Note to Instructors

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Note to Instructors

• Please review the comments (notes) below each
  slide before instructing this session.

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Monroe-Livingston Regional EMS Protocol Update

• Basic EMT Version
• Effective April 1, 2007

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Hard Copies of the Protocols

• http//mlrems.org/forms.php

( http//mlrems.org/MLREMS20200720Protocols20FI
NAL.pdf )
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Objective

• Review new content and layout of protocols
• Identify significant changes to BLS protocols

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Protocol Development Process

• Protocol Subcommittee develops suggested changes
• Protocols distributed for 30 day public comment
  period
• Changes are made based on public comment and
  submitted to REMAC for approval
• REMAC approved protocols taken to the SEMAC
  meeting for state approval

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Protocol Subcommittee

• Robert Breese, EMT-P James Capparelli, EMT-P
• Jeremy Cushman, MD (Chair) Rollin Terry
  Fairbanks, MD
• Chris Forsyth, EMT-P Dick Garrett, EMT-P
• Dan Hays, PharmD Marc Lampell, MD
• Aaron Marks, EMT-P Bryan McKinley, EMT-P
• Richard Race, EMT-P Erik Rueckmann, MD
• Rick Russotti, EMT-P Manish Shah, MD
• Sheri Strollo, EMT-P Terry Taylor, EMT-P

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Major Changes

• Format changes
• Educational content decreased
• Improved ease of reading
• New resources added
• In some cases, dramatic changes to existing
  protocols

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New Resources Added

• BLS Pharmacology
• ALS Pharmacology
• Appendices
• Adult and Pediatric GCS
• Adult and Pediatric Trauma Triage Criteria
• Pediatric Normal Vital Signs and Airway Equipment
• Rule of Nines Chart
• Emergency Department Contact Information
• Dopamine and Epinephrine Infusion Charts

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Protocol Organization

• Section 1
• Standing orders, radio/phone failure, DNR,
  termination of resuscitation and obvious death
• Section 2
• Combined patient care protocols (adult and peds)
• Section 3
• Adult Cardiac Life Support
• Section 4
• Pediatric Cardiac Life Support

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Protocol Organization

• Section 5
• BLS Pharmacology
• Section 6
• ALS Pharmacology
• Section 7
• Regional Policies/Procedures
• Section 8
• SCT Protocols
• Section 9
• HAZMAT Protocols
• Appendix

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Pediatrics

• No longer a separate section on pediatrics EXCEPT
  for PALS
• Pediatric specific medications and protocols are
  delineated by the teddy bear

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Medical Control Communication Requirements

• Medical control may be contacted at any time by
  any level if there is a question or concern, or
  if the provider would like additional guidance
• New format for indicating medical control contact
  requirements
• The format is as follows

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1.0 Routine Standing Orders

• Identifies routine care expected on all patients
• Determination of decisional capacity
• Bringing appropriate equipment to patient side
• Documenting vital signs on every patient
• Oxygen as needed to maintain saturation 96
  (New)
• Blood Glucose determination (BLS if available)
  (New)
• Contacting receiving hospital for unstable or
  potentially unstable patients
• Timely transport and crew safety
• Vascular access, airway management and ECG
  monitoring as appropriate

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1.1 Radio/Phone Failure

• Radio/Phone failure occurs when
• No cellular service, telephones or radios at the
  scene
• No physician is available
• Agency is operating outside of region as part of
  a declared disaster mutual aid plan
• All protocols become standing orders with the
  exception of
• EMT-CC EMT-P and EMT-P Physician consult lines
  are absolute on-line and cannot be performed
  unless direct physician order
• Absolute On-Line All providers must obtain
  direct physician order to perform

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1.2 On-Scene Medical Personnel

• Personal physician
• Must write and sign orders on PCR
• Bystander Physician
• Must accompany patient to the hospital AND write
  and sign orders on PCR
• RN/PA/LPN, etc
• May assist with patient care but only under the
  direction of the EMS provider and may not assume
  responsibility for patient care
• Other Pre-Hospital Providers
• Off-duty personnel may assist with patient care
  but may not be in charge of or assume
  responsibility for patient care

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1.3 Do Not Resuscitate Orders

• Valid DNR includes
• NYS approved document, bracelet, or necklace
• Properly documented nursing home or hospital DNR
  form
• Properly documented MOLST form
• If pulse present provide oxygen, suction, and
  comfort measures
• If pulse absent contact police

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1.4 Termination of Resuscitation

• ALL criteria must be met for field termination
  with ABSOLUTE ON-LINE physician authorization
• Age 18 or older
• Non-traumatic, non-hypothermic.
• ECG is asystole confirmed in three leads,
  ventricular standstill, or pulseless
  idioventricular rhythm with a rate lt10 beats per
  minute.
• Cardiac arrest protocols have been followed for
  at least 25 minutes, including successful
  intubation or advanced alternate airway, IV/IO
  access, adequate CPR, and appropriate
  pharmacologic therapy.
• There has been no return of a perfusing cardiac
  rhythm at any time during at least 25 minutes of
  resuscitative measures.
• Patient is not in a public place.
• Appropriate emotional support by family,
  neighbors, clergy, police, or EMS crewmembers is
  available at the scene if the family is present.

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1.5 Obvious Death

• If any ONE of the following conditions are met
  and the patient is pulseless, CPR need not be
  begun
• Body decomposition
• Rigor mortis with warm air temperature
• Dependent lividity
• Injury not compatible with life (i.e.
  decapitation, burned beyond recognition, massive
  open or penetrating trauma to the head or chest
  with obvious organ destruction)
• If a bystander or first responder has initiated
  CPR OR if the patient was submerged in water for
  greater than one hour, you MUST contact medical
  control

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2.0 AIRWAY MANAGEMENT ADULT

• All levels
• Oxygen therapy is covered under standing orders
• Hyperventilation no longer used.
• Ventilatory rates 10-12/minute in the adult

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2.1 AIRWAY MANAGEMENTPEDIATRIC

• All Levels
• BVM rate listed at 12-20
• Hyperventilation is strongly discouraged.
• Spontaneous respirations supported as needed (up
  to limits)

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2.2 AIRWAY OBSTRUCTION - ADULT

• All Levels
• Simplified language and matches 2005 AHA
  Guidelines
• No abdominal thrusts for unconscious patient,
  perform CPR instead
• No blind finger sweeps

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2.3 AIRWAY OBSTRUCTION - PEDIATRIC

• ALL Levels
• Meets 2005 AHA Guidelines
• Language simplified and altered to agree with
  standing orders
• Unconscious patients receive CPR
• No abdominal thrusts
• No blind finger sweeps

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2.4 ALTERED MENTAL STATUS

• All Levels
• Transport guidelines simplified with confusing
  wording removed
• Blood glucose determination has been approved for
  BLS with referral to appropriate protocol if BG lt
  80 mg/dL
• Remember that BLS cannot cancel ALS for altered
  mental status or syncopal patients

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2.5 ANAPHYLAXIS/ALLERGIC REACTION

• All Levels
• Combined protocol
• Epinephrine in the form of an Epi-Pen should be
  administered ONLY if evidence of shock, airway
  swelling or significant respiratory distress
• Adult Epi-Pen may be administered by standing
  order if patient has one previously prescribed
  otherwise, must contact medical control prior to
  administering
• Pediatric Epi-Pen should be used for children
  less than 30 kg (66 pounds)

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2.6 APPARENT LIFE THREATENING EVENT (ALTE)

• ALTE - An episode in an infant or child less than
  2 years old which is frightening to the observer
  and is characterized by one or more of the
  following
• Apnea (central or obstructive)
• Skin color change cyanosis, erythema (redness),
  pallor, plethora (fluid overload)
• Marked change in muscle tone
• Choking or gagging not associated with feeding or
  a witnessed foreign body aspiration
• Seizure-like activity
• Why a protocol?
• Incidence of ALTE is about 7.5 in the pediatric
  EMS population
• Overwhelming (83) of patients have no apparent
  illness/distress
• But 48 of these non-ill children had
  significant illnesses upon ED evaluation

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2.6 APPARENT LIFE THREATENING EVENT (ALTE)

• New protocol
• Pediatric only protocol infants or children lt 2
  years old
• All Levels
• Routine care
• Most children will appear completely normal and
  healthy
• Child should be evaluated by ALS and ALS should
  not be cancelled upon BLS arrival
• Strongly encourage transport (medical control
  REQUIRED for parent/guardian refusal)

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2.7 BEHAVIORAL EMERGENCIES

• ALL Levels
• Simplified wording and language
• Reference to Management of Violent or Potentially
  Violent Behavior procedures
• Consider ALS for sedation if you must physically
  restrain patients

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2.8 BURNS

• Combined Adult/Pediatric Protocol
• All Levels
• Simplified language and combined all aspects
• Remove patient from source of burn, and
  cool/decontaminate appropriately
• Pain management should be considered
• ALS providers may now give first dose morphine by
  standing order for burn patients

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2.9 CHEST PAIN/THREATENED MYOCARDIAL INFARCTION

• ALL Levels
• Nitroglycerin warnings regarding Erectile
  Dysfunction (ED) meds (e.g., Viagra, Levitra,
  Cialis) added.
• Can administer NTG once every 5 minutes up to 3
  doses provided patients systolic BP is greater
  than 120
• Aspirin 75-81 mg x4 by mouth added for EMTs
• Contraindicated only in patients who are
  allergic, actively bleeding, or are having
  symptoms of a stroke

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2.10 CHEST TRAUMA

• All Levels
• Formatting change with simplification of language
  to remove redundancy
• No specific BLS treatment other than routine
  trauma care

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2.11 Conducted Energy Devices

• To standardize treatment of the Taser patient
• -Patients will be in police custody
• -Treatment should be a cooperative venture
  between Police and EMS
• -Define High Risk Patient
• BLS may not remove Taser Probes, removal by ALS
  providers only

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2.12 Croup

• Treatment of a common Pediatric Respiratory
  Disorder
• -Treatment with Humidified High Flow O2
• If patient is unable to ventilate refer to Airway
  Obstruction Protocol

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2.13 Diabetic Emergencies

• BLS assessment of Blood Glucose, if agency
  approved
• If Patient is able to speak, offer oral sugar
  if they are unable to speak clearly, then no
  material (glucogel, etc) should be placed in the
  mouth.

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2.14 Fluid Challenge/Replacement

• Care within this protocol outside scope of
  practice of the EMT-B
• Should familiarize oneself with indications for
  fluid challenge/replacement, however, to
  appropriately request ALS resources

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2.15 Head Trauma

• Patients head should not be lower than body
• Maintain cervical spine immobilization
• BVM ventilations (if needed) should be at 10/min
• Hyperventilation is bad for head injury patients

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2.16 Hyperthermia/Heat Exhaustion/Heat Stroke

• Defined as a Core Body Temperature of gt40.6C
  (105F)
• Institute proper cooling of the patient
• Do not cool too fast to induce shivering!

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2.17 Hypotension/Shock

• Shock is inadequate tissue perfusion
• Shock may be present even in a normotensive
  patient
• Treat underlying cause of shock

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2.18 Hypothermia

• Core body temperature of lt35C (95F)
• Avoid rough handling of patient
• Assess heart rate for 1 full minute
• Passive re-warming
• Remove wet clothes
• Warm ambulance/blankets

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2.19 Nausea/Vomiting

• Treatment of Nausea/Vomiting without head injury
• Assure scene safety take universal precautions
• No significant changes for BLS providers, ALS may
  administer phenergan

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2.20 Near Drowning

• Treatment is routine supportive medical care
• Do not use Heimlich to remove water from Lungs
• Spinal precautions per protocol

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2.21 Neonatal Resuscitation

• Care of the Critical Newborn
• -The primary concerns of newborn resuscitation
  are adequate
• oxygenation, airway patency and warmth.
• All Levels
• If respirations lt 30 or heart rate lt 100
• - Ventilate with 100 oxygen using neonatal or
  small child bag-valve mask at a rate of 40-60 per
  min.
• CPR for Heart Rate lt 60
• - Begin chest compressions at rate of 120 per
  minute utilizing a compression/ventilation ratio
  of 31. Begin timely transport.

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2.22 Obstetric Emergencies

• Protocol has been dramatically simplified, but no
  changes for BLS providers
• For any delivery, contact medical control as
  indicated to assist with instructions specific to
  scenario

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2.23 Pain Management

• BLS should consider calling for ALS if they have
  a patient with pain gt 4 out of 10 due to
• burns, amputation or isolated extremity fracture
  / dislocation without evidence of head injury
• In these circumstances, ALS may administer
  morphine for pain control by standing order.

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2.24 Poisoning / Overdose

• Assure adequate airway
• Attempt to locate/bring poison to hospital if
  possible
• Activated charcoal is an online medical control
  medication

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2.25 Pulmonary Edema

• Assess signs, symptoms
• Position patient in position of comfort
• Oxygen, assist ventilations as necessary
• Timely transport

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2.26 Rapid Sequence Induction

• Outside of BLS scope of practice, however
  indications and contraindications are reviewed
  for reference
• Indications
• Actual or Potential airway compromise
• GCS 8
• Combativeness that threatens airway
• Smoke inhalation with airway compromise
• Contra-indications
• lt16 years old or lt40 kg
• Neuromuscular disease muscular dystrophy, ALS,
  etc
• Renal dialysis patients
• Paralysis or burns more than 24 hours old

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2.27 Re-establishing Patient Medication IV

• Does not apply to BLS
• This protocol allows ALS providers to
  re-establish certain patient medications in the
  field

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2.28 Respiratory Distress / Bronchospasm

• High flow oxygen
• May assist with patients own nebulizer
• BLS administration of albuterol
• Patient is between 1 and 65
• Patient has a history of asthma with prescribed
  albuterol
• Administer 5mg albuterol via nebulizer (2.5 mg
  for pediatrics)
• Additional doses per medical control
• Consider ALS intercept, do not delay care on
  scene
• ALS cannot release to BLS after medication
  administration

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2.29 Sedation

• Does not apply to BLS
• This protocol allows ALS providers to provide
  pain control and sedation for painful procedures
  (cardioversion, pacing, or after one is intubated)

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2.30 Seizure

• Assure adequate airway
• Consider possible causes
• Begin timely transport with ALS intercept
• Assess blood glucose if able

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2.31 Stroke / CVA

• Familiarize oneself with the Cincinnati Stroke
  Scale
• Treatment is supportive
• Airway patency
• Do not hyperventilate
• Consider causes for mental status change
• Assess BG if able

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2.32 Vascular Access

• Does not apply to BLS
• This protocol defines the types of intravenous
  access that may be obtained by advanced providers

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3.0 Cardiac Arrest General

• General Information
• Start CPR immediately
• Hard and fast
• Good BLS airway
• CPR should be continued at all times, except
  during defibrillation and / or interruptions for
  less than 10 seconds for patient transfer
• Defibrillation should not be preformed in a
  moving ambulance
• If ALS not available, no more than 3 shocks
  should be delivered on scene begin transport
  ASAP
• All subsequent Section 3 Protocols relate to ALS
  care

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4.0 Pediatric Cardiac Arrest General

• General Information
• Start CPR immediately
• Hard and fast
• Good BLS airway
• CPR should be continued at all times, except
  during defibrillation and / or interruptions for
  less than 10 seconds for patient transfer
• Defibrillation should not be preformed in a
  moving ambulance
• If ALS not available, no more than 3 shocks
  should be delivered on scene begin transport
  ASAP
• All subsequent Section 4 Protocols relate to ALS
  care

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Dont forget!

• Also available in your protocols
• BLS Medication Appendices
• Reference Appendix
• Adult and Pediatric GCS, Rule of 9s, infusion
  charts, etc.
• Policies/Procedures, HazMat Protocols, SCT
  Protocols available on www.mlrems.org (All to be
  updated for 2008)

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Questions, comments and suggestions for the
future.