PROTOCOL UPDATE
ALABAMA EMS PROTOCOLS
PARAMEDIC
EDITION 5
JUNE, 2010 UPDATE
1
PROTOCOL UPDATE
• IF YOU IDENTIFY MISTAKES IN THE
PROTOCOLS OR IF YOU HAVE
SUGGESTIONS FOR PROTOCOL CHANGES
EMAIL: John.Campbell@adph.state.al.us
2
PURPOSE OF PROTOCOLS
• IMPROVE PATIENT CARE
• PROVIDE OFF-LINE MEDICAL DIRECTION
• REPRESENT STANDARD OF CARE
• PROVIDE QI STANDARDS
• PROVIDE EDUCATION STANDARDS
3
TITLE PAGE & TABLE OF
CONTENTS
• TABLE OF CONTENTS UPDATED WITH
CHANGES
– Added two new Patient Care Protocols
• 4.26 Respiratory Illness/Influenza
• 4.27 Respiratory Illness – Mass Casualty Emergency
• Renumbered:
–
–
–
–
–
–
–
4.28
4.29
4.30
4.31
4.32
4.33
4.34
Seizures
Shock
Stroke
Suspected Spinal Injury
Syncope
Vaginal Bleeding
Vomiting and Nausea
4
SECTION 4
TREATMENT PROTOCOLS
5
ALLERGIC REACTION 4.4
• Because it is more rapidly absorbed and reaches
•
•
•
higher blood levels, IM epinephrine for allergic
reactions is now preferred to SQ epinephrine
IV epinephrine has been associated with
iatrogenic overdoses and cardiac complications
and its use for allergic reactions is discouraged
except for anaphylactic shock where the 1:10,000
solution can be given but is Category B
The 1:1000 solution is NEVER given IV
The Epipen can still be used but its needle may be
too short to reach the muscle in some obese
patients
6
CARDIAC ARREST 4.8
• Under “Physical Assessment, Part B” changed
“closed chest massage” to “chest compressions”
to reflect current terminology
7
CARDIAC ARREST 4.8
• Treatment of adult VFib/Pulseless Vtach, Part J:
– Added that if you substitute vasopressin for the first dose of
epinephrine, you can give subsequent doses of epinephrine
– Because of the current shortage of 1:10,000 epinephrine this
may temporarily have to be the preferred medication for
Vfib/Pulseless Vtach in adults
8
CARDIAC MEDICATIONS 4.9
• Corrected category of Amiodarone (Cat. A)
9
CARDIAC SYMPTOMS/ACUTE
CORONARY SYNDROME 4.10
• Added wording to stress that women, diabetics, and all
•
•
adult medical patients over the age of 50 years have an
increased risk of coronary artery disease.
Also stressed that all adult patients complaining of
epigastric pain should have an ECG performed
Noted that all Ambulance services must have the
capability to perform 12-lead ECGs on patients by June
of 2013
10
CONGESTIVE
HEART FAILURE 4.14
• Changed dose of Furosemide from
20-40mg to 40mg to simplify the dosage
11
4.26 Respiratory Illness/Influenza
NEW PROTOCOL
For Routine Use During a Flu Epidemic
12
4.26 Respiratory Illness/Influenza
1. Follow General Patient Care Protocol 4.1
2. Be sure you are using appropriate standard precautions
A. If Dispatch advises of the potential for acute febrile respiratory
illness symptoms on scene, you should don PPE for suspected
cases of influenza prior to entering the scene. This includes
disposable N-95 mask, eye protection (shield or goggles), and
disposable non-sterile gloves.
B. If Dispatch has not identified individuals with symptoms of
acute febrile respiratory illness symptoms on scene, you should
stay more than 6 feet away from the patient and bystanders
with symptoms and exercise appropriate routine respiratory
droplet precautions while assessing all patients for suspected
cases of influenza. If patient has signs or symptoms of
influenza, you should don the PPE described above before
coming in close contact with the patient.
13
4.26 Respiratory Illness/Influenza
3. Signs
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
and Symptoms of Influenza:
Rapid onset of symptoms
Difficulty breathing with exertion
Doctor has already diagnosed influenza
Cough
Fever
Shaking Chills
Pleuritic chest pain
Sore throat (no difficulty breathing or swallowing)
Nasal congestion
Runny nose
Muscle aches
Headache
14
4.26 Respiratory Illness/Influenza
4. All EMS personnel engaged in aerosol generating
activities (e.g. endotracheal intubation, bag-mask
ventilation, nebulizer treatment, or CPAP [use expiratory
filter]) should wear the PPE described in 2.a.
5. All patients with acute febrile respiratory illness should
wear a surgical mask, if tolerated by the patient.
6. Encourage good patient compartment vehicle
airflow/ventilation (turn on exhaust fan) to reduce the
concentration of aerosol accumulation when possible.
15
4.26 Respiratory Illness/Influenza
TRANSPORT OF PATIENTS TO
HEALTHCARE FACILITIES
• When transporting a patient with symptoms of acute
febrile respiratory illness, you should notify the receiving
healthcare facility so that appropriate infection control
precautions may be taken prior to patient arrival.
Patients with febrile respiratory illness should wear a
surgical mask, if tolerated.
16
4.26 Respiratory Illness/Influenza
INTERFACILITY TRANSPORT
• EMS personnel involved in the transfer of patients with confirmed
influenza or suspected infectious respiratory illness should use
standard droplet and contact precautions for all patient care
activities. This should include wearing disposable N-95 mask, eye
protection [shield or goggles], disposable non-sterile gloves and
gown. If the transported patient can tolerate a surgical mask, its
use can help to minimize the spread of infectious droplets in the
patient care compartment. Encourage good patient compartment
vehicle airflow/ventilation (turn on exhaust fan) to reduce the
concentration of aerosol accumulation when possible. Any
nonessential equipment that can be removed from the patient
compartment of the ambulance before transport will hasten the time
needed to disinfect and return to service.
17
4.26 Respiratory Illness/Influenza
CLEANING VEHICLE AFTER TRANSPORTING AN
INFLUENZA PATIENT
• After the patient has been removed and prior to cleaning, the air
within the vehicle may be exhausted by opening the doors and
windows of the vehicle while the ventilation system is running. This
should be done outdoors and away from pedestrian traffic. Routine
cleaning methods should be employed throughout the vehicle and
on non-disposable equipment.
• Routine cleaning with soap or detergent and water to remove soil
and organic matter, followed by the proper use of disinfectants, are
the basic components of effective environmental management of
influenza. Reducing the number of influenza virus particles on a
surface through these steps can reduce the chance of hand transfer
of virus particles. Influenza viruses are susceptible to inactivation
by a number of chemical disinfectants readily available from
consumer and commercial sources.
18
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
NEW PROTOCOL
Not for Routine Use
19
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
• This protocol is designed to be implemented only when there is a
significant respiratory disease that has impacted the health care
system to the extent that hospital beds are full, few or no
ventilators are available for new patients with respiratory failure, the
EMS/Dispatch work force is significantly depleted due to
absenteeism, and the calls for EMS support overwhelm resources to
manage all calls. When the Governor proclaims a state of
emergency, the Alabama Public Health Department (ADPH) Office of
EMS & Trauma (OEMS&T) will activate this protocol to provide
authorization for the adjustment in the prehospital standard of care.
Depending upon the Governor’s proclamation, ADPH OEMS&T may
activate this protocol statewide or on a regional or local basis.
20
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
1. Follow General Patient Care Protocol 4.1.
2. Be sure you are using appropriate standard precautions
A. If Dispatch advises of the potential for acute febrile respiratory
illness symptoms on scene, you should don PPE for suspected
cases of influenza prior to entering the scene. This includes
disposable N-95 mask, eye protection (shield or goggles), and
disposable non-sterile gloves.
B. If Dispatch has not identified individuals with symptoms of
acute febrile respiratory illness symptoms on scene, you should
stay more than 6 feet away from the patient and bystanders
with symptoms and exercise appropriate routine respiratory
droplet precautions while assessing all patients for suspected
cases of influenza. If patient has signs or symptoms of
influenza, you should don the PPE described above before
coming in close contact with the patient.
21
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
3. Signs and Symptoms of Influenza
•
•
•
•
•
•
•
•
•
•
•
•
Rapid onset of symptoms
Difficulty breathing with exertion
Doctor has already diagnosed influenza
Cough
Fever
Shaking Chills
Pleuritic chest pain
Sore throat (no difficulty breathing or swallowing)
Nasal congestion
Runny nose
Muscle aches
Headache
22
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
4. If patient has critical vital signs, immediately
transport to Emergency Department
a. Critical Vital Signs: Adult
If present, immediately transport to an Emergency
Department
•
•
•
•
•
•
•
Pulse: equal or greater than 130 beats per minute
Respiratory Rate: equal or greater than 30 breaths per minute
Systolic Blood Pressure: Less than 90 mm/Hg
Pulse Oximeter: Less than 92 on room air
Temperature: Febrile
Level of Consciousness: Responds only to Pain or is Unresponsive
Lung sounds: Rales or Wheezing
23
Critical Vital Signs: Pediatric:
If present, immediately transport to Emergency Department
Vital Signs
Neonates
Infants
Children
Capillary refill:
> 2 seconds
> 2 seconds
> 2 seconds
Resp. rate:
<30 or >45
or increased work of
breathing
<20 or >45
or increased work of
breathing
<15 or >45
or increased work of
breathing
Systolic Blood pressure
< 60 mmHg
< 70 mmHg
Under age 10
< 70 + (2 X age in years)
Pulse Oximeter
< 92 on room air
< 92 on room air
< 92 on room air
Temperature
Febrile
Febrile
Febrile
Level of Consciousness
responds only to pain or is
unresponsive
responds only to pain or is
unresponsive
responds only to pain or is
unresponsive
Lung sounds
Rales or Wheezing
Rales or Wheezing
Rales or Wheezing
24
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
5. If patient has “normal” vital signs, then evaluate
for signs and symptoms of influenza.
a. “Normal” Vital Signs Adult with respiratory illness
• Pulse: Less than 130 beats per minute
• Respiratory Rate: Less than 30 breaths per minute
• Systolic Blood Pressure: equal or greater than 91 mmHg
• Pulse Oximeter equal or greater than 92
• Temperature: Afebrile
• Level of Consciousness: Alert or responds to verbal stimuli
• Lung sounds: Clear
25
b. “Normal” Vital Signs Pediatric Patient with Respiratory Illness
Vital Signs
Neonates
Infants
Children
Capillary refill:
< 2 seconds
< 2 seconds
< 2 seconds
Unlabored breathing or
resp. rate:
30-45
20-45
15-45
Systolic Blood pressure
> 60 mmHg
> 70 mmHg
Under age 10
> 70 + (2 X age in years)
Pulse Oximeter
> 92
> 92
> 92
Temperature
Afebrile
Afebrile
Afebrile
Level of Consciousness
Alert or responds to
verbal stimuli
Alert or responds to
verbal stimuli
Alert
Lung sounds
Clear
Clear
Clear
26
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
6. If patient has three (3) or more signs or symptoms of influenza,
transport patient to alternate care facility (if available).
7. If patient has two (2) or fewer signs or symptoms of influenza, call
On-line Medical Direction (OLMD) to determine if patient may be left
on-scene, self quarantine, and refer to nurse/public health hotline
(insert phone number here) for further assistance.
8. Endotracheal intubation should not be performed on any patient
except by direct order of the OLMD physician (Cat. B).
9. Because of the danger of EMS personnel becoming infected,
aerosol-generating procedures such as advanced airway procedures,
use of bag-mask, and nebulizer treatments should not be performed
on patients with acute febrile respiratory illness except by direct
order of the OLMD physician (Cat. B). CPAP with expiratory filter is
still Category A.
27
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
10.If OLMD orders advanced airway procedures, use of bag-mask, or
nebulizer treatments on a patient with acute febrile respiratory
illness, EMS personnel must be in PPE as described in 2.a above.
11.All patients with acute febrile respiratory illness should wear a
surgical mask, if tolerated by the patient.
12.Encourage good patient compartment vehicle airflow/ventilation
(turn on exhaust fan) to reduce the concentration of aerosol
accumulation when possible.
28
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
TRANSPORT OF PATIENTS TO
HEALTHCARE FACILITIES
• When transporting a patient with symptoms of acute
febrile respiratory illness, you should notify the receiving
healthcare facility so that appropriate infection control
precautions may be taken prior to patient arrival.
Patients with febrile respiratory illness should wear a
surgical mask, if tolerated.
29
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
INTERFACILITY TRANSPORT
• EMS personnel involved in the transfer of patients with confirmed
influenza or suspected infectious respiratory illness should use
standard droplet and contact precautions for all patient care
activities. This should include wearing disposable N-95 mask, eye
protection [shield or goggles], disposable non-sterile gloves and
gown. If the transported patient can tolerate a surgical mask, its
use can help to minimize the spread of infectious droplets in the
patient care compartment. Encourage good patient compartment
vehicle airflow/ventilation (turn on exhaust fan) to reduce the
concentration of aerosol accumulation when possible. Any
nonessential equipment that can be removed from the patient
compartment of the ambulance before transport will hasten the time
needed to disinfect and return to service.
30
4.27 Respiratory Illness/Influenza
MASS CASUALTY EMERGENCY
CLEANING VEHICLE AFTER TRANSPORTING AN
INFLUENZA PATIENT
• After the patient has been removed and prior to cleaning, the air
within the vehicle may be exhausted by opening the doors and
windows of the vehicle while the ventilation system is running. This
should be done outdoors and away from pedestrian traffic. Routine
cleaning methods should be employed throughout the vehicle and
on non-disposable equipment.
• Routine cleaning with soap or detergent and water to remove soil
and organic matter, followed by the proper use of disinfectants, are
the basic components of effective environmental management of
influenza. Reducing the number of influenza virus particles on a
surface through these steps can reduce the chance of hand transfer
of virus particles. Influenza viruses are susceptible to inactivation
by a number of chemical disinfectants readily available from
consumer and commercial sources.
31
STROKE 4.30
• Added that the EMS personnel should attempt to bring a
•
•
knowledgeable friend or family member with the stroke
patient
Added that if the patient with stroke symptoms has no
signs of CHF then they should receive a 500cc IV bolus
of Normal Saline
Added under SPECIAL PRECAUTIONS: Many patients
with stroke are taking diuretics and are volume depleted.
Administer one bolus of fluid as noted above, unless
there are obvious signs of acute heart failure. This may
improve cerebral circulation.
32
4.34 VOMITING AND NAUSEA
• Changed name to Vomiting and Nausea
• Under “Specific Information Needed”
added:
B. Is the patient nauseated?
C. If vomiting, is the cause known?
K. History of vomiting when receiving narcotics?
33
4.34 VOMITING AND NAUSEA
• Under “NOTES:” added:
1. Ondansetron may be used in cases of nausea
to prevent vomiting
2. Ondansetron may be used to prevent nausea
when administering morphine, especially if
there is a history of vomiting after receiving
narcotics
34
SECTION 5
MEDICATIONS
35
5.10 DIPHENHYDRAMINE
• Changed :”dystonic reaction” to
“extrapyramidal symptoms” or
“extrapyramidal reaction” to reflect current
terminology in EMS texts
36
5.12 EPINEPHRINE
• Changed administration to IM for allergic
reaction except for anaphylactic shock
where it can be given IVP if the doctor
orders (CAT B)
• Stressed that the 1:1000 solution (vial) is
never given IV
37
5.13 FUROSEMIDE
• Changed dose from 20-40mg to 40mg to
simplify the dose
38
SECTION 6
PROCEDURES
39
6.5 ENDOTRACHEAL INTUBATION
• Under “PROCEDURE” added:
7. Monitor tube placement with qualitative CO2
detector or preferably a quantitative
waveform CO2 monitor (Use of one or the
other is MANDATORY)
After June 2013 the waveform capnography
will be required.
40
6.5 ENDOTRACHEAL INTUBATION
• Under “NOTES” added:
6. BY June 2013 all ALS services must have the
ability to monitor patients with waveform
capnography
41
SECTION 9
ACCEPTABLE EMS EQUIPMENT
AND DEVICES
42
9.1 BLIND INSERTION AIRWAY
DEVICES
• Noted that the King Airway may be used if
the service medical director approves
43
ALERT! BEFORE USING NEW
PRTOTOCOLS:
• EACH SERVICE MUST NOTIFY AND PROVIDE YOUR
SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF THE
5TH EDITION PROTOCOLS (June 2010 edition) AND A
COPY OF THIS UPDATE PRESENTATION
– It is OK for the medical director to download the material
instead
• EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL
DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS
ARE AWARE THAT THE PROTOCOLS HAVE BEEN
UPDATED AND WHERE TO GET THE MATERIAL
– The service is not responsible for furnishing copies of the
protocols or update slide presentation
44
NEW PROTOCOLS CAN BE USED
• WHEN EVERYONE IN A SERVICE HAS BEEN
UPDATED
– TURNED ON SERVICE BY SERVICE NOT INDIVIDUAL
BY INDIVIDUAL
– TURN IN ROSTER TO REGIONAL EMS AGENCY NOT
TO OFFICE OF EMS & TRAUMA
• Also acknowledge that you have updated your off-line
medical director and provided copy of protocols
– REGIONAL EMS AGENCY WILL NOTIFY YOU WHEN
YOU CAN START USING NEW PROTOCOLS
– EVERY SERVICE MUST BE UPDATED BY OCTOBER
1ST, 2010
45
QUESTIONS?
46