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2013AlabamaTreatmentProtocolChanges
ScopeofPractice1.01
UnderProcedures,Item3,clarifyscopeofpracticeforIntermediateEMTstostate
that“electricaltherapy”includesdefibrillationandsynchronizedcardioversion.
DeathintheField1.03
UnderTraumaticCardiacArrestSpecialConsiderations,seconditem,deletesecond
sentence,“Inasmallpercentageofthesecases,heroiceffortsinthehospitalsetting
canbelifesavingandOLMDmaydirectyoutotreatthepatientusingtheShock
Protocol.”
DisputesatScene1.04
Renametheprotocol“DisputesRegardingPatientCare.”
UnderPurpose,addtothesentence,”uponhospitalarrival,oranytimethepatientis
inthecareoftheEMSprovider.”
DocumentationofCare1.05
AddStandardizedAbbreviationssection.
MedicalDirectionHospitals1.07
UnderKeyPoints,thirdparagraph,deletereferraltoRegionalMedicalControlPlan
andspecifythatATCCcanbecontactedforassistanceincontactingamedical
controlhospital.
UpdatestoMedicalDirectionHospitals:Region1–namesupdatedtoaddMadison;
Region3–ChiltonMedicalCenterisclosed.
MedicalManagementoftheScene1.08
UnderGuidelines,itemtwo,addsentence,“Itistheresponsibilityofthehighest
levelEMSPonthescenetodeterminetheappropriatelevelofcarefortransportof
thepatient.WhenthehighestlevelEMSPonthescenedeterminesthatalowerlevel
ofcareisappropriateforthepatient,thatEMSPmayturnoverpatientcaretoan
EMSPlicensedatalowerlevelofcarewhoiswillingtoacceptpatientcare
responsibilities.”
UnderGuidelines,itemthree,addAdvancedEMTtothelist.
UnderGuidelines,itemfour,replace“IntermediateEMTorParamedic”with“EMSP.”
PatientRights1.12
Replace“takento”with“transportedto”throughoutsection.
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PhysicianMedicalDirection1.13
UnderKeyPoints,addsentenceatendofparagraphtwo,“Theon‐linemedical
directionphysicianmustbeskilledinandavailableforbothadultandpediatric
medicaldirection.”
TraumaSystem1.16
Under“EnteringaPatientintotheTraumaSystem,”addtheunderlinedtothe
followingsentence:Theinitialuniton‐sceneshouldenterthepatientintothe
AlabamaTraumaSystembutiftheyhavenotdoneso,itbecomestheresponsibility
ofthetransportingservice(groundorair)beforethereceivingfacilityisselected.
ForhelicopterEMS(HEMS),itispreferabletorequestapreliminaryreceiving
facilityfromATCCpriortoarrivalonthesceneandthenlaterenterthepatientinto
theATCCassoonasislogisticallypossible.Afterassessingatraumasituationand
makingthedeterminationthatthepatientshouldbeenteredintotheAlabama
TraumaSystem,theEMSPlicensedatthehighestlevelshouldcontacttheATCCat
theearliestpracticaltimebeforethereceivingfacilityisselectedandprovidethe
followinginformation.ThehighestlevelEMSPonthescenemaydelegatethecallto
ATCCtoalowerlevelEMSPifpatientcaredutiesrequirethehigherlevelEMSP’s
attention:
1. EMSPservice
2. LocationofTraumaScene
3. Age&Sexofthepatient(s)
4. ReasonforEntryandMechanismofInjury
5. Patientassessment
a. AirwayStatus
b. VitalsignsandGCS
c. AreasofInjury
d. Environmentalissuesorco‐morbidfactors
6. Transportationtype
7. Transportationtiming
Thirdparagraphfromtheendchangeto,“ATCCwillprovideauniqueidentification
numberthatmustbeenteredintothee‐PCR.”
HelicopterEMS2.04
CombinedthreeexistingHelicopterEMSprotocolsintoonedocumentwithchanges
toverbiageabouttimingofenteringpatientsintoregionalizedsystemsofcare.
AdrenalInsufficiency3.03
NewprotocolthatallowsparamedicstoassistpatientswithAdrenalInsufficiency
withadministrationoftheirownIMsteroids.
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18.
AllergicReaction3.04
UnderDrugs/ProceduresAdvanced,defineprecautionsforIMepinephrinefor
patientsage65orolderorwithhistoryofheartdiseaseoruncontrolled
hypertension.
AlteredMentalStatus3.05
UnderTreatment,addabenzodiazepineoptionfortreatmentof“exciteddelirium”
usingexistingbenzodiazepinedrugscarriedalreadyandonlywithonlinemedical
direction.
Suggestuseofwaveformcapnography.
Amputation3.06
UnderKeyPoints,fourthbullet,add,“Ifrequired,contactATCCforassistancein
locatingahospitalwithreimplantationcapabilities.”
UnderKeyPoints,fifthbullet,notateTraumaSystementrycriteria,“Amputations
proximaltothewristsoranklesmustbeenteredintotheAlabamaTraumaSystem
whereapplicable.”
Burns3.08
UnderKeyPoints,finalbullet,notateTraumaSystementrycriteria:
a. partial‐thicknessburnsof>10%TBSA
b. burnsofface,hands,feet,genitalia,perineum,ormajorjoints
c. thirddegreeburns
d. electricalburns,includinglightninginjury
e. chemicalburns
f. inhalationinjury
g. burninjuryinpatientswithco‐morbidmedicalconditions
h. burns>15%TBSAandconcomitanttrauma
CardiacDysrhythmia(Pediatric)3.12
Deletereferencetoendotrachealdrugadministration.
ChestPain3.13
Changenameto“ChestPainorSuspectedACS.”
UnderKeyPoints,fifthbullet,specifyECGshouldbedonepriortoleavingthescene.
Inthesixthbulletadd,Theperformanceofa12leadECGatthesceneandits
transmittaltothereceivinghospitalcansignificantlyshortenthetimeto
reperfusingtreatment.
FracturesandDislocations3.17
UnderKeyPoints,addthirdbullet,notateTraumaSystementrycriteria,“Patients
withfracturesoftwoormoreproximallongbonesorpelvicfracturesshouldbe
enteredintotheAlabamaTraumaSystemwhereapplicable.”
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HeadTrauma3.18
UnderHistoryandPhysicalExam,lastbullet,add“CSFdrainingfromheador
mouth”asphysicalfindingsforheadtrauma.
UnderKeyPoints,notateTraumaSystementrycriteria,“PatientswithHeadInjury
andGCS<13orprolongedlossofconsciousnessshouldbeenteredintotheAlabama
TraumaSystemwhereapplicable.”
RespiratoryDistress3.29
UnderTreatment,bulletfive,addstrongerrecommendationforCPAPtobe
attemptedunlesstherearecontraindicationstoCPAP.
Seizure3.30
UnderDrugs/ProceduresParamedic,addIMasanoptionformidazolamin
treatmentofseizures,butforpediatricpatientsIMwillbeonlyifunabletoestablish
IV(reference:NEnglJMed2012;366:591‐600).
Shock3.31
UnderTreatment,thirdbullet,addnotationforhemorrhagecontrolthatarterial
tourniquetshouldbeplacedproximaltothewoundandatleast2inchesabovethe
kneeorelbow.
SpinalInjury3.32
UnderKeyPoints,lastbullet,notateTraumaSystementrycriteria,“Patientswith
oneormoreacutelyparalyzedlimbsinthesettingofacutetraumashouldbe
enteredintotheAlabamaTraumaSystemwhereapplicable.”
Stroke3.33
UnderKeyPoints,addthefollowingbullet,“Whenpossiblebringaknowledgeable
friendorfamilymemberwiththepatienttoassistwithprovidingthepatient’s
historyatthehospital.Ifitisnotpossibletobringthatpersonwithyou,attemptto
obtainacellphonenumberforsomeonewhocanprovidethereceivinghospital
withpatienthistoryanddetailsoftheevent.”
Procedures4
DeletePulseOximetryproceduredescription.
AddCanographyprocedure4.02.
ChestDecompression4.04Procedure,notatethatEMSPcancallATCCformedical
directionfromtraumacenter.Changeprimaryindicationsystolicbloodpressure
criteriafrom60mmHgto80mmHgfortreatmentoftensionpneumothorax,add
subcutaneousairinanintubatedpatientasasecondaryindication.
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ECG4.06Precautions,addlanguagetoemphasizeacquisitionofECGand
transmissionpriortotransport.
HemostaticAgents4.10Contraindications,notethatopenabdominalorchest
woundsmaybetreatedwithhemostaticagentimpregnatedgauze,butnotwith
powderedhemostaticagents(thisisduetoriskofembolization).
IntraosseousTherapy4.11,deletereferencetoendotrachealdrugadministration.
Medications5
AlbuterolandIpratropium5.02,addIpratropiumasanoptionaldrugthatmaybe
combinedwithalbuterol.
Amiodarone5.03
1. ChangefromLidocainemandatoryandamiodaroneoptionaltoEITHER
amiodaroneorlidocaineismandatory(mustcarryoneortheother).
2. Addtoarrhythmiasprotocolsforwidecomplexwithpulse(3.11and3.12).
3. Addarepeatdoseinpedsforrefractoryvf/pulselessvttobeconsistentwith
AHAguidelines“mayrepeatupto2times.”
Aspirin5.04Indications,clarifylanguagesothatitisclearthatitisforpatientswith
suspectedAcuteCoronarySyndromes(ChestpainorAcuteCoronarySyndrome
3.13).
Dopamine5.10
1. ChangetoCategoryA.
2. AddtoCardiacDysrhythmiaAdult3.10bradycardia.
3. Changechartin5.10toread“drops/min”insteadof“ml/hr.”
Fentanyl5:12,addasanoptionaldrugformanagementofseverepaintoreflect
currentEMSstandardofcare.
Morphine5.21Administration,add“SlowIVPush.”
Naloxone5.22PrecautionsandSideEffects,thirdbullet,specifynottoputaneedle
inpatient’snose.
Nitroglycerin5.23Administration,stateinCHF3.15andChestPain3.13orACS3.13
thattotalofthreedosesmaybegiven.
Vasopressin5.30PrecautionsandSideEffects,addstatementaboutpulseoximetry
notreliableaftergivingvasopressinduetovasoconstriction.
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AcceptableEquipment6
UnderBlindInsertionAirwayDevices6.01,removecombitubeduetohigherdegree
ofcomplicationsanddifficultyofuse(1yeargraceperiod).
Deleteneedledecompressionlist.Recommendspecifyingany14gaugecatheterat
least3cminlengthonregularequipmentlist.
CPAPremovelist.
UnderHemostaticAgents6.03,removeQuikclot1stResponseduetoinferiorclinical
efficacy.
Disaster7
AddUSARmarkingsystemforSearchandRescue7.02.
AddStart/JumpstartTriageforMassCasualties7.03.Notationmadethatadifferent
systemcanbeusedifdesired.
Forms8
DoNotAttemptResuscitation(DNAR)Form8.02.
STEMIchecklist8.04:ModeofTransmission:changetoablank,strikePCR#and
changetoATCCNumber.
Strokechecklist8.05:StrikePCR#andchangetoATCCNumber,addablankfor
HistorianCellPhone#.
ExpandedScopeofPractice–OptionalModule(Section9)
NewoptionalmodulethatincludesthepreviouslyapprovedRapidSequence
IntubationprotocolandaddsNeedleCricothyriodotomyandanExpandedScopeof
Practicemedicationlist.
QualityAssurance,addaquarterlyExpandedScopeofPracticeQAMeeting
requirementforMedicalDirectorsofparticipatingapprovedservicesaswellasa
requirementforeverypatientcareencounterusingtheExpandedScopeofPractice
tobereviewedbytheServiceMedicalDirectoraswellastheStateEMSMedical
Director.
RequirestheServiceMedicalDirectortoformulateaserviceplanfor
implementationandtosubmitprotocolsforExpandedScopeofPractice
medicationstotheADPHOfficeofEMSforapproval.
UpdateexistingRSIprotocoltoallowserviceMedicalDirectorstoapprove
providerswhomaynotmeetpreviouslydesignatedexperiencerequirements,
allowsuseofhigh‐fidelitysimulationforaportionofongoingairwaymanagement
credentialing,changenumberofrequiredintubationsforskillsmaintenancefrom
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threeperquartertoeightperyear,emphasizewaveformcapnography,add
recommendationforvideolaryngoscopywithrequirementforvideolaryngoscopy
byJune2015,deletecisatracurium,addketamineandrocuroniuminlightofdrug
shortagesituationtoreflectcurrentpractice,andupdatecontraindicationssection.
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