies • Protocol has been dramatically simplified, but no changes for BLS providers • For any delivery, contact medical control as indicated to assist with instructions specific to scenario

44. 2.23 Pain Management • BLS should consider calling for ALS if they have a patient with pain > 4 out of 10 due to: burns, amputation or isolated extremity fracture / dislocation without evidence of head injury In these circumstances, ALS may administer morphine for pain control by standing order.

45. 2.24 Poisoning / Overdose • Assure adequate airway • Attempt to locate/bring poison to hospital if possible • Activated charcoal is an online medical control medication

46. 2.25 Pulmonary Edema • Assess signs, symptoms • Position patient in position of comfort • Oxygen, assist ventilations as necessary • Timely transport

47. 2.26 Rapid Sequence Induction • Outside of BLS scope of practice, however indications and contraindications are reviewed for reference: Indications: • Actual or Potential airway compromise • GCS ≤ 8 • Combativeness that threatens airway • Smoke inhalation with airway compromise Contra-indications: • <16 years old or <40 kg • Neuromuscular disease: muscular dystrophy, ALS, etc • Renal dialysis patients • Paralysis or burns more than 24 hours old

48. 2.27 Re-establishing Patient Medication IV • Does not apply to BLS • This protocol allows ALS providers to re-establish certain patient medications in the field

49. 2.28 Respiratory Distress / Bronchospasm • High flow oxygen • May assist with patient’s own nebulizer • BLS administration of albuterol • Patient is between 1 and 65 • Patient has a history of asthma with prescribed albuterol • Administer 5mg albuterol via nebulizer (2.5 mg for pediatrics) • Additional doses per medical control • Consider ALS intercept, do not delay care on scene • ALS cannot release to BLS after medication administration

50. 2.29 Sedation • Does not apply to BLS • This protocol allows ALS providers to provide pain control and sedation for painful procedures (cardioversion, pacing, or after one is intubated)