Protocol Update

1
Protocol Update

• Version 6.032

Updated January 20, 2006
Created by Central Mass EMS Corp. (Region II
EMS) Visit us! www.cmemsc.org
2
Overview

• General Changes
• Specific Protocol Changes
• New Protocols
• Appendix Changes
• Administrative Requirements and Advisories
  released since last protocol update
• Conclusion

3
General Changes
4
General Changes

• New Format (redundancy eliminated)
• Preamble updated (see 13)
• Generic names for all medications also bold
  typed
• Drug Reference edited to include only those
  medications on Medications List (see Appendix A)

5
General Changes, continued

• Use of nasal Naloxone wherever Naloxone allowed
• Blood glucose threshold changed in all pertinent
  protocols from 100 to 70

6
General Changes, continued

• Reference to Follow AED Protocol replaced in
  all pertinent protocols with
• Use AED according to the standards of the
  American Heart Association or as otherwise noted
  in these protocols and other advisories.

7
Specific Protocol Changes
8
Asystole/Cardiac Arrest (1.1)

• Paramedic Standing Orders
• Administer a 250cc bolus of IV Normal Saline if
  warranted

9
Atrial Fibrillation (1.2) andAtrial Flutter (1.3)

• NOTE For rate control in adult patients
  currently prescribed a beta-blocker
• Paramedic Medical Control
• Administer Metoprolol Bolus 2.5mg-5mg slow IV
  Push over 2 minutes
• Repeat dosing in 5 minute intervals to a max of
  15mg

10
Atrial Fibrillation (1.2) andAtrial Flutter
(1.3), continued

• CAUTION
• Do not mix IV Metoprolol with IV Ca blockers

11
Chest Pain (1.5)

• Name changed to Acute Coronary Syndrome
• Paramedic Standing Orders Morphine dose 2.0-4.0
  mg
• Medical Control Lidocaine and repeat bolus
  removed

12
Post Resuscitation (1.6)

• Paramedic Standing Orders
• Dopamine 10.0mcg/kg per minute if BP is lt 80
  systolic after fluid bolus

13
VTach with Pulses (1.11)

• Paramedic Standing Orders Amiodarone 150mg in
  10cc normal saline IV over 8-10 minutes added
• Medical Control Amiodarone 150mg-300mg in 10ml
  Normal Saline IV over 8-10 minutes (changed from
  1-2 minutes)

14
Hypothermia (2.4)

• Paramedic Standing orders
• Thiamine administration removed

15
Nerve Agent Exposure (2.6)

• First Responders may administer nerve agent
  antidotes (Mark-1 kits) to fellow authorized
  public employees
• (This change was initially released as an OEMS
  Advisory on January 18, 2005)

16
Abdominal Pain (3.1)

• Medical Control
• Patients with severe pain and a BP gt 110
  systolic may be considered for pain management
  under Adult Pain Management Protocol (3.14)

17
Allergic Reaction/Anaphylaxis (3.2) and Pediatric
Anaphylaxis(5.2)

• NOTE section deleted referring to authorized
  EPI course.
• All EPI training should now be completed within
  the Initial EMT course.
• Further refresher training of EPI may be done
  through continuing education.

18
CHF/Pulmonary Edema (3.5)

• Paramedic Standing Orders
• Dobutamine infusion deleted

19
CHF/Pulmonary Edema (3.5) and Hypertensive
Emergencies (3.7)

• Nitrate note changed to
• Do not administer Nitroglycerin if patient (male
  or female) has taken any medication in the
  phosphodiesterase-type-5 inhibitor category
  within the last 48 hours.

20
Obstetrical Emergencies (3.8)

• Pitocin (Oxytocin) removed
• Eclamptic Seizures
• Lorazepam 2-4mg slow IV Push or IM -OR-
• Diazepam 5-10mg slow IV Push or IM

21
Seizures (3.9)

• Paramedic Standing Orders Lorazepam 2-4mg slow
  IV Push or IM over 2-3 minutes
• CAUTION note added In patients with head injury
  or hypotension, the use of Diazepam or Lorazepam
  may be contraindicated

22
Shock/Hypotension (3.10)

• Medical Control Options deleted
• Second IV of NS/LR
• Dobutamine Infusion 2-20µg/kg/minute
  (duplication)
• Norepinephrine Infusion

23
Acute Stroke (3.11)

• Edited for consistency with current Stroke POE
  guidelines
• Reference to Massachusetts Stroke Scale (MASS)
• Reference to Thrombolytic Checklist included in
  Basic Procedures

24
Spinal Injury (4.7)

• Paramedic Medical Control Option deleted
• Methylprednisolone (Solumedrol) IV infusion over
  30 minutes

25
Newborn Resuscitation (5.1)

• NOTE section referring to AED use removed
  from Basic and Intermediate procedures

26
Pediatric Seizures (5.7)

• Paramedic Standing Orders
• Cardiac Monitor 12 lead ECG-manage dysrhythmias
  removed
• Naloxone HCL removed
• Diazepam 0.25mg/kg IV/IO to max 5-10mg or Rectal
  Diazepam 0.5mg/kg -OR-
• Lorazepam 0.05-0.1mg/kg IV/IO (dilute 11 NS) or
  IM to max 2mg

27
Pediatric Seizures, continued

• Medical Control Note
• Reference to seizure activity changed from 30
  minutes to 10 minutes

28
Pediatric VFib/Pulseless VTach (5.12)

• Paramedic Standing Orders Epinephrine doses
  reformatted
• Initial dose IV/IO 0.01mg/kg ET
  0.1mg/kg(110,000, 0.1mL/kg)
• Subsequent doses same
• May repeat every 3-5 minutes
• IV/IO doses up to 0.02mg/kg of 110,000 may be
  effective

29
New Protocols
30
Adult Upper Airway Obstruction (3.15)

• Modeled after Pediatric Upper Airway Obstruction
  (5.11)
• Provides guidance for Tracheostomy tube
  obstruction management in the adult

31
Diabetic Emergencies (3.16)

• Referenced in Altered Mental Status Protocol
  (3.3)
• Hypoglycemia threshold changed from 100 to 70

32
Appendix Changes
33
Appendix A Medication List

• Additional Nerve Agent Antidotes added to the
  Optional Medication List

34
Appendix C Cessation of Resuscitation

• Refer to AR 5-515 (2/1/05)
• Current valid DNR
• Trauma inconsistent with survival
• Body condition clearly indicates biological death

35
Appendix D Rescue Airway

• Name changed to Emergent Advanced Airway
• Paramedic Medical Control Option Sedative
  medications may be allowed

36
Appendix D, continued

• If intubation unsuccessful, insert LMA,
  Combi-Tube, or other approved rescue device
• Grading Airway figures added

37
Appendix N Inter-facility Transfers

• Updated version to be released soon

38
Appendix Q MASS

• Massachusetts Stroke Scale
• Facial Droop
• Arm Weakness
• Speech Disturbance

39

• Administrative Requirements
• and
• OEMS Advisories Review

40
Administrative Requirements 2005

• AR 5-610 Responding to Scenes Involving Minors
  Refusing Treatment or Transport
• Refers to minors that have an emergency medical
  condition (or potential for one)
• Use reasonable judgment in determining if patient
  is minor (lt18) or emancipated

41
ARs 2005, continued

• AR 5-610 (Minors), continued
• Refusal for lt18 must be made by parent or legal
  guardian
• Document in detail findings, actions and reasons
• Services should also develop policies with own
  legal counsel to establish guidelines

42
ARs 2005, continued

• AR 5-520 Requirements for Basic Intermediate
  EMT Use of Glucose Monitoring
• Optional skill for EMT-B and I
• Requires agreement for medical director oversight
• Service must provide appropriate training
  associated records

43
ARs 2005, continued

• AR 5-520(Glucometer) continued
• QA/QI program in place that includes yearly
  training review
• Glucose results must be documented
• Blood borne pathogen policies must be adhered to
• Glucose monitoring device must meet department
  requirements

44
ARs 2005, continued

• AR 5-520(Glucometer) continued
• Manufacturers instructions for control runs,
  use, care cleaning must be followed
• CLIA (Clinical Laboratories Improvement
  Amendments) waiver must be obtained

45
ARs 2005, continued

• AR 5-615 Cancellation of ALS
• Affiliate hospital and/or service medical
  director must establish written guidelines
• BLS must complete assessment and treatment
  according to state protocols
• Careful documentation by BLS and ALS

46
ARs 2005, continued

• AR 5-620 ALS Transfer of Calls to BLS
• If patient contact established by ALS, must
  complete assessment treatment according to
  state protocols
• If ALS intervention initiated, must attend to
  patient during transport
• May transfer care to BLS if ALS intervention is
  not needed or anticipated
• Documentation of encounter required

47
ARs 2005, continued

• AR 2-360 Dept. Assessment of Info Reported by EMS
  Personnel per 105 CMR 170.937
• EMTs/EFRs must file written report with both
  DPH/OEMS and own service within 5 days of
• any conviction of misdemeanor or felony
• loss or suspension of drivers license

48
Advisories 2004

• Administration of Medications by Paramedics to
  Persons Not Being Transported
• Dont do it
• On-Line CPR Training
• Not valid unless it also includes practical
  skills evaluation

49
Advisories 2005

• Ventricular Assist Devices
• Do not do chest compressions
• Use in accordance with manufacturers
  instructions
• AED Use for ages 1-8
• Adult AED allowed if pediatric AED is not
  available

50
Advisories 2005, continued

• Paramedic Medical Control Option Allows bypass
  of closest facility to transport to PCI (aka
  angioplasty) facility for patients with
• ST elevation AND
• Cardiogenic shock or CHF or contraindications to
  thrombolysis

51
Conclusion

• Summary
• Verbal Assessment
• Online Resources
• Regional Office
• www.cmemsc.org
• OEMS
• www.mass.gov/dph/oems