PROTOCOL UPDATE ALABAMA EMS PROTOCOLS PARAMEDIC EDITION 5 JUNE, 2010 UPDATE 1

PROTOCOL UPDATEPROTOCOL UPDATEALABAMA EMS PROTOCOLSALABAMA EMS PROTOCOLS

PARAMEDICPARAMEDIC

EDITION 5 EDITION 5

JUNE, 2010 UPDATE JUNE, 2010 UPDATE

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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: [email protected]@adph.state.al.us

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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

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TITLE PAGE & TABLE OF TITLE PAGE & TABLE OF CONTENTSCONTENTS

• TABLE OF CONTENTS UPDATED WITH TABLE OF CONTENTS UPDATED WITH CHANGESCHANGES– Added two new Patient Care ProtocolsAdded two new Patient Care Protocols

• 4.26 Respiratory Illness/Influenza4.26 Respiratory Illness/Influenza• 4.27 Respiratory Illness – Mass Casualty Emergency4.27 Respiratory Illness – Mass Casualty Emergency• Renumbered:Renumbered:

– 4.28 Seizures4.28 Seizures– 4.29 Shock4.29 Shock– 4.30 Stroke4.30 Stroke– 4.31 Suspected Spinal Injury4.31 Suspected Spinal Injury– 4.32 Syncope4.32 Syncope– 4.33 Vaginal Bleeding4.33 Vaginal Bleeding– 4.34 Vomiting and Nausea4.34 Vomiting and Nausea

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SECTION 4SECTION 4

TREATMENT PROTOCOLSTREATMENT PROTOCOLS

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ALLERGIC REACTION 4.4ALLERGIC REACTION 4.4

• Because it is more rapidly absorbed and reaches Because it is more rapidly absorbed and reaches higher blood levels, higher blood levels, IM epinephrine for allergic IM epinephrine for allergic reactions is now preferred to SQ epinephrinereactions is now preferred to SQ epinephrine

• IV epinephrine has been associated with IV epinephrine has been associated with iatrogenic overdoses and cardiac complications iatrogenic overdoses and cardiac complications and its use for allergic reactions is discouraged and its use for allergic reactions is discouraged except for anaphylactic shock where the 1:10,000 except for anaphylactic shock where the 1:10,000 solution can be given but is Category Bsolution can be given but is Category B

• The 1:1000 solution is The 1:1000 solution is NEVERNEVER given IV given IV• The Epipen can still be used but its needle may be The Epipen can still be used but its needle may be

too short to reach the muscle in some obese too short to reach the muscle in some obese patientspatients

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CARDIAC ARREST CARDIAC ARREST 4.84.8

• Under “Physical Assessment, Part B” Under “Physical Assessment, Part B” changed “closed chest massage” to “chest changed “closed chest massage” to “chest compressions” to reflect current compressions” to reflect current terminologyterminology

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CARDIAC ARREST CARDIAC ARREST 4.84.8

• Treatment of adult VFib/Pulseless Vtach, Treatment of adult VFib/Pulseless Vtach, Part J:Part J:– Added that if you substitute vasopressin for the first Added that if you substitute vasopressin for the first

dose of epinephrine, you can give subsequent doses of dose of epinephrine, you can give subsequent doses of epinephrineepinephrine

– Because of the current shortage of 1:10,000 epinephrine Because of the current shortage of 1:10,000 epinephrine this may temporarily have to be the preferred this may temporarily have to be the preferred medication for Vfib/Pulseless Vtach in adultsmedication for Vfib/Pulseless Vtach in adults

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CARDIAC MEDICATIONS 4.9CARDIAC MEDICATIONS 4.9

• Corrected category of Amiodarone Corrected category of Amiodarone (Cat. A)(Cat. A)

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

• Added wording to stress that women, diabetics, Added wording to stress that women, diabetics, and all adult medical patients over the age of 50 and all adult medical patients over the age of 50 years have an increased risk of coronary artery years have an increased risk of coronary artery disease.disease.

• Also stressed that all adult patients complaining Also stressed that all adult patients complaining of epigastric pain should have an ECG performedof epigastric pain should have an ECG performed

• Noted that all Ambulance services must have the Noted that all Ambulance services must have the capability to perform 12-lead ECGs on patients by capability to perform 12-lead ECGs on patients by June of 2013June of 2013

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CONGESTIVECONGESTIVEHEART FAILURE 4.14HEART FAILURE 4.14

• Changed dose of Furosemide from Changed dose of Furosemide from

20-40mg to 40mg to simplify the 20-40mg to 40mg to simplify the dosagedosage

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4.26 Respiratory 4.26 Respiratory Illness/InfluenzaIllness/Influenza

NEW PROTOCOLNEW PROTOCOLFor Routine Use During a Flu EpidemicFor Routine Use During a Flu Epidemic

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1. 1. Follow General Patient Care Protocol 4.1Follow General Patient Care Protocol 4.1

2. 2. Be sure you are using appropriate standard Be sure you are using appropriate standard precautionsprecautionsA. If Dispatch advises of the potential for acute febrile A. If Dispatch advises of the potential for acute febrile

respiratory illness symptoms on scene, you should don PPE respiratory illness symptoms on scene, you should don PPE for suspected cases of influenza prior to entering the for suspected cases of influenza prior to entering the scene. This includes disposable N-95 mask, eye protection scene. This includes disposable N-95 mask, eye protection (shield or goggles), and disposable non-sterile gloves.(shield or goggles), and disposable non-sterile gloves.

B. If Dispatch has not identified individuals with symptoms of B. If Dispatch has not identified individuals with symptoms of acute febrile respiratory illness symptoms on scene, you acute febrile respiratory illness symptoms on scene, you should stay more than 6 feet away from the patient and should stay more than 6 feet away from the patient and bystanders with symptoms and exercise appropriate bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all routine respiratory droplet precautions while assessing all patients for suspected cases of influenza. If patient has patients for suspected cases of influenza. If patient has signs or symptoms of influenza, you should don the PPE signs or symptoms of influenza, you should don the PPE described above before coming in close contact with the described above before coming in close contact with the patient.patient.

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3. 3. Signs and Symptoms of InfluenzaSigns and Symptoms of Influenza::

a.a. Rapid onset of symptomsRapid onset of symptoms

b.b. Difficulty breathing with exertionDifficulty breathing with exertion

c.c. Doctor has already diagnosed influenzaDoctor has already diagnosed influenza

d.d. CoughCough

e.e. FeverFever

f.f. Shaking ChillsShaking Chills

g.g. Pleuritic chest painPleuritic chest pain

h.h. Sore throat (no difficulty breathing or swallowing)Sore throat (no difficulty breathing or swallowing)

i.i. Nasal congestionNasal congestion

j.j. Runny noseRunny nose

k.k. Muscle achesMuscle aches

l.l. HeadacheHeadache

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4. 4. All EMS personnel engaged in aerosol generating All EMS personnel engaged in aerosol generating activities (e.g. endotracheal intubation, bag-mask activities (e.g. endotracheal intubation, bag-mask ventilation, nebulizer treatment, or CPAP [use ventilation, nebulizer treatment, or CPAP [use expiratory filter]) should wear the PPE described expiratory filter]) should wear the PPE described in 2.a.in 2.a.

5. 5. All patients with acute febrile respiratory illness All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the should wear a surgical mask, if tolerated by the patient.patient.

6. 6. Encourage good patient compartment vehicle Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when the concentration of aerosol accumulation when possible.possible.

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TRANSPORT OF PATIENTS TOTRANSPORT OF PATIENTS TOHEALTHCARE FACILITIESHEALTHCARE FACILITIES• When transporting a patient with symptoms of When transporting a patient with symptoms of

acute febrile respiratory illness, you should notify acute febrile respiratory illness, you should notify the receiving healthcare facility so that the receiving healthcare facility so that appropriate infection control precautions may be appropriate infection control precautions may be taken prior to patient arrival. Patients with febrile taken prior to patient arrival. Patients with febrile respiratory illness should wear a surgical mask, if respiratory illness should wear a surgical mask, if tolerated. tolerated.

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INTERFACILITY TRANSPORTINTERFACILITY TRANSPORT• EMS personnel involved in the transfer of patients with EMS personnel involved in the transfer of patients with confirmed influenza or suspected infectious respiratory confirmed influenza or suspected infectious respiratory illness should use standard droplet and contact precautions illness should use standard droplet and contact precautions for all patient care activities. This should include wearing for all patient care activities. This should include wearing disposable N-95 mask, eye protection [shield or goggles], disposable N-95 mask, eye protection [shield or goggles], disposable non-sterile gloves disposable non-sterile gloves and gownand gown. If the transported . If the transported patient can tolerate a surgical mask, its use can help to patient can tolerate a surgical mask, its use can help to minimize the spread of infectious droplets in the patient minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment care compartment. Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. the concentration of aerosol accumulation when possible. Any nonessential equipment that can be removed from the Any nonessential equipment that can be removed from the patient compartment of the ambulance before transport will patient compartment of the ambulance before transport will hasten the time needed to disinfect and return to service.hasten the time needed to disinfect and return to service.

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CLEANING VEHICLE AFTER TRANSPORTING CLEANING VEHICLE AFTER TRANSPORTING AN INFLUENZA PATIENTAN INFLUENZA PATIENT• After the patient has been removed and prior to cleaning, the air After the patient has been removed and prior to cleaning, the air

within the vehicle may be exhausted by opening the doors and within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment.vehicle and on non-disposable equipment.

• Routine cleaning with soap or detergent and water to remove Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective disinfectants, are the basic components of effective environmental management of influenza. Reducing the number environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can of influenza virus particles on a surface through these steps can reduce the chance of hand transfer of virus particles. Influenza reduce the chance of hand transfer of virus particles. Influenza viruses are susceptible to inactivation by a number of chemical viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial disinfectants readily available from consumer and commercial sources.sources.

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MASS CASUALTY EMERGENCYMASS CASUALTY EMERGENCYNEW PROTOCOLNEW PROTOCOLNot for Routine UseNot for Routine Use

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MASS CASUALTY EMERGENCYMASS CASUALTY EMERGENCY• This protocol is designed to be implemented only when This protocol is designed to be implemented only when

there is a significant respiratory disease that has impacted there is a significant respiratory disease that has impacted the health care system to the extent that hospital beds are the health care system to the extent that hospital beds are full, few or no ventilators are available for new patients with full, few or no ventilators are available for new patients with respiratory failure, the EMS/Dispatch work force is respiratory failure, the EMS/Dispatch work force is significantly depleted due to absenteeism, and the calls for significantly depleted due to absenteeism, and the calls for EMS support overwhelm resources to manage all calls. EMS support overwhelm resources to manage all calls. When the Governor proclaims a state of emergency, the When the Governor proclaims a state of emergency, the Alabama Public Health Department (ADPH) Office of EMS & Alabama Public Health Department (ADPH) Office of EMS & Trauma (OEMS&T) will activate this protocol to provide Trauma (OEMS&T) will activate this protocol to provide authorization for the adjustment in the prehospital standard authorization for the adjustment in the prehospital standard of care. Depending upon the Governor’s proclamation, of care. Depending upon the Governor’s proclamation, ADPH OEMS&T may activate this protocol statewide or on a ADPH OEMS&T may activate this protocol statewide or on a regional or local basis.regional or local basis.

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4.27 Respiratory 4.27 Respiratory Illness/InfluenzaIllness/Influenza MASS CASUALTY EMERGENCY MASS CASUALTY EMERGENCY 1.1. Follow General Patient Care Protocol 4.1.Follow General Patient Care Protocol 4.1.

2. 2. Be sure you are using appropriate standard precautionsBe sure you are using appropriate standard precautionsA. If Dispatch advises of the potential for acute febrile respiratory A. If Dispatch advises of the potential for acute febrile respiratory

illness symptoms on scene, you should don PPE for suspected illness symptoms on scene, you should don PPE for suspected cases of influenza prior to entering the scene. This includes cases of influenza prior to entering the scene. This includes disposable N-95 mask, eye protection (shield or goggles), and disposable N-95 mask, eye protection (shield or goggles), and disposable non-sterile gloves.disposable non-sterile gloves.

B. If Dispatch has not identified individuals with symptoms of B. If Dispatch has not identified individuals with symptoms of acute febrile respiratory illness symptoms on scene, you should acute febrile respiratory illness symptoms on scene, you should stay more than 6 feet away from the patient and bystanders stay more than 6 feet away from the patient and bystanders with symptoms and exercise appropriate routine respiratory with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected droplet precautions while assessing all patients for suspected cases of influenza. If patient has signs or symptoms of cases of influenza. If patient has signs or symptoms of influenza, you should don the PPE described above before influenza, you should don the PPE described above before coming in close contact with the patient.coming in close contact with the patient.

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MASS CASUALTY EMERGENCYMASS CASUALTY EMERGENCY3.3. Signs and Symptoms of InfluenzaSigns and Symptoms of Influenza• Rapid onset of symptomsRapid onset of symptoms

• Difficulty breathing with exertionDifficulty breathing with exertion

• Doctor has already diagnosed influenzaDoctor has already diagnosed influenza

• CoughCough

• FeverFever

• Shaking ChillsShaking Chills

• Pleuritic chest painPleuritic chest pain

• Sore throat (no difficulty breathing or swallowing)Sore throat (no difficulty breathing or swallowing)

• Nasal congestionNasal congestion

• Runny noseRunny nose

• Muscle achesMuscle aches

• HeadacheHeadache

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4.27 Respiratory 4.27 Respiratory Illness/InfluenzaIllness/Influenza MASS CASUALTY EMERGENCY MASS CASUALTY EMERGENCY 4. 4. If patient has critical vital signs, immediately If patient has critical vital signs, immediately transport to Emergency Departmenttransport to Emergency Department

a.a. Critical Vital Signs: AdultCritical Vital Signs: AdultIf present, immediately transport to an If present, immediately transport to an Emergency DepartmentEmergency Department• Pulse: equal or greater than 130 beats per minutePulse: equal or greater than 130 beats per minute

• Respiratory Rate: equal or greater than 30 breaths per minuteRespiratory Rate: equal or greater than 30 breaths per minute

• Systolic Blood Pressure: Less than 90 mm/HgSystolic Blood Pressure: Less than 90 mm/Hg

• Pulse Oximeter: Less than 92 on room airPulse Oximeter: Less than 92 on room air

• Temperature: FebrileTemperature: Febrile

• Level of Consciousness: Responds only to Pain or is UnresponsiveLevel of Consciousness: Responds only to Pain or is Unresponsive

• Lung sounds: Rales or WheezingLung sounds: Rales or Wheezing

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Capillary refill: > 2 seconds > 2 seconds > 2 seconds

Resp. rate: <30 or >45 or increased work of breathing

<20 or >45or increased work of breathing

<15 or >45or increased work of breathing

Systolic Blood pressure < 60 mmHg < 70 mmHg Under age 10< 70 + (2 X age in years)

Pulse Oximeter < 92 on room air < 92 on room air < 92 on room air

Temperature Febrile Febrile Febrile

Level of Consciousness responds only to pain or is unresponsive

responds only to pain or is unresponsive

responds only to pain or is unresponsive

Lung sounds Rales or Wheezing Rales or Wheezing Rales or Wheezing

Critical Vital Signs: Pediatric: If present, immediately transport to Emergency

Department

Vital Signs Neonates Infants Children

4.27 Respiratory 4.27 Respiratory Illness/InfluenzaIllness/Influenza MASS CASUALTY EMERGENCY MASS CASUALTY EMERGENCY 5. 5. If patient has “normal” vital signs, then If patient has “normal” vital signs, then evaluate for signs and symptoms of influenza.evaluate for signs and symptoms of influenza.

a. a. “Normal” Vital Signs Adult with respiratory illness“Normal” Vital Signs Adult with respiratory illness• Pulse: Less than 130 beats per minutePulse: Less than 130 beats per minute

• Respiratory Rate: Less than 30 breaths per minuteRespiratory Rate: Less than 30 breaths per minute

• Systolic Blood Pressure: equal or greater than 91 mmHgSystolic Blood Pressure: equal or greater than 91 mmHg

• Pulse Oximeter equal or greater than 92Pulse Oximeter equal or greater than 92

• Temperature: Afebrile Temperature: Afebrile

• Level of Consciousness: Alert or responds to verbal stimuliLevel of Consciousness: Alert or responds to verbal stimuli

• Lung sounds: ClearLung sounds: Clear

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Capillary refill: < 2 seconds < 2 seconds < 2 seconds

Unlabored breathing or resp. rate:

30-45 20-45 15-45

Systolic Blood pressure > 60 mmHg > 70 mmHg Under age 10> 70 + (2 X age in years)

Pulse Oximeter > 92 > 92 > 92

Temperature Afebrile Afebrile Afebrile

Level of Consciousness Alert or responds to verbal stimuli

Alert or responds to verbal stimuli

Alert

Lung sounds Clear Clear Clear

b. “Normal” Vital Signs Pediatric Patient with Respiratory Illness

Vital Signs Neonates Infants Children

4.27 Respiratory 4.27 Respiratory Illness/InfluenzaIllness/Influenza MASS CASUALTY EMERGENCY MASS CASUALTY EMERGENCY 6. If patient has three (3) or more signs or symptoms of influenza, 6. If patient has three (3) or more signs or symptoms of influenza, transport patient to alternate care facility (if available).transport patient to alternate care facility (if available).

7. If patient has two (2) or fewer signs or symptoms of influenza, 7. If patient has two (2) or fewer signs or symptoms of influenza, call On-line Medical Direction (OLMD) to determine if patient call On-line Medical Direction (OLMD) to determine if patient may be left on-scene, self quarantine, and refer to nurse/public may be left on-scene, self quarantine, and refer to nurse/public health hotline (insert phone number here) for further assistance.health hotline (insert phone number here) for further assistance.

8. Endotracheal intubation should not be performed on any patient 8. Endotracheal intubation should not be performed on any patient except by direct order of the OLMD physician (Cat. B). except by direct order of the OLMD physician (Cat. B).

9. Because of the danger of EMS personnel becoming infected, 9. Because of the danger of EMS personnel becoming infected, aerosol-generating procedures such as advanced airway aerosol-generating procedures such as advanced airway procedures, use of bag-mask, and nebulizer treatments should procedures, use of bag-mask, and nebulizer treatments should not be performed on patients with acute febrile respiratory not be performed on patients with acute febrile respiratory illness except by direct order of the OLMD physician (Cat. B). illness except by direct order of the OLMD physician (Cat. B). CPAP with expiratory filter is still Category A. CPAP with expiratory filter is still Category A.

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4.27 Respiratory 4.27 Respiratory Illness/InfluenzaIllness/Influenza MASS CASUALTY EMERGENCY MASS CASUALTY EMERGENCY

10.If OLMD orders advanced airway procedures, use of bag-10.If OLMD orders advanced airway procedures, use of bag-mask, or nebulizer treatments on a patient with acute mask, or nebulizer treatments on a patient with acute febrile respiratory illness, EMS personnel must be in PPE as febrile respiratory illness, EMS personnel must be in PPE as described in 2.a above. described in 2.a above.

11.All patients with acute febrile respiratory illness should 11.All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient.wear a surgical mask, if tolerated by the patient.

12.Encourage good patient compartment vehicle 12.Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce the airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible.concentration of aerosol accumulation when possible.

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4.27 Respiratory 4.27 Respiratory Illness/InfluenzaIllness/Influenza MASS CASUALTY MASS CASUALTY

EMERGENCY EMERGENCY TRANSPORT OF PATIENTS TOTRANSPORT OF PATIENTS TO

HEALTHCARE FACILITIESHEALTHCARE FACILITIES• When transporting a patient with symptoms of When transporting a patient with symptoms of

acute febrile respiratory illness, you should notify acute febrile respiratory illness, you should notify the receiving healthcare facility so that the receiving healthcare facility so that appropriate infection control precautions may be appropriate infection control precautions may be taken prior to patient arrival. Patients with febrile taken prior to patient arrival. Patients with febrile respiratory illness should wear a surgical mask, if respiratory illness should wear a surgical mask, if tolerated. tolerated.

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EMERGENCY EMERGENCY INTERFACILITY TRANSPORTINTERFACILITY TRANSPORT

• EMS personnel involved in the transfer of patients with EMS personnel involved in the transfer of patients with confirmed influenza or suspected infectious respiratory confirmed influenza or suspected infectious respiratory illness should use standard droplet and contact precautions illness should use standard droplet and contact precautions for all patient care activities. This should include wearing for all patient care activities. This should include wearing disposable N-95 mask, eye protection [shield or goggles], disposable N-95 mask, eye protection [shield or goggles], disposable non-sterile gloves and gown. If the transported disposable non-sterile gloves and gown. If the transported patient can tolerate a surgical mask, its use can help to patient can tolerate a surgical mask, its use can help to minimize the spread of infectious droplets in the patient minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment care compartment. Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. the concentration of aerosol accumulation when possible. Any nonessential equipment that can be removed from the Any nonessential equipment that can be removed from the patient compartment of the ambulance before transport will patient compartment of the ambulance before transport will hasten the time needed to disinfect and return to service.hasten the time needed to disinfect and return to service.

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EMERGENCY EMERGENCY CLEANING VEHICLE AFTER TRANSPORTING CLEANING VEHICLE AFTER TRANSPORTING

AN INFLUENZA PATIENTAN INFLUENZA PATIENT• After the patient has been removed and prior to cleaning, the air After the patient has been removed and prior to cleaning, the air

within the vehicle may be exhausted by opening the doors and within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment.vehicle and on non-disposable equipment.

• Routine cleaning with soap or detergent and water to remove Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective disinfectants, are the basic components of effective environmental management of influenza. Reducing the number environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can of influenza virus particles on a surface through these steps can reduce the chance of hand transfer of virus particles. Influenza reduce the chance of hand transfer of virus particles. Influenza viruses are susceptible to inactivation by a number of chemical viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial disinfectants readily available from consumer and commercial sources.sources.

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STROKE 4.30STROKE 4.30

• Added that the EMS personnel should attempt to Added that the EMS personnel should attempt to bring a knowledgeable friend or family member with bring a knowledgeable friend or family member with the stroke patientthe stroke patient

• Added that if the patient with stroke symptoms has Added that if the patient with stroke symptoms has no signs of CHF then they should receive a 500cc IV no signs of CHF then they should receive a 500cc IV bolus of Normal Salinebolus of Normal Saline

• Added under SPECIAL PRECAUTIONS: Many patients Added under SPECIAL PRECAUTIONS: Many patients with stroke are taking diuretics and are volume with stroke are taking diuretics and are volume depleted. Administer one bolus of fluid as noted depleted. Administer one bolus of fluid as noted above, unless there are obvious signs of acute heart above, unless there are obvious signs of acute heart failure. This may improve cerebral circulation.failure. This may improve cerebral circulation.

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4.34 VOMITING AND 4.34 VOMITING AND NAUSEANAUSEA

• Changed name to Vomiting and Changed name to Vomiting and NauseaNausea

• Under “Specific Information Needed” Under “Specific Information Needed” added:added:B. Is the patient nauseated?B. Is the patient nauseated?

C. If vomiting, is the cause known?C. If vomiting, is the cause known?

K. History of vomiting when receiving K. History of vomiting when receiving narcotics?narcotics?

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4.34 VOMITING AND 4.34 VOMITING AND NAUSEANAUSEA

• Under “NOTES:” added:Under “NOTES:” added:1. Ondansetron may be used in cases of 1. Ondansetron may be used in cases of

nausea to prevent vomitingnausea to prevent vomiting

2. Ondansetron may be used to prevent 2. Ondansetron may be used to prevent nausea when administering morphine, nausea when administering morphine, especially if there is a history of especially if there is a history of vomiting after receiving narcoticsvomiting after receiving narcotics

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SECTION 5SECTION 5

MEDICATIONSMEDICATIONS

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5.10 DIPHENHYDRAMINE5.10 DIPHENHYDRAMINE

• Changed :”dystonic reaction” to Changed :”dystonic reaction” to “extrapyramidal symptoms” or “extrapyramidal symptoms” or “extrapyramidal reaction” to reflect “extrapyramidal reaction” to reflect current terminology in EMS textscurrent terminology in EMS texts

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5.12 EPINEPHRINE5.12 EPINEPHRINE

• Changed administration to IM for Changed administration to IM for allergic reaction except for allergic reaction except for anaphylactic shock where it can be anaphylactic shock where it can be given IVP if the doctor orders (CAT B)given IVP if the doctor orders (CAT B)

• Stressed that the 1:1000 solution Stressed that the 1:1000 solution (vial) is never given IV(vial) is never given IV

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5.13 FUROSEMIDE5.13 FUROSEMIDE

• Changed dose from 20-40mg to Changed dose from 20-40mg to 40mg to simplify the dose40mg to simplify the dose

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SECTION 6SECTION 6

PROCEDURESPROCEDURES

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6.5 ENDOTRACHEAL 6.5 ENDOTRACHEAL INTUBATIONINTUBATION

• Under “PROCEDURE” added:Under “PROCEDURE” added:7. Monitor tube placement with qualitative 7. Monitor tube placement with qualitative

CO2 detector or preferably a CO2 detector or preferably a quantitative waveform CO2 monitor quantitative waveform CO2 monitor (Use of one or the other is MANDATORY)(Use of one or the other is MANDATORY)

After June 2013 the waveform After June 2013 the waveform capnography will be required.capnography will be required.

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6.5 ENDOTRACHEAL 6.5 ENDOTRACHEAL INTUBATIONINTUBATION

• Under “NOTES” added:Under “NOTES” added:6. BY June 2013 all ALS services must 6. BY June 2013 all ALS services must

have the ability to monitor patients with have the ability to monitor patients with waveform capnographywaveform capnography

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Tube Confirmation?Tube Confirmation?

Abnormal CapnogramAbnormal CapnogramAbnormal CapnogramAbnormal Capnogram• ApneaApnea

• Complete loss of waveform Complete loss of waveform indicates no COindicates no CO22 present present

• Tube misplacement or Tube misplacement or dislodged dislodged

• ApneaApnea

• Complete loss of waveform Complete loss of waveform indicates no COindicates no CO22 present present

• Tube misplacement or Tube misplacement or dislodged dislodged

Time

50403020100

CASE STUDYCASE STUDYSingle Vehicle Single Vehicle Deceleration MVCDeceleration MVC

• Single Unrestrained Male VictimSingle Unrestrained Male Victim

• Obvious closed head injury with Obvious closed head injury with comacoma

• Complex laceration of face and Complex laceration of face and scalpscalp

• Bleeding from mouth and noseBleeding from mouth and nose

• Bilateral rib injuries but no flail Bilateral rib injuries but no flail chestchest

CASE STUDYCASE STUDY

• BLS ambulance service – rapid transportBLS ambulance service – rapid transport

• Initial Vitals: Initial Vitals: – Resp. 20 bpm Resp. 20 bpm – SBP 107mmHgSBP 107mmHg– Pulse 110 bpmPulse 110 bpm– SPO2 78%SPO2 78%– ETCO2 monitor not yet attachedETCO2 monitor not yet attached– GCS 7 GCS 7


• Patient immediately intubated using RSIPatient immediately intubated using RSI

• Vitals after intubation: Vitals after intubation: – Resp. 12 bpm by vent Resp. 12 bpm by vent – SBP 85mmHgSBP 85mmHg– Pulse 118 bpmPulse 118 bpm– SPO2 67%SPO2 67%– ETCO2 44ETCO2 44– GCS 3GCS 3

CO2 Waveform

WHAT SHOULD BE DONE?WHAT SHOULD BE DONE?

• WHAT ABOUT THE SEVERE HYPOXIA?WHAT ABOUT THE SEVERE HYPOXIA?

• IS THE TUBE IN THE TRACHEA?IS THE TUBE IN THE TRACHEA?

• SHOULD THE TUBE BE REPLACED?SHOULD THE TUBE BE REPLACED?


• In spite of hypoxia tube was left in place In spite of hypoxia tube was left in place because CO2 level and waveform because CO2 level and waveform confirmed tube was in placeconfirmed tube was in place

• Patient found to have bilateral pulmonary Patient found to have bilateral pulmonary contusions causing the hypoxia plus contusions causing the hypoxia plus internal bleeding causing shockinternal bleeding causing shock

• Also had ruptured trachea with Also had ruptured trachea with development of severe edemadevelopment of severe edema– If tube had been pulled it probably could not If tube had been pulled it probably could not

have been replaced have been replaced

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

• THIS IS FROM LAST YEAR’S THIS IS FROM LAST YEAR’S UPDATE!!!UPDATE!!!

5353

SECTION 9SECTION 9

ACCEPTABLE EMS EQUIPMENT ACCEPTABLE EMS EQUIPMENT AND DEVICESAND DEVICES

5454

9.1 BLIND INSERTION 9.1 BLIND INSERTION AIRWAY DEVICESAIRWAY DEVICES

• Noted that the King Airway may be Noted that the King Airway may be used if the service medical director used if the service medical director approvesapproves

5555

WHAT ABOUT WHAT ABOUT TOURNIQUETS?TOURNIQUETS?

5656

5757

CAT Tourniquet

5858

5959

6060

6161

RATCHET TOURNIQUET

6262

MAT Tourniquet

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 2010 edition) EDITION PROTOCOLS (June 2010 edition) AND A COPY OF THIS UPDATE PRESENTATIONAND A 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

6363

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, 2010, 2010

6464

QUESTIONS?QUESTIONS?

BREMSS STEMI SYSTEMUPDATE

STEMI / ISSUES

•Machine Read/Interpretation

•Over-Triage

•Definitions

STEMI

• This term used throughout the plan refers to the current STEMI definition by the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines of ST segment elevations greater than or equal to 1mm in 2 or more contiguous limb leads or greater than or equal to 2mm in 2 or more contiguous precordial leads lacking features of non-infarction causes of ST-segment elevation (e.g. early repolarization, pericarditis, left ventricular hypertrophy, incomplete bundle branch block.)

Cardiovascular Disease Progression

HEART DISEASE

Acute Myocardial Infarction

ST E levation M yocardial I nfarction

Cardiovascular Disease ProgressionHEART DISEASE



ECG Normal

Arteriolosclerosis

Atherosclerosis

Hypertension ?

HEART DISEASE



ECG Normal ECG Normal or Dysrhythmia

Arteriolosclerosis

Chest Pain Arm Pain Jaw Pain

Atherosclerosis Silent - 50 %

Hypertension ? ST- Normal Deviation

HEART DISEASE



ECG Normal ECG Normal or Dysrhythmia

1MM > 2 > contiguous limb leads

Arteriolosclerosis

Chest Pain Arm Pain Jaw Pain

2 MM > 2 >contiguous precordial leads

Atherosclerosis Silent - 50 %

Hypertension ? ST- Normal Deviation

STEMI

•EMT-P DISCRETION –not a STEMI UNLESS – OLMD agrees ATCC will connect

AMERICAN HEART ASSOCIATION

ECC UPDATE

GUIDELINES 2010

•Released to media on October 18•Released to National Faculty on Nov. 11• Instructor updates via webinar•Make sure ALL instructors have current

username / password for instructor network

•www.ahainstructornetwork.org•Stay in touch!

http://www.ahainstructornetwork.org/

How to stay in touch?

•www.bremss.org

•www.adph.org/ems

•State newsletter

•BREMSS newsletter

•Send BREMSS your e-mail address

http://www.bremss.org/

http://www.adph.org/ems

Documents

PROTOCOL UPDATE ALABAMA EMS PROTOCOLS PARAMEDIC EDITION 5 JUNE, 2010 UPDATE 1