2010 REMAC Protocol Update: Acting on the Evidence

1. 2010 REMAC Protocol Update: Acting on the Evidence John Freese, M.D., FAAEM Medical Director of Training / OLMC Director of Prehospital Research New York City Fire Department and Department of Emergency Medicine St. Vincent’s Hospital - Manhattan

2. Introduction As has become our routine, with the coming of the New Year so come our new protocols. And again this year, there are a number of changes designed to continue to ensure that we provide the best, most medically appropriate care for our patients.

3. Auld Lang Syne But in the tradition of the New Year, let’s begin by looking back and gaining some perspective….

4. Auld Lang Syne In Memoriam – Dr. Gary Lombardi (January 14, 1951 – October 12, 2009) - joined NYC EMS as an ambulance driver in 1968 - graduate of the City’s first paramedic class in 1974 - earned his medical degree in 1982 - returned to NYC EMS in 1895 - published the first cardiac arrest study in New York City (the PHASE Study) in 1994 - continued to work as an OLMC (“telemetry”) physician until July 2009 - one of the most beloved and influential physicians in the New York City EMS system, and he will be missed

5. Auld Lang Syne We’ve come a long way in the past six years. Just a few years ago in this system: - Some patients waited in pain while you called for orders. - Other patients continued to seize while you called for orders. - STEMI patients went to the nearest hospital regardless of the hospital’s ability to provide the best possible care… - …and the same was true for stroke patients… - …and victims of sexual assaults… - …and post-arrest patients. - All patients with head and spine injuries required immobilization. - Cardiac arrest patients received care that resulted in significant interruptions in CPR, unnecessary / unproven drugs, etc. - There was no protocol to deal with weapons of mass destruction. - BLS providers had to wait for ALS in order to treat anaphylaxis unless the patient happened to have an Epi-Pen. - Hydroxocobalamin, CPAP, etomidate, ipratropium and alternative airways were not part of the care that we provided. - And the list goes on and on.

6. Today in New York City STEMI patients, sexual assault victims, patients with acute strokes, and post-arrest patients are transported to hospitals whose capabilities are best suited to treat their condition. Our cardiac arrest protocols have been optimized to ensure a focus on the basic principles of resuscitation and, as a result, patients are more likely to achieve ROSC today than ever before. BLS care has been expanded to include the administration of albuterol to a wider range of patients, the use of autoinjectors for anaphylaxis and WMD events, expanded defibrillation capabilities through the application of adult AEDs for pediatric patients and infants, the application of selective spinal immobilization, and a number of other improvements related to the care of medical and trauma patients. And ALS care has seen a large number of changes including the administration of benzodiazepines and narcotics under standing orders, waveform capnography monitoring for airway placement and maintenance, the option to administer benzodiazepines for the sedation of agitated / violent patients, the addition of medications such as etomidate and hydroxocobalamin and vasopressin, the use of biphasic defibrillation and alternative advanced airways, mandatory 12-lead EKG capability and transmission, CPAP, management of severe asthma exacerbations under standing orders, and the list goes on.

7. But We Can’t Stop Now Over 1.2 million patients each year depend upon you for their emergency medical care. And they have a right to expect that the care that you provide will be based on the latest medical science. That is why our protocols have and will continue to evolve. Medications and skills that have been proven to be effective will be added, and others that have been shown to lack effectiveness will be removed. But each of these decisions must come from an analysis of the latest science and our own data. They must be evidence-based.

8. Evidence-Based Medicine The concept of evidence-based medicine is fairly simple. Our understanding of human physiology, pharmacology, and medicine are evolving at an incredible rate. And in addition to keeping up with these changes, we owe it to our patients to ensure that we incorporate this knowledge into the care that we provide. In short, we need to ensure that the medicine that we practice is based upon the evidence of what works, what doesn’t work, and - when the exact answer is not known - what the most recent knowledge tells us is likely to be the best decision for our patients. That is evidence-based medicine.

9. Evidence-Based EMS To understand the basis for the yearly changes that have been incorporated into our protocols, just consider the number of studies and articles in the medical literature that have been published in recent years: As you can see, the number of articles published in the medical literature has increased every year in each of these categories. And keeping up with this rapidly growing and evolving body of knowledge has led to the annual protocol changes, including those for 2010.

10. And Now… The Protocols The 2010 New York City REMAC Protocols will take effect on April 1, 2010. This self-tutorial presentation is meant to guide you through the changes that will take effect on that date and to provide you with some information to support / explain these changes. As with all such presentations in the past, this presentation is meant to serve as one person’s view of these changes, the rationale behind them, and associated explanations and should not supersede the guidance and thoughts of other medical directors, agency directives, etc.

11. General Operating Procedures – BLS - Oxygen Administration - Initiating Transport BLS Protocols - 401 – Respiratory Distress / Failure - 407 – Wheezing - 410 – Anaphylactic Reaction - 421 – Head and Spine Injuries - 423 – Chest Injuries - 425 – Bone and Joint Injuries - 428 – Burns - 430 – Emotionally Distrubed Patient - 431 – Heat-Related Emergencies General Operating Procedures – ALS - Interpretation of Protocols - Communications with Medical Control Facilities - Prehospital Sedation ALS Protocols - 500-A and 500-B – Smoke / Cyanide - 502 – Obstructed Airway - 503-A – Ventricular Fibrillation / Pulseless Ventricular Tachycardia - 503-B – Pulseless Electrical Activity (PEA) / Asystole - 504 – Suspected Myocardial Infarction - 505-A – Supraventricular Tachycardia - 505-B – Atrial Fibrillation / Atrial Flutter - 505-C – Ventricular Tachycardiac with a Pulse / Wide Complex Tachycardia of Uncertain Type - 505-D – Bradydysrhythmias and Complete Heart Block - 506 – Acute Pulmonary Edema - 510 – Anaphylactic Reaction - 521 – Head Injuries - 540 – Obstetric Complications - 551 – Pediatric Obstructed Airway - 555 – Pediatric Anaphylactic Reaction 2010 Protocol Changes

12. BLS Changes

13. General Operating Procedures - BLS

14. General Operating Procedures - BLS The following sections of the GOPs that are related to BLS care have been changed, effective April 1, 2010: - Oxygen administration - Initiating Transport

15. General Operating Procedures - BLS Oxygen Administration In assessing a patient’s respiratory status, the decision to provide assisted ventilations must take into account the ability of the patient’s respiratory function to effectively accomplish its two primary functions – oxygen delivery and carbon dioxide exchange, or oxygenation and ventilation. Failure of either of these two essential functions, or failure to correct them via supplemental oxygen administration, should be the factor that causes us to assist a patient via bag-valve-mask.

16. General Operating Procedures - BLS Most of us learned in our initial EMT-B training, as it said in the GOPs, that “a respiratory rate less than eight or greater than twenty-four, assisted ventilations may be required.” And the key word in that sentence is “may.” Think about most of the patients for whom you have cared whose respiratory rate was less than eight or greater than twenty-four. Most of them needed no respiratory assistance. In fact, in 2009, FDNY EMTs and paramedics cared for over 25,000 adult patients with those respiratory rates, and the vast majority of them did not receive BVM ventilation / airway management.

17. General Operating Procedures - BLS That is the reason for the first change in the oxygen administration section of the GOPs. The reference to respiratory rate has been removed and replaced with language that actually addresses the problem for which we want to assist ventilations – hypoxia, inadequate ventilation, and/or (for the ALS providers) an inability to maintain airway protection.

18. General Operating Procedures - BLS Oxygen Administration – Assisted Ventilation Hypoxia is the lack of sufficient oxygen, particularly within the tissues of the body. Hypoxemia is the lack of sufficient oxygen within the blood and typically results in tissue hypoxia as well. In assessing the patient for signs of hypoxia, we need to look for signs of both hypoxia and hypoxemia.

19. General Operating Procedures - BLS Cyanosis is the most easily recognizable sign of hypoxemia. When the blood is unable to obtain sufficient oxygen to completely fill “the available spots” on the hemoglobin that it contains, it takes on a bluish color that is visible in the skin (particularly in more pale or fair-skinned individuals), mucous membranes, and nail beds. But even cyanosis is not a reliable sign of the need for artificial ventilation – some patients may normally be mildly cyanotic (COPD – blue bloaters), some may have cyanosis due to other causes (drug toxicity), and others may improve simply by providing supplemental oxygen. What we need to look for are other signs and symptoms of hypoxia.

20. General Operating Procedures - BLS The list below gives additional signs and symptoms of hypoxia. When several of these are present, with or without cyanosis, and are not rapidly corrected with supplemental oxygen, the patient is likely (but not universally) likely to need assisted ventilation.

21. General Operating Procedures - BLS Inadequate ventilation results in an inability of the body to rid itself of carbon dioxide. Assuming that the patient has an adequate cardiac output so that carbon dioxide can be brought to the lungs, only two other things determine the ability of a patient to successfully ventilate themselves – respiratory rate and tidal volume (the amount of air that passes in and out of the respiratory system with each breath).

22. General Operating Procedures - BLS The amount of air that is exchanged over one minute is determined by the respiratory rate and tidal volume, and this is a good marker for adequate respiration. Minute Volume = RR x Tidal Volume (VT) Since most of us breathe twelve times per minute and 500cc (or ½ liter) per breath, the average patient needs six liters of minute ventilation to successfully eliminate carbon dioxide from the body. With that in mind, let’s consider a couple of scenarios…

23. General Operating Procedures - BLS Scenario #1: A patient with deep sighing breaths (800-1,000mL / breath) at a rate of ten breaths per minute would have a minute volume of 8-10 liters. Unless signs of hypoxia were present, assisted ventilations would not be needed. Scenario #2: A patient with shallow respirations (~300ml per breath) at that same rate (ten per minute) would have a minute volume of three liters. Because their minute volume would provide less than half of the ventilation that their body is likely to require, assisted ventilation would likely be needed. Scenario #3: A patient with those same shallow respirations (~300ml per breath) and rate (ten per minute) who just lost consciousness after severe hyperventilation may require no assisted ventilation – their body is just making up for the fact that they “blew off” too much CO2, so the low ventilation rate that you are witnessing is all that they require for the moment.

24. General Operating Procedures - BLS The point is that, regardless of the patient’s ventilation rate, your assessment of their ventilation status and a decision about their need for assisted ventilations has to take the bigger picture into account. What is their respiratory rate and volume? Is their ventilation sufficient to meet their needs at the present time? Do they demonstrate other signs of inadequate ventilation (sonorous respirations, altered mental status, etc)? Are they also demonstrating signs of hypoxia?

25. General Operating Procedures - BLS The final point in assessing a patient’s need for assisted ventilation is more of an ALS point, because it deals with airway protection. A patient’s ability to protect their airway from saliva, vomit, and other foreign substances is essential for proper respiratory function and is most easily assessed via the gag reflex. For these patients, assisted ventilation may also be needed because of inadequate oxygenation or ventilation, but BVM ventilation alone runs a high risk for inducing vomiting and causing further compromise of oxygenation and ventilation due to the fluids and other substances that then enter the lungs.

26. General Operating Procedures - BLS So, for patients with an inability to protect their airway who also have respiratory compromise or hypoxia that does not respond to supplemental oxygen, assisted ventilation may be needed. But this risk of inducing vomiting and aspiration require caution, including assuring that ventilations are delivered slowly over one second to prevent the forceful movement of air into the stomach (gastric insufflation). And when ALS is present, the lack of airway protection is best treated by performing endotracheal intubation to restore airway protection, prevent gastric insufflation, and allow for more controlled and monitored ventilation.

27. General Operating Procedures - BLS The other change to this GOP is the removal of references to mouth-to-mouth or mouth-to-nose ventilation. Because all ambulances are required to have ventilation equipment, including pocket masks, there is no reason that a provider should have to perform these tasks. That said, it is also not forbidden by these protocols, so if there were a need for such respiratory assistance, providers retain the option to perform this potentially life-saving skill.

28. General Operating Procedures - BLS As our protocols continue to evolve and our treatments become more specific, there are likely to be instances for which BLS providers should wait for ALS arrival instead of transporting the patient to the nearest 911 facility. When this is the case, that will need to be specified in the individual protocols. The GOPs were simply changed to reflect this expectation.

29. General Operating Procedures - BLS One example of where this is currently the case would be cardiac arrests. If ALS is not on scene, BLS should not attempt to immediately transport the patient. Instead, the patient should be treated according to BLS Protocol 403. And we expect that other protocols may also change to reflect this need for ALS evaluation in the future.

30. 2010

31. 2010 BLS Protocol Changes Changes which will take effect on April 1, 2010 have been made to the following BLS Protocols: - 401 – Respiratory Distress / Failure - 407 – Wheezing - 410 – Anaphylactic Reaction - 421 – Head and Spine Injuries - 423 – Chest Injuries - 425 – Bone and Joint Injuries - 428 – Burns - 430 – Emotionally Disturbed Patient - 431 – Heat-Related Emergencies

32. 2010 BLS Protocol Changes - 401 Three changes were made to this protocol: • A reference was added to the MOLST forms. • As previously discussed, references to respiratory rate have been replaced in favor of the terms hypoxia and inadequate respiration. • References to mouth-to-nose and mouth-to-mouth ventilation have been removed.

33. 2010 BLS Protocol Changes - 407 In 2007, the FDNY enacted a dispatch algorithm that was designed to shift a significant number of asthma calls from ALS to BLS response. This was done with the knowledge that the majority of asthma patients do not require ALS care, that BLS provider can safely and effectively administer albuterol, and that the patients likely to need only BLS care can be identified via a series of questions at the time of dispatch. This program has been incredibly effective, moving thousands of calls to a BLS response with only 2-3% of initially dispatched BLS calls requiring a subsequent ALS response / care. But despite that success, within that 2-3% of patients there may be a few for whom more aggressive and immediate treatment is needed. Hence the change to this protocol.

34. 2010 BLS Protocol Changes - 407 Beginning in July of this past year, BLS ambulances were required to carry epinephrine autoinjectors for the treatment of anaphylaxis. This was done with the knowledge that BLS providers are capable of recognizing anaphylaxis and, when ALS is not present, administering epinephrinee via autoinjector safely and effectively in order to avoid respiratory failure and arrest. So, if you can provide it in this manner for anaphylaxis, why not for the critical asthma patient?

35. 2010 BLS Protocol Changes - 407 In December, along with the rest of our protocol changes, the SEMAC approved a protocol change that would allow EMTs to utilize epinephrine autoinjectors for the treatment of critical asthmatics when ALS was not present. This change will allow patients to receive the much-needed medication that they would otherwise have to await while ALS responded to the scene.

36. 2010 BLS Protocol Changes - 407 For patients asthmatic patients who require BVM ventilation and for whom ALS is not immediately available, this new protocol will allow EMTs to administer a single epinephrine autoinjector prior to ALS arrival, prior to transport, or while en route to the emergency department.

37. 2010 BLS Protocol Changes - 407 Why epinephrine? You have all listened to the lungs of a critical asthmatic and heard thee eerie lack of any lung sounds or air movement. When this degree of bronchospasm occurs, the patient is unable to move enough air (tidal volume) to allow for the delivery of albuterol into the lower airways were it is needed. Epinephrine, as in anaphylaxis, is able to be absorbed into the blood stream and delivered to the lungs. There, through the same mechanism as albuterol, it produces relaxation of the smooth muscle within the airways, aka bronchodilation.

38. 2010 BLS Protocol Changes - 407 When faced with a critical asthmatic who requires BVM ventilation, one EMT should assemble the necessary airway equipment while the other EMT obtains and administers an epinephrine autoinjector. Administration of the epinephrine should not wait for BVM ventilation to be initiated. In fact, it should be done simultaneously or even before ventilation is begun. If ALS has been requested and is able to arrive before patient transport, notify the paramedics of the epinephrine administration. Ensure that the use of the autoinjector is also properly documented in your ePCR / ACR.

39. 2010 BLS Protocol Changes - 410 Because there is little risk of causing significant adverse cardiac effects (chest pain, angina, myocardial infarction) in young patients, this protocol has been modified to allow for the use of an epinephrine autoinjector to anaphylaxis patients under standing orders despite the patient not having been prescribed an epinephrine autoinjector. Use of epinphrine autoinjectors, under standing orders or as a medical control option, must be reported to REMAC by the agency.

40. 2010 BLS Protocol Changes - 421 The wording of this protocol required a little clarification. Specifically, the criteria that allow for selective spinal immobilization were not meant to be limited to the time of your evaluation of the patient. Rather, if any of these signs or symptoms were present since the time of the injury, even if they have resolved upon your evaluation, the patient requires immobilization.

41. 2010 BLS Protocol Changes - 423 The use of bulky dressings is no longer recommended for the treatment of flail segments. While the thought (like with sandbags, for those who remember them) used to be that by applying pressure to the affected area, you could stop the paradoxical movement that resulted in hypoventilation of that part of the lung beneath the injury. While this may be true, the benefit is limited and probably outweighed by the pain that is causes the patient and the fact that they then breathe more shallowly as a result.

42. 2010 BLS Protocol Changes - 423 Instead, if the patient is hypoventilating as a result of the suspected flail segment, consider the need for positive pressure ventilation. If transport is delayed or prolonged, you should also consider calling for ALS assistance.

43. 2010 BLS Protocol Changes - 425 Over five years ago, the REMAC approved the use of morphine by ALS providers under standing orders for the treatment of pain resulting from isolated extremity injuries in adults and children. But as you know, most known extremity injuries and mechanisms resulting in these injuries (falls, pedestrian struck, MVAs) are dispatched as BLS call-types in our system.

44. 2010 BLS Protocol Changes - 425 While our dispatch algorithms for these calls not likely to change to an ALS call in the immediate future, there are certainly situations in which delayed or prolonged transport may allow for ALS response in order to provide pain management. So, a note was added to this protocol as a reminder of this option.

45. 2010 BLS Protocol Changes - 425 Some examples of when this may be appropriate include: - MVAs with prolonged extrication and an isolated extremity injury - an entrapped extremity (i.e. construction site or involving machinery) where extrication is required - falls with severe pain from a hip injury that prevents patient movement But remember that transport should not be delayed simply to provide pain management, particularly when the patient’s pulses in the affected extremity are lost, and such requests are only appropriate for injury isolated to one extremity.

46. 2010 BLS Protocol Changes - 428 A more recent change to the ALS protocols also allows for the use of morphine under standing orders by our paramedics for the treatment of severe pain resulting from burns. So, a note similar to the one added to BLS Protocol 425 was also added to this protocol. When transport is delayed or the patient’s pain is so severe that it prevents appropriate treatment, consider ALS assistance for the provision of pain management.

47. 2010 BLS Protocol Changes - 428 Also added to this section was the removal of the universal use of saline-moistened dressings for the treatment of burn injuries in order to remain compliant with the latest recommendations from the burn experts. Due to the risk of hypothermia and wound contamination, saline-moistened dressings should only be applied to burns that are less than 10% total body surface area (BSA). Larger burns require treatment with dry, sterile dressings only.

48. 2010 BLS Protocol Changes - 430 Similar to Protocols 425 and 428, a note has been added to this protocol as a reminder. If an EDP requires significant physical restraint, a request for ALS should be considered. Under Protocol 530, paramedics may administer sedation to severely agitated / violent EDPs.

49. 2010 BLS Protocol Changes - 431 The recommendation that patients be given normal saline to drink has been removed. If you wonder why, drink some.  As anyone who has ever accidentally swallowed water while swimming in the ocean can tell you, saline solutions are a quick way to induce nausea and vomting.

50. ALS Changes