Welcome & Thank You
for Participating
in the
San Joaquin County EMS
Agency’s
Policy Update
Course
Course Objectives
 Gain
a general understanding and
background necessary to successfully
implement the following new policies
on:
 Major Trauma Triage and patient
destination
 C-Spine Immobilization
 Minimally Interrupted Cardiac
Resuscitation (MICR)
Trauma Triage and Patient
Destination
EMS Policy No. 5210
Major Trauma Triage Criteria
EMS Policy No. 5210 Major Trauma
Triage Criteria
A.
Physiologic Criteria:
1. Glasgow motor score of less than 5.
2. Systolic blood pressure of less than:
a. 90 for age 14 and older.
b. 80 for age 7 to 14 years.
c. 70 for age 1 to 6 years.
3. Respiratory rate <10 or >29 (<20 in infant
< one year).
EMS Policy No. 5210 Major Trauma
Triage Criteria
B.
Anatomic Criteria:
1.
Penetrating injuries to the head, neck, chest,
abdomen, and proximal to the elbow or knee.
2.
Flail chest.
3.
Two or more long bone fractures (humerus or
femur).
4.
Crushed, degloved, or mangled extremity.
5.
Amputation proximal to wrist or ankle.
EMS Policy No. 5210 Major Trauma
Triage Criteria
B.
Anatomic Criteria (cont):
6. Pelvic fracture.
7. Open or depressed skull fracture.
8. Traumatic paralysis.
9. Extremity injury with loss of distal circulation.
10. Partial or full thickness thermal, chemical, or
electrical burns greater than 9% total body
surface.
11. Inhalation burns.
EMS Policy No. 5210 Major Trauma
Triage Criteria
C.
Mechanism of Injury:
1. Auto versus pedestrian or bicyclist with the
patient being:
a. Run over.
b. Thrown a significant distance.
2. Falls involving a pediatric patient from a
height greater than 10 feet or twice the
height of the child.
EMS Policy No. 5210 Major Trauma
Triage Criteria
D. Paramedic judgment: Paramedics may use
their judgment to classify a patient as major
trauma patient when the patient:
1.
2.
3.
Has a significant complaint or obvious signs of
injury, and;
Has experienced a high risk mechanism of injury;
and
Has one or more of the following comorbid factors:
a. Age greater than 55 or less than 10.
b. Anticoagulation therapy.
c. Burns.
d. Time-sensitive extremity injury.
e. Pregnancy greater than 20 weeks.
EMS Policy No. 5210 Major Trauma
Triage Criteria
4. Examples of high risk mechanism of injury
include:
a. High energy motor vehicle or motorcycle crash.
b. Blast injuries.
c. Falls:
i. Adults greater than 20 feet.
ii. Pediatrics greater than 2 feet times the height
of the child.
EMS Policy No. 5210 Major Trauma
Triage Criteria
E. Examples of the application of paramedic
judgment include:
1. Motor vehicle crash, with a pregnant patient
complaining of abdominal pain, with
seatbelt marks across abdomen.
2. Fall from the top of a bunk bed, with a child
less than 5 years of age, with an obvious
femur fracture.
3. Fall from an extension ladder, adult greater
than 60 years of age, on anticoagulation
therapy, complaining of pain all over.
EMS Policy No. 5210 Major Trauma
Triage Criteria
III.
Multi-casualty Incidents (MCIs):
A. Initial triage:
1.
Prehospital personnel shall use START
triage methodology for the initial assessment
of patients during a trauma MCI.
2.
Patients classified as “Immediate” using
START criteria are major trauma patients.
EMS Policy No. 5210 Major Trauma
Triage Criteria
III.
Multi-casualty Incidents (MCIs):
B. Secondary triage:
1. When resources and circumstances allow
prehospital personnel shall re-triage patients
using the criteria in this policy.
2.
Patients meeting physiologic or anatomic
criteria shall be classified as “Immediate”
patients.
3.
Patients meeting mechanism of injury or
paramedic judgment criteria shall be
classified as “Delayed” patients.
EMS Policy No. 5215
Trauma Patient Destination
EMS Policy No. 5215 Trauma Patient
Destination
Two Primary Trauma Catchment Areas
II.
A.
Northern Catchment Area – All of San Joaquin
County, except for the southern catchment
area.
B.
Southern Catchment Area – South of State
Highway 120 in San Joaquin County
Ambulance Zones E and F; and the area within
the city limits of Escalon.
EMS Policy No. 5215 Trauma Patient
Destination
III.
Adult Major Trauma Patient Destinations:
A.
Northern catchment area – San Joaquin
General Hospital.
B.
Southern catchment area – Doctors Medical
Center or Memorial Medical Center.
C.
If the assigned trauma center is unavailable or
at capacity, adult major trauma patients shall
be transported to the next closest trauma
center.
EMS Policy No. 5215 Trauma Patient
Destination
IV.
Pediatric Major Trauma Patients:
A.
Northern catchment area – U.C. Davis Medical
Center
B.
Southern catchment area – U.C. Davis Medical
Center.
C.
If the U.C. Davis Medical Center is unavailable
or at capacity, pediatric major trauma patients
shall be transported to the closest trauma
center.
EMS Policy No. 5215 Trauma Patient
Destination
Multi-casualty Incidents (MCIs):
V.
A.
B.
Trauma patients triaged as “Immediate” shall
be preferentially transported to designated
trauma centers utilizing available trauma
centers in San Joaquin, Stanislaus, and
Sacramento Counties.
When possible pediatric trauma patients
triaged as “Immediate” shall be preferentially
transported to the U.C. Davis Medical Center.
EMS Policy No. 5215 Trauma Patient
Destination
V.
Multi-casualty Incidents (MCIs):
During a trauma MCI, the Disaster Control
Facility (DCF) shall include at a minimum all of
the following trauma centers in their
emergency department poll:
C.
1.
San Joaquin General Hospital;
2.
Doctors Medical Center;
Memorial Medical Center;
U.C. Davis Medical Center;
Kaiser Hospital South Sacramento.
3.
4.
5.
EMS Policy No. 5215 Trauma Patient
Destination
V.
Multi-casualty Incidents (MCIs):
D.
As specified in EMS Policy No. 5210, on
secondary triage an “Immediate” patient
includes patients meeting START criteria and
patients meeting physiologic or anatomic major
trauma triage criteria.
EMS Policy No. 5215 Trauma Patient
Destination
VI.
Specialty Considerations:
Unmanageable Airway: Transport to closest
receiving hospital.
Isolated Burn Injuries:
A.
B.
1.
Patients with partial or full thickness thermal,
chemical, or electrical burns greater than 9%
total body surface shall be transported to the
level I trauma center at the UC Davis Medical
Center.
EMS Policy No. 5215 Trauma Patient
Destination
VI.
Specialty Considerations:
Isolated Burn Injuries:
B.
2.
3.
C.
Inhalation burns with a manageable airway shall be
transported to the closest trauma center based on
assigned trauma service area.
Paramedics should consult with the base hospital on all
other types of burns injuries to obtain a destination.
Isolated Spinal Cord Injuries: Patients with spinal
cord trauma or traumatic paralysis without comorbid
trauma injuries shall be transported to the level I
trauma center at the UC Davis Medical Center.
EMS Policy No. 5215 Trauma Patient
Destination
VII.
A.
B.
Air Ambulance Transport Considerations:
When ground ambulance transport is readily
available air ambulance scene time should be kept to
an absolute minimum.
Ground ambulance transport of a major trauma
patient should not be delayed for the arrival of an air
ambulance.
EMS Policy No. 5215 Trauma Patient
Destination
VIII. Non-Emergent
Trauma Patient Destination
Considerations:
Questions?
EMS Policy No. 5115
Cervical Spine Immobilization
EMS Policy No. 5115 Cervical Spine
Immobilization

Turning the approach to C-Spine
Immobilization 180 Degrees
 Old Approach: Everybody is immobilized
 New Approach: Only patients requiring
immobilization are immobilized
EMS Policy No. 5115 Cervical Spine
Immobilization
The policy premise
II. When to immobilize c-spine
III. When not to immobilize c-spine
IV. Techniques and equipment to perform
immobilization
V. Pediatrics
VI. Adults
VII. Moving patients on-scene
VIII. Special Considerations
I.
EMS Policy No. 5115 Cervical Spine
Immobilization
I.
What is the basis for the new approach?
 Decrease unnecessary immobilizations
 Reduce risks and complications
○ Spinal immobilization may cause harm and
interfere with care (e.g. penetrating trauma)
EMS Policy No. 5115 Cervical Spine
Immobilization
Prehospital personnel shall apply cervical spine
immobilization to patients injured from blunt force
trauma when:
II.
Conscious patients with one or more of the following:
A.
1.
2.
3.
4.
5.
Posterior midline tenderness or pain;
Distal numbness, tingling, weakness, or parethesia;
Paralysis
Neck guarding or restricted range of motion;
GCS motor score or less than 5 as a result of blunt force
trauma or intoxicants
B. Unconscious adult patients suffering from blunt
force mechanism of injury, except ground level falls.
EMS Policy No. 5115 Cervical Spine
Immobilization
III.
Prehospital personnel shall not apply cervical
spine immobilization to patients injured in the
following circumstances:
A.
Patients injured solely from penetrating trauma;
B.
Unconscious adult patients experiencing a ground level
fall;
C.
Patients in cardiac arrest.
EMS Policy No. 5115 Cervical Spine
Immobilization
IV.
Pediatric cervical spine immobilization shall be
performed (depending upon circumstances) as
follows:
A.
Soft c-collars, KEDs, or similar device.
B.
If already in a car seat:
C.
1)
Rear-facing seat - may be immobilized and extricated.
2)
High-back front facing seat - may be extricated in seat, but
then placed in a pediatric immobilization device (PID). If
child too agitated, do not force the use of the immobilization
device.
If restrained in booster – place in PID
EMS Policy No. 5115 Cervical Spine
Immobilization
V.
Adult cervical spine immobilization shall
be performed by selecting the most
effective methods and tools for the
specific situation to prevent gross
movement of the spine.
Do not interfere with necessary
treatment
EMS Policy No. 5115 Cervical Spine
Immobilization

Approved equipment includes:
 Soft cervicle collars.
 Kendrick Extrication Device (KED) or
Fasplint or similar device.
 Any combination of equipment including
pillows and blankets or other commercially
available immobilization device approved by
the EMS Agency to ensure comfort and
spinal immobilization on the gurney.
EMS Policy No. 5115 Cervical Spine
Immobilization
VII.
Approved devices for moving patients on
scene include:
 Pull sheets and other flexible devices.
 Scoops, Long backboards and Miller Boards
may be used on-scene, but DO NOT
transport patients to the hospital on
backboards.
 Self extrication by patients is allowed.
(Easier on patient – less movement)
EMS Policy No. 5115 Cervical Spine
Immobilization
IV.
Special Circumstances:
 Agitated patients may need to be removed
from spinal immobilization.
 Most patients in spinal immobilization will
benefit from being placed in semi-fowlers.
 ALS personnel may discontinue spinal
immobilization upon reassessment of the
patient.
 Do not use hard collars or apply adhesive
tape to the patient’s skin.
Questions?
Minimally Interrupted
Cardiac Resuscitation
MICR Section Objectives

Understand the scientific data that supports
implementing MICR

Understand the SJCEMSA MICR Policy
Discussion Topics

Why Minimally Interrupted Cardiac
Resuscitation (MICR)?

Curriculum
 SJCEMSA MICR Policy
 Pit Crew Concept
 Critical Task Approach
○ Talk through scenarios
○ Demo the scenarios
○ Practice the scenarios
Why MICR?

MICR optimizes the chance of surviving
cardiac arrest with favorable
neurological outcomes.
Cardiac Arrest Treatment
The links in the “Chain of Survival”
1. Early Recognition and Calling EMS
2. Early CPR
3. Early defibrillation
4. ALS (medications, IV, intubation)
THINK ABOUT THIS!!!
What
if adding ALS
…subtracts chest
compressions?
“A” ALWAYS COMES FIRST in ABCs
…RIGHT???

How could ADDING intubation with a high
success rate fail to improve outcome?

Speculation in 2004:
 ANYTHING that interrupts CCs is bad!!!
○EVEN AIRWAY??????
○“C” comes BEFORE “A”
2004: Starting to Figure it Out
In
Cardiac Arrest…it’s
not the ABCs…
CABs!!!
It’s the…
Starting to Figure it Out in 2004
 The implications:
○ Less is more: CPR more important than ALS
 Rescue breaths create major CC
interruptions
 Studies from animal lab
○ Interrupting CCs is REALLY bad
 Potential detrimental effects of doing
ventilation during CPR
Issue #1: Adverse Effects of
Positive Pressure Ventilation

During CPR…PPV:
 Increases intra-thoracic pressure
 Decreases venous return to the chest
 Decreases coronary blood flow
 Decreases cerebral blood flow
Aufderheide: Circulation. 2004;109:1960-1965.
Ventilation Rate During
Out-of-Hospital CPR
--13 OHCA patients
--Ventilation during CPR
--Mean rate: 37±3 per minute (range 15-49)
Aufderheide. Circulation 2004; 109:1960-5
Issue #2: Chest Compression
Interruptions During CPR
 Experienced paramedics:
 Conventional CPR (15:2)
 Two breaths: 16 seconds
 39 CC/min
 42% of cycle with CC
 “CC-only” CPR (50:2)
 Two breaths: 3 sec. after 50
 84 CC/min (119% increase)
 93% of cycle with CC
5/12
7/12
Blood pressure
Blood Flow with Conventional CPR vs. CO-CPR
Conventional CPR
Blood pressure
Time
COCPR
Time
Berg et al, 2001
What About Oxygenation?

In sudden cardiac arrest:
 Lungs and arterial circulation are WELL
oxygenated
 Animal data:
○ Arterial oxygenation remains acceptable for 5-10
min of CCs…without PPV
○ CCs alone create significant ventilation
 Key: Circulate the oxygen that’s already
present…and…supply supplemental oxygen to
enrich the passive ventilation that occurs during
CCs
Issue #3: ETI is the Best Way to
Provide PPV
 BUT…what matters most in CPR?:
 Coronary and cerebral perfusion pressure
 Remember
what happens during
PPV:
 Intrathoracic pressure increases
 Venous return to the heart decreases
 Coronary/cerebral perfusion pressures
decrease
Issue #3: ETI is the Best Way to
Provide PPV
 Ironically:
Whatever improves
ventilation worsens CPP…and
outcome
 ETI worse than BVM
 BVM worse than POI
Issue #4: Big Hints From Clinical
Experience
--Case Reports:
--Early in arrest…trying to push the hands
away
--A Bystander in Seattle:
“Why is it every time I press on his chest he
opens his eyes and every time I stop to breathe
for him he goes back to sleep?”
EMS Care: “Minimally-Interrupted Cardiac
Resuscitation”

Based upon the emerging evidence, we are
adopting an alternative protocol to ACLS:
 Removes ventilations entirely early in the
resuscitation
 Emphasizes that NOTHING interrupts CCs
 Single shocks
 After shock, immediately resume CCs
○ No rhythm check
○ No pulse check
 Epinephrine given during compression cycles if
no CC interruption will result
 POI until late in resuscitation
Minimally-Interrupted Cardiac
Resuscitation (MICR)
-Passive O2
Insufflation—100% FIO2
-Begin IV/IO without
interrupting CCs
200 chest
compressions
Single shock if
indicated without
pulse check or
rhythm analysis
Analysis
200 chest
compressions
Single shock if
indicated without
pulse check or
rhythm analysis
Analysis
CC
Only•
Analysis
EMS
arrival
Single shock if
indicated without
pulse check or
rhythm analysis
200 chest
compressions
Administer 1 mg
IV/IO epinephrine
without interrupting
CCs
200 chest
compressions
-Std ACLS – 30:2
-Consider ETI without
interrupting CCs
• If adequate bystander chest compressions are provided, EMS providers
perform immediate rhythm analysis
Survival to Hospital Discharge (%)
Survival:
MICR v. Conventional ACLS
30
(36/128)
MICR
ACLS
aOR = 3.0
25
20
15
10
5
0
(61/1686)
(55/598)
(38/348)
9.2
10.9
28.1
3.6
All cardiac arrests
Witnessed with VF
Bobrow, et al. JAMA 2008 Vol. 299 No. 10
Favorable Neurologic Outcomes
aOR = 2.2
75.5 %
57.9 %
Percent
among
survivors
CPC = 1, 2
ACLS
MICR
Panchal, et al SAEM 2010
Bag-Valve-Mask Vs. Passive
Oxygen Insufflation (POI)

Recall the evidence:
 Theoretical reasons to believe:
○ PPV may be detrimental
○ Over-ventilation IS detrimental
 Clinical care
○ Strong evidence that overventilation/hyperventilation is routine
Survival: POI Versus BVM
% Survival to Hospital Discharge
50%
POI
BVM
21/46
40%
30%
aOR
1.7 (0.9-3.1)
20%
aOR
5.7 (2.3-14.2)
45.7%
14/77
24/206
30/376
10%
11.7%
0%
18.2%
8.0%
All Rhythms
Witnessed VF
The Arizona Experience
SURVIVAL BY
Overall
Witnessed VF
Overall Survival
2.1 (CI: 1.1-4.2)
YEAR 5.8 (CI: 1.8-18.9)
2004
2009
2011
3.0%
7.0%
10.2%
31.3%
19.4%
57.9%
Real-time CPR Feedback
Chest Compression Depth
 Chest Compression Rate
 Length of Pre-Shock Pauses
 Length of Post-Shock Pauses
 Percentage of Time Doing Chest
Compressions

MICR Has Come of Age
Improving Cardiac Resuscitation: Evolution or Revolution?
Arthur L. Kellermann, MD, MPH
From the Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA.
MICR Has Come of Age
Unlearn Decades of Training that ABCs
are the Priority
Improving Cardiac Resuscitation: Evolution or Revolution?
Arthur L. Kellermann, MD, MPH
From the Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA.
Questions on the Science
behind MICR?
EMS Policy No. 5710 – ALS
Medical Cardiac Arrest

Policy Focus: Process to perform
efficient & effective resuscitation

Policy Goal: Return of Spontaneous
Circulation
EMS Policy No. 5710 – ALS
Medical Cardiac Arrest

Definitions:
 MICR
 MICR Algorithm
 MICR Rounds
 Passive Oxygen Insufflation (POI)
 Pit Crew
EMS Policy No. 5710 – ALS
Medical Cardiac Arrest
I.
Preserve cerebral and coronary
function through meticulous attention to
procedure.
A. Accomplish the following in rank order:
1. High quality chest compressions
2. Apply ECG/AED
3. Initiate POI
4. Provide epinephrine IV/IO
EMS Policy No. 5710 – ALS
Medical Cardiac Arrest
B.
Use a team (pit crew) approach.
II.
Maintain compression rate and
alternate chest compressions between
team members (200-230 comps).
Initiate an advanced airway and treat
underlying ECG rhythm after MICR has
been provided for four MICR Rounds.
III.
EMS Policy No. 5710 – ALS
Medical Cardiac Arrest
III.
Initiate ACLS and an advanced airway
after MICR has been provided for four
MICR Rounds.
IV.
The first MICR Round is measured
from the time that the first EMS
personnel on-scene initiates the MICR
procedure (compressions), regardless
of whether ALS treatment has begun.
EMS Policy No. 5710 – ALS
Medical Cardiac Arrest
V.
Contraindications for MICR
A. Traumatic arrest
B. Pediatric arrest
C. Cardiac arrest due to known respiratory
problem (e.g. asthma)
D. Drowning
E. Obstructed Airway (including when vomitus
prevents effective POI).
EMS Policy No. 5710 – ALS
Medical Cardiac Arrest
PROCEDURE:
I. Obtain patient history, down time, etc.
II. Treatment
A. Begin compressions immediately. Only do
a rhythm check immediately if arrest
witnessed by EMS personnel and
AED/ECG is already applied.
PROCEDURE:
Treatment
II.
A. 1. First MICR Round
•
200 Compressions
•
Apply AED/ECG
•
Apply POI
•
Admin Epi
PROCEDURE:
Treatment
II.
A. 2. Subsequent MICR Rounds
•
Stop compressions to allow AED to analyze
rhythm
•
Switch compression techs during analysis
•
Immediately continue compressions during AED
charge-up to defibrillate (30 if possible)
•
Apply a single shock (if indicated)
PROCEDURE:
II.
Treatment
A. 2. Subsequent MICR Rounds
a) Monitor airway – head re-position and
suction if needed.
b)Minimize chest compressions
interruptions for defibrillation.
c)Rotate chest compression duties between
Pit Crew members every MICR Round.
PROCEDURE:
II.
Treatment
A. 3. Complete four MICR Rounds before
transitioning to ACLS care.
4. Follow treatment path as appropriate for
Asystole, V-fib and Pulseless VTach, or
PEA.
5. For return of spontaneous circulation, see
EMS Policy No.5726, Return of
Spontaneous Circulation.
PROCEDURE:
III.
Transition to ACLS Care
A. Place either a King Airway or ET Tube.
Minimize interruptions to chest compressions.
B. Add ventilations at ratio of 8 to 10 per minute
with continuous compressions at 100 per
minute.
C. Use waveform capnography.
D. Do Not Hyperventilate!
PROCEDURE:
IV.
Base Hospital Direction and Patient
Transport

If no ROSC following 15 minutes of
resuscitation contact the Base Hospital.

If the patient displays PEA or V-fib, expect an
order to transport the patient.

Do not transport unless per Base order or due
to scene safety.
Pit Crew Concept
SJCEMSA Policy No. 5710-A Medical
Cardiac Arrest – Pit Crew Appendix A
 Specific roles and responsibilities are
guidelines
 Regardless of number of Pit Crew members,
critical tasks take precedence
Pit Crew Critical Tasks
1.
Uninterrupted Compressions
2.
Placement of AED or monitor for
analysis/shock
3.
Placement of OPA airway and 100%
oxygen by non-rebreather mask
Airway
Leader
Compression
Tech
Compression
Leader
Medication
Leader
II. Pit Crew Procedures

Ensure enough space

Perform proper chest compressions
 Rate, Depth, Recoil
 Alternate compressions techs every MICR
Round
MICR Priorities

Compression Leader and Compression
Tech alternate every MICR Round

Compression Tech places AED during
first MICR Round

Pit Crew member not providing
compressions applies OPA and Oxygen.

When ALS arrives, starting an IV/IO
should be initial and ongoing focus
during MICR Rounds.
MICR Considerations and
Lesson’s Learned
1.
First crew on-scene move patient to an
area with 5’x7’ minimum space.
2.
Position monitor/AED near patient’s left
shoulder and airway bag at patient’s
right shoulder.
3.
MICR Rounds begin when first EMS
crew begins implementing MICR.
Considerations
4.
When ambulance crew arrives, first
report:
 # MICR Round currently working
 Compression count
5.
ALS monitors programed for a
30-second window of opportunity to
defibrillate after “shock advised”. AED
monitors are limited to 15 seconds or
less
Considerations
6.
If Pit Crew members know their jobs for
the first round, it will tend to go
smoothly
7.
ALS crewmembers must focus on IV/IO
and Epi, not monitor or airway.
8.
Compression Techs count silently until
“170”, then count backwards when 10
compressions remain.
Considerations
9.
Switching between compression techs
is driven by good communication.
9.
When performing endotracheal
intubation, prepare for success and
speed. Otherwise apply a King airway.
10. Learn
to communicate with family
members about ending resuscitative
efforts (included when transporting).