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Paramedic Protocol Update 2009

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Title: Paramedic Protocol Update 2009


1
Paramedic Protocol Update 2009
  • Westchester Regional Emergency Medical Services
    Council

2
Introduction
  • Each agency will be provided with CD containing
    the protocol roll-out training materials.
  • Protocol roll-out presentations cover all changes
    by section (Adult Medical, Pediatric Medical,
    Trauma, etc.).
  • Agencies are expected to deliver content to
    affiliated paramedics. Agency Medical Director
    should approve delivery mechanism (i.e.,
    classroom session, computer delivery, follow-up
    quiz ??)

3
Introduction
  • Protocols also included on CD in PDF format. Will
    also be posted on WREMSCO website. No field
    guides initially as additional changes are
    expected.
  • Protocol implementation date July 1, 2009
  • Agency Medical Director must affirm that
    affiliated paramedics have received training
    (affirmation form included on CD).

4
Overview
  • New Format indicating STANDING ORDERS, MEDICAL
    CONTROL OPTIONS, and NOTATIONS.
  • Each protocol initiates with M1.0-Routine Medical
    Care or T1.0-Routine Trauma Care.
  • To be carried out in conjunction with appropriate
    policies, procedures, and advisories.
  • Separate Interfacility Transport Protocols under
    development

5
  • New Format

6
Trauma Protocols
  • Westchester Regional Paramedic Protocol Update
    2009

7
Routine Trauma Care T1.0
  • Replaces old trauma protocols
  • Consolidated Routine Medical Care, airway,
    transport consideration, fluid resuscitation for
    shock, analgesics for pain management, and
    CPR/rapid transport for Traumatic arrest.
  • Added Directs provider to Airway Management
    Protocols, Trauma Transport Algorithm, and Pain
    Management Protocol.

8
Trauma Report Appendix 2.3
9
Adult Medical Protocols
  • Westchester Regional Paramedic Protocol Update
    2009

10
Adult Medical Protocols
  • New Standard Operating Procedures for Advanced
    Airway Management, Tension Pneumothorax, and
    Intravenous Access (separate document)
  • Endotracheal drug administration has been removed
    from all protocols
  • Pediatric protocols now in separate pediatric
    section

11
Adult Medical Protocols
  • Routine Medical Care M1.0 - Pulse Oximetry now a
    Standing Order
  • Airway Management M2.0 - Etomidate now a standing
    order.
  • If patient needs facilitated advanced airway
    management
  • Consider ETOMIDATE 0.3 mg/kg IV or IO, perform
    ENDOTRACHEAL INTUBATION, and
  • CONTACT MEDICAL CONTROL
  • Bronchospasm/Asthma/COPD M3.0 -
    Methylprednisolone and Magnesium Sulfate now
    Standing Orders. Terbutaline now administered IM
    route.

12
Adult Medical Protocols
  • Cardiac M4.0 - Refers to appropriate
    sub-protocol. 12 lead ECG added.
  • Acute Coronary Syndrome M4.1 - NITROGLYCERIN
    should be given with caution to patients taking
    erectile dysfunction (ED) medications (i.e.,
    Viagra, Cialis, Levitra), or suspected inferior
    wall or right ventricle (RV) myocardial
    infarctions (MI)
  • Acute Pulmonary Edema Congestive Heart Failure
    M4.2 - Administer CPAP if available. Medical
    Control Option for Lasix changed from 40-80 mg to
    80-120 mg

13
Adult Medical Protocols
  • Bradycardia M4.3 - TCP now before atropine.
    Dopamine under Medical Control Options now 2-10
    mcg/kg/min
  • Supraventricular Tachycardia Divided into two
    new protocols
  • Narrow Complex Tachycardia Unstable M4.4 - Fluid
    challenge now Standing Order. Doses of energy for
    Cardioversion depend on the underlying rhythm.
    Diltiazem added as Medical Control Option
  • Narrow Complex Tachycardia Stable M4.5 -
    Diltiazem 15-25mg as Standing Order for ATRIAL
    FLUTTER, ATRIAL FIBRILLATION or MULTIFOCAL ATRIAL
    TACHYCARDIA unless patient has a known history of
    Wolff-Parkinson-White Syndrome (WPW)

14
Adult Medical Protocols
  • Wide Complex Tachycardia Unstable M4.6 - Doses of
    energy for Cardioversion depend on the underlying
    rhythm. Total maximum dose of Amiodarone in
    Standing Orders is now 2.2gm/24 hrs.
  • Wide Complex Tachycardia Stable M4.7 - Standing
    Order of Amiodarone to 150 mg/100 ml of D5W.
    Repeat if VT persists. Max 2.2 gm/24 hrs.
    Procainamide now Medical Control Option only.

15
Adult Medical Protocols
  • Cardiac (Arrest) Non-Traumatic Cardiopulmonary
    Arrest M5.0 - This protocol directs the EMS
    provider to two new protocols
  • M5.1 Shockable Rhythm
  • M5.2 Non-Shockable Rhythm
  • Notes for consideration of the following
    medications for all Cardiac Arrests have been
    added
  • SODIUM BICARBONATE 1 mEq/kg IVP or IO with
    suspected hyperkalemia, profound acidosis,
    tricyclic antidepressant, cocaine, or
    diphenhydramine overdoses. Dose may be repeated
    at 0.5 mEq/kg every 10 minutes.
  • DEXTROSE 50 IVP or IO if clinically indicated
    may be repeated once.
  • NALOXONE 2 mg IV or IO if clinically indicated.
  • DOPAMINE 400 mg in 250 ml 0.9 Normal Saline
    initiate drip at 5 - 10 mcg/kg/min.
  • CALCIUM CHLORIDE 250 500 mg IVP or IO may be
    repeated to a maximum of 1 gm. Only indicated
    with hyperkalemia, hypocalcemia, or calcium
    channel blocker toxicity.

16
Adult Medical Protocols
  • Cardiac Arrest Shockable Rhythm (VF or Pulseless
    VT) M5.1 Follows latest CPR guidelines single
    shocks, CPR _at_ 2 min. intervals. Precordial thump
    removed. Standing Order added for Magnesium
    Sulfate for known Hypomagnesemia or Torsades.
  • Cardiac Arrest Non-Shockable Rhythm M5.2 Prompt
    to Search for and treat for contributing factors
    address as appropriate. Vasopressin now a
    Standing Order but under review.

17
Adult Medical Protocols
  • Field Termination of Resuscitation Efforts M5.3
    Grief counseling removed.
  • Altered Mental Status M6.0 Naloxone dose now 0.4
    mg IV, IN, or IM, may be repeated up to 8 mg.
  • Anaphylactic Reaction M7.0 - Standing Orders now
    for Methylprednisolone, rapid fluid infusion, and
    Albuterol. Epinephrine is indicated as follows
  • Cardiovascular collapse present, 110,000 1 mg
    IVP
  • Mild reaction, 11,000 0.3 ml IM
  • If patient is taking beta-blockers, also
    administer GLUCAGON 1 mg IM or IV.

18
Adult Medical Protocols
  • Toxic Exposure / Poisoning M8.0 For Carbon
    Monoxide (CO) exposure with history and
    signs/symptoms - Monitor CO levels
    (if available) - 100 oxygen therapy
  • Non-Traumatic Shock M9.0 Dobutamine added as a
    Medical Control Option
  • 400mg/250 ml NS ,initiate drip at 5 10
    mcg/kg/min.
  • May be titrated in increments of 5 mcg/kg/min
    until desired therapeutic effect is reached (max
    dose of 25 mcg/kg/min)
  • Post Partum Hemorrhage M10.0 - Oxytocin now a
    Standing Order after delivery of placenta

19
Adult Medical Protocols
  • Obstetrical Toxemia of Pregnancy M11.0
    PRE-ECLAMPSIA now defined as combination of BP
    140/90 or greater, peripheral edema, and
    symptoms headache, visual disturbances, upper
    abdominal pain. Magnesium Sulfate 4 gm/250 ml NS
    over 20 minutes now a Standing Order for
    Pre-Eclampsia and Eclampsia.
  • Seizures M12.0 measure serum glucose, and
    treat hypoglycemia after initiating Routine
    Medical Care. Standing Order now for a
    Benzodiazepine(Diazepam, Lorezapam, or
    Midazolam).

20
Pediatric Medical Protocols
  • Westchester Regional Paramedic Protocol Update
    2009

21
Pediatric Medical Protocols
  • Endotracheal drug administration has been removed
    from all protocols
  • 14 years or younger for pediatric patient

22
Pediatric Medical Protocols
  • Pediatric Airway Management P1.0 Etomidate dose
    0.3 mg/kg IV or IO now a Medical Control Option
    for all Paramedics. Continuous EKG, pulse
    oximetry and wave-form capnography added.
  • Bronchospasm / Asthma P2.0 Separated from
    Croup/Epiglottitis in old protocol. Albuterol 2.5
    mg plus one unit dose of Ipratropium 0.5 mg via
    nebulizer may be repeated once if needed under
    standing orders. Dexamethasone 0.6 mg/kg IM added
    as a Medical Control Option.

23
Pediatric Medical Protocols
  • Croup/Epiglottitis P3.0 Nebulized Epinephrine
    or Racemic Epinephrine now a Standing Order.
    Dexamethasone 0.6 mg/kg IM added as a Medical
    Control Option
  • Cardiac P4.0 Refers to appropriate
    sub-protocol. 12 lead ECG added.
  • Bradycardia P4.1 - Now states If increased
    vagal tone, or primary AV Block, administer
    Atropine 0.02 mg/kg IV or IO minimum dose
    0.1mg maximum single dose
  • 0.5 mg for children
  • 1 mg for adolescents.
  • If inadequate response, may repeat once

24
Pediatric Medical Protocols
  • Narrow Complex Tachycardia P4.2 If Sinus
    Rhythm, consider Fluid Challenge of 0.9 Normal
    Saline (10-20 ml/kg rapid infusion) if indicated
    search for and treat any causes found as
    appropriate
  • Wide Complex Tachycardia P4.3 New protocol.
    Apply cardiac monitor to determine rhythm.
  • If patient is Unstable
  • If it does not delay CARDIOVERSION, administer
    ADENOSINE 0.1 mg/kg IV or IO first to determine
    if the rhythm is SVT with aberrant conduction.
  • SYNCHRONOUS CARDIOVERSION 0.5 J/kg 1 J/kg if
    no change, repeat at 2 J/kg (c) consider
    sedation / analgesia, CONTACT MEDICAL CONTROL.
  • If rhythm FAILS TO COVERT after 2nd CARDIOVERSION
    to a supraventricular rhythm, CONTACT MEDICAL
    CONTROL

25
Pediatric Medical Protocols
  • Cardiac (Arrest) Non-Traumatic Cardiopulmonary
    Arrest P5.0 This protocol directs the EMS
    provider to two new protocols
  • P5.1 Shockable Rhythm
  • P5.2 Non-Shockable Rhythm
  • Cardiac Arrest Shockable Rhythm (VF or Pulseless
    VT) P5.1 Follows latest CPR guidelines single
    shocks, CPR _at_ 2 min. intervals. Precordial thump
    removed. In the event of return of spontaneous
    circulation (ROSC), CONTACT MEDICAL CONTROL for
    post-resuscitation care.

26
Pediatric Medical Protocols
  • Cardiac Arrest Non-Shockable Rhythm P5.2 Search
    for and treat for contributing factors address
    as appropriate.
  • Altered Mental Status P6.0 For documented or
    suspected hypoglycemia
  • Administer DEXTROSE 1g/kg IV or IO
  • For patients 40 kg or less, DEXTROSE 25 4 ml/kg
  • For patients 40 kg or more, DEXTROSE 50 2 ml/kg
  • if no response in 5 minutes, repeat the same
    dose.

27
Pediatric Medical Protocols
  • Anaphylactic Reaction P7.0 Standing Orders for
    Methylprednisolone, Albuterol, and rapid fluid
    infusion added. Prior to initiating Routine
    Medical Care, Epinephrine is indicated as
    follows
  • Cardiovascular collapse present, 11,000 0.01
    mg/kg (max dose 0.3mg) IM
  • Post RMC, if patient still manifests
    Cardiovascular collapse, administer Epinephrine
    110,000 0.01 mg/kg IV or IO
  • Toxic Exposure / Poisoning P8.0 For Carbon
    Monoxide (CO) exposure with history and
    signs/symptoms - Monitor CO levels
    (if available) - 100 oxygen
    therapy

28
Pediatric Medical Protocols
  • Non-Traumatic Shock P9.0 Fluid Challenge 0.9
    Normal Saline IV or IO 5-10 ml/kg, rapid
    infusion may be repeated as needed. Avoid in the
    presence of pulmonary edema
  • Note PALS recommends giving smaller volumes if
    myocardial dysfunction or distributive shock is
    present of suspected but more rapid infusion
    boluses may be needed to correct hypotensive or
    septic shock.
  • REMAC contends that infusion volumes of 20 ml/kg
    may be necessary. Plans to appeal to SEMAC.

29
Pediatric Medical Protocols
  • Neonatal Resuscitation P10.0 Now states If
    thick meconium is observed in amniotic fluid AND
    the newborn demonstrates absent or depressed
    respirations, heart rate under 100 per minute, or
    poor muscle tone
  • Clear the airway using endotracheal intubation
    and directly suction the endotracheal tube.
  • Repeat the procedure until the endotracheal tube
    is clear of thick meconium up to a maximum of
    three (3) times.
  • DO NOT re-intubate once the airway has been
    cleared of thick meconium unless the newborn
    still meets the criteria in STEP 2.

30
Pediatric Medical Protocols
  • Seizures P11.0 After initiating Routine Medical
    Care, measure serum glucose, for hypoglycemia
    administer
  • DEXTROSE 1g/kg IV or IO
  • For patients 40 kg or less, DEXTROSE 25 4 ml/kg
  • For patients 40 kg or more, DEXTROSE 50 2 ml/kg
  • If no response in 5 minutes, repeat the same
    dose.
  • GLUCAGON 0.1 mg/kg IM if IV or IO route is not
    available, up to a maximum dose of 1 mg.
  • Standing Order now for a Benzodiazepine(Diazepam
    , Lorezapam, or Midazolam).

31
Special Protocols
  • Westchester Regional Paramedic Protocol Update
    2009

32
Pain Management S1.0
  • Replaces old protocols 31 and 31a
  • Changed For patients presenting with need for
    pain management (a) with a SBP greater than 110
    mmHg
  • MORPHINE 0.1 mg/kg IV or IO (maximum 5 mg) (b)
    For continued pain, repeat once (maximum total
    dose 10 mg)
  • Contact Medical Control

33
Pain Management S1.0
  • Replaces old protocols 31 and 31a
  • Added Notes a b.
  • a. Pain management is CONTRAINDICATED for
    patients presenting with (including but not
    limited to)
  • Altered Mental Status, Moderate or Severe Head
    Trauma, Overdoses, or Hypotension
  • b. If HYPOVENTILATION develops
  • in the ADULT PATIENT, administer NALOXONE up to 2
    mg IV, IO or IN.
  • in the PEDIATRIC PATIENT, administer NALOXONE 0.1
    mg/kg IV, IM, IO or IN

34
Rapid Sequence Intubation S2.0
  • Replaces old protocol S-1
  • Added Note b. Once medication is used to
    facilitate intubation, whether or not it is
    successful, the patients respiratory effort MUST
    be monitored with CONTINUOUS WAVEFORM
    CAPNOGRAPHY.

35
Nerve Agent Antidotes S3.0
  • Replaces old protocol S-2
  • Added Commercially available DuoDoteTM
    auto-injectors, or the previously manufactured
    Mark I kits, may be possessed / used by a
    paramedic only under the following conditions…
  • Changed Directs provider to Adult Administration
    Protocol (S3.1) and Pediatric Administration
    Protocol (S3.2)
  • (Continued on Next Slide)

36
Nerve Agent Antidote-Adult S3.1
  • Changed Standing Orders now
  • MILD - 1 MARK I KIT /1 DUODOTETM KIT or ATROPINE
    2 mg IV, IM or IO every 5 minutes until
    secretions resolve / PRALIDOXIME 1 g IV, IM or IO
    over 10 minutes
  • MODERATE - 2 MARK I KITS / 2 DUODOTETM KITS or
    ATROPINE 4 mg IV, IM or IO every 5 minutes until
    secretions resolve / PRALIDOXIME 2 g IV, IM or IO
    over 10 minutes
  • SEVERE - 3 MARK I KITS /3 DUODOTETM KITS or
    ATROPINE 6 mg IV, IM or IO every 5 minutes until
    secretions resolve / PRALIDOXIME 2 g IV, IM or IO
    over 10 minutes
  • (Continued on Next Slide)

37
Nerve Agent Antidote-Pediatric S3.2
  • Changed Standing Orders now
  • MODERATE - 2 MARK I KITS / 2 DUODOTE KITS or
    ATROPINE 0.02 mg/kg IV, IM or IO every 5 minutes
    until secretions resolve / PRALIDOXIME 40 mg/kg
    IV, IM or IO over 10 minutes
  • SEVERE - 3 MARK I KITS /3 DUODOTE KITS or
    ATROPINE 0.04 mg IV, IM or IO every 5 minutes
    until secretions resolve / PRALIDOXIME 40 mg/kg
    IV, IM or IO over 10 minutes
  • If the patient is presenting with MILD exposure
    symptoms, CONTACT MEDICAL CONTROL.
  • 1 MARK I KIT /1 DUODOTE KIT or ATROPINE 0.02
    mg/kg IV, IM or IO every 5 minutes until
    secretions resolve / PRALIDOXIME 40 mg/kg IV, IM
    or IO over 10 minutes

38
Standard Operating Procedures
  • Westchester Regional Paramedic Protocol Update
    2009

39
Standard Operating Procedures
  • Three new procedures
  • Advanced Airway Management
  • Tension Pneumothorax
  • Intravenous Access

40
Advanced Airway Management
  • Includes
  • Endotracheal Intubation (ETT)
  • Laryngeal Mask Airway (LMA)
  • Multi-lumen Airway (i.e. Combitube)
  • Foreign Body Airway Removal via direct
    Laryngoscopy
  • Needle Cricothyrotomy
  • Tracheal Suctioning (including meconium
    aspiration)
  • Gastric Decompression
  • Needle Decompression
  • Rapid Sequence Intubation (RSI)
  • May only be performed by with approval of WREMAC

41
Advanced Airway Management
  • Must document PRIMARY confirmation of ETT
    placement using
  • Qualitative Methods
  • Colormetric end-tidal CO2 detectors
  • Quantitative Methods
  • Digital end-tidal CO2 detectors
  • Wave form capnography

42
Advanced Airway Management
  • Document secondary confirmation using accepted
    clinical parameters per ACLS guidelines.
  • Continuous Waveform Capnography must be monitored
    if medication is used to facilitate intubation.

43
Tension Pneumothorax
  • Evidence of respiratory/cardiovascular compromise
    and two of the following
  • - Absent/decreased breath sounds on affected
    side - Tracheal deviation - Subcutaneous
    emphysema
  • Pleural decompression is indicated using a large
    bore over the needle catheter or other REMAC
    approved device.
  • Procedure may be repeated if signs and symptoms
    recur.

44
Intravenous Access
  • IV KVO of NS or IV lock unless fluid challenge is
    required.
  • IV NS with large bore (18ga or larger) catheter
    for patients requiring rapid volume replacement.
  • Peripheral veins (not external jugular) should be
    used as primary access site.
  • IO may be used only if other sites are not
    accessible.
  • IO med administration is preferred over ETT if no
    IV.
  • Blood drawing as indicated. Before med
    administration.

45
Future SOPs
  • Additional SOPs will be added as needed

46
Questions
  • WREMSCO Office
  • 914-231-1616
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