0405 Protocol Revision New Medication Review

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04-05 Protocol Revision New Medication Review
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Overview
-New protocols effective 7/1/05 -Regions
distribute books through services -Available on
the web at www.maine.gov/dps/ems -Every ED and
Pharmacy Director received a copy and letter from
MEMS
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ANTICONVULSANTS
Diazepam is not as good as other benzodiazepines
in controlling seizures
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ANTICONVULSANTS
Head to head, Lorazepam is best but has to be
refrigerated (Can be kept un-refrigerated for 3
weeks but at 4.00/unit, cost becomes an issue).
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ANTICONVULSANTS
Midazolam Is As Good As Diazepam With Better Side
Effect Profile
-Does not need to be refrigerated -Causes less
respiratory compromise -Works well IV,
intranasal, IM, Rectal
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ANTICONVULSANTS
Midazolam Will Be Mandatory Lorazepam Will Be
Optional
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ANTICONVULSANTS
Midazolam (Versed) Classification
Benzodiazepine, Sedative-Hypnotic Mechanism of
Action Short acting benzodiazepine. Mediates
the inhibitory GABA neurotransmitter. MDPB
Indications Anticonvulsant, Pre-medication for
Cardioversion Onset of Action IV1-5 minutes,
IM 5-15 minutes Maximum Effect 20-60
minutes Half life 1-4 hours Contraindications
Acute narrow angle glaucoma Precautions May
cause respiratory depression. May cause
hypotension.
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ANTICONVULSANTS
Midazolam (Versed) Dosage and Administration Adu
lt 3-5 mg IV 3-5 mg IM (Contact OLMC for
alternative route dosing) Pediatric 0.02mg/kg
IV NTE 4mg 0.2mg/kg IM NTE 10mg 10mg
Buccal 0.3mg/kg Rectal NTE 10mg
Note MEMS protocol books are incorrect. Please
make appropriate changes
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ANTICONVULSANTS
Lorazepam (Ativan) Classification
Benzodiazepine, Anxiolytic, Sedative-Hypnotic Mech
anism of Action Mediates inhibitory GABA
neurotransmitter. MEMS Indications
Anti-Convulsant, Pre-medication for
Cardioversion Onset of Action IV 1-5 minutes,
IM 15-30 minutes Maximum Effect IV Immediate,
IM 60-90 minutes Half life 10-20
hours Contraindications Acute narrow angle
glaucoma Precautions May cause respiratory
depression. May required reduced dose for
impaired renal function. Uptake is too slow for
rectal administration.
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ANTICONVULSANTS
Lorazepam (Ativan) Dosage and Administration
Adult 2-4mg IV 2-4mg IM (Contact OLMC
for alternative routes) Pediatric 0.03mg/kg
IV NTE 2mg 0.04mg/kg IM NTE 4mg 0.05-0.15 mg
Buccal
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ANTICONVULSANTS
Pediatric Seizures
Intermediate and above should consider Narcan if
respirations Titrate to improve respiratory drive (Contact
medical control for this option)
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ANALGESIA
MDPB Looked To Replace Meperidine
(Demerol) -Lowest potency opiod is often under
dosed. -Rated as having extreme potency in
causing serotonergic syndrome (See serotonergic
syndrome handout)
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ANALGESIA
To avoid confusion and errors, MDPB Wanted One
Narcotic Fentanyl Fentanyl provided an accepted
alternative with potent effects, easy dosing and
few side effects.
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ANALGESIA
Fentanyl -80X more potent than Morphine -Has
little histamine response (0.3 incidence of
hypotension associated with administration) Ther
efore it has minimal effect on blood pressure
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ANALGESIA
But what about use in cardiac patients?
-Fentanyl is supported by the MEMS Cardiac
Advisory Committee The theoretic vasodilatory
effects of MS in cardiac patients is better
accomplished by administration of nitrates.
Analgesic effects can be obtained using any
narcotic.
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ANALGESIA
Fentanyl Citrate (Fentanyl) Classification
Narcotic (opiate) Agonist, Analgesic Mechanism of
Action Potent narcotic agonist Indications
Short acting analgesia Onset of Action IV
Immediate, IM 7-15 minutes Maximum Effect IV
1-5 minutes Duration IV 30-40
minutes Contraindications Hypersensitivity Precau
tions May increase ICP, May cause respiratory
depression
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ANALGESIA
Fentanyl Citrate (Fentanyl) Dosage and
Administration Adult 25-50 micrograms IV q
10 minutes NTE 200 micrograms 25-50
micrograms IM
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ANALGESIA
Fentanyl Continued
Contact Medical Control -If further dosing
needed -If vital signs are not stable -With
dosage questions such as Pediatrics
Abnormal vital signs Coincident drug use
(including alcohol) by patient -If IV cannot be
established -If analgesia needed for other than
isolated extremity trauma
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ANALGESIA
Note Fentanyl 25-50 micrograms may be given as
a standing order for isolated extremity fractures.
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CARDIAC
Nitroglycerine
If patient has BP 100 and has had NTG before,
it is ok to give NTG without IV access. Viagra
changed to erectile dysfunction for precaution
in NTG administration
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CARDIAC
Fentanyl may be used in place of morphine for
cardiac analgesia -MONA (Morphine, Oxygen,
Nitrates, ASA) Becomes FONA (Fentanyl, Oxygen,
Nitrates, ASA)
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CARDIAC
Acute Pulmonary Edema
Furosemide 40mg now standing order for APE
patient
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CARDIAC
Acute Pulmonary Edema
Intermediates may now administer nitroglycerin in
APE
with medical control
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CARDIAC
Acute Pulmonary Edema
NTG 0.4 mg sub lingual or 1 spray -Repeat X2 at 5
minute intervals if systolic BP100 -Note If
patient has BP 100 had NTG before, it is ok to
give NTG without IV access. -Discuss with medical
control if patient has taken erectile dysfunction
medication within the past 72 hrs.
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CARDIAC
Recognizing Acute Pulmonary Edema
Acute vs. Chronic onset History of
APE -Including medications Crackles
(rales) -Beware new onset wheezes Elevated
BP -You can have hypotension with APE as
well Other Signs and symptoms -Severe
agitation, JVD, etc.
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CARDIAC

• Basic EMTs and ASA
• 162mg (or 324mg depending on hospital preference)
  Aspirin is now a standing order for Basic EMTs
  to administer to adults with chest pain of
  suspected cardiac origin.
• -Medical Control is not necessary

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CARDIAC

• Basic EMTs and ASA
• ASA is given for cardiac related pain only
  Question allergies
• ASA should be given in the acute setting even if
  the patient is taking daily ASA
• Consult medical control for patients with severe
  GI history (bleeding ulcers, etc.)

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CARDIAC
Pediatric AED Use

• For Children 1 and
• Not for infants (
• CPR for one minute
• Use Pediatric Pads if available
• If chest is too small, do not overlap use
  anterior posterior position

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OPTHALMOLOGY
Tetracaine Drops -Standing order for eye pain,
chemical exposures or abrasions to the eye.
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OPTHALMOLOGY
Tetracaine Hydrochloride Drops (0.5Solution) Cla
ssification Fast acting ophthalmic
anesthetic Mechanism of Action Blocks sodium
membrane permeability (Nervous conduction) Onset
of Action 25 30 seconds Duration 15
minutes Contraindications Penetrating trauma,
Hypersensitivity to local anesthetics Precautions
Guard against rubbing of the eye during
anesthesia. All patients administered drops
should be transported for further evaluation.
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OPTHALMOLOGY
Tetracaine Hydrochloride Drops (0.5Solution) Do
sage and Administration 1-2 drops to each
affected eye (.1cc/drop) (with continuous NS
flush in the event of chemical exposure)
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OTHER PROTOCOL CHANGES
Airway Algorithm

• -Intermediate and Paramedic Services
• Mandatory addition of LMAs
• Optional addition of Combitubes and intubation
  assistive devices (tube changers, etc.)
• MEMS will assign a future compliance date

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Airway Training Module
OTHER PROTOCOL CHANGES

• Rolled out around the state over the next few
  months
• Required for all intermediates and paramedics
• MEMS BLS I/Cs will be encouraged to take the
  program as well.
• A completion date has not yet been set, but
  personnel are not allowed to use the new
  equipment until they have been trained

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OTHER PROTOCOL CHANGES
Intermediate Drug Administration

• Intermediates may administer medications up to
  the level of their training with a paramedic
  present without calling medical control.

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OTHER PROTOCOL CHANGES

• Epinephrine 11000 should now be given IM rather
  than SQ
• -Absorption rates are dramatically improved with
  this method.

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OTHER PROTOCOL CHANGES

• Guideline for Diabetic Signoff
• This is not permission to signoff or force
  someone to come to hospital
• It is really a consultation
• To be sure signoff is appropriate, nothing
  missed, and possibly to convince a patient who
  needs to be seen to go to the hospital

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OTHER PROTOCOL CHANGES

• Guideline for Diabetic Signoff
• Appropriate refusal PLUS
• OLMC
• IDDM
• -Not first crisis
• -Afebrile
• -only 1 amp D50 used
• -Left in care of responsible adult
• -Patient agrees to food and is able to recheck
  sugar

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OTHER PROTOCOL CHANGES

• The following new sections have been added to
  the protocols and should be reviewed by all
  providers
• -Hypothermia
• -Trauma Triage
• -Sexual Assault
• -Child Abuse
• -LMA Sizes

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SUMMARY

• Many changes
• Some providers will require more review than
  others
• Relearning and unlearning is hard cues can be
  helpful
• QI is important

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REFERENCES
Ped Emer Care 1997 92-4 Annals of Emer. Med.
1989635-9 NEJM 2001 631-7 J Ped Child Health
2002 582-6 J Child Neurology 2002 123-6 J Ped
Child Health 2004 556-558 Wilson, BA, Shannon,
M, Stang, C. Prentice Hall Nurses Drug Guide
(2005 edition). Pearson Education Inc.,
2005 Beck, Richard. Drug References for EMS
Providers. Delmar Publishers, 2002 http//www.rxl
ist.com
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CREDITS
This program developed by Dan Batsie, NREMT-P,
Steven Diaz, MD, Joanne Lebrun, MS and Paul
Marcolini, BS, WEMT-P, CCEMT-P Content from
Maine EMS Prehospital Protocols 2005