2015 Space Coast EMS Protocol Updates

(on SpaceCoastEMS-MedicalDirector.com)

John McPherson MD, MBA, MPHMedical Director

Major Protocol ChangesMedications and procedures

on SpaceCoastEMS-MedicalDirector.com1. Tranexamic Acid –drug manual, protocol2. Left Ventricular Assist Device-procedure and TS 3. Stroke destination after 3 hrs onset-protocol4. Spinal immobilization protocol5. Aeromedical transport guidelines6. Helmet Removal protocol

Tranexamic Acid (TXA)Indications –

Severe traumatic hemorrhagic shock with persistent SBP < 90 and HR > 110 after 1 liter NS infused Severe traumatic hemorrhagic shock developing PEA with HR > 30 and ETCO2 > 10

Dosage – 1 gram in 100 ml NS infused over 10 minutesTraumatic arrest - 1 g IVP

Time of dosage – Most effective if given in 1 hourNot to be given if > 3 hours after trauma

Left Ventricular Assist Device Pumps blood from the lower chamber of the heart

Mechanical pump surgically implanted into failing hearts as patients await heart transplantation.

Left Ventricular Assist Device

In 1982 Barney Clark received the first Jarvik-7 Artificial Heart invented by Dr. Robert Jarvik

Left Ventricular Assist DeviceAbnormal physical exams findings

Auscultation of heart sounds – abnormal continuous low machine like sound Manual BP unreliable and often not obtainable Automatic BP reading obtainable Radial pulse often not obtainable Pulse oxemetry not obtainable or unreliable

Cardiopulmonary arrest – determined by heart auscultation and apnea Chest compressions precordial between the visible LV and aortic tubes if externalized

Left Ventricular Assist Device

BLS complaint/symptomsNausea, vomiting, diarrhea, URITreat and transport as per protocol

ALS complaint/symptomsHypoglycemia, abdominal pain, CVA, traumaTreat and transport to nearest appropriate facility

Left Ventricular Assist Device

ALS Cardiopulmonary complaint/symptomsCall out to LVAD center

Transport to local hospitals – COPD exacerbation, pneumonia, CVA, dehydration,

Transport to LVAD center – STEMIs, CHF, unstable arrhythmias, respiratory failure – OTI

Cardiopulmonary arrest – Transport to nearest Emergency Department

Left Ventricular Assist DeviceContacting LVAD Center

Patient, family, health care designee will have called the LVAD Center hotline and can hand you the phone or give you the hotline phone number

LVAD Centers in FloridaTampa General; Florida Hospital, Orlando; Mayo, Jacksonville; Jacksonville Memorial, Miami

Aero medical TransportGround Transport to nearest LVAD center if unstableOrders from receiving LVAD center could be followedVideo with more details to be available on Target Solutions

Wearable Cardioverter Defibrillator VestWearable Cardioverter-defibrillator Vest are now made by Zoll and other manufactures and will become more prevalent as patients be will be wearing these as instructed by cardiologists while awaiting permanent pacemaker placement. If your patient is in cardiac arrest or unstable VT with the vest on simply take the vest off and treat arrhythmias by protocol –

THE VEST IS NOT WORKING

Wearable Cardioverter Defibrillator Vest

New StrokeForm

New Stroke Form (Part 1)

New Stroke Form (Part 2)

New Stroke Form (Part 3)

New Stroke Form (Part 4)

Change in Aeromedical Transport GuidelinesSee protocol guidelines handout

D

B

C

F

A

Mainland

I95/Eau Gallie – HRMCGround (I-95/Eau Gallie) – 7 milesAir – (I-95/Eau Gallie)– 6 miles

Eau Gallie/US1 - HRMCGround (Eau Gallie/US1) – 4 MilesAir – (Eau Gallie/US1)– 2 miles

I95/Port Malabar Rd. – HRMCGround – 8 milesAir – 5 miles

US1/Port Malabar Rd. – HRMCGround – 5 milesAir – 5 miles

Barrier Island

Eau Gallie/A1A – HRMCGround – 7 milesAir – 4 miles

St. 64 – HRMCGround – 7 milesAir – 5 miles

A

B

E

F

EC

D

B

D

B

C

F

AA

B

E

F

E

C

D

Mainland

I95/Pineda – HRMCGround (I-95/Pineda)– 12 milesAir – (I-95/Pineda)– 9.6 miles

Pineda/US1 - HRMCGround ( Pineda/US1) – 10 MilesAir – (Pineda/US1)– 9 miles

I95/Malabar Rd. – HRMCGround – 7 milesAir – 6 miles

US1/Malabar Rd. - HRMCGround – 9.57 MilesAir – 6.52 miles

Barrier Island

Pineda/A1A – HRMCGround – 13 milesAir – 9 miles

St. 64 – HRMCGround – 7 milesAir – 4.8 miles

Spinal Immobilization ProtocolSUMMARY• * Best use of the LSB may be for extricating the

unconscious patient or providing a firm surface for patient extraction from the scene or for chest compressions

• * Long Spine Boards (LSB) have both risks and benefits for patients and have NOT shown to improve outcomes

• * LSB and C-collar immobilization only for trauma if significant mechanism of injury with midline cervical tenderness, distracting injury, intoxication, altered mental status, neurological complaints - numbness, weakness, not able to ambulate, with spinal pain, tenderness or spinal deformity.

Spinal immobilization Protocol (cont)

When in doubt immobilizePneumonic

N-neuro exam with focal deficits S-significant mechanism of injury A-altered mental status I-intoxication evidence D-distracting injuries S-spinal injury: point tenderness over the

posterior spinous processes of the C, T, or LS spine

Spinal immobilization Protocol – Scenarios (cont)85 yof NHP with dementia – fall with head trauma and lower back pain

Point tenderness - LS posterior spinous processesNo cervical posterior spinous process tendernessIMMOBILIZE SPINE???

Spinal immobilization Protocol – Scenarios (cont)

40 yom s/p MVC, ejected with open fracture right femur, A and O x 3, abrasion forehead with NO cervical posterior spinous process tenderness

IMMOBILIZE???

Spinal immobilization Protocol – Scenarios (cont)

25 yom fall from ladder with weakness lower extremities and difficulty walking, no posterior cervical spinous process tenderness, no neck pain.

LS posterior spinous process tendernessIMMOBILIZE????

Helmet Removal Protocol

Summary • Do not remove helmet unless necessary for

respiratory resuscitation • Remove face mask • Stabilize helmet to body, ie tape

To be discussed in hands on training

Protocol/Drug Manual changes Metoprolol (lopressor)- DM and protocol

- contraindications for MI/ ACS with Pulmonary Edema =Cardiogenic Shock

Glucose checks- protocol - move to Level I intervention - glucose checks with all IVs IV fluid boluses- protocol - 500ml NS or LR rather than 250ml Other indications for 12 Lead ECGs/cardiac alerts - OD pt with Digoxin- frequently hav rapid or slow HR -dialysis patients with suspicion of hyperK+ -symptomatic tachycardia > 140 -symptomatic bradycardia requiring TCP or medication

Protocol and Drug manual Changes

Capnography for the head injury patient - target 40mmHg non-herniating patient -target 35mmHg herniating patient Epinepherine drips for symptomatic bradycardia RV (IWMI)infarction care -no metropolol -detected by ST elevation > in lead III than II - 1 liter fluid bolus before NTG in IWMIs Polymorphic VT- defibrillate not sync

cardioversion

EXPANDED CARDIAC ALERT PROTOCOL

Call Cardiac Alert and transmit ECG if:Anginal type chest pain with

Inverted T-wavesST depressionsHypotension – SBP < 90

Symptomatic tachyarrhythmia not responding to treatment Symptomatic bradycardia not responding to treatment

Minor Protocol and Drug Manual Changes

Humeral IOs Adults -procedure, TS D50 in IOs – protocol -adults not pediatric No blood draws for hospitals – protocol Blood Draws for law enforcement- protocol,

procedure Amiodarone - runs of PVCs in the setting of

chest pain or MI-protocol and DM Solumedrol for pediatric patients-protocol, DM

Minor Protocol and Drug Manual Changes

ASHI in introduction-protocol Ketamine and solumedrol change in

contraindications-Protocol, DM Atropine - remove RSI- protocol, DM lidocaine - no more drips – protocol, DM ETT confirmation by Capnography only-protocol,

DM Double Sequential defib at 720j-protocol -study Limited lights and sirens- sop, protocol