Region X SOP
Review
Changes and Rationales
ECRN CE Mod IV 2011
Condell Medical Center
EMS System
WATCH FOR INFORMATION ON
CRITICAL MEDICATION SHORTAGES
Objectives and preparation by Sharon Hopkins, RN, BSN, EMT-P
Revised 2.1.12
1
Objectives
Upon successful completion of this module, the ECRN
will be able to:
Discuss changes to the Region X SOP’s
Discuss changes in drug administration based on
the 2010 AHA guideline changes
Acknowledge changes in oxygen administration
Review the SOP drugs
Acknowledge resources in the SOP’s for
medication information
2
Objectives
Review the indications for EMS treatments
Review contents in the skills section
Review contents in the reference section
Review case scenarios
Successfully complete the quiz with a score
of 80% or better
3
Critical Shortage Medications
• Nation-wide issue
• Will need to flexible in responding to
alternatives
• Critical shortage:
Diazepam (Valium)
Etomidate
Fentanyl
Ondansetron (Zofran)
Contingency Plan – Med
Shortage
Diazepam (Valium) currently unavailable
Midazolam (Versed) to be used
Fentanyl is in limited supply
Consider use of Morphine
In absence of Etomidate, reserve field
intubation attempts to
unconscious/unresponsive patients
without a gag reflex (can check for a blink
reflex – if present still has a gag reflex)
ECRN must consult ED MD for orders not
stated in the SOP’s
Credible Source for Changes
• AHA
– Every 5 years scientific assembly meets with
worldwide representation
• Research results affect changes to BLS,
ACLS, PALS, NALS programs
• Illinois Emergency Medical Services for Children
(EMSC)
– Oversees policies, procedures and care of the
pediatric population
• International Trauma Life Support
– International representation for trauma care
6
Region X SOP Formatting
• Where applicable, if there is an adult
protocol, there is generally a matching
pediatric protocol
• Multiple reference pages:
• - skills/charts for quick access
• - pediatric normal vital signs
• - Wong-Baker pain scale
• - 2010 AHA CPR guidelines
• -12 lead placement
7
Formatting cont’d
• Drug dosing charts based on weights
– Pediatric chart
• 1 table for cardiac medications
• 2 tables for general medications
• Pediatric weight ranges 2 Lbs to 98 Lbs
–1 Kg to 44 Kg
• Lists mL for drawing up the medications at
the patient’s side
• Lists mg for aid in documentation
8
Broselow Tape
• Broselow tape available and used as a
reference tool
• Benefit
– Guides in choosing equipment sizes
• Limitations
– Not all meds in ml which is information
needed when at the beside
– May not be as familiar with drug name used
• Diazepam for Valium; Naloxone for Narcan;
crystalloids for normal saline
Formatting cont’d
– Adult chart
• Lists medications that must be given by
weight
–Etomidate
–Fentanyl
–Lidocaine for drug assisted intubation
• Adult weight ranges 88 Lbs to 300 Lbs
–40 kg – to 136 Kg
10
Abbreviations for Documentation
• Last 2 pages list out abbreviations, acronyms,
symbols
– Common and medically accepted list
• Hospital and EMS resources
• Watch use of abbreviations for misinterpretation
– ie: MSO4 is morphine (MgSO4 is mag sulfate and
sounds similar!!!)
• Whenever possible, words should be fully
spelled out to avoid confusion
11
Global Change
• Oxygen administration
– Patient must be assessed for need before
automatically administering oxygen
Breathlessness
Signs of heart failure
Signs of shock
SpO2 <94%
– O2 not required/not found useful
• Uncomplicated acute MI (AMI) or ACS
patient without signs of hypoxemia or heart
failure
12
Pulse Oximetry vs Capnography
• Capnography gives an instant and current
snapshot of patient’s ventilation status
– Measures exhaled CO2
– Changes immediately if perfusion returns
(ROSC) or if ventilation drops
• Pulse oximetry change is delayed in time
from the actual incident
– Can also be falsely elevated in carbon
monoxide exposure giving false sense of
security
Capnography
• Departments that have the device will use the
device
• Normal readings (patient perfusing and
ventilating self) are 35-45 mmHg
– Just like a blood gas result
• Readings during effective CPR are >10 mmHG
• Reading <8 mmHg during CPR require
reevaluation of technique, equipment and
patient
Global Reinforcement
• Fluid challenges
– Global formula is 20 mL/kg all ages
• Adults receive fluid in increments of 200 mL
– Move toward total goal (usually 1 – 2L)
– Reassess as you move past each 200 mL
increment
• Pediatric total calculated at 20 mL/kg
– As you move toward total goal, reassess every
200 mL
• Example: Pediatric patient to get 480 mL of fluid
– Reassess at 200 mL; 400mL; then 80mL
15
Securing the Airway
• A vague term:
- indicates to do what is necessary to ventilate
and oxygenate the patient after your
assessment of the situation
Question: The patient has snoring respirations
– What would be done initially for the airway?
• Reposition the patient
–One of the least attempted maneuvers
–Often most overlooked technique
16
Question - Securing the Airway
• The patient is unresponsive and breathing
4 times per minute
– What would be the initial response for airway?
• Begin to support ventilations via BVM
– 5-6 breaths per minute
• EMS is working a full arrest
– They have performed CPR, defibrillated, secured
IV access, and started medications
– What can now be done to secure the airway?
• Intubate the patient (ETT, King airway, combitube)
• Apply cervical collar to keep tube in place
17
Predicting Difficult Intubation
• A tool: Mallampati score
• The pharynx is viewed (the oral cavity)
– Scoring
•
•
•
•
I – Entire tonsil or tonsillar bed visible
II – Upper half of tonsil or tonsil bed seen
III – Soft and hard palates are clearly visible
IV – Only hard palate is visible
– The higher the score, the higher the degree of
potential intubation difficulty, the more likely
an alternate airway device is used
18
Mallampati Score
• EMS can use Mallampati Score as a tool
but not obligated to
• Do not expect report to include this score!19
Alternative to Endotracheal
Intubation
• EMS may place the King airway - more
likely if failure with ETT
• Some EMS may place the combitube- rare
• If unable to place a device, may assist
ventilations via BVM
– Non-intubated patient with a pulse
• Ventilate once every 5-6 seconds
– Intubated patient with any device
• Ventilate once every 6-8 seconds
Alternate Airway Devices
• King Airway
• Combitube
Global Additions
• Pain is considered the 5th vital sign
– All trauma patients and many medical patients
need pain evaluated and documented
• Time of onset
• EMS to be as specific as possible
– Most important to obtain and communicate to
ED staff in presence of suspected acute
stroke
22
CPR Changes
• Change from A-B-C to C-A B
– After assessing responsiveness, begin
compressions
• Add 2 ventilations after the initial compressions
– There was too long of a delay in starting
compressions
– There is always residual oxygen left in the lungs
• Immediately resume compressions after
each defibrillation attempt
• Change compressors every 2 minutes
during 10 second pause to check rhythm
23
CPR changes cont’d
• Pulse checks performed ONLY if there is a
rhythm viewed that should produce a pulse
– So NO pulse check for VF or asystole
• ROSC - If patient is resuscitated from cardiac
arrest, remains unconscious, and pulse is
maintained for a minimum of 5 minutes, start to
cool the patient
– Ice packs in areas with superficial blood
vessels
• Back of neck, axilla (armpits), groin, over IV
24
site
Withdrawing Resuscitation
• Medical Control consultation for an order
– Patient normothermic adult
– Unwitnessed arrest
– Airway secured and IV/IO placement
– Patient remains in asystole
– No response to at least 20 minutes ALS care
• EMS needs time of order and name of MD
authorizing withdrawal
– Will continue efforts in pediatric population
• An exception may be extenuating circumstances
Medication Additions
• Etomidate – Drug Assisted Intubation
• Fentanyl – pain control
• Atrovent (Ipratropium Bromide) –
bronchodilator & dries secretions
• Zofran (Ondansetron)– nausea/vomiting
– New SOP for adult and peds
Medication Deletions
• Benzocaine – replaced with Etomidate
• Lidocaine – for any cardiac patient;
replaced with Amiodarone
– Still use for head insult with Drug Assisted
Intubation and comfort with infusion via IO site
• Lidocaine drip – no use for a drip now
• Any Albuterol dose will be mixed with
Atrovent for 1st time (Duoneb); repeats just
Albuterol alone
Medication Changes
• Etomidate replaces Benzocaine, Versed
and Morphine for Drug Assisted Intubation
• Adenosine attempted once in stable adult
monomorphic VT before Amiodarone
• Adenosine as a trial in STABLE peds
probable VT with adequate perfusion prior
to Amiodarone
• Amiodarone started sooner in adult
unstable VT requiring cardioversion
Medication Changes cont’d
• Versed 1st line med for active seizures and
behavioral situations – can be given IN
(intranasally) avoiding needle stick
potential
• Fentanyl – 1st pain med over Morphine
– Morphine still 1st for Acute Coronary
Syndrome and burns if IV line is established
SOP Revisions
• The following are SOP revisions effective
February 1, 2012
– Affects Condell and Highland Park EMS
System paramedics
– Vista System paramedics will follow previous
version SOP until March 1, 2012
Drug Assisted Intubation
• Name change to SOP
– Better reflects what is being done
• Lidocaine necessary if head insult - medical or
trauma (1.5 mg/kg IVP/IO)
– Eliminates cough reflex to prevent  ICP
• Etomidate (0.3 mg/kg IVP/IO; max 20mg)
– As hypnotic, sedative
• Replaces initial Versed, Morphine, Benzocaine
• Versed (2 mg IVP/IO every 2 min to max 20mg)
– To keep patient sedated
31
Peds Drug Assisted Intubation
• NEW!!!
• Similar to adult process
• Added Atropine as a pre-medication
– Avoid potential bradycardia from stimulation
during intubation attempts
Peds Drug Assisted Intubation
• Lidocaine necessary if head insult medical or
trauma (1.5 mg/kg IVP/IO)
– Eliminates cough reflex to prevent  ICP
• Atropine (0.02 mg/kg IVP/IO – max 0.5 mg)
– To blunt a bradycardic response when introducing
equipment into the airway
• Etomidate (0.3 mg/kg IVP/IO; max 20mg)
– As hypnotic, sedative
• Replaces Versed, Morphine, Benzocaine
• Versed (0.1 mg IVP/IO to max 10mg)
– To keep patient sedated after intubation
– Contact Medical Control if additional sedation is
required
33
Asystole/PEA
• Atropine eliminated
– Not found to be of any benefit in asystole or PEA
• Lots of CPR, CPR, CPR
• No pulse checks for asystole
• DO perform pulse check with each rhythm check
for PEA
– Maybe some intervention reestablished a pulse
• Search for causes – H’s and T’s
• If ROSC, cool patient
• If sustained asystole, consider withdrawing effort
– With Medical Control approval in adult patient
34
Adult Bradycardia & AV Blocks
• Determine stability of patient
– What is their mental status?
• Altered level of consciousness first
indicator to change when circulation
diminished
– What is the blood pressure?
• Feel for a radial pulse
–What is the quality and rate?
–If they have a radial pulse, they have at
least a minimal blood pressure
• B/P is the last compensation factor to
35
change in decreased perfusion states
Adult Bradycardia
• Administer Atropine while reaching out
and applying the TCP
– “When their alive, give them 0.5” (mg IVP/IO)
– If no response to Atropine (response not likely
in second degree Type II or 3rd degree heart
blocks)
• Begin pacing
– Valium is relatively longer acting than Versed
» Used for sedation
– Fentanyl is for pain associated with pacing
• Dopamine is to support B/P
36
Adult Acute Coronary Syndrome
• Obtaining a 12 lead as soon as possible will help
direct patient care
– To give or hold Nitroglycerin
• Held in presence of ST elevation in II, III, aVF
(inferior wall MI)
• Held if Viagra type drug use past 24-48 hours
• Held if systolic B/P <90
– Results determine activation of hospital cardiac alert
• Aspirin is important to inhibit platelet aggregation
– Better to get an extra dose than to not have a
dose
– Can hold if patient reliable and DID take ASA
• Per AHA, Morphine is the preferred drug in AMI 37
Adult Cardiogenic Shock
• EMS starts at 5 mcg/kg/min
• Expanded dose ranges added for dopamine
 5 mcg/kg/min
 10mcg/kg/min
 15mcg/kg/min
 20mcg/kg/min
• Easy way to calculate 5 mcg/kg/min
–
–
–
–
–
Determine patient weight in pounds
Take first 2 numbers
Subtract 2
That’s where to start the minidrip
(Ex: 180 #  18 – 2 = 16 mini drips per minute)
38
Adult SVT/Rapid A Fib/Flutter
• Determine if the patient is stable or not
Check level of consciousness
Check blood pressure
• Patient determined to be unstable or
relatively stable
–Remember that patients will have
symptoms if pulse rapid
»Having symptoms doesn’t necessarily
make someone unstable, just
symptomatic
39
Valsalva Maneuvers if Stable
• Need to stimulate the vagus nerve to slow
down the impulses in rapid heart rates
– Have patient bear down (carefully) for 10
seconds
– Have patient blow through a straw
• Can’t blow through a straw?
–Have patient stick their thumb in their
mouth and blow against the thumb
–Effective for pediatric population
40
Managing Sedation & Pain with
Cardioversion
• Cardioversion is a painful procedure
• Versed used to sedate/relax the patient
and act as a hypnotic
– Not something you want to have memory of!
• Fentanyl can be used to manage any
complaints of pain after the procedure
– There may be residual discomfort in the chest
41
Adult VF/Pulseless VT
• Begin CPR (C-A-B) until defibrillator ready
• Biphasic joules amount is based on brand
of defibrillator
• Resume CPR immediately after each
shock is delivered
• Alternate Epinephrine 1:10,000 with 2
rounds of Amiodarone (300mg 1st dose,
then 150 mg 2nd dose in 3-5 minutes)
– Amiodarone more effective and
studied/effects reviewed more than Lidocaine
42
Adult VT with Pulse
• Stable monomorphic
– From beat to beat the complexes have same
shape and form
– Trial dose of Adenosine
• Trying to determine if rhythm is SVT with
aberrancy or VT
• Relatively safe for diagnosis and treatment
• NOT okay if irregular or polymorphic VT
– May deteriorate to VF
• If SVT with aberrancy, may transiently slow down
or convert to sinus rhythm
43
Monomorphic vs Polymorphic VT
•Monomorphic – complexes appear the same
• Polymorphic – complexes change beat to beat
44
Adult VT with Pulse
• Polymorphic VT
– Complexes vary from beat to beat
– If stable, treatment with Amiodarone
• Amiodarone must be administered slowly in the
non-arrested patient (over 10 minutes)
– Watch for hypotension
• Unstable patient with any tachycardia
– Losing consciousness
– Poor perfusion (B/P <90 mmHg)
• Need to cardiovert
45
Cardioversion
• Start at relatively low doses/joules
• Increase joules as needed
• This is a painful procedure
– Versed used to sedate patient and as amnesic
• Relatively short acting
• Benefit – it can be given IN via MAD
– Manage pain with Fentanyl
• Will want/need an IV in this population at some
time – more unstable patient
46
Adult & Peds Seizures
• Why is Versed used?
– Shorter acting than Valium
• Both are Benzodiazepines
– Versed can also be given via the IN
route via MAD
• Reduces exposure to inadvertent
needle sticks
47
Adult & Peds Seizures
• Need to determine cause of seizure activity
– If epileptic, head injury, brain tumor type
causes, patient will most likely respond to a
Benzodiazepine (i.e.: Versed)
– If seizure due to lowered blood sugar level, the
patient needs glucose
• The brain is starving for sugar, needs
Glucose
• Glucagon is a hormone to release sugar
stores if available; it is not sugar
– Given IM/IN in absence of IV access
48
Adult & Peds Burns
• Why is Morphine used for pain for the
patient with burns?
– Morphine is longer acting than Fentanyl
• Therefore, less doses should have to
administered in the field
– In burns, we know why the patient is having
pain; don’t need it “worn off” for assessment
at hospital
• In absence of IV access,
Fentanyl can be given
IN via MAD
49
Adult & Peds Pain Management
• Fentanyl 0.5 mcg/kg (adult & peds)
– Synthetic narcotic
– Relatively short acting
– If respiratory depression, can be reversed
with Narcan
• Support respirations via BVM if needed
– Can be given variety of routes
• IVP/IN/IO
– Dose calculated by patient weight
• FYI - A 875 pound patient would get 198 mcg
(max is 200 mcg)
50
Adult & Peds Nausea Management
• Zofran (ondansetron) is a frequently used
medication
– Adults & peds >40kg – 4mg
– Peds <40 kg 0.1mg/kg
• If nausea is relieved, the patient
may not need other medication
for a secondary problem
(i.e.: abdominal pain with nausea)
• Often causes drowsiness
– Watch airway for aspiration
precautions
51
Peds Bradycardia
• The pediatric etiology of bradycardia is
different than the adult population
• First drug is Epinephrine 1:10,000
– 0.01 mg/kg IVP/IO
– Repeated every 3-5 minutes if no response
• Medical Control to be contacted to
consider Atropine order
– Most peds patients do not have sick hearts so
usually do not respond to Atropine
52
Peds VF/Pulseless VT
• Begin CPR (C-A-B) until defibrillator ready
• Defibrillation is 2 joules/kg; then 4j/kg
• Resume CPR immediately after each
shock is delivered
• Alternate Epinephrine 1:10,000 with 2
rounds of Amiodarone (5mg/kg 1st dose,
then 5 mg/kg 2nd dose in 3-5 minutes)
– Amiodarone more effective and
studied/effects reviewed more than Lidocaine
53
SOP Skill References
• Placed in the SOP’s as a quick “how-to”
reference
• Step by step detail to complete a skill
• Located at the back of the SOP’s
54
King Airway
• New to the Region
• Alternative airway adjunct
• Used as a backup when intubation with the
endotracheal tube cannot be accomplished
• Cannot be used in presence of a gag reflex
– Check for the blink reflex, if present then gag is
still present
– Etomidate used to sedate the patient
• Will control the gag reflex
55
King Airway
• Contraindications
– Height less than 4 feet
• Our tubes sizes are #3, #4, #5
– Sizes match up with heights
» #3 for 4-5' heights (yellow tip) (think 3-4-5)
» #4 for 5-6' heights (red tip) (think 4-5-6)
» #5 for >6' heights (purple tip) (think 5-6)
– Do not want to insert with diseased/damaged
esophagus
• Could tear through esophageal wall
56
King Airway
•
•
•
•
Distal cuff sits in and seals esophagus
Proximal cuff seals oropharynx
Air enters trachea between the cuffs
King does NOT fully protect the airway from
potential aspiration following vomiting
– ETT is superior in aspiration protection
– Decision by ED MD to extubate King airway and
replace with ETT prior to admission
• No meds administered thru King airway
• Ventilate once every 6-8 seconds via King
57
Endotracheal Tube vs King Airway
58
Assessing Placement of Advanced
Airway Devices
• Usual steps
– Chest rise and fall
– 5 point auscultation
– ETCO2 detector
• Look for yellow
– If capnography,
reading 35-40 mmHg
59
Removing King Airway
• Prepare alternate airway equipment
• Deflate cuffs
– One pilot used for both cuffs
– Can hold 45-90 ml air depending on size tube
• Extubate similar to removing an ETT
• Prepare to oxygenate and ventilate patient
as needed
• Secure airway with appropriate alternate
method
MADD
• Used for medications that can be given
intranasally (IN)
– Fentanyl IN/IVP/IO
– Glucagon IN/IM
• IN works as slowly as IM injection
– Narcan IN/IVP/IO
– Versed IN/IVP/IO
• Max volume per nares is 1 mL
– Can use divided doses if necessary
– If dose <0.5 mL, place in one nostril
61
Intraosseous Infusions
• Regardless of site used, equipment is the same
Site preparation material / cleanser
Drill
Needle
Primed EZ connect tubing
Primed IV tubing spiked to IV fluid bag
Pressure bag
Method to secure the site
• Lidocaine useful for pain control during infusion
62
Humeral IO Site
• Used as a backup to a peripheral IV site
• Situation in which you NEED IV access
• Proximal humeral site a backup in the
adult patient population
– Primary site should be the proximal tibial area
63
Sizing an IO Needle
• Assess patient to determine the size needle to
use for the site used
– Palpate over your wrist in line with the thumb
• Do you feel the bone?
• If you feel the child’s tibia like this, use the shorter pink
needle
– Palpate the inside crook of your elbow
• Do you feel the meatiness?
• If you feel the child’s tibia like this, use the middle sized blue
needle
– Humeral site for the adult
• Always use the long yellow needle
64
Adult
Humeral
Head Site
Need to keep
arm
immobilized
after needle
placement
65
Tibial Insertion Site
• Palpate over site to determine length
needle required
66
Inserting the IO Needle
• Needle inserted until resistance is felt
– You are touching bone
• Look to see at least one black line
– If no black lines are visible the needle is too
short
• Then drill to
seat the needle
in the bone
67
Removing an IO Needle
• Establish an alternate IV site
• Stop IO infusion system
• Remove IV tubing and EZ connect extension
tubing
• Connect a syringe to needle hub
– Gives you something to hold onto
• As you turn syringe clockwise, exert steady,
gentle pull
– Turning counter clockwise just disconnects the syringe
– It takes quite a few turns to remove the needle
• As the needle is removed, place bandaid over site
Needle Decompression
• Site remains the 2nd intercostal site,
midline of the clavicle
• Flutter valve not necessary
– Air will enter the larger diameter (trachea vs
needle in the chest)
69
2010 AHA CPR Guidelines
• You should have been updated in the
2010 AHA guidelines by now or heard of
the changes
• Key points
– Push hard, push fast (rate at least
100/minute)
– Ventilate slower
• 1 breath every 6 seconds
• Immediately resume CPR after each
defibrillation attempt
• Switch compressors every 2 minutes
70
ROSC & Cooling
• Return of spontaneous circulation
–
–
–
–
Following cardiac arrest
Patient remains unconscious & unresponsive
Pulse is present at least 5 minutes
B/P able to be maintained >90
• Not recommended for respiratory arrest
• Remember – if patient is able to complain about
the coldness of the ice packs, they don’t need to
be cooled
• Ice packs used by EMS
71
SOP References
• Placed in the SOP’s to be immediately available
for review as needed
• Are adjuncts to the SOP’s
• Useful information available that can be
referenced
– Nice to have available when you are not sure of a
process
– Contains reference tables of norms
• Vital signs
• Equipment
72
Pain Scales
• Wong-Baker FACESTM Pain Rating Scale
–
–
–
–
Useful for 3 year-old and older
Useful for non-English speaking patients
Point to the face and read the description
Ask the patient to point to the face that describes their
pain
• FLACC Pain Scale
– An observer related method to assess for pain
– Evaluates the face, legs, activity, crying, and
consolability
•
Copyright 1983, Wong-Baker FACESTM Foundation, www.WongBakerFACES.org.
Used with permission.
73
74
Peds Cardiac Medication Chart
• Provides information in a quick reference format
• Includes information on:
–
–
–
–
–
–
–
Adenosine (Adenocard)
Amiodarone (Cordarone)
Atropine
Epinephrine 1:10,000
Versed (midazolam)
Cardioversion joules
Defibrillation joules
• Great reference for drawing up medication and
documenting the mg administered
75
Peds Medical Medication Chart
• Provides information in a quick reference format
• Includes dosing information on:
–
–
–
–
–
–
–
Dextrose 25%
Dextrose 12.5%
Glucagon
Narcan (Naloxone)
NS IV fluid challenge
Valium (Diazepam)
Epinephrine 1:1000
76
Peds Medical Medication Chart
cont’d
• On additional sheet:
– Etomidate
– Fentanyl
– Lidocaine (Xylocaine)
– Ondansetron ( Zofran)
– Morphine
– Benadryl (Diphenhydramine)
77
Adult Weight Based Medication
Chart
• Provides information in a quick reference
format
• Includes dosing information on:
– Etomidate 0.3 mg/kg IVP/IO
– Fentanyl 0.5 mcg/kg IN/IVP/IO
– Lidocaine 1.5 mg/kg IVP/IO (DAI)
78
Drug Information List
• Reference guide listing information on
medications used in the Region X SOP’s
– Information not all inclusive
• Supplement to other drug reference
material
79
Region X Drug Route Options
• Lists routes appropriate for the list of
medications used in the Region x SOP’s
• Choice of drug route is based upon patient
assessment at the time of need
• If any question of the appropriateness of
the route, Medical Control will be
contacted and consulted
• For ANY orders from Medical Control, the
ECRN MUST consult with the ED MD
80
Region X SOP Medications
• The following are medication guidelines
• Each medication lists the SOP it is
associated with
– Currently, there are shortages for
manufacturing of some medications
– Note, substitutions may need to be
considered
81
Adenosine in Region X SOP’s
(Adenocard)
• To slow the ventricular response
• Can be a diagnostic tool
Adult stable SVT
Adult stable monomorphic Ventricular
Tachycardia
Pediatric Tachycardia with Adequate
Perfusion (probable stable SVT or stable VT)
Pediatric Tachycardia with Poor Perfusion –
probable SVT
82
Albuterol in Region X SOP’s
• As a bronchodilator
Adult Asthma/COPD with Wheezing
Peds Asthma
Adult & Peds Allergic Reaction, Anaphylaxis if
wheezing
Croup if wheezing
• First dose only mixed with Atrovent (duoneb treatment)
83
Amiodarone in Region X SOP’s
• Antidysrhythmic
Adult and Pediatric Ventricular Fibrillation(VF)
/ PulselessVentricular Tachycardia
Adult stable/unstable Ventricular Tachycardia
or Wide Complex Tachycardia with a pulse
Pediatric Tachycardia with Adequate Perfusion
– probable VT
Pediatric Tachycardia with Poor Perfusion –
with orders from Medical Control
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Aspirin in Region X SOP’s
• To block platelet aggregation/clumping
Acute Coronary Syndrome
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Atropine in Region X SOP’s
• To increase the heart rate
Adult symptomatic bradycardia
Pediatric bradycardia not responsive to
Epinephrine 1:10,000 and under Medical
Control orders
In Pediatric Drug Assisted Intubation
• To blunt the reflexive bradycardia from
vagal stimulation during intubation attempts
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Atrovent® in Region X SOP’s
(Ipratropium Bromide)
• Ih-prah-trow-pea-um
• Bronchodilator, to reduce bronchospasm
– Dries secretions
• Mixed with first dose Albuterol only
Adult Asthma/COPD with Wheezing
Pediatric Asthma
Adult and Pediatric Allergic Reaction /
Anaphylaxis if wheezing
Croup if wheezing
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Benadryl in Region X SOP’s
(Diphenhydramine)
• Antihistamine to stop the release of
histamines and stop the resultant signs
and symptoms that occur
Adult and Pediatric Allergic Reaction and
Anaphylaxis
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Dextrose in Region X SOP’s
• To replace low sugar levels
Adult and Pediatric Altered Mental Status if
blood sugar <60
Stroke if blood sugar <60
Diabetic Emergencies if blood sugar <60
Adult and Pediatric Seizures if blood sugar
<60
Head Injuries if blood sugar <60
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Dopamine in Region X SOP’s
• To support failing blood pressures by
improving contractility
Adult Bradycardia when Atropine ineffective
Cardiogenic Shock
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Epinephrine 1:1000
in Region X SOP’s
• Bronchodilator, vasoconstrictor
Adult Asthma/COPD with Wheezing
For severe distress; Medical Control order only
Adult and Pediatric Allergic Reaction and
Anaphylaxis with airway involvement
(FYI: IM route faster than SQ absorption in
shock states)
Pediatric Asthma with Medical Control orders
Pediatric Croup and Epiglottitis if not
improving with initial treatments
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Epinephrine 1:10,000
in Region X SOP’s
• Vasoconstrictor to support perfusion
Adult and Pediatric Asystole and PEA
Adult and Pediatric Ventricular Fibrillation
(VF) / Pulseless Ventricular Tachycardia (VT)
Adult and Pediatric Anaphylaxis with Medical
Control orders for worsening condition
Pediatric Bradycardia
Peds patients do not respond to Atropine as they
generally do not have diseased hearts
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Etomidate in Region X SOP’s
• Short acting hypnotic
Adult Drug Assisted Intubation
Pediatric Drug Assisted Intubation
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Fentanyl in Region X SOP’s
• For pain relief
• Can be given a variety of routes (IN, IVP, IO)
Adult and Pediatric Pain Management
Adult Bradycardia with TCP application
Adult Supraventricular Tachycardia if cardioverted
Adult Rapid Atrial Flutter / Fibrillation (Narrow
Complex Tachycardia) if cardioverted
Adult Ventricular Tachycardia or Wide Complex
Tachycardia (Patient with a Pulse) if cardioverted
Adult & peds Burns if no IV access
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Glucagon in Region X SOP’s
• Hormone to stimulate the release of sugar
stores (is not a sugar)
Adult and Pediatric Altered Mental Status if
no IV access and blood sugar <60
Stroke if no IV access and blood sugar <60
Diabetic if no IV access and blood sugar <60
Adult and Pediatric Seizures if no IV access
and blood sugar <60
Head Injury if no IV access and blood sugar
<60
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Lasix in Region X SOP’s
• Diuretic
Pulmonary Edema
Hypertensive Emergency
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Lidocaine in Region X SOP’s
• To blunt the cough reflex to prevent an
increase in intracranial pressure during
intubation
Adult Drug Assisted Intubation
Pediatric Drug Assisted Intubation
• For pain relief during infusion of fluids via
IO sites
Adult EZ IO insertion
Pediatric EZ IO insertion
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Morphine in Region X SOP’s
• Opioid, narcotic, pain relief, reduces
preload via vasodilation
Acute Coronary Syndrome
Pulmonary Edema
Adult and Pediatric Burns if IV access
available
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Narcan in Region X SOP’s
(Naloxone)
• Narcotic antagonist to reverse respiratory
depression
Adult and Pediatric Altered Mental Status
Adult and Pediatric Pain Management if
respiratory depression occurs following
Fentanyl
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Nitroglycerin in Region X SOP’s
• Venodilator to reduce the preload and
reduce the work load of the heart
Acute Coronary syndrome
Pulmonary Edema
Hypertension Emergency with orders from
Medical Control
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Valium in Region X SOP’s
(Diazepam)
• Benzodiazepine
• Relax the patient, reduce anxiety, amnesic
Adult Bradycardia when the TCP is used
Adult and Pediatric Heat Emergencies if the
patient begins to shiver during the cooling
process
Behavioral Emergencies – if additional
sedation required after Versed
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Verapamil in Region X SOP’s
• To slow down rapid atrial fibrillation and
flutter
Adult Supraventricular Tachycardia (Narrow
Complex Tachycardia (SVT) - stable
Adult Rapid Atrial Flutter / Fibrillation (Narrow
Complex Tachycardia) - stable
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Versed in Region X SOP’s
(Midazolam)
• Benzodiazepine
• Relax the patient, reduce anxiety, amnesic
Adult and Pediatric Drug Assisted Intubation
Cardioversion with unstable rapid Atrial Fibrillation /
flutter, unstable SVT, unstable VT
Adult and Pediatric Seizures
Head Injuries if seizure activity
Hypertensive OB if actively seizing
Pediatric Tachycardia requiring cardioversion
Behavioral Emergencies – Adult
Medical Control order for peds patient
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Zofran® in Region X SOP’s
(Ondansetron)
• On-dan-sah-tron
• Antinausea, antiemetic
Adult and Pediatric Nausea
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Case Scenario Practice
• Read the cases
• Determine the appropriate ECRN
response
• Click on the slide / press “page down” and
the answer will appear
Case Scenario #1
• EMS arrives to the ED with a patient that has
been intubated
• Report did not indicate any trauma
• Why would the patient have a cervical collar in
place?
– Applying a cervical collar after intubation minimizes
neck movement
– The distal tip of the ETT is less likely to slip out of
place if a cervical collar is applied along with the
usual methods of securing the airway in place
Case Scenario #2
• EMS is on the scene of a full arrest
• The adult patient has remained in asystole
• What medications would have been
given?
– Epinephrine 1:10,000 1 mg every 3-5 minutes
• Can EMS withdraw resuscitative efforts?
– After Medical Control is contacted for an order
• If EMS must transport the body, can they
bring the patient to the hospital?
– Yes, the hospital may have to take the body
that cannot be left at the scene
Case Scenario #3
• EMS calls with an adult patient with
symptomatic bradycardia
• What drug and dose has been given?
– Atropine 0.5 mg IVP/IO
– May be repeated every 3-5 minutes to a max
of 3mg
• When should a TCP be applied?
– If the patient is unresponsive to Atropine
Case Scenario #3
• What is different about treatment for a
symptomatic pediatric bradycardia?
– Initial medication is Epinephrine 1:10,000
0.01 mg/kg IVP/IO
– Epi repeated every 3-5 minutes if no response
– For persistent bradycardia with hypotension,
Medical Control contacted for orders
• Medical Control may consider
Atropine 0.02 mg/kg IVP/IO
Case Scenario #4
• EMS calls with report of a patient with chest pain
• 12 lead EKG reveals ST elevation in II, III, aVF
• What medications are given; which are held?
– Aspirin should be given (324 mg chewed)
• Can be held if patient reliable and Ems sure dose
was taken
– Consult with ED MD regarding nitroglycerin
• Can cause hypotension
• Patient should also be screened for Viagra type
drug use past 24-480 (causes hypotension
resistant to treatment)
Case Scenario #5
• When would EMS begin to cool a patient
who had been worked as an arrest?
– Patient suffered a cardiac arrest (not
respiratory arrest)
– After the patient has pulses for at least 5
minutes
– Blood pressure maintained >90 systolic
– Patient remains unresponsive
Case Scenario #6
• How can Fentanyl be administered for Region X
EMS?
 IN via MAD
 IVP
 IO
• What are additional/alternative methods to
address pain control?
 Positioning
 Immobilization
 Elevation
 Ice
 Distraction
Case Scenario #7
• EMS is on the scene of a patient in
pulmonary edema
• What treatment/medications are you
anticipating have been given if the patient
is relatively stable?
– Nitroglycerin repeated every 5 minutes x3
– CPAP started after first NTG given
– Lasix 40 mg IVP (80 mg if on med at home)
– Morphine 2 mg IVP; repeated every 2 minutes
to max of 10 mg if B/P remains >90
Case Scenario #8
• EMS calls with a patient from a minor MVC
• The 15 year-old female wants to sign a
release; she has no complaints/injuries
– This patient is pregnant
– Can she sign a release/refusal?
• Yes, she is emancipated due to the
pregnancy
• If she remains the parent after delivery, she
remains emancipated regardless of where
she is living
Case Scenario #9
• EMS calls for a conscious, alert,
cooperative patient who refuses transport
• The patient’s Durable Power of Attorney
for Healthcare is also present
– The DPOA wants the patient transported
• Who gets to speak for the patient?
– The DPOA gets to speak when the patient is
no longer able to speak for themselves
• Follow the wishes of the patient at this point
Case Scenario #10
• EMS calls from the scene for an imminent
delivery
• If report includes a non-delivered breech birth or
a prolapsed cord, what specific information do
you want to hear in report?
– Confirm that someone has fingers inserted
into the vagina during transport
• For a stuck breech, create an airway for the infant
• For a prolapsed cord, push against the presenting
part to allow blood flow through the cord
Case Scenario #11
• In what circumstances would the King
airway be used?
– Difficult/challenging intubation
• 2 failed attempts via endotracheal tube (ETT)
• Poor visibility of anatomy
• Short, thick necks
• SOP skill reference:
– “Cardiac or respiratory arrest, unresponsive
medical or trauma patient without a gag reflex
in which endotracheal intubation is unable to
be established.”
Case Scenario #12
• In which cases is EMS mandated
reporters?
– Suspected child abuse
– If release signed, then domestic violence
reported to local police
• Local community informational brochure to be
offered to patient that signs a release
– Suspected elder abuse/neglect
Bibliography
• 2010 American Heart Association Guidelines for CPR
and ECC
• ITLS 6th Edition
• Illinois Emergency Medical Services for Children.
Pediatric Prehospital Protocols. January 2008.
• Region X EMS Standard Operating Procedures 2011
Teaching Document
• CMC EMS System November 2011 CE
• CMC EMS System October 2011 CE
• CMC EMS System September 2011 CE
• www.Kiingsystems.com/wpcontact/uploads/2010/09/INFM-63-KLTSS.pdf
• www.WongBakerFACES.org
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