PROTOCOL UPDATEPROTOCOL UPDATEALABAMA EMS PROTOCOLSALABAMA EMS PROTOCOLS

EDITION 5 EDITION 5

JUNE, 2009 UPDATE JUNE, 2009 UPDATE

11

PROTOCOL UPDATEPROTOCOL UPDATE

• IF YOU IDENTIFY MISTAKES IN THE IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL SUGGESTIONS FOR PROTOCOL CHANGES EMAIL: CHANGES EMAIL: John.Campbell@adph.state.al.usJohn.Campbell@adph.state.al.us

22

PURPOSE OF PROTOCOLS PURPOSE OF PROTOCOLS

• IMPROVE PATIENT CAREIMPROVE PATIENT CARE

• PROVIDE OFF-LINE MEDICAL PROVIDE OFF-LINE MEDICAL DIRECTION DIRECTION

• REPRESENT STANDARD OF CARE REPRESENT STANDARD OF CARE

• PROVIDE QI STANDARDS PROVIDE QI STANDARDS

• PROVIDE EDUCATION STANDARDS PROVIDE EDUCATION STANDARDS

33

GENERAL CHANGEGENERAL CHANGE

• CHANGED THE WORD “DRUG” TO CHANGED THE WORD “DRUG” TO “MEDICATION” THROUGHOUT THE “MEDICATION” THROUGHOUT THE PROTOCOLSPROTOCOLS

44

TITLE PAGE & TABLE OF TITLE PAGE & TABLE OF CONTENTSCONTENTS

• CHANGED TO 5CHANGED TO 5THTH EDITION EDITION• TABLE OF CONTENTS UPDATED WITH TABLE OF CONTENTS UPDATED WITH

CHANGESCHANGES– Has been alphabetized and renumbered Has been alphabetized and renumbered

(except General Patient Care and (except General Patient Care and Communications were left as 4.1 & 4.2Communications were left as 4.1 & 4.2

– Deleted Coma, 4.15 and combined it with Deleted Coma, 4.15 and combined it with Altered Mental Status, 4.5 Altered Mental Status, 4.5

– No new Patient Care Protocols addedNo new Patient Care Protocols added• Two protocols were extensively rewrittenTwo protocols were extensively rewritten

– Added one new medication (Ondansetron)Added one new medication (Ondansetron)

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PREFACEPREFACE• Dr. Campbell’s email address correctedDr. Campbell’s email address corrected• Clarified the EMT’s responsibility to refuse Clarified the EMT’s responsibility to refuse

to accept orders that are not in his/her to accept orders that are not in his/her scope of privilegescope of privilege

• Added that a pediatric patient is defined Added that a pediatric patient is defined as someone aged 15 years or younger as someone aged 15 years or younger unless otherwise noted in the protocolsunless otherwise noted in the protocols

• Noted that anything referring to a Noted that anything referring to a pediatric patient will be in Tahoma font, pediatric patient will be in Tahoma font, in bold, and colored greenin bold, and colored green

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SECTION 2SECTION 2PATIENTS RIGHTSPATIENTS RIGHTS

• #6:Corrected to explain that families of #6:Corrected to explain that families of patients do not have the same rights as patients do not have the same rights as the patients themselves. While as a the patients themselves. While as a general rule the EMT should take the general rule the EMT should take the patient to the hospital the patient’s family patient to the hospital the patient’s family wants, if the hospital is inappropriate or is wants, if the hospital is inappropriate or is on diversion, OLMD must be called and on diversion, OLMD must be called and his/her orders followedhis/her orders followed

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SECTION 2SECTION 2PATIENTS RIGHTSPATIENTS RIGHTS

• #7: Added that, while an ambulance #7: Added that, while an ambulance service does not have to take a patient out service does not have to take a patient out of town if it leaves the community without of town if it leaves the community without ambulance service, that is not a license to ambulance service, that is not a license to ignore the trauma system and always take ignore the trauma system and always take the trauma patient to the local hospital. the trauma patient to the local hospital. – If the ambulance service is unable to comply If the ambulance service is unable to comply

with the regional trauma plan, the service must with the regional trauma plan, the service must contact the office of EMS & Trauma to develop contact the office of EMS & Trauma to develop a plan to correct this.a plan to correct this.

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SECTION 3.3SECTION 3.3PHYSICIAN MEDICAL PHYSICIAN MEDICAL DIRECTIONDIRECTION• Clarifies that medication orders may Clarifies that medication orders may

be signed by an OLMD physician or be signed by an OLMD physician or by the service’s medical director.by the service’s medical director.

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SECTION 3.4SECTION 3.4MEDICATION AND PROCEDURE MEDICATION AND PROCEDURE CLASSIFICATIONCLASSIFICATION• Added list of pediatric Category A Added list of pediatric Category A

and Category B medications since and Category B medications since they are not the same as the adult they are not the same as the adult Category A and Category B Category A and Category B medicationsmedications

1010

SECTION 3.4SECTION 3.4MEDICATION AND PROCEDURE MEDICATION AND PROCEDURE CLASSIFICATIONCLASSIFICATION• Added Hemostatic Agents, CPAP, and Added Hemostatic Agents, CPAP, and

Ondansetron to the list of required Ondansetron to the list of required medications and procedures.medications and procedures.– All are Category AAll are Category A– CPAP is optional for ALS nontransport CPAP is optional for ALS nontransport

servicesservices

1111

SECTION 3.5SECTION 3.5OPTIONAL MEDICATIONS AND OPTIONAL MEDICATIONS AND PROCEDURESPROCEDURES

• Removed CPAP and Hemostatic Removed CPAP and Hemostatic Agents from the list of optional Agents from the list of optional medications and proceduresmedications and procedures– CPAP remains optional to ALS CPAP remains optional to ALS

nontransport servicesnontransport services

1212

SECTION 4SECTION 4

TREATMENT PROTOCOLSTREATMENT PROTOCOLS

1313

GENERAL PATIENT CARE 4.1GENERAL PATIENT CARE 4.1

• Clarified that when filling out the ePCR, Clarified that when filling out the ePCR, the General Patient Care protocol can be the General Patient Care protocol can be listed if there is no specific protocol for use listed if there is no specific protocol for use in treating the patientin treating the patient

1414

COMMUNITCATIONS 4.2COMMUNITCATIONS 4.2

• For stable patients and patients only For stable patients and patients only requiring Cat. A treatment, added requiring Cat. A treatment, added that the EMT may notify the nurse that the EMT may notify the nurse or or paramedic paramedic at the receiving hospitalat the receiving hospital– Some hospitals have paramedics answer Some hospitals have paramedics answer

the phonethe phone

1515

ALTERED MENTAL STATUS ALTERED MENTAL STATUS 4.54.5• Combined COMA 4.15 with this protocolCombined COMA 4.15 with this protocol• You should review this entire protocol as You should review this entire protocol as

there are so many changesthere are so many changes

1616

BURNS 4.7BURNS 4.7

• For burn patients with wheezing, changed For burn patients with wheezing, changed albuterol to Category A for adultsalbuterol to Category A for adults

1717

CARDIAC ARREST CARDIAC ARREST 4.84.8

• Added that if the patient is in cardiac Added that if the patient is in cardiac arrest, and has a venous port, you may arrest, and has a venous port, you may access the port if you have been trained access the port if you have been trained and have the proper equipmentand have the proper equipment– This requires your medical director to see what This requires your medical director to see what

type of ports are being used in your area and type of ports are being used in your area and see that you are trained how to access that see that you are trained how to access that particular portparticular port

– Some ports require special needles to accessSome ports require special needles to access

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QUICK REFERENCE TO QUICK REFERENCE TO CARDIAC MEDICATIONS CARDIAC MEDICATIONS 4.94.9

• INFANTS AND CHILDREN (Age one month t 8 INFANTS AND CHILDREN (Age one month t 8 years)years)– Under Sodium Bicarbonate changed “Dilute 50% with Under Sodium Bicarbonate changed “Dilute 50% with

D5W” to “Dilute 50% with NS”D5W” to “Dilute 50% with NS”– Also changed dose from 1 mEq/dose to 1mEq/kg initial Also changed dose from 1 mEq/dose to 1mEq/kg initial

dosedose

1919

CARDIAC SYMPTOMS/ACUTE CARDIAC SYMPTOMS/ACUTE CORONARY SYNDROME 4.10CORONARY SYNDROME 4.10

• Added note that this protocol is for adults only. Added note that this protocol is for adults only. you should contact OLMD for chest pain in you should contact OLMD for chest pain in pediatric patients (age 15 or less). pediatric patients (age 15 or less).

• Aspirin to be given to adults unless 324mg or Aspirin to be given to adults unless 324mg or more has already been given in the last 24 hoursmore has already been given in the last 24 hours– If the patient has only had a baby aspirin (81 mg) you If the patient has only had a baby aspirin (81 mg) you

should give another four baby aspirinshould give another four baby aspirin• Aspirin is almost never given to pediatric patients Aspirin is almost never given to pediatric patients

(CAT. B) because of danger of Reye’s syndrome(CAT. B) because of danger of Reye’s syndrome

2020

PEDIATRIC BRADYCARDIA PEDIATRIC BRADYCARDIA 4.114.11

• Added that epinephrine and atropine are CAT AAdded that epinephrine and atropine are CAT A– Epinephrine may be repeated every 3-5 minutes until Epinephrine may be repeated every 3-5 minutes until

heart rate is 80 or aboveheart rate is 80 or above– Atropine may be repeated once in 5 minutes if heart Atropine may be repeated once in 5 minutes if heart

rate is not 80 or above (maximum total dose of 1 mg)rate is not 80 or above (maximum total dose of 1 mg)• Added that external pacing is for age 14 and Added that external pacing is for age 14 and

above and is CAT Babove and is CAT B

2121

CHILDBIRTH 4.12CHILDBIRTH 4.12

• Changed the order of clamping and Changed the order of clamping and cutting the cord to the correct place cutting the cord to the correct place in the sequence of carein the sequence of care– It was originally listed after wrapping the It was originally listed after wrapping the

baby in a blanket and taking the vital baby in a blanket and taking the vital signssigns

2222

CONGESTIVECONGESTIVEHEART FAILURE 4.14HEART FAILURE 4.14

• Added that the patient should be put Added that the patient should be put in the upright sitting positionin the upright sitting position

• Made nitroglycerin and CPAP Cat. AMade nitroglycerin and CPAP Cat. A

• Kept lasix and morphine as CAT. BKept lasix and morphine as CAT. B– This was to bring our protocols in line This was to bring our protocols in line

with current treatment of CHFwith current treatment of CHF

2323

COMA 4.15COMA 4.15

• Deleted this protocol and combined Deleted this protocol and combined its content with ALTERED MENTAL its content with ALTERED MENTAL STATUS 4.5STATUS 4.5

2424

NEAR DROWNING 4.22NEAR DROWNING 4.22

• Added near drowning as a CAT. A Added near drowning as a CAT. A indication for use of CPAPindication for use of CPAP

2525

POISONS AND OVERDOSES POISONS AND OVERDOSES 4.234.23

• Since paramedics no longer carry Since paramedics no longer carry syrup of ipecac, deleted the list of syrup of ipecac, deleted the list of conditions in which you should not conditions in which you should not induce vomitinginduce vomiting

• The protocol now simply states “DO The protocol now simply states “DO NOT INDUCE VOMITING” NOT INDUCE VOMITING”

2626

RESPIRATORY DISTRESS RESPIRATORY DISTRESS 4.254.25

• Added that for pulmonary edema, Added that for pulmonary edema, nitroglycerin and CPAP are CAT. A nitroglycerin and CPAP are CAT. A and all other treatments (lasix and and all other treatments (lasix and morphine) are CAT B.morphine) are CAT B.– This reflects current treatment of This reflects current treatment of

pulmonary edemapulmonary edema

2727

SEIZURES 4.26SEIZURES 4.26

• Protocol has been changed to allow Protocol has been changed to allow either diazepam or lorazepam for either diazepam or lorazepam for treatment of seizurestreatment of seizures– Some doctors prefer lorazepamSome doctors prefer lorazepam– The only drawback to lorazepam is that The only drawback to lorazepam is that

it has only a 60-day unrefrigerated shelf-it has only a 60-day unrefrigerated shelf-lifelife

2828

SHOCK 4.27SHOCK 4.27

• Added that if external bleeding from Added that if external bleeding from an extremity cannot be controlled by an extremity cannot be controlled by pressure, application of a tourniquet pressure, application of a tourniquet is the reasonable next step in is the reasonable next step in hemorrhage controlhemorrhage control– This reflects current treatment and This reflects current treatment and

current National Registry testingcurrent National Registry testing

2929

SHOCK 4.27SHOCK 4.27

• Added to use a hemostatic agent if Added to use a hemostatic agent if unable to stop severe bleeding with unable to stop severe bleeding with pressure or a tourniquetpressure or a tourniquet

• Added that if the patient is in Added that if the patient is in hypovolemic shock and the patient hypovolemic shock and the patient has a venous port, you may access has a venous port, you may access the port if you have been trained and the port if you have been trained and have the proper equipmenthave the proper equipment

3030

STROKE 4.28STROKE 4.28

• Protocol has been rewritten to reflect Protocol has been rewritten to reflect the current national guidelines for the current national guidelines for diagnosis and treatment of the diagnosis and treatment of the stroke patientstroke patient

• You should review the entire protocol You should review the entire protocol since so many changes have been since so many changes have been mademade

3131

VOMITING 4.32VOMITING 4.32

• Deleted “NAUSEA”Deleted “NAUSEA”

• Changed treatment of vomiting from Changed treatment of vomiting from diphenhydramine to ondansetron diphenhydramine to ondansetron (Zofran)(Zofran)– The cost of injectable ondansetron is The cost of injectable ondansetron is

now reasonable now reasonable

3232

SECTION 5SECTION 5

MEDICATIONSMEDICATIONS

3333

ALBUTEROL 5.3ALBUTEROL 5.3

• Added burns and CHF as adult CAT. A Added burns and CHF as adult CAT. A use of albuteroluse of albuterol– Still CAT B for pediatric burns with Still CAT B for pediatric burns with

wheezingwheezing

3434

ASPIRIN 5.5ASPIRIN 5.5

• Added that aspirin is CAT. B for Added that aspirin is CAT. B for pediatric patients because it may be pediatric patients because it may be associated with Reye’s syndromeassociated with Reye’s syndrome

3535

DIPHENHYDRAMINE 5.10DIPHENHYDRAMINE 5.10

• Changed diphenhydramine to a Changed diphenhydramine to a secondary medication for treating secondary medication for treating vomitingvomiting

3636

FUROSEMIDE 5.13FUROSEMIDE 5.13

• Added a pediatric dose (CAT. B)Added a pediatric dose (CAT. B)– 0.5 to 1mg/kg IV given slowly over 2 0.5 to 1mg/kg IV given slowly over 2

minutesminutes

3737

LORAZEPAM 5.17LORAZEPAM 5.17

• Added that lorazepam may be used Added that lorazepam may be used in place of diazepamin place of diazepam– Rather than only if you can’t get Rather than only if you can’t get

diazepamdiazepam•Lorazepam was originally added to the Lorazepam was originally added to the

protocols because for a time diazepam was protocols because for a time diazepam was unavailableunavailable

3838

MAGNESIUM SULFATE 5.18MAGNESIUM SULFATE 5.18

• added pediatric dose for treating added pediatric dose for treating torsade (CAT. B)torsade (CAT. B)– 25 to 50mg/kg IV or IO Maximum dose 25 to 50mg/kg IV or IO Maximum dose

is 2 gramsis 2 grams

3939

NITROGLYCERIN 5.21NITROGLYCERIN 5.21

• Added that nitroglycerin is Added that nitroglycerin is contraindicated for pediatric patients contraindicated for pediatric patients in the EMS settingin the EMS setting

4040

NITROUS OXIDE 5.22 NITROUS OXIDE 5.22

• Added that use of nitrous oxide is Added that use of nitrous oxide is CAT. B for pediatric patientsCAT. B for pediatric patients

4141

ONDANSETRON 5.24 ONDANSETRON 5.24

• Added new medication, ondansetron Added new medication, ondansetron (Zofran) for treatment of vomiting(Zofran) for treatment of vomiting– Ondansetron is non-sedating but has Ondansetron is non-sedating but has

been too expensive to use in the pastbeen too expensive to use in the past• It is now generic and inexpensiveIt is now generic and inexpensive

4242

SODIUM BICARBONATE 5.26 SODIUM BICARBONATE 5.26

• Added that for children between the Added that for children between the ages of one month and 8 years of ages of one month and 8 years of age the sodium bicarbonate should age the sodium bicarbonate should be diluted 50% with NSbe diluted 50% with NS

4343

THIAMINE 5.27 THIAMINE 5.27

• Added that there is almost no Added that there is almost no indication for thiamine (CAT. B) use indication for thiamine (CAT. B) use in a childin a child– Only use is for treatment of Beriberi, a Only use is for treatment of Beriberi, a

disease caused by a lack of thiamine disease caused by a lack of thiamine (not an emergency condition)(not an emergency condition)

4444

VASOPRESSIN 5.28 VASOPRESSIN 5.28

• Added that vasopressin use is Added that vasopressin use is contraindicated for pediatric cardiac contraindicated for pediatric cardiac arrestarrest

4545

SECTION 6SECTION 6

PROCEDURESPROCEDURES

4646

CONTINUOUS POSITIVE CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) 6.3AIRWAY PRESSURE (CPAP) 6.3

• Added near drowning as an Added near drowning as an indication for use of CPAPindication for use of CPAP

• Added a note that CPAP is not used Added a note that CPAP is not used in children under the age of 12 in children under the age of 12 because of lack of complete because of lack of complete development of their respiratory development of their respiratory systemsystem

4747

ENDOTRACHEAL INTUBATION ENDOTRACHEAL INTUBATION 6.56.5

• Added that orotracheal intubation is Added that orotracheal intubation is CAT. B for children and nasotracheal CAT. B for children and nasotracheal intubation is contraindicated in intubation is contraindicated in childrenchildren

4848

SECTION 8SECTION 8

ADMINISTRATIVE PROTOCOLSADMINISTRATIVE PROTOCOLS

4949

DOCUMENTATON OF CARE 8.2DOCUMENTATON OF CARE 8.2

• Added that ePCRs must be Added that ePCRs must be completed and transmitted to the completed and transmitted to the office of EMS & Trauma within 168 office of EMS & Trauma within 168 hours (one week) of the provided hours (one week) of the provided medical caremedical care

5050

TRAUMA SYSTEM PROTOCOL TRAUMA SYSTEM PROTOCOL 8.58.5

• Changed the protocol to reflect Changed the protocol to reflect suggestions made by the pediatric suggestions made by the pediatric workgroup and the State Trauma workgroup and the State Trauma Advisory CouncilAdvisory Council

• Physiologic CriteriaPhysiologic Criteria– Added that a BP of <90mmHg refers to Added that a BP of <90mmHg refers to

an adult or a child 6 years of age or an adult or a child 6 years of age or olderolder

5151

TRAUMA SYSTEM PROTOCOL TRAUMA SYSTEM PROTOCOL 8.58.5• Physiologic Criteria (cont.)Physiologic Criteria (cont.)

– Added that respiratory distress rates in Added that respiratory distress rates in children are:children are:•<20 or >60 in a newborn<20 or >60 in a newborn

•< 20 or > 40 in a child three years or < 20 or > 40 in a child three years or youngeryounger

•<12 or >29 in a child four years or older<12 or >29 in a child four years or older

– Added that head trauma with any neurologic Added that head trauma with any neurologic changes in a child 5 years or younger puts changes in a child 5 years or younger puts the child in the trauma systemthe child in the trauma system

5252

SECTION 9SECTION 9

ACCEPTABLE EMS EQUIPMENT ACCEPTABLE EMS EQUIPMENT AND DEVICESAND DEVICES

5353

BOUGIE FOR DIFFICULT BOUGIE FOR DIFFICULT INTUBATIONS 9.2INTUBATIONS 9.2

• Added this optional equipment to the Added this optional equipment to the list of acceptable equipmentlist of acceptable equipment– Bougie, Endotracheal Tube IntroducerBougie, Endotracheal Tube Introducer

•15 French by 60-70cm for 6.0 to 11.0 ET 15 French by 60-70cm for 6.0 to 11.0 ET tubestubes

5454

BOUGIEBOUGIE

5555

DEVICES TO PERFORM DEVICES TO PERFORM CHEST DECOMPRESSION CHEST DECOMPRESSION 9.4 9.4 • Added: Becton Dickinson Angiocath Added: Becton Dickinson Angiocath

14 gauge by 3.25 inches long14 gauge by 3.25 inches long

5656

HEMOSTATIC AGENTS 9.5HEMOSTATIC AGENTS 9.5

• Added QuikClot Combat Gauze Added QuikClot Combat Gauze – Kaolin basedKaolin based– Currently being used by military in combat in IraqCurrently being used by military in combat in Iraq

• Added WoundStat Added WoundStat – Granular combination of smectite and polymerGranular combination of smectite and polymer

5757

SECTION 10SECTION 10

FORMSFORMS

5858

REQUEST TO BE TAKEN TO REQUEST TO BE TAKEN TO A HOSPITAL ON DIVERSION A HOSPITAL ON DIVERSION 10.210.2• Removed “the patient’s family” as Removed “the patient’s family” as

being able to sign to take the patient being able to sign to take the patient to a hospital on diversionto a hospital on diversion

5959

STROKE CHECKLIST 10.4STROKE CHECKLIST 10.4

• Rewrote stroke checklist to reflect Rewrote stroke checklist to reflect the new Stroke Protocolthe new Stroke Protocol

6060

ALERT! BEFORE USING NEW ALERT! BEFORE USING NEW PRTOTOCOLS:PRTOTOCOLS:• EACH SERVICE MUST NOTIFY AND PROVIDE YOUR EACH SERVICE MUST NOTIFY AND PROVIDE YOUR

SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF THE 5THE 5THTH EDITION PROTOCOLS (June 09 edition) AND EDITION PROTOCOLS (June 09 edition) AND A COPY OF THIS UPDATE PRESENTATIONA COPY OF THIS UPDATE PRESENTATION– It is OK for the medical director to download the material It is OK for the medical director to download the material

insteadinstead

• EACH SERVICE MUST BE SURE THE ON-LINE EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL DIRECTORS AT YOUR MEDICAL DIRECTION MEDICAL DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS ARE AWARE THAT THE PROTOCOLS HOSPITALS ARE AWARE THAT THE PROTOCOLS HAVE BEEN UPDATED AND WHERE TO GET THE HAVE BEEN UPDATED AND WHERE TO GET THE MATERIALMATERIAL– The service is not responsible for furnishing copies of the The service is not responsible for furnishing copies of the

protocols or update slide presentationprotocols or update slide presentation

6161

NEW PROTOCOLS CAN BE NEW PROTOCOLS CAN BE USEDUSED• WHEN EVERYONE IN A SERVICE HAS BEEN WHEN EVERYONE IN A SERVICE HAS BEEN

UPDATEDUPDATED– TURNED ON SERVICE BY SERVICE NOT TURNED ON SERVICE BY SERVICE NOT

INDIVIDUAL BY INDIVIDUALINDIVIDUAL BY INDIVIDUAL– TURN IN ROSTER TO REGIONAL EMS AGENCY TURN IN ROSTER TO REGIONAL EMS AGENCY

NOT TO OFFICE OF EMS & TRAUMANOT TO OFFICE OF EMS & TRAUMA• Also acknowledge that you have updated your off-line Also acknowledge that you have updated your off-line

medical director and provided copy of protocolsmedical director and provided copy of protocols– REGIONAL EMS AGENCY WILL NOTIFY YOU REGIONAL EMS AGENCY WILL NOTIFY YOU

WHEN YOU CAN START USING NEW WHEN YOU CAN START USING NEW PROTOCOLSPROTOCOLS

– EVERY SERVICE MUST BE UPDATED BY EVERY SERVICE MUST BE UPDATED BY OCTOBER 1OCTOBER 1STST, 2009, 2009

6262

QUESTIONS?QUESTIONS?

6363