CNYEMS CNYEMS 2008 Protocol Additions 2008 Protocol Additions

Phase 1Phase 1Medical Director, Daniel Olsson, Medical Director, Daniel Olsson,

DODO

Executive Director, Susie Executive Director, Susie SurprenantSurprenant

Central New York EMSCentral New York EMS

50 Presidential Plaza50 Presidential Plaza

Jefferson Tower, Suite LL1Jefferson Tower, Suite LL1

Syracuse, New York 13202Syracuse, New York 13202

PurposePurpose

The purpose of the lesson is to The purpose of the lesson is to familiarize Advanced Life Support familiarize Advanced Life Support (ALS) providers with the following new (ALS) providers with the following new CNYEMS protocols:CNYEMS protocols:Severe Pain Severe Pain

ManagementManagementAntiemesAntiemesisisAdult Intraosseous Adult Intraosseous AccessAccess

Severe Pain ManagementSevere Pain Management

Protocol will allow EMT-CC and Protocol will allow EMT-CC and Paramedics to administer Morphine as Paramedics to administer Morphine as a Standing Order for the following a Standing Order for the following indications:indications:– Patients with pain secondary to:Patients with pain secondary to:

Severe burns without hemodynamic Severe burns without hemodynamic compromisecompromise

Suspected extremity fractures or dislocations Suspected extremity fractures or dislocations with severe painwith severe pain

Severe Pain ManagementSevere Pain Management

Contraindications (for standing order):Contraindications (for standing order):– Painful conditions not listed under Painful conditions not listed under

“indications (for standing order)”“indications (for standing order)”– Altered mental statusAltered mental status– HypoventilationHypoventilation– HypotensionHypotension– Significant non-extremity traumatic Significant non-extremity traumatic

injuriesinjuries– Known hypersensitivity to medicationKnown hypersensitivity to medication

Severe Pain ManagementSevere Pain Management

Steps:Steps:– Routine Medical CareRoutine Medical Care– Assess patient eligibility Assess patient eligibility – If patient is eligible for standing orderIf patient is eligible for standing order

Morphine 4mg IV Morphine 4mg IV Dose may be repeated once after 5 minutes as needed Dose may be repeated once after 5 minutes as needed

(standing order)(standing order) Additional Morphine 4mg IV every 5 minutes as needed Additional Morphine 4mg IV every 5 minutes as needed

up to 20mg (requires Medical Control order)up to 20mg (requires Medical Control order)

– If patient is ineligible for standing order a If patient is ineligible for standing order a Medical Control order must be obtained Medical Control order must be obtained for for allall doses doses

AntiemesisAntiemesis

Protocol applies to EMT-CC and EMT-PProtocol applies to EMT-CC and EMT-P

Indications:Indications:– For the prevention and treatment of For the prevention and treatment of

nausea and vomitingnausea and vomiting

Contraindications:Contraindications:– Know hypersensitivity to medicationKnow hypersensitivity to medication

AntiemesisAntiemesis

Protocol uses Ondansetron (Zofran) as Protocol uses Ondansetron (Zofran) as the Antiemeticthe Antiemetic

Agencies may use either the generic Agencies may use either the generic or brand name version of this or brand name version of this medicationmedication

Ondansetron (Zofran)Ondansetron (Zofran)

Indications:Indications:– Nausea and vomiting Nausea and vomiting

Contraindications:Contraindications:– Known hypersensitivity to this, or other, Known hypersensitivity to this, or other,

antiemetic medications (Anzemet, Kytril, Aloxi)antiemetic medications (Anzemet, Kytril, Aloxi)

Ondansetron (Zofran)Ondansetron (Zofran)

Side Effects:Side Effects:– blurred vision or temporary blindness;blurred vision or temporary blindness;– fever;fever;– slow heart rate, trouble breathing;slow heart rate, trouble breathing;– anxiety, agitation, shivering;anxiety, agitation, shivering;– feeling light-headed, fainting; orfeeling light-headed, fainting; or– urinating less than usual or not at allurinating less than usual or not at all

Ondansetron (Zofran)Ondansetron (Zofran)

Side Effects (continued):Side Effects (continued):– diarrhea or constipation;diarrhea or constipation;– weakness or tired feeling;weakness or tired feeling;– headache;headache;– dizziness or drowsiness;dizziness or drowsiness;

Ondansetron (Zofran)Ondansetron (Zofran)

Use Zofran with caution in patients taking Use Zofran with caution in patients taking the following medications:the following medications:– phenytoin (Dilantin), phenobarbital (Luminal);phenytoin (Dilantin), phenobarbital (Luminal);– carbamazepine (Carbatrol, Tegretol);carbamazepine (Carbatrol, Tegretol);– tramadol (Ultram); ortramadol (Ultram); or– rifampin (Rifadin, Rimactane, Rifater)rifampin (Rifadin, Rimactane, Rifater)

AntiemesisAntiemesis

Steps:Steps:– Routine Medical/Trauma CareRoutine Medical/Trauma Care– Ondansetron (Zofran) 0.1mg/kg up to 4mg IVOndansetron (Zofran) 0.1mg/kg up to 4mg IV– Repeat once after 2 minutes as neededRepeat once after 2 minutes as needed– Additional dose per Medical Control OrderAdditional dose per Medical Control Order

Adult Intraosseous AccessAdult Intraosseous Access

Protocol allows for the use of Adult IO Protocol allows for the use of Adult IO devices to obtain vascular accessdevices to obtain vascular access

Written generically so that agencies may Written generically so that agencies may choose which device to use choose which device to use

Device may be used in any FDA approved Device may be used in any FDA approved access siteaccess site

Adult Intraosseous AccessAdult Intraosseous Access

Devices currently available include:Devices currently available include:– EZ IOEZ IO®® – Bone Injection Gun (BIGBone Injection Gun (BIG®®) ) – FAST1FAST1TMTM

EZ-IOEZ-IO®®

Approved for use in Approved for use in patients weighing 3kg or patients weighing 3kg or moremore

Allows access in both the Allows access in both the Proximal Humerus and Proximal Humerus and Proximal TibiaProximal Tibia

Further information Further information available at available at http://www.vidacare.com/Phttp://www.vidacare.com/Products/index_4_29.htmlroducts/index_4_29.html

Bone Injection Gun (BIGBone Injection Gun (BIG®®))

Approved for all Approved for all patients regardless of patients regardless of age or weightage or weight

Approved for use in Approved for use in the Tibiathe Tibia

Further information Further information available at available at http://www.waismed.cohttp://www.waismed.com/unique-79.htmm/unique-79.htm

FAST1FAST1™™

Approved for use in Approved for use in adult patientsadult patients

Allows for sternal Allows for sternal accessaccess

Futher information Futher information available at available at http://www.pyng.com/http://www.pyng.com/

Adult Intraosseous AccessAdult Intraosseous Access

Indications:Indications:– Patients who require IV access and a peripheral Patients who require IV access and a peripheral

IV cannot be established in 2 attempts or 90 IV cannot be established in 2 attempts or 90 seconds seconds andand in patients who exhibit 1 or more in patients who exhibit 1 or more of the following:of the following: An altered mental status (GCS of 8 or less)An altered mental status (GCS of 8 or less) Hemodynamic instability (Systolic BP <90)Hemodynamic instability (Systolic BP <90) Patients requiring sedation/paralysis for airway Patients requiring sedation/paralysis for airway

managementmanagement

Adult Intraosseous AccessAdult Intraosseous Access The Adult IO is Optional Equipment for the The Adult IO is Optional Equipment for the

CNYEMS Region.CNYEMS Region.

Agencies that elect to carry this equipment must Agencies that elect to carry this equipment must provider didactic and skill instruction on the device provider didactic and skill instruction on the device per manufacturer’s guidelines.per manufacturer’s guidelines.

This instruction must be completedThis instruction must be completed

prior to the device being used in the field.prior to the device being used in the field.

Adult Intraosseous AccessAdult Intraosseous Access

IO may be considered prior to peripheral IV IO may be considered prior to peripheral IV attempts in the following situations:attempts in the following situations:– Cardiac arrestCardiac arrest– Evidence of profound hypovolemia with Evidence of profound hypovolemia with

alteration in mental statusalteration in mental status

Adult Intraosseous AccessAdult Intraosseous Access

Contraindications:Contraindications:– Evidence of fracture in bone of insertion siteEvidence of fracture in bone of insertion site– Known previous orthopedic Known previous orthopedic

procedures/hardware in bone of insertion siteprocedures/hardware in bone of insertion site– Known pre-existing medical condition such as Known pre-existing medical condition such as

tumor near insertion site or sternotomytumor near insertion site or sternotomy– Infection or vascular compromise at Infection or vascular compromise at

insertion siteinsertion site– Inability to locate landmarksInability to locate landmarks

Adult Intraosseous AccessAdult Intraosseous Access

Steps:Steps:– Routine Medical CareRoutine Medical Care– Prepare equipment, to include: IO driver, IO needle of Prepare equipment, to include: IO driver, IO needle of

appropriate size, Alcohol swab, IV and/or extension set, appropriate size, Alcohol swab, IV and/or extension set, 10 ml syringe, Tape, Pressure bag, Sharps container10 ml syringe, Tape, Pressure bag, Sharps container

– Locate and cleanse FDA approved insertion siteLocate and cleanse FDA approved insertion site– Stabilize and insert the IO needle setStabilize and insert the IO needle set– Remove driver while stabilizing Remove driver while stabilizing

catheter hubcatheter hub

Adult Intraosseous AccessAdult Intraosseous Access

Steps (Continued):Steps (Continued):– Remove stylet and secure in a sharps containerRemove stylet and secure in a sharps container– Confirm proper placementConfirm proper placement– Consider Lidocaine 20-50 mg IO slow in conscious Consider Lidocaine 20-50 mg IO slow in conscious

patientpatient– Flush catheter rapidly with 10 ml of normal salineFlush catheter rapidly with 10 ml of normal saline– Place pressure bag and inflate; Begin infusionPlace pressure bag and inflate; Begin infusion– Dress site and secure tubingDress site and secure tubing– Continue to monitor patient and infusion siteContinue to monitor patient and infusion site

Protocol AdditionsProtocol Additions All ALS providers must successfully complete the All ALS providers must successfully complete the

quiz in order to maintain their ALS privileges in quiz in order to maintain their ALS privileges in Central New York. You will be directed from the Central New York. You will be directed from the next slide to take the test. next slide to take the test.

Inserts for the protocol books will be provided to Inserts for the protocol books will be provided to agencies.agencies.

Click on the link for the three protocols.Click on the link for the three protocols.– New ALS ProtocolsNew ALS Protocols

Protocols go into effect February 1, 2008Protocols go into effect February 1, 2008..

Protocol Additions TestProtocol Additions Test

Click appropriate link below to take test – you will be directed to login to your CNYEMS account in an Internet

browser. Login and proceed from there with the test. (You may have to close the presentation).

Protocol AdditionsTest