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Paramedic Protocol Update 2009

Westchester Paramedic Protocol Update 5/09 - Overview. 2. Introduction. Each agency will be provided with CD containing the protocol roll-out training materials.Protocol roll-out presentations cover all changes by section (Adult Medical, Pediatric Medical, Trauma, etc.).Agencies are expected to

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Paramedic Protocol Update 2009

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    1. Westchester Paramedic Protocol Update 5/09 - Overview 1 Paramedic Protocol Update 2009 Westchester Regional Emergency Medical Services Council

    2. Westchester Paramedic Protocol Update 5/09 - Overview 2 Introduction Each agency will be provided with CD containing the protocol roll-out training materials. Protocol roll-out presentations cover all changes by section (Adult Medical, Pediatric Medical, Trauma, etc.). Agencies are expected to deliver content to affiliated paramedics. Agency Medical Director should approve delivery mechanism (i.e., classroom session, computer delivery, follow-up quiz ??)

    3. Westchester Paramedic Protocol Update 5/09 - Overview 3 Introduction Protocols also included on CD in PDF format. Will also be posted on WREMSCO website. *No field guides initially as additional changes are expected. Protocol implementation date – July 1, 2009 Agency Medical Director must affirm that affiliated paramedics have received training (affirmation form included on CD).

    4. Westchester Paramedic Protocol Update 5/09 - Overview 4 Overview New Format indicating STANDING ORDERS, MEDICAL CONTROL OPTIONS, and NOTATIONS. Each protocol initiates with M1.0-Routine Medical Care or T1.0-Routine Trauma Care. To be carried out in conjunction with appropriate policies, procedures, and advisories. Separate Interfacility Transport Protocols under development

    5. Westchester Paramedic Protocol Update 5/09 - Overview 5 New Format

    6. Westchester Paramedic Protocol Update 5/09 - Overview 6 Trauma Protocols Westchester Regional Paramedic Protocol Update 2009

    7. Westchester Paramedic Protocol Update 5/09 - Overview 7 Routine Trauma Care T1.0 Replaces old trauma protocols Consolidated: Routine Medical Care, airway, transport consideration, fluid resuscitation for shock, analgesics for pain management, and CPR/rapid transport for Traumatic arrest. Added: Directs provider to Airway Management Protocols, Trauma Transport Algorithm, and Pain Management Protocol.

    8. Westchester Paramedic Protocol Update 5/09 - Overview 8 Trauma Report Appendix 2.3

    9. Westchester Paramedic Protocol Update 5/09 - Overview 9 Adult Medical Protocols Westchester Regional Paramedic Protocol Update 2009

    10. Westchester Paramedic Protocol Update 5/09 - Overview 10 Adult Medical Protocols New Standard Operating Procedures for Advanced Airway Management, Tension Pneumothorax, and Intravenous Access (separate document) Endotracheal drug administration has been removed from all protocols Pediatric protocols now in separate pediatric section

    11. Westchester Paramedic Protocol Update 5/09 - Overview 11 Adult Medical Protocols Routine Medical Care M1.0 - Pulse Oximetry now a Standing Order Airway Management M2.0 - Etomidate now a standing order. If patient needs facilitated advanced airway management: Consider ETOMIDATE 0.3 mg/kg IV or IO, perform ENDOTRACHEAL INTUBATION, and CONTACT MEDICAL CONTROL Bronchospasm/Asthma/COPD M3.0 - Methylprednisolone and Magnesium Sulfate now Standing Orders. Terbutaline now administered IM route.

    12. Westchester Paramedic Protocol Update 5/09 - Overview 12 Adult Medical Protocols Cardiac M4.0 - Refers to appropriate sub-protocol. 12 lead ECG added. Acute Coronary Syndrome M4.1 - NITROGLYCERIN should be given with caution to patients taking erectile dysfunction (ED) medications (i.e., Viagra, Cialis, Levitra), or suspected inferior wall or right ventricle (RV) myocardial infarctions (MI) Acute Pulmonary Edema Congestive Heart Failure M4.2 - Administer CPAP if available. Medical Control Option for Lasix changed from 40-80 mg to 80-120 mg

    13. Westchester Paramedic Protocol Update 5/09 - Overview 13 Adult Medical Protocols Bradycardia M4.3 - TCP now before atropine. Dopamine under Medical Control Options now 2-10 mcg/kg/min Supraventricular Tachycardia – Divided into two new protocols Narrow Complex Tachycardia Unstable M4.4 - Fluid challenge now Standing Order. Doses of energy for Cardioversion depend on the underlying rhythm. Diltiazem added as Medical Control Option Narrow Complex Tachycardia Stable M4.5 - Diltiazem 15-25mg as Standing Order for ATRIAL FLUTTER, ATRIAL FIBRILLATION or MULTIFOCAL ATRIAL TACHYCARDIA unless patient has a known history of Wolff-Parkinson-White Syndrome (WPW)

    14. Westchester Paramedic Protocol Update 5/09 - Overview 14 Adult Medical Protocols Wide Complex Tachycardia Unstable M4.6 - Doses of energy for Cardioversion depend on the underlying rhythm. Total maximum dose of Amiodarone in Standing Orders is now 2.2gm/24 hrs. Wide Complex Tachycardia Stable M4.7 - Standing Order of Amiodarone to 150 mg/100 ml of D5W. Repeat if VT persists. Max 2.2 gm/24 hrs. Procainamide now Medical Control Option only.

    15. Westchester Paramedic Protocol Update 5/09 - Overview 15 Adult Medical Protocols Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest M5.0 - This protocol directs the EMS provider to two new protocols: M5.1 – Shockable Rhythm M5.2 – Non-Shockable Rhythm Notes for consideration of the following medications for all Cardiac Arrests have been added: SODIUM BICARBONATE 1 mEq/kg IVP or IO with suspected hyperkalemia, profound acidosis, tricyclic antidepressant, cocaine, or diphenhydramine overdoses. Dose may be repeated at 0.5 mEq/kg every 10 minutes. DEXTROSE 50% IVP or IO if clinically indicated; may be repeated once. NALOXONE 2 mg IV or IO if clinically indicated. DOPAMINE 400 mg in 250 ml 0.9% Normal Saline; initiate drip at 5 - 10 mcg/kg/min. CALCIUM CHLORIDE 250 – 500 mg IVP or IO; may be repeated to a maximum of 1 gm. Only indicated with hyperkalemia, hypocalcemia, or calcium channel blocker toxicity.

    16. Westchester Paramedic Protocol Update 5/09 - Overview 16 Adult Medical Protocols Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) M5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. Standing Order added for Magnesium Sulfate for known Hypomagnesemia or Torsades. Cardiac Arrest Non-Shockable Rhythm M5.2 – Prompt to Search for and treat for contributing factors; address as appropriate. Vasopressin now a Standing Order but under review.

    17. Westchester Paramedic Protocol Update 5/09 - Overview 17 Adult Medical Protocols Field Termination of Resuscitation Efforts M5.3– Grief counseling removed. Altered Mental Status M6.0– Naloxone dose now 0.4 mg IV, IN, or IM, may be repeated up to 8 mg. Anaphylactic Reaction M7.0 - Standing Orders now for Methylprednisolone, rapid fluid infusion, and Albuterol. Epinephrine is indicated as follows: Cardiovascular collapse present, 1:10,000 1 mg IVP Mild reaction, 1:1,000 0.3 ml IM If patient is taking beta-blockers, also administer GLUCAGON 1 mg IM or IV.

    18. Westchester Paramedic Protocol Update 5/09 - Overview 18 Adult Medical Protocols Toxic Exposure / Poisoning M8.0 – For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy Non-Traumatic Shock M9.0 – Dobutamine added as a Medical Control Option 400mg/250 ml NS ,initiate drip at 5 – 10 mcg/kg/min. May be titrated in increments of 5 mcg/kg/min until desired therapeutic effect is reached (max dose of 25 mcg/kg/min) Post Partum Hemorrhage M10.0 - Oxytocin now a Standing Order “after delivery of placenta”

    19. Westchester Paramedic Protocol Update 5/09 - Overview 19 Adult Medical Protocols Obstetrical Toxemia of Pregnancy M11.0 – PRE-ECLAMPSIA now defined as – combination of BP 140/90 or greater, peripheral edema, and symptoms: headache, visual disturbances, upper abdominal pain. Magnesium Sulfate 4 gm/250 ml NS over 20 minutes now a Standing Order for Pre-Eclampsia and Eclampsia. Seizures M12.0 – “measure serum glucose”, and treat hypoglycemia after initiating Routine Medical Care. Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam).

    20. Westchester Paramedic Protocol Update 5/09 - Overview 20 Pediatric Medical Protocols Westchester Regional Paramedic Protocol Update 2009

    21. Westchester Paramedic Protocol Update 5/09 - Overview 21 Pediatric Medical Protocols Endotracheal drug administration has been removed from all protocols 14 years or younger for pediatric patient

    22. Westchester Paramedic Protocol Update 5/09 - Overview 22 Pediatric Medical Protocols Pediatric Airway Management P1.0 – Etomidate dose 0.3 mg/kg IV or IO now a Medical Control Option for all Paramedics. Continuous EKG, pulse oximetry and wave-form capnography added. Bronchospasm / Asthma P2.0 – Separated from Croup/Epiglottitis in old protocol. Albuterol 2.5 mg plus one unit dose of Ipratropium 0.5 mg via nebulizer may be repeated once if needed under standing orders. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option.

    23. Westchester Paramedic Protocol Update 5/09 - Overview 23 Pediatric Medical Protocols Croup/Epiglottitis P3.0 – Nebulized Epinephrine or Racemic Epinephrine now a Standing Order. Dexamethasone 0.6 mg/kg IM added as a Medical Control Option Cardiac P4.0 – Refers to appropriate sub-protocol. 12 lead ECG added. Bradycardia P4.1 - Now states “ If increased vagal tone, or primary AV Block, administer Atropine 0.02 mg/kg IV or IO – minimum dose 0.1mg; maximum single dose: 0.5 mg for children 1 mg for adolescents. If inadequate response, may repeat once”

    24. Westchester Paramedic Protocol Update 5/09 - Overview 24 Pediatric Medical Protocols Narrow Complex Tachycardia P4.2 – If Sinus Rhythm, consider Fluid Challenge of 0.9% Normal Saline (10-20 ml/kg rapid infusion) if indicated; search for and treat any causes found as appropriate Wide Complex Tachycardia P4.3 – New protocol. Apply cardiac monitor to determine rhythm. If patient is Unstable: If it does not delay CARDIOVERSION, administer ADENOSINE 0.1 mg/kg IV or IO first to determine if the rhythm is SVT with aberrant conduction. SYNCHRONOUS CARDIOVERSION 0.5 J/kg – 1 J/kg; if no change, repeat at 2 J/kg (c); consider sedation / analgesia, CONTACT MEDICAL CONTROL. If rhythm FAILS TO COVERT after 2nd CARDIOVERSION to a supraventricular rhythm, CONTACT MEDICAL CONTROL

    25. Westchester Paramedic Protocol Update 5/09 - Overview 25 Pediatric Medical Protocols Cardiac (Arrest) Non-Traumatic Cardiopulmonary Arrest P5.0 – This protocol directs the EMS provider to two new protocols: P5.1 – Shockable Rhythm P5.2 – Non-Shockable Rhythm Cardiac Arrest Shockable Rhythm (VF or Pulseless VT) P5.1 – Follows latest CPR guidelines; single shocks, CPR @ 2 min. intervals. Precordial thump removed. “In the event of return of spontaneous circulation (ROSC), CONTACT MEDICAL CONTROL for post-resuscitation care.”

    26. Westchester Paramedic Protocol Update 5/09 - Overview 26 Pediatric Medical Protocols Cardiac Arrest Non-Shockable Rhythm P5.2 – Search for and treat for contributing factors; address as appropriate. Altered Mental Status P6.0 – For documented or suspected hypoglycemia: Administer DEXTROSE 1g/kg IV or IO: For patients 40 kg or less, DEXTROSE 25% 4 ml/kg For patients 40 kg or more, DEXTROSE 50% 2 ml/kg if no response in 5 minutes, repeat the same dose.

    27. Westchester Paramedic Protocol Update 5/09 - Overview 27 Pediatric Medical Protocols Anaphylactic Reaction P7.0 – Standing Orders for Methylprednisolone, Albuterol, and rapid fluid infusion added. Prior to initiating Routine Medical Care, Epinephrine is indicated as follows: Cardiovascular collapse present, 1:1,000 0.01 mg/kg (max dose 0.3mg) IM Post RMC, if patient still manifests Cardiovascular collapse, administer Epinephrine 1:10,000 0.01 mg/kg IV or IO Toxic Exposure / Poisoning P8.0 – For Carbon Monoxide (CO) exposure with history and signs/symptoms - Monitor CO levels (if available) - 100% oxygen therapy

    28. Westchester Paramedic Protocol Update 5/09 - Overview 28 Pediatric Medical Protocols Non-Traumatic Shock P9.0 – Fluid Challenge 0.9% Normal Saline IV or IO 5-10 ml/kg, rapid infusion; may be repeated as needed. Avoid in the presence of pulmonary edema Note: PALS recommends giving smaller volumes if myocardial dysfunction or distributive shock is present of suspected but more rapid infusion boluses may be needed to correct hypotensive or septic shock. REMAC contends that infusion volumes of 20 ml/kg may be necessary. Plans to appeal to SEMAC.

    29. Westchester Paramedic Protocol Update 5/09 - Overview 29 Pediatric Medical Protocols Neonatal Resuscitation P10.0 – Now states: If thick meconium is observed in amniotic fluid AND the newborn demonstrates absent or depressed respirations, heart rate under 100 per minute, or poor muscle tone: Clear the airway using endotracheal intubation and directly suction the endotracheal tube. Repeat the procedure until the endotracheal tube is clear of thick meconium up to a maximum of three (3) times. DO NOT re-intubate once the airway has been cleared of thick meconium unless the newborn still meets the criteria in STEP 2.

    30. Westchester Paramedic Protocol Update 5/09 - Overview 30 Pediatric Medical Protocols Seizures P11.0 – After initiating Routine Medical Care, “measure serum glucose”, for hypoglycemia administer: DEXTROSE 1g/kg IV or IO: For patients 40 kg or less, DEXTROSE 25% 4 ml/kg For patients 40 kg or more, DEXTROSE 50% 2 ml/kg If no response in 5 minutes, repeat the same dose. GLUCAGON 0.1 mg/kg IM if IV or IO route is not available, up to a maximum dose of 1 mg. Standing Order now for “a Benzodiazepine”(Diazepam, Lorezapam, or Midazolam).

    31. Westchester Paramedic Protocol Update 5/09 - Overview 31 Special Protocols Westchester Regional Paramedic Protocol Update 2009

    32. Westchester Paramedic Protocol Update 5/09 - Overview 32 Pain Management S1.0 Replaces old protocols 31 and 31a Changed: For patients presenting with need for pain management (a) with a SBP greater than 110 mmHg: MORPHINE 0.1 mg/kg IV or IO (maximum 5 mg) (b); For continued pain, repeat once (maximum total dose 10 mg) Contact Medical Control

    33. Westchester Paramedic Protocol Update 5/09 - Overview 33 Pain Management S1.0 Replaces old protocols 31 and 31a Added: Notes a & b. a. Pain management is CONTRAINDICATED for patients presenting with (including but not limited to): Altered Mental Status, Moderate or Severe Head Trauma, Overdoses, or Hypotension b. If HYPOVENTILATION develops: in the ADULT PATIENT, administer NALOXONE up to 2 mg IV, IO or IN. in the PEDIATRIC PATIENT, administer NALOXONE 0.1 mg/kg IV, IM, IO or IN

    34. Westchester Paramedic Protocol Update 5/09 - Overview 34 Rapid Sequence Intubation S2.0 Replaces old protocol S-1 Added: Note b. Once medication is used to facilitate intubation, whether or not it is successful, the patient’s respiratory effort MUST be monitored with CONTINUOUS WAVEFORM CAPNOGRAPHY.

    35. Westchester Paramedic Protocol Update 5/09 - Overview 35 Nerve Agent Antidotes S3.0 Replaces old protocol S-2 Added: Commercially available DuoDoteTM auto-injectors, or the previously manufactured Mark I kits, may be possessed / used by a paramedic only under the following conditions… Changed: Directs provider to Adult Administration Protocol (S3.1) and Pediatric Administration Protocol (S3.2) (Continued on Next Slide)

    36. Westchester Paramedic Protocol Update 5/09 - Overview 36 Nerve Agent Antidote-Adult S3.1 Changed: Standing Orders now: MILD - 1 MARK I KIT /1 DUODOTETM KIT or ATROPINE 2 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 1 g IV, IM or IO over 10 minutes MODERATE - 2 MARK I KITS / 2 DUODOTETM KITS or ATROPINE 4 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes SEVERE - 3 MARK I KITS /3 DUODOTETM KITS or ATROPINE 6 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 2 g IV, IM or IO over 10 minutes (Continued on Next Slide)

    37. Westchester Paramedic Protocol Update 5/09 - Overview 37 Nerve Agent Antidote-Pediatric S3.2 Changed: Standing Orders now: MODERATE - 2 MARK I KITS / 2 DUODOTE KITS or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes SEVERE - 3 MARK I KITS /3 DUODOTE KITS or ATROPINE 0.04 mg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes If the patient is presenting with MILD exposure symptoms, CONTACT MEDICAL CONTROL. 1 MARK I KIT /1 DUODOTE KIT or ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes until secretions resolve / PRALIDOXIME 40 mg/kg IV, IM or IO over 10 minutes

    38. Westchester Paramedic Protocol Update 5/09 - Overview 38 Standard Operating Procedures Westchester Regional Paramedic Protocol Update 2009

    39. Westchester Paramedic Protocol Update 5/09 - Overview 39 Standard Operating Procedures Three new procedures: Advanced Airway Management Tension Pneumothorax Intravenous Access

    40. Westchester Paramedic Protocol Update 5/09 - Overview 40 Advanced Airway Management Includes: Endotracheal Intubation (ETT) Laryngeal Mask Airway (LMA) Multi-lumen Airway (i.e. Combitube) Foreign Body Airway Removal via direct Laryngoscopy Needle Cricothyrotomy Tracheal Suctioning (including meconium aspiration) Gastric Decompression Needle Decompression Rapid Sequence Intubation (RSI)* *May only be performed by with approval of WREMAC

    41. Westchester Paramedic Protocol Update 5/09 - Overview 41 Advanced Airway Management Must document PRIMARY confirmation of ETT placement using: Qualitative Methods Colormetric end-tidal CO2 detectors Quantitative Methods Digital end-tidal CO2 detectors Wave form capnography

    42. Westchester Paramedic Protocol Update 5/09 - Overview 42 Advanced Airway Management Document secondary confirmation using accepted clinical parameters per ACLS guidelines. Continuous Waveform Capnography must be monitored if medication is used to facilitate intubation.

    43. Westchester Paramedic Protocol Update 5/09 - Overview 43 Evidence of respiratory/cardiovascular compromise and two of the following: - Absent/decreased breath sounds on affected side - Tracheal deviation - Subcutaneous emphysema Pleural decompression is indicated using a large bore over the needle catheter or other REMAC approved device. Procedure may be repeated if signs and symptoms recur.

    44. Westchester Paramedic Protocol Update 5/09 - Overview 44 IV KVO of NS or IV lock unless fluid challenge is required. IV NS with large bore (18ga or larger) catheter for patients requiring rapid volume replacement. Peripheral veins (not external jugular) should be used as primary access site. IO may be used only if other sites are not accessible. IO med administration is preferred over ETT if no IV. Blood drawing as indicated. Before med administration.

    45. Westchester Paramedic Protocol Update 5/09 - Overview 45 Additional SOPs will be added as needed

    46. Westchester Paramedic Protocol Update 5/09 - Overview 46 Questions WREMSCO Office 914-231-1616

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