halton region ems acp spring 2008 cme

1. Halton Region EMS ACP Spring 2008 CME

3. Agenda Presentations: Changes to Medical Directives Cardiac Arrest Trauma TOR Stations: ROC Primed Excited Delirium Station CVAD, IN atomizer device i i

4. Changes to ACP Medical Directives

5. When can I start using the new Directives???? After attending the CME After you have been issued the official Medical Directives book.

6. 2008 Medical Directives The SOCPC/Halton Region EMS 2008 medical directives have been adopted/edited from current provincial medical directives All medics are responsible for reviewing the current medical directives so that they recognize any and all changes and apply them appropriately

7. New Format Airway Breathing Circulation Altered LOC Sedation Protocols Cardiac Arrest Research Reference Material

8. Intubation Page: 5 Indications: Include Airway control Total dose of Lidocaine including IV is 5 mg/kg

9. Intubation Confirmation Protocol Page: 10 ETCO2 adapter for pediatrics < 15kg Out: ZOLL ESeries you do not have to zero the capnostat Note: ETCO2 with waveform must be one of your methods of tube confirmation Print off strip at time of confirmation and at time of transfer of care and document accordingly on the ACR

10. Facilitation of Awake Intubations (New Protocol) Page 8 Indications: The patient requires critical airway control or protection and/or ventilatory assistance (i.e. the patient will likely sustain cardiac arrest in the pre-hospital environment without intubation) AND The patient is combative to the extent that attempts at intubation are not possible

11. Facilitation of awake Intubations Contraindications: Patients <12 y/o and/or <40 kg Status asthmaticus Patients at risk of a communicable respiratory illness during a declared outbreak. Procedure: Follow algorithm.

13. Tension Pneumothorax Protocol Page 19 Indications: �or markedly decreased breath sounds� #5: Along the border of 3rd rib New equipment: 12G 3� needle

14. Anaphylaxis/ Severe Asthma Page 20 Epi 1:1000 now via the SC route versus IM

15. IV Access & Fluid Administration Protocol Page 22 1a: Maximum two (2) attempts EXCLUDING those en route 1c: External Jugular if the patient is unconscious (One side only EXCEPT if VSA) 4:Add �and pediatric patient with suspected DKA�

16. IO Access Protocol Page 24 Change age < 12 years of age (consistency in book) Procedure 1: Medications may be administered via ETT (after a patch) if IV/IO route is delayed. Why patch prior to ETT administration? Paramedic safety��. think SARS

17. CVAD Protocol Page 25 �f� aspirate 3-5 ml of blood to remove instilled Heparin New Note: Huber needle only for accessing Subcutaneous Implanted Port

18. Ischemic Chest Pain Protocol Page 26 Clarification, alternating NTG and MS Q5 minutes 12 Lead ECG as per protocol ASA NTG 5 min VS NTG 5 min VS NTG 5 min VS MS 5 min VS NTG 5 min VS MS 5 min VS NTG 5 min VS MS 5 min VS NTG 5 min VS MS 5 min VS MS 5 min VS

19. Acute Pulmonary Edema Protocol Page 28 Lasix removed from medical directives. You may patch for Lasix when you suspect pulmonary edema 2� to fluid overload.

20. Unstable Bradycardia Protocol Page 29 Now patch because you have to patch for sedation/analgesia anyways with patients whose BP< 100. Dr. Cheskes would not want to be paced without sedation����

21. Stable Tachycardia Protocol Page 31 No patch for Adenosine for SVT Indications Contraindications

22. Suspected Opioid Overdose Page39 Administered IV, SC, IM NEW: Now IN as an administration route

23. Seizure Protocol Page 40 Maximum single dose of Midazolam is 0.2mg/kg up to 5mg and can be administered IM, IN or buccal Midazolam may be repeated in 5 minutes if the seizure has not stopped Diazepam may be repeated in 2 minutes if the seizure has not stopped No IV established give Midazolam; once an IV is established you can give Diazepam as a 2nd dose

24. Pediatric Analgesia for Trauma Page 42 New Protocol: Morphine only Dose 0.05mg/kg IV (Not exceeding 2 mg) q 10 minutes to a maximum of 2 doses

25. Morphine versus Fentanyl

26. Patient Sedation Protocol Page 43 Only use 2-5 mg Midazolam IV/IM/IN, Diazepam removed from protocol After 5 minutes a subsequent dose 2-5mg. combative patients IV/IM/IN intubated patients IV/IM/IN procedural sedation IV ?Why IV only for procedural sedations?

27. Midazolam As of July 1 2008 Midazolam will be supplied as 10mg/2ml. New Tracking sheets will be issued

28. Taser Probe Removal Protocol Page 46 Changes: No age restriction

29. Neonatal Resuscitation Protocol Page 58 Epinephrine 0.1 ml/kg of 1:10000 IV/IO Epinephrine 1 ml/kg of 1:10000 ETT

30. Foreign Body Airway Obstruction Cardiac Arrest Protocol � Adult & Pediatric Page 60 ACP #2 directly to #5b: After compressions go directly to laryngoscopy and Magil forceps.

31. Research ITD New Protocol ACP carry the device since it is a controlled medical device for study only, PCP or Fire can use the ITD once ACP is on scene.

32. Are you having a bad day???

33. Cardiac Arrest with ROC Primed

34. Adult cardiac arrest Upfront CPR as per the configuration of the AED for all patients > 8 years old Joules settings: 120 Joules 150 Joules 200 Joules Lidocaine ETT route only if no IV established (Patch)

35. Cardiac Arrest Page: 52 Cardiac arrests should all be started in AED mode No drugs administered during 1st 2min round of CPR for VF only No longer require ETCO2 wave form to confirm intubation (numerical value in AED mode is sufficient)

36. Zoll �E� Series in AED mode Scenario Moving the patient to the ambulance with ongoing CPR a) Disconnect the defibrillation pads. (This will avoid an inadvertent auto-analysis/auto-charge.) b) Reconnect the defibrillation pads in back of unit. c) Press Analyze to do final rhythm analysis before transport. d) Turn Zoll OFF then ON (This will disable the auto-analysis/auto-charge feature.) e) Ignore voice prompts from this point on. f) Transport.

37. Zoll �E� Series in AED mode Scenario ROSC a) Turn Zoll OFF then ON. (This will disable the auto-analysis/auto-charge feature.) b) Ignore voice prompts from this point on (unless patient re-arrests). b) If needed, disconnect pads temporarily to move patient. c) If patient re-arrests - Press Analyze (This will enable the auto-analysis/auto-charge feature.)

38. ROC Primed Launch Start date July 1st 2008

39. ROC Primed Hospitals Joseph Brant Memorial Hospital Oakville Trafalgar Memorial Hospital Trillium Mississauga Hospital *******NOT ROC Primed******* Georgetown Milton Do not use an ITD when transporting to non ROC hospitals

40. What else do I need to do? Data card Envelope system Call the enrollment line at Georgian CACC

41. Trauma TOR

42. Trauma TOR Please refer to the following pages in the medical directives: PCP Blunt Traumatic Arrest Protocol: Page 49 ACP Blunt Traumatic Arrest Protocol: Page 50 Penetrating Traumatic Arrest Protocol: Page 51 i i

43. Trauma TOR What is it? New directive for treatment of VSA trauma patients Who does it apply to? Patients who are in cardiac arrest as a result of blunt or penetrating trauma AED use applies to patients who are = to 8 PCP- manual mode applies to patients who are = to 1 and < 8 ACP- manual defibrillation applies to patients of all ages i i

44. Trauma TOR Who can Trauma � Termination of Resuscitation be considered for? Patients who are = to 16 years old Patients who are < 16 years old will be resuscitated and transported What if the patient is obviously dead? These patients are Code 5 and are not covered under this directive

45. Blunt Trauma Procedure: Confirm absence of spontaneous respirations and palpable pulse in a patient with signs of blunt trauma Begin CPR Attach defib pads and assemble airway equipment Perform analysis or rhythm check

46. Blunt Trauma PCP: Shockable Rhythm: If the rhythm is shockable deliver one shock Continue CPR and transport No further analysis en route Non-shockable Rhythm: Check pulse and continue CPR if needed If there is no pulse AND Monitor heart rate is > 0, initiate transport Monitor heart rate is = 0, contact BHP for possible trauma-TOR

47. Blunt Trauma ACP: Shockable Rhythm: If the rhythm is shockable deliver one shock Continue CPR and transport No further defibrillation en route Asystole or PEA: Continue CPR Contact BHP for possible trauma-TOR

48. Penetrating Trauma Confirm cardiac arrest Absence of spontaneous respirations Absence of palpable pulse Absence of pupillary response Absence of movement Begin CPR Do not attach defib pads, attach monitoring electrodes

49. Penetrating Trauma PCP and ACP: If monitor heart rate is 0 AND there is no pupillary response AND no spontaneous movement contact BHP for possible Trauma-TOR If monitor heart rate is > 0 and the emergency department is < 20 minutes away initiate transport If monitor heart rate is > 0 AND no pupillary response AND no spontaneous movement AND the emergency department is = 20 minutes away contact BHP for possible Trauma-TOR

50. Penetrating Trauma

51. If there are no obvious signs of trauma treat the patient using full medical cardiac arrest directives PCP�s are expected to contact BHP in these circumstances for possible Trauma-TOR without waiting for ACP�s to arrive Final Notes

52. Still having a bad day??