2014 - 15 EMS Protocol Committee 2015 EMS Protocol Training Module.

2014 - 15 EMS Protocol Committee

2015 EMS Protocol

Training Module

Overview of Changes

New FormatAddition of an Appendix sectionAddition of the Initial Treatment / Universal

Patient Care Protocol

BLS Protocol Additions / Deletions / Revisions Deletion of MAMP and TAMP Addition of 6102 Spinal Immobilization Revision of 6110 Burns

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Overview of Changes

Addition of 6214 Return of Spontaneous Circulation – ROSC Revision of 6302 Bronchospasm Revision of 6501 Allergic Reaction / Anaphylaxis Revision of 6504 Snake Bite Revision of 6605 Unconscious / Altered Mental Status Revision of 6606 Overdose / Ingestion / Poisoning Revision of 6607 Behavioral Emergencies / Patient Restraint Addition of 6700 series - Children with Special Healthcare

Needs Addition of 7000 series - BLS Procedural Protocols

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Overview of Changes

BLS Medication Additions / Deletions / Revisions Addition of Combi-vent / Duo-Neb (Albuterol and Atrovent

combined) Addition of Narcan® Addition of Zofran® ODT Addition of Tetracaine Removal of Activated Charcoal

ALS Protocol Additions / Deletions / Revisions Deletion of MAMP and TAMP Addition of 4102 Spinal Immobilization Revision of 4110 Burns Addition of 4111 Eye Injuries 4

Overview of Changes

Revision of 4202 Chest Pain Discomfort / ACS Revision of 4203 Severe Hypertension Revision of 4205 Cardiac Arrest Revision of 4208 Adult Tachycardia Addition of 4214 Return of Spontaneous Circulation – ROSC Revision of 4302 Bronchospasm Revision of 4303 Pulmonary Edema Revision of 4501 Allergic Reaction / Anaphylaxis Revision of 4504 Snake Bite Revision of 4602 Stroke / TIA Revision of 4603 Seizures

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Overview of Changes

Revision of 4604 Diabetic Emergencies Revision of 4605 Unconscious / Altered Mental Status Revision of 4606 Overdose / Ingestion / Poisoning Revision of 4607 Behavioral Emergencies / Patient

Restraint Addition of 4700 series Children with Special

Healthcare Needs Revision of 4902 Patient Comfort / Pain Management Addition of 4903 Rapid Sequence Intubation Revision of 8000 series ALS Procedural Protocols Addition of 9203 LVAD

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Overview of Changes

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ALS Medication Additions / Deletions / Revisions Addition of Combi-vent / Duo-Neb (Albuterol and Atrovent

combined) Addition of Magnesium Sulfate Addition of Zofran® ODT Addition of Midazolam Addition of Tetracaine Addition of Diltiazem Addition of Labetalol Addition of Haloperidol Addition of Etomidate (Approved RSI squads ONLY) Addition of Succinylcholine (Approved RSI squads ONLY) Addition of Vecuronium (Approved RSI squads ONLY)

Overview of Changes

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ALS Medication Additions / Deletions / Revisions Removal of Activated Charcoal Removal of Toradol® Reclassification of Sodium Bicarbonate to optional Removal of Lorazepam Removal of Ipratropium Bromide (Atrovent ®) by itself

Purpose of Training

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This training is designed to familiarize the EMS provider with use and content of the revised protocols.

All EMS providers shall be responsible to read and review each protocol in its entirety.

These protocols are to utilized as a guide to patient care and are not designed to be a teaching tool.

Most of the protocols have change in some capacity. Some minor and some major.

Utilizing the Protocols

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The West Virginia EMS Statewide Protocols are designed to enable EMS personnel to provide a wide variety of treatments to many types of patients. Understanding the organization and terminology of the protocols is important and will vastly improve the usability by the EMS provider.

These protocols have been accepted by the MPCC to move West Virginia forward and better the care we provide to our patients.


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A new look Header:

Footer:


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Classifications of Levels of Care: (first digit) 1000 - CCT-RN 2000 - CCT-Paramedic 3000 - C3-IFT (Inter-facility Transport Paramedic) 4000 - Paramedic 5000 - Open 6000 - EMT

7, 8 and 9 thousand series are used as follows: 7000 - BLS Procedural Protocols 8000 - ALS Procedural Protocols 9000 - Special Operational Policies and Protocols


Category of Care: (second digit) 4100 - Trauma 4200 - Cardiac 4300 - Respiratory 4400 - Pediatrics 4500 - Environmental 4600 - Medical 4700 - Special Healthcare Needs 4800 - Open 4900 - Special Treatment Protocols

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Shaded boxes with icons indicate that specific contact is required with Medical Command (red telephone) or the Medical Command Physician (physician) in order to perform specific treatments.


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For the purposes of these protocols, any patient under the age of 12 years will be considered a pediatric patient. Certain patients who are larger or smaller than the norms for their age may require modification of treatment. Providers should consult with Medical Command as needed in making this determination.


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In addition to this protocol release, the Scope of Practice as well as the Required Equipment List has been updated.

Equipment that is directly related to patient care is required to be approved by the MPCC. Equipment not listed on the equipment list that is directly incorporated into patient care is prohibited without MPCC approval.

Initial Treatment / Universal Patient Care

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The Initial Treatment / Universal Patient Care Protocol is the first protocol within these guidelines and replaces MAMP and TAMP.

It is to be used universally on all patients as a starting point for assessment and treatment prior to moving on to a specific protocol.

This protocol is designed to establish support at the beginning of patient care while identifying specific signs and symptoms that will direct the EMS provider to a more complaint specific protocol.

Initial Treatment / Universal Patient Care

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The Initial Treatment / Universal Patient Care protocol is designed to guide the EMS provider in the initial and ongoing approach to assessment and management of medical and trauma patients.

Components of the Initial Treatment / Universal Patient Care Protocol:

Scene Size Up Primary Survey Secondary Survey

6101-Severe External Bleeding

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This protocol was adjusted to incorporate the use of tourniquets appropriately.

The use of the Patient Comfort / Pain Management Protocol has been added.

Hemostatic agents were changed to be optional equipment.

6102-Spinal Immobilization

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New Protocol

Spinal Immobilization is indicated in patients who have been exposed to a mechanism that could cause spinal injury.

This protocol will guide the EMS provider in the decision to perform or not to perform spinal immobilization.

If the EMS provider has any doubt after working through this protocol...Perform Immobilization!

6103-Spinal Trauma

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This protocol indicates treatment for patients who have suffered spinal trauma.

This protocol may or may not be utilized in conjunction with 6102 Spinal Immobilization.

Low Risk and High Risk criteria have been added: Low Risk Mechanisms High Risk Mechanisms Nexus Criteria

6110-Burns

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This protocol was revised to combine multiple protocols into one.

NEVER ATTEMPT TO REMOVE PATIENT FROM AN IMMEDIATELY DANGEROUS TO LIFE AND HEALTH (IDLH) ENVIRONMENT UNLESS TRAINED, CERTIFIED, AND PROPERLY EQUIPPED. NEVER PLACE YOURSELF OR YOUR CREW IN DANGER. Decontamination, if necessary, should be done by appropriate certified personnel.

6110-Burns

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This protocol will guide the EMS provider in the following:

Thermal Burns Dry Chemical Burns Liquid Chemical Burns Major and Minor Burn Criteria:

6110-Burns

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Rule of Nines added to protocol:

6205-Adult Cardiac Arrest

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6214 ROSC protocol added as the end component

Reversible causes added:

6214-Return Of Spontaneous Circulation

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New Protocol

Components of 6214 Return Of Spontaneous Circulation / ROSC Protocol:

Follow the Initial Treatment / Universal Treatment Protocol Assist Ventilations as needed Consider ALS assist Continually reassess ABC’s Contact Medical Command for additional treatment

6302-Bronchospasm

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Protocol revised to define minimal, moderate, and severe distress.

Initial treatment medication changed to Albuterol and Ipratropium Bromide combined (Combi-Vent / Duo-Neb) unless contraindicated.

Initial treatment is a standing order.

Second dose of medication requires MCP order.

Epinephrine 1:1000 added to protocol in cases of continued severe distress in patients < 35 years old with MCP order.

6303-Pulmonary Edema

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New Protocol.

In patients with severe distress, consider CPAP if available per protocol 7301.

If wheezing is evident: administer Albuterol and Ipratropium Bromide combined (Combi-Vent / Duo-Neb) standing order for first dose unless contraindicated.

6410-Newborn Infant Care

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Addition of the Apgar Scoring Chart:

6412-Allergic Reaction / Anaphylaxis (Ped.)

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Epinephrine 0.3 mg 1:1000 IM added as an alternative to the optional Epi Pen Jr.® per MCP order.

If symptoms continue or worsen after initial treatment; Albuterol may be administered per MCP order. Combi-Vent / Duo-Neb Shall Not be utilized in pediatric patients.

6501-Allergic Reaction / Anaphylaxis (Adult)

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Epinephrine 0.3 mg 1:1000 IM added as an alternative to the optional Epi Pen®.

If symptoms continue or worsen after initial treatment; Albuterol combined with Ipratropium Bromide (Combi-Vent / Duo-Neb), unless contraindicated, may be administered per MCP order.

6504-Snake Bite / Envenomation

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Protocol revised to include Item E. The EMS provider shall locate the fang puncture(s) and mark with a pen the edge of erythema (redness around bite mark). This should be done at the initial assessment and every five (5) minutes thereafter.

6604-Diabetic Emergencies

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Hypoglycemia treatments shall relate to blood glucose levels < 60 mg/dl.

Administer oral glucose ONLY to patients who can maintain an open airway.

In patients that are not conscious or cannot maintain an open airway, simply secure the airway and request ALS assist and consult Medical Command.

6605-Unconscious/Altered Mental Status

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The use of this protocol requires the patient to have a Glasgow Coma Score < 12.

This protocol is intended to guide the management of patients with a decreased level of consciousness who have no history of trauma.

Patients who exhibit with a blood glucose level > 60 mg/dl but remain unconscious or with an altered mental status; may be administered Naloxone 2 mg intranasal via atomizer per MCP order.


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Possible causes added as follows:

6606-Overdose/Toxic Ingestion/Poisoning

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Protocol incorporates the following: Alcohol Narcotics / Opiates Patients who exhibit with a blood glucose level > 60 mg/dl

and have suspected narcotic overdose complicated by respiratory depression; may be administered Naloxone 2 mg intranasal via atomizer per MCP order.


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Examples: Morphine, Heroin, Demerol, Dilaudid, Methadone, Fentanyl, Oxycodone, Codeine, and others.

Tricyclic Antidepressants Examples: Amitriptyline (Elavil®), Amoxapine (Asendin®),

Clomipramine (Anafranil®), Doxepin (Sinequan®, Adepin®), Imipramine (Tofranil®) and Nortriptyline.

Cholinergics Examples: Pesticides (Organophosphates, Carbamates) and nerve

gas agents (Sarin, Soman) are the most common exposures.


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Calcium Channel Blockers Examples: Verapamil (Calan®, Isoptin®), Nifedipine (Procardia®,

Procardia XL®, Adalat®, Adalat CC®), Nicardipine (Cardene®, Carden SR®), Isradipine (DynaCirc®, DynaCirc SR®), Amlodipine (Norvasc®), Nisoldipine (Sular®), Diltiazem (Cardizem®, Dilacor XR®, Tiamate®, Teczem®, and Tiazac®), and Bepridil (Vascor®).

Beta Blockers Examples: Atenolol (Tenormin®), Betaxolol (Kerlone®, Betoptic®),

Carteolol (Cartrol®), Carvedilol (Coreg®), Labetalol (Trandate®, Normodyne®), Metoprolol (Lopressor®, Toprol XL®), Propranolol (Inderal®, InnoPran®), Sotalol (Betapace®), Timolol (Blocadren®).


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Stimulants Examples: Cocaine (Coke, crack, flake, rocks, snow),Methamphetamine

(Desoxyn, crank, glass, ice, speed), Methylphenidate (Ritalin®), Methylenedioxyamphetamine (MDA, Adam), Methylenedioxymethamphetamine (MDMA, Eve, Ecstasy), Methylenedioxypyrovalerone (Bath Salts, Ivory Wave, Ivory Coast, Purple Wave, Vanilla Sky)

6607-Behavioral Emergencies

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This protocol was revised to incorporate the SAFER mnemonic: Stabilize the situation by containing and lowering the

stimuli. Assess and acknowledge the crisis. Facilitate the identification and activation of resources. Encourage patient to use resources and take actions in his/her best

interest. Recovery or referral: leave patient in care of responsible person or

professional.

Commercially available soft restraints are permitted for patient restraint.

6608-OB/GYN

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6609-Nausea/Vomiting

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This new protocol is designed to guide the BLS provider in treating patients with nausea and/or vomiting.

The BLS provider may administer Ondansetron (Zofran®) 4 mg tablet dissolved in the mouth by standing order. Repeat doses require Medical Command order.

6700 Series

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The 6700 series has been added to guide the EMS provider in care for Children with Special Healthcare Needs. (CSHCN)

This series will evolve in future protocol revisions to incorporate adults with special healthcare needs as well.

Children with Special Health Care Needs (CSHCN) can present unique challenges for providers. The caregiver is your best source of information as they care for the child on a daily basis.

6700 Series

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The EMS provider needs to have a working knowledge of the Pediatric Assessment Triangle (PAT) as it is a general reference for each of the 6700 series protocols.

Appearance Work of Breathing Circulation of Skin

The EMS provider shall read and understand the content of each of the 6700 series protocols.

6700 Series

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The 6700 Series CSHCN protocols consist of the following:

6701 General Assessment 6702 Central Venous Lines 6703 CSF Shunt 6704 Feeding Tubes 6705 Apnea Monitors 6706 Internal Pacemaker / Defibrillator 6707 Ventilator Support / BiPap

7000 Series

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The 7000 series protocols are a new addition to incorporate BLS Procedural Treatments.

The 7000 Series consists of the following: 7102 Morgan Lens (optional) The Morgan Lens is a BLS skill and training shall be provided by

the Squad Training Officer prior to use. The BLS provider may administer 2 drops of Tetracaine prior to

irrigation.

7000 Series

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7301 Continuous Positive Airway Pressure (CPAP)CPAP has been shown to rapidly improve vital signs, gas

exchange, work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in certain patients who suffer respiratory distress from CHF, pulmonary edema, asthma, COPD, or pneumonia.

In patients with CHF, CPAP can improve hemodynamics by reducing preload and afterload, however it may cause hypotension.

7000 Series

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7403 STOMA / Tracheostomy Suction ManagementThe majority of adults and children with tracheostomies are

dependent on the tube as their primary airway. In patients with CHF.

Obstruction may be due to thick secretions, mucous plug, blood clot, foreign body, or kinking or dislodgement of the tube. Work expeditiously and deliberately to reestablish airway patency and support oxygenation/ventilation.

DO NOT wait for cyanosis, bradycardia, and/or apnea to develop before intervening.

7000 Series

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Tracheal suctioning should be carried out regularly for patients with a tracheostomy. The frequency varies between patients and is based on individual assessment.

Tracheal damage may be caused by suctioning. This can be minimized by using the appropriate sized suction catheter and only suctioning within the tracheostomy tube.

9000 Series

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The 9000 series Special Operational Policies and Treatment Protocols have minimal changes throughout consisting mostly of format and grammatical corrections.

9203 Left Ventricular Assist Device (LVAD) was added as an informational protocol to assist the EMS provider in treatment priorities when encountering these patients.

When treating an LVAD patient it is critical to listen to the patient and the caregiver.

LVAD patients should rarely have CPR performed.LVAD patients are rarely pronounced in the field.There will always be an emergency contact number on the LVAD control unit.LVAD patients require transport to an LVAD facility.

Appendix

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The 2015 protocols have an appendix section that can be easily amended when necessary.

The appendix section consist of the following:Appendix A – Fibrinolytic ChecklistAppendix B – Diversion Alert Status FormAppendix C – Pediatric ReferencesAppendix D – Assessment MnemonicsAppendix E – Glasgow Coma ScaleAppendix F – Approved AbbreviationsAppendix G – Cincinnati Pre-hospital Stroke ScaleAppendix H – EMS Patient Care without Telecommunications

Ondansetron (Zofran®)

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Class: Antiemetic, Serotonin Receptor Antagonist

Dosage: 4mg tablet dissolved in the mouth.

Actions: Antiemetic - The mechanism by which Ondansetron works to control nausea and vomiting is not fully understood; it is believed that the antiemetic properties occur as a result of serotonin receptor antagonism.

Indications: Adults with nausea and vomiting.

Ondansetron (Zofran®)

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Contraindications: History of allergic reaction to Ondansetron or to any medicine similar to Ondansetron, including Dolasetron (Anzemet), Granisetron (Kytril), or Palonosetron (Aloxi).

Side Effects: Constipation, diarrhea, dry mouth, headache, dizziness, drowsiness/sedation, Anaphylaxis (rare), fatigue, malaise, chills, cardiac dysrhythmia (rare), hypotension, bronchospasm, muscle pain.

Combi-Vent / Duo-Neb

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Class: Sympathomimetic, Parasympatholitic

Dosage: Is a unit dose of Albuterol 2.5 mg mixed with a unit dose of Ipratropium Bromide 0.5 mg (Combi-vent / Duo-Neb®) via nebulizer.

Actions: Combination of beta2 and anticholenergic effects.

Indications: Relief of bronchospasm in adult patients with reversible obstructive airway disease and acute attacks of bronchospasm.


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Contraindications: Prior hypersensitivity to any of its components or to atropine, soy lecithin, bromide or flourocarbons and cardiac dysrhythmias associated with tachycardia.

Side Effects: Restlessness, apprehension, dizziness, headache, blurred vision, dry mouth, palpitations, increase in BP, dysrhythmias, increased hypoxemia.

Tetracaine

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Class: Topical ophthalmic anesthetic

Dosage: 2 drops in the affected eye prior to irrigation.

Actions: Superficial anesthesia. Inhibits conduction of nerve impulses from sensory nerves.

Indications: Patient comfort prior to eye irrigation.

Tetracaine

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Contraindications: Known hypersensitivity or open globe injury (i.e. laceration to the eyeball).

Side Effects: Burning or stinging sensation, irritation, and possible epithelial damage and systemic toxicity.

Naloxone (Narcan®)

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Class: Synthetic opioid antagonist

Dosage: 2 mg administer intranasal (IN) via atomizer. Administration should be delivered 1 mg per nostril.

Actions: Reverses all effects due to opioid (morphine-like) agents. This drug will reverse the respiratory depression and all central and peripheral nervous system effects.

Naloxone (Narcan®)

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Indications: To reverse respiratory and central nervous system depression induced by opiates.

Contraindications: Not clinically significant.

Side Effects: Naloxone may induce opiate withdrawal in patients who are physically dependent. Patients may also exhibit with tachycardia, nausea, vomiting, hypertension, and diaphoresis.


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This protocol was adjusted to incorporate the use of tourniquets appropriately.

The use of the Patient Comfort / Pain Management Protocol has been added.

Hemostatic agents were changed to be optional equipment.


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New Protocol

Spinal Immobilization is indicated in patients who have been exposed to a mechanism that could cause spinal injury.

This protocol will guide the EMS provider in the decision to perform or not to perform spinal immobilization.

If the EMS provider has any doubt after working through this protocol...Perform Immobilization!

4103-Spinal Trauma

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This protocol indicates treatment for patients who have suffered spinal trauma.

This protocol may or may not be utilized in conjunction with 4102 Spinal Immobilization.

Low Risk and High Risk criteria have been added: Low Risk Mechanisms High Risk Mechanisms Nexus Criteria

4108-Hypoperfusion / Shock

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The initial Dopamine drip has been revised to start at 5 micrograms/kg/min per MCP order.

The Dopamine drip may then be titrated at 5 - 20 micrograms/kg/min in an effort to an effort to improve perfusion per MCP order.

4110-Burns

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NEVER ATTEMPT TO REMOVE PATIENT FROM AN IMMEDIATELY DANGEROUS TO LIFE AND HEALTH (IDLH) ENVIRONMENT UNLESS TRAINED, CERTIFIED, AND PROPERLY EQUIPPED. NEVER PLACE YOURSELF OR YOUR CREW IN DANGER. Decontamination, if necessary, should be done by appropriate certified personnel.

4110-Burns

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This protocol will guide the EMS provider in the following:

Thermal Burns Dry Chemical Burns Liquid Chemical Burns Major and Minor Burn Criteria:

4110-Burns

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Rule of Nines added to protocol:

4111-Eye Injuries

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New Protocol for ALS

This protocol is a simple guide to treatment of eye injuries that previously was absent from the ALS protocols.

This protocol includes: Penetrating Trauma Ultraviolet light exposure Loss of vision

4202-Chest Pain Discomfort / ACS

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The administration of Aspirin was moved to early on in the protocol.

The administration of Morphine has been changed to a standing order of 2 mg every 5 minutes to a total dose of 10 mg or relief of pain. In the presence of hypotension or bradycardia the ALS provider should consider the use of Fentanyl.

The protocol was revised to incorporate a standing order for Fentanyl at 50 micrograms repeated every 5 minutes to a total dose of 150 micrograms.

4202-Chest Pain Discomfort / ACS

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4203-Severe Hypertension

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This protocol is a complete rewrite.

This protocol is utilized in patients that have a systolic BP > 240 mm/hg and/or a diastolic BP > 120 mm/hg. These pressures must be taken manually and repeated in opposing arms.

The treatment goal is to reduce the MAP by 10 - 15% of the initial value. DO NOT reduce BP to normal range in these patients.

4203-Severe Hypertension

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Treatment of hypertension requires two successive readings of a systolic BP > 240 mm/hg and/or a diastolic BP > 120mm/hg.

Consider intervention if patient is symptomatic per MCP order.

Treatment per MCP order includes the following: Labetalol: 10 mg over two (2) minutes repeated in 10 minutes

at 20 mg. Nitroglycerin: 0.4 mg SL every 3 - 5 minutes to a maximum of

1.2 mg. Morphine: 2 - 10 mg.


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4214 ROSC protocol added as the end component.

Reversible causes added:

Sodium Bicarbonate classified as optional for treatment of reversible causes.


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Protocol indicates the administration of Amiodarone 300 mg and treatment of reversible causes. Consider 150 mg dose if no conversion in 3 - 5 min.

May substitute Lidocaine 1.0 - 1.5 mg/kg IV/IO repeated at 0.5 - 0.75 mg/kg IV/IO at 10 min. intervals to a max dose of 3 mg/kg.

In cases of Torsades administer Magnesium Sulfate 1 gram diluted in 10 ml NS over 5 - 20 minutes.

4208-Adult Tachycardia

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The revised protocol begins with a HR > 150 bpm and one of the following: BP < 90 mm/hg or altered level of consciousness. (The old protocol required all three).

In cases of SVT the protocol has changed to administration of Adenosine 6 mg repeated at 12 mg one (1) time.


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In cases of Atrial Fibrillation, Atrial Flutter, or SVT with no conversion after Adenosine; administer Diltiazem (Cardizem®) 0.25 mg/kg slow IVP repeated in 15 minutes at 0.35 mg/kg slow IVP Per MCP order.

4211-Symptomatic Bradycardia

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In patients that require Transcutaneous Pacing, consider pre-medication with Midazolam (Versed®) 2 mg.

The protocol now includes a standing order for Fentanyl (Sublimaze®) 50 micrograms slow IV repeated at 50 micrograms every 5 minutes not to exceed a total cumulative dose of 150 micrograms for pain management during TCP.


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New Protocol

Components of 4214 Return Of Spontaneous Circulation / ROSC Protocol:

Follow the Initial Treatment / Universal Treatment Protocol. Assist Ventilations as needed. Consider reversible causes. Continually reassess ABC’s. If the patient remains unconscious consider cooling with cool

IV fluid (if available) and cold packs applied to the groin, neck, and axilla.

Contact Medical Command for additional treatment.


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The protocol also defines post resuscitation treatment as follows: Consider the administration of Amiodarone Infusion or Lidocaine infusion if the patient was resuscitated following an episode of VF/VT and is without profound bradycardia or high-grade heart block (2nd degree Type II or 3rd degree or idioventricular rhythm) Per MCP order.

Note: Continue using the anti-arrhythmic medication that was administered during resuscitation.

4302-Bronchospasm

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Initial treatment medication changed to Albuterol and Ipratropium Bromide combined (Combi-Vent / Duo-Neb) standing order if not contraindicated.

Second dose of medication requires MCP order.

Epinephrine 1:1000 added to protocol in cases of continued severe distress in patients < 35 years old with MCP order.


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This protocol is a complete rewrite.

If patient has rales along with JVD and initial blood pressure is > 180 systolic; administer Nitroglycerine 0.4 mg every 3 – 5 minutes up to a total of three (3) doses or 1.2 mg.

Obtain a manual BP between doses of Nitroglycerine.


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If the patient has taken Sildenafil (Viagra®) or Vardenafil (Levitra®) within last 24 hours, or Tadalafil (Cialis®) within the last 72 hours Nitrogycerin should be withheld and treat as follows:

If patient DOES NOT currently take Furosemide (Lasix); administer Furosemide 40 mg IV/IO standing order.

If patient DOES currently take Furosemide (Lasix); administer Furosemide 80 mg IV/IO standing order.

4402- Pediatric Hypoperfusion / Shock

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The initial Dopamine drip has been revised to start at 5 micrograms/kg/min per MCP order.

The Dopamine drip may then be titrated at 5 - 20 micrograms/kg/min in an effort to an effort to improve perfusion per MCP order.

4403-Pediatric Seizure

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In the pediatric seizure patient suspected of hypoglycemia (blood glucose < 60 mg/dl); treat as follows: Patient 1 month of age or younger – If blood glucose is < 60

mg/dl, administer 5.0 -10.0 ml/kg Dextrose 10% IV/IO (D10 is prepared by mixing 40 ml of NS with 10 ml of D50W).

Patient older than 1 month but younger than 2 years old – If blood glucose is < 60 mg/dl, administer 2 - 4 ml/kg of D25 IV/IO; (D25 is prepared by mixing 25 ml NS with 25 ml D50W).

Patient 2 years of age or older - If blood glucose is < 60 mg/dl, administer D50W 1 - 2 ml/kg IV/IO. Maximum dose is 25 grams.


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In the pediatric seizure patient with abnormal glucose levels and no IV, Glucagon may be administered as follows: Patient < 20 kg, administer Glucagon 0.5 mg IM standing

order. Patient > 20 kg, administer Glucagon 1 mg IM standing

order.


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If seizure lasts longer than five (5) minutes or two (2) or more episodes of seizure activity occur between which the patient does not regain consciousness:

Administer Midazolam (Versed®) IV/IO 0.1 mg/kg per MCP order.

If no IV access is available, administer Midazolam (Versed®) 0.2 mg/kg intranasal (IN) via atomizer per MCP order.

4410-Newborn Infant Care

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4411-Pediatric Diabetic Emergencies

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In the pediatric diabetic patient suspected of hypoglycemia (blood glucose < 60 mg/dl); treat as follows: Patient 1 month of age or younger – If blood glucose is < 60

mg/dl, administer 5.0 - 10.0 ml/kg Dextrose 10% IV/IO (D10 is prepared by mixing 40 ml of NS with 10 ml of D50W).

Patient older than 1 month but younger than 2 years old – If blood glucose is < 60 mg/dl, administer 2 - 4 ml/kg of D25 IV/IO; (D25 is prepared by mixing 25 ml NS with 25 ml D50W).

Patient 2 years of age or older – If blood glucose is < 60 mg/dl, administer D50W 1 - 2 ml/kg IV/IO. Maximum dose is 25 grams.

4412-Allergic Reaction / Anaphylaxis (Ped.)

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Pediatric patients in minimal distress may be administered Diphenhydramine (Benadryl®) 1 mg/kg maxed at 25 mg as a standing order.

Patients in moderate to severe distress shall be administered Epinephrine 1:1000 as follows: Epinephrine 0.3 mg IM for patients > 30 kg standing order. Epinephrine 0.15 mg IM for patients < 30 kg standing order.

4501-Allergic Reaction / Anaphylaxis (Adult)

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Adult patients in mild distress may be administered Diphenhydramine (Benadryl®) 25 mg slow IV/IO or IM repeated in 30 minutes if no improvement as a standing order.

If symptoms continue or worsen after initial treatment; Albuterol combined with Ipratropium Bromide (Combi-vent / Duo-Neb) may be administered standing order if not contraindicated.

4504-Snake Bite / Envenomation

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Protocol revised to include Item F. The EMS provider shall locate the fang puncture(s) and mark with a pen the edge of erythema (redness around bite mark). This should be done at the initial assessment and every five (5) minutes thereafter.

4603-Seizures

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In the seizure patient suspected of hypoglycemia (blood glucose < 60 mg/dl), treat per 4604 Diabetic Emergencies Protocol.

If seizure lasts longer than five (5) minutes or two (2) or more episodes of seizure activity occur between which the patient does not regain consciousness, administer:

Midazolam (Versed®) 2 mg IV/IO standing order. If no IV access is available, administer Midazolam (Versed®) 5

mg intranasal (IN) via atomizer or IM standing order.

4604-Diabetic Emergencies

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Hypoglycemia treatments shall relate to blood glucose levels < 60 mg/dl.

If patient is malnourished, has HIV/AIDS, receives dialysis, is a known alcoholic, or has other grossly impaired nutritional status, administer: Thiamine 100 mg slow IVP over one (1) minute.


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The use of this protocol requires the patient to have a Glasgow Coma Score < 12.

This protocol is intended to guide the management of patients with a decreased level of consciousness who have no history of trauma.

Administration of Narcan® has changed to read: If blood glucose level is > 60, administer Naloxone 0.4 mg/minute up to 2 mg IV titrated to restore the respiratory drive. If IV cannot be established, administer 2 mg intranasal (IN) via atomizer, or intramuscular (IM).


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Possible causes added as follows:


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Protocol incorporates the following: Alcohol

For alcohol withdrawal with severe agitation, tachycardia, hypertension, or hallucinations, administer Midazolam 2 mg IV/IO/IM or 5 mg (IN) via atomizer standing order.

Seizures secondary to alcohol withdrawal should be treated per 4603 Seizure Protocol.


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Narcotics / Opiates Patients who exhibit with a blood glucose level > 60 mg/dl and

have suspected narcotic overdose complicated by respiratory depression; may be administered Naloxone 0.4 mg/minute up to 2 mg IV titrated to restore the respiratory drive or 2 mg Intranasal.

Examples: Morphine, Heroin, Demerol, Dilaudid, Methadone, Fentanyl, Oxycodone, Codeine, and others.

Tricyclic Antidepressants Examples: Amitriptyline (Elavil®), Amoxapine (Asendin®),

Clomipramine (Anafranil®), Doxepin (Sinequan®, Adepin®), Imipramine (Tofranil®) and Nortriptyline.


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Cholinergics Examples: Pesticides (Organophosphates, Carbamates) and

nerve gas agents (Sarin, Soman) are the most common exposures.

For serious signs and symptoms, administer Atropine 2 mg IV. Repeat every five (5) minutes as needed standing order.

Calcium Channel Blockers Examples: Verapamil (Calan®, Isoptin®), Nifedipine

(Procardia®, Adalat®) Nicardipine (Cardene®), Isradipine (DynaCirc®), Amlodipine (Norvasc®), Nisoldipine (Sular®), Diltiazem (Cardizem®).


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For serious signs and symptoms (altered mental status, HR < 60 bpm, conduction delays, SBP < 90 mm Hg, slurred speech, nausea/vomiting): administer Atropine 1 mg IV standing order.

Beta Blockers Examples: Atenolol (Tenormin), Betaxolol, Carteolol

(Cartrol), Carvedilol (Coreg), Labetalol (Trandate, Normodyne), Metoprolol (Lopressor, Toprol XL), Propranolol (Inderal, InnoPran), Sotalol (Betapace), Timolol (Blocadren).

Patients with serious signs and symptoms should be administered a 20 ml/kg fluid bolus as well as Glucagon 2 mg IV standing order for initial dose.


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Stimulants Examples: Cocaine (Coke, crack, flake, rocks,

snow),Methamphetamine (Desoxyn, crank, glass, ice, speed), Methylphenidate (Ritalin), Methylenedioxyamphetamine (MDA, Adam), Methylenedioxymethamphetamine (MDMA, Eve, Ecstasy), Methylenedioxypyrovalerone (Bath Salts, Ivory Wave, Ivory Coast, Purple Wave, Vanilla Sky).

Patients with tachydysrhythmias may be administered Midazolam (Versed) 2 mg slow IV titrated to effect standing order.


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Cyanide Exposure (optional) This protocol allows for departments to carry medications to counteract

cyanide exposure (Cyanokit®). This is an optional equipment.


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This protocol was revised to incorporate the SAFER mnemonic: Stabilize the situation by containing and lowering the stimuli. Assess and acknowledge the crisis. Facilitate the identification and activation of resources. Encourage patient to use resources and take actions in his/her

best interest. Recovery or referral: leave patient in care of responsible person

or professional.

Commercially available soft restraints are permitted for patient restraint.


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Chemical Restraint: If psychotic/behavioral agitation is suspected,

administer Midazolam 5 mg IM or IN standing order.

If patient remains agitated or aggressive in five (5) minutes, administer Haloperidol 5 mg IM standingorder.

If dystonic reaction (dyskinesia) is noted secondary to Haloperidol administer Diphenhydramine 25 mg IV or IM standing order.

4608-OB/GYN

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4700 Series

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The 4700 series has been added to guide the EMS provider in care for Children with Special Healthcare Needs. (CSHCN)

This series will evolve in future protocol revisions to incorporate adults with special healthcare needs as well.

Children with Special Health Care Needs (CSHCN) can present unique challenges for providers. The caregiver is your best source of information as they care for the child on a daily basis.

4700 Series

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The EMS provider needs to have a working knowledge of the Pediatric Assessment Triangle (PAT) as it is a general reference for each of the 4700 series protocols.

Appearance Work of Breathing Circulation of Skin

The EMS provider shall read and understand the content of each of the 4700 series protocols.

4700 Series

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The 4700 Series CSHCN protocols consist of the following:

4701 General Assessment 4702 Central Venous Lines 4703 CSF Shunt 4704 Feeding Tubes 4705 Apnea Monitors 4706 Internal Pacemaker / Defibrillator 4707 Ventilator Support / BiPap

4901-Airway Management

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This protocol has been revised to include post intubation management for patients that show need for sedation/pain management to facilitate tolerating the endotracheal tube as follows: Midazolam 2 mg IV/IO every five (5) minutes to a

maximum dose of 10 mg standing order. Hold for systolic BP < 90 mmHg.

AND/OR

Fentanyl (Sublimaze®) 50 micrograms slow IV repeated at 50 micrograms every five (5) minutes not to exceed a total cumulative dose of 150 micrograms standing order. Additional doses require MCP order.

4902-Patient Comfort / Pain Management

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Pain management in the field may be indicated when there is isolated trauma to extremities, severe burns, amputations, or other pain symptoms. These patients may be treated as follows: Fentanyl (Sublimaze®) 50 micrograms slow IV repeated at

50 micrograms every five (5) minutes not to exceed a total cumulative dose of 150 micrograms standing order.

OR Morphine Sulfate 2 mg slow IV may repeat every five (5)

minutes up to 10 mg or until pain is relieved.

4903-Rapid Sequence Intubation Guidelines

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RSI is a new protocol and will be optional. Squads that perform RSI will be required to meet the following requirements:

A Squad Medical Director (SMD) must apply in writing to the WVOEMS State Medical Director for a particular squad to be considered for the RSI program. An Memorandum of Understanding (MOU) shall be established between the Squad Director, Squad Medical Director, and WVOEMS State Medical Director.

Each individual Squad Medical Director will choose candidates for the program.


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The Squad Medical Director will be responsible for establishing initial and continuing education, performance improvement, etc.

Continuing education by the SMD will be held monthly for the first year. The Squad Medical Director should directly observe the RSI paramedic perform an intubation and RSI sequence once a quarter (This can be in a clinical or classroom setting).

The RSI protocol is for adults only at this time (12 years old and up).

The Squad must agree to purchase, store, and replace the necessary medications.


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Squads entering the program shall be required to have video assisted laryngoscopy equipment.

Squads participating in this program shall be required to have wave form capnography available.

Every RSI intubation is to be enrolled in the squad’s quality assurance program.

A minimum of two (2) Paramedics is required throughout transport on any RSI call.

At the 12 month point in the program, the SMD must reapply with the WVOEMS State Medical Director to continue the program.


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Candidates shall have at least three (3) years experience as an active and certified WVOEMS ALS EMS provider.

All candidates shall be required to perform a minimum of ten (10) intubations at a WVOEMS accredited training facility utilizing simulation. These intubations must be directly observed by a WVOEMS approved instructor and/or the Squad Medical Director. These intubations may also be obtained in an operating room setting, if available.

4903-Rapid Sequence Intubation

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This protocol is ONLY for paramedics who have been specifically trained to perform this skill and have approval from the WVOEMS State Medical Director and corresponding Squad Medical Director.

Rapid Sequence Intubation (RSI) should only be performed if a rapid airway is indicated, and benefits outweigh potential risks.

All education will be provided by the Squad Medical Director.

8000 Series

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The 8000 Series consists of the following: 8102 Morgan Lens (optional) The Morgan Lens is a BLS skill and training shall be provided by

the Squad Training Officer prior to use. The EMS provider may administer 2 drops of Tetracaine prior

to irrigation. 8201 Intraosseous Placement The significant change to this protocol is the placement for

adult patients. The order or insertion sites for the adult are as follows unless contraindicated: proximal humerus, proximal tibia, then distal tibia.

8000 Series

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8301 Continuous Positive Airway Pressure (CPAP)CPAP has been shown to rapidly improve vital signs, gas

exchange, work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in certain patients who suffer respiratory distress from CHF, pulmonary edema, asthma, COPD, or pneumonia.

In patients with CHF, CPAP can improve hemodynamics by reducing preload and afterload, however it may cause hypotension.

8000 Series

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8302 Chest Decompression Chest decompression procedures have been revised to

only utilize mid-clavicular placement utilizing a 14 or 16 gauge, 3¼ inch IV catheter (Pediatric: 16 gauge, 1 ¼ inch).

8401 Percutaneous Cricothyrotomy This protocol is utilized in any clinical situation in which a

definitive airway is necessary, and all other methods have failed or are otherwise not indicated.

Cricothyrotomy may be accomplished utilizing commercially available kits such as Quick Trach I® or Quick Trach II®.

8000 Series

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8403 STOMA / Tracheostomy Suction ManagementThe majority of adults and children with tracheostomies are

dependent on the tube as their primary airway in patients with CHF.

Obstruction may be due to thick secretions, mucous plug, blood clot, foreign body, or kinking or dislodgement of the tube. Work expeditiously and deliberately to reestablish airway patency and support oxygenation/ventilation.

DO NOT wait for cyanosis, bradycardia, and/or apnea to develop before intervening.

8000 Series

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Tracheal suctioning should be carried out regularly for patients with a tracheostomy. The frequency varies between patients and is based on individual assessment.

Tracheal damage may be caused by suctioning. This can be minimized by using the appropriate sized suction catheter and only suctioning within the tracheostomy tube.

9000 Series

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The 9000 series Special Operational Policies and Treatment Protocols have minimal changes throughout consisting mostly of format and grammatical corrections.

9203 Left Ventricular Assist Device (LVAD) was added as an informational protocol to assist the EMS provider in treatment priorities when encountering these patients.

When treating an LVAD patient it is critical to listen to the patient and the caregiver.

LVAD patients should rarely have CPR performed.LVAD patients are rarely pronounced in the field.There will always be an emergency contact number on the LVAD control unit.LVAD patients require transport to an LVAD facility.

Appendix

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The 2015 protocols have an appendix section that can be easily amended when necessary.

The appendix section consists of the following:Appendix A – Fibrinolytic ChecklistAppendix B – Diversion Alert Status FormAppendix C – Pediatric ReferencesAppendix D – Assessment MnemonicsAppendix E – Glasgow Coma ScaleAppendix F – Approved AbbreviationsAppendix G – Cincinnati Prehospital Stroke ScaleAppendix H – EMS Patient Care without Telecommunications


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Class: Sympathomimetic, Parasympatholitic

Dosage: Is a unit dose of Albuterol 2.5 mg mixed with a unit dose of Ipratropium Bromide 0.5 mg (Combi-vent / Duo-Neb®) via nebulizer.

Actions: Combination of beta2 and anticholenergic effects.

Indications: Relief of bronchospasm in adult patients with reversible obstructive airway disease and acute attacks of bronchospasm.


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Contraindications: Prior hypersensitivity to any of its components or to atropine, soy lecithin, bromide or flourocarbons and cardiac dyshythmias associated with tachycardia.

Side Effects: Restlessness, apprehension, dizziness, headache, blurred vision, dry mouth, palpitations, increase in BP, dysrhythmias, increased hypoxemia.

Tetracaine

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Class: Topical ophthalmic anesthetic

Dosage: 2 drops in the affected eye prior to irrigation.

Actions: Superficial anesthesia. Inhibits conduction of nerve impulses from sensory nerves

Indications: Patient comfort prior to eye irrigation.

Tetracaine

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Contraindications: Known hypersensitivity or open globe injury (i.e. laceration to the eyeball).

Side Effects: Burning or stinging sensation, irritation, and possible epithelial damage and systemic toxicity.

Haloperidol (Haldol®)

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Class: Antipsychotic agent, major tranquilizer

Dosage: 5 mg IM/IN. If dystonic reaction occurs, follow with 25 mg of Benadryl.

Actions: Haloperidol is a potent, long-acting Butyrophenone derivative. Haloperidol interferes with the effects of neurotransmitters in the brain which are the chemical messengers that nerves manufacture and release to communicate with one another.


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Indications: Used for management of manifestations of psychotic disorders and for the treatment of agitated states in acute and chronic psychoses.

Contraindications: Combativeness from trauma, Hypersensitivity to Haloperidol, Parkinson's disease, seizure disorders, coma, alcoholism, severe mental depression, CNS depression, Thyrotoxicosis, and cocaine overdose.


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Side Effects: Parkinson like symptoms, restlessness, lethargy, headache, exacerbation of psychotic symptoms, tachycardia, hypotension, hypertension (with overdose), nausea, vomiting, bronchospasm, laryngospasm, respiratory depression, dry mouth, hyper-salivation, drooling. Extrapyramidal reactions (cervical and lumbar muscle spasms) may occur.

Midazolam (Versed®)

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Class: Sedative Hypnotic

Dosage: 2 mg IV/IO and 5 mg IM/IN

Actions: Short acting benzodiazepine with sedative hypnotic and amnestic properties.

Indications: Adults requiring sedation such as intubated patients, seizure patients, and combative patients.

Midazolam (Versed®)

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Contraindications: Hypotension, acute narrow-angle glaucoma, known hypersensitivity to Midazolam

Side Effects: Respiratory depression, apnea, hypotension, amnesia

Magnesium Sulfate

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Class: Electrolyte

Dosage: 1 gm diluted in 10 ml NS administered over 5 - 20 minutes

Actions: Central Nervous system depressant. Replaces electrolyte deficiencies.

Indications: Eclampsia and Torsades des pointes

Magnesium Sulfate

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Contraindications: Myasthenia Gravis and impaired renal function (i.e. to include dialysis patients).

Side Effects: May cause: flushing, sweating, itchiness and rash, drowsiness, headache, respiratory depression, hypotension, bradycardia, and other arrhythmias.

Diltiazem (Cardizem®)

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Class: Calcium Channel Blocker, antidysrhythmic

Dosage: 0.25 mg/kg slow IVP repeated in 15 minutes at 0.35 mg/kg slow IVP.

Actions: Binds to open calcium channels preventing repolarization until dissociation. Decreases SA nodal discharge, AV nodal conduction, afterload and myocardial contractility.

Diltiazem (Cardizem®)

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Indications: Stable uncontrolled new onset atrial flutter or fibrillation. Second line medication for stable narrow complex tachydysrhythmias.

Contraindications: Known hypersensitivity, shock or hypotension, W.P.W., sick sinus syndrome, high degree heart block (2nd type II or 3rd degree), heart failure and ventricular tachycardia.

Side Effects: Hypotension, dysrhythmias, nausea and vomiting, headaches.

Labetalol

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Class: Nonselective beta-blocker, Selective alpha-1 blocker (inhibits peripheral vasoconstriction).

Dosage: 10 mg slow IVP over 1 - 2 minutes repeated in 10 minutes at 20 mg slow IVP.

Actions: Lowers blood pressure by decreasing cardiac output and causing vasodilation. It is metabolized by the liver and excreted by the kidneys.

Labetalol

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Indications: Acute management of hypertensive crisis.

Contraindications: Asthma/COPD with respiratory symptoms, known sensitivity to labetalol, bradycardia, CHF, heart block, cardiogenic shock.

Side Effects: Symptomatic orthostatic hypotension (do not let patients stand after administration), bradycardia, hypotension, dyspnea, fatigue.

SUMMARY

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It is extremely important all EMS providers read through each individual protocol respectively.

These protocols allow all West Virginia EMS providers to provide better, more comprehensive, care to our patients resulting in favorable outcomes.

Better care is accomplished through new treatment options, new medications, evidence based treatment modalities, and a comprehensive understanding of the protocols.

2014 - 15 EMS Protocol Committee 2015 EMS Protocol Training Module.

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Transcript of 2014 - 15 EMS Protocol Committee 2015 EMS Protocol Training Module.