Protocols 2015

REMO Medical Advisory Committee for the Collaborative Protocols

REMS Notes

• This presentation will have numerous REMS notes throughout. The presentation from REMO is intended to be presented in-person. The REMS notes inserted throughout allow us to present this in an online format.

• The REMS notes will follow the protocol in the presentation.

REMS Note

• In cardiac arrest protocols, Epinephrine 1:10,000 IV has been moved to the AEMT level. No significant relevance to us.

REMS Note

• No changes to the v-fib/v-tach protocol (other than the previously mentioned Epi for AEMTs)

• However, Dr. Dailey wanted to stress the use of Sodium Bicarb if acidosis is the suspected primary cause of cardiac arrest.– i.e. If a patient in excited delirium goes into

cardiac arrest, Sodium Bicarb should be the FIRST medication given, followed by epinephrine (if necessary)

No prehospital hypothermia

REMS Note

• No prehospital hypothermia. Nothing new there.

• For pressor therapy, consult the appropriate shock protocol.

REMS Note

• Norepinephrine has replaced dopamine in the medication formulary.

• The full presentation on norepi is later in this CME.• Norepinephrine may only be administered AFTER 2L saline

bolus.• Just note, norepinephrine comes in 4mg vials which are

mixed in 1000mL saline. This creates a 4mcg/mL concentration.

• Administration begins at 2mcg/min or 30 gtts/min (with 60 drip set) and is titrated up to 20mcg/min

• Pre-mix bags are NOT currently available.

REMS Note

• The definition of “wide complex” tachycardia has not changed, however the way it is expressed in the protocol has change.

• Dr. Dailey says this is not intended to insult Paramedics, but rather was a specific request from several agencies.

REMS Note

• Excited delirium’s protocol change warrants a presentation of its own. This presentation will come out within a few weeks.

• Haldol and Ketamine have been added to protocol as Physician Options. Note that Ketamine may only be used by Paramedics regardless of OLMC approval. AEMTs and CCs cannot give Ketamine (No significant relevance to REMS)

REMS Note

• Versed should still be the first medication administered as quickly as possible if the patient is a danger.

• Haldol works best for acutely psychotic patients – those who truly do not know what they’re doing or are hallucinating.

• Ketamine works best for those in true excited delirium such as those intoxicate, on PCP, or cocaine.

• Ketamine should not be given to the acutely psychotic or those with history of schizophrenia as it could worsen their condition.

• Ketamine and Haldol are Medical Control only.

REMS Note

• Ketamine has been added to the Procedural Sedation protocol.

• With Medical Control approval, Ketamine may be administered for sedation. As Ketamine is long acting, etomidate should still be used for short procedures such as cardioversion.

• Ketamine is better suited for long duration procedures like airway control and transdermal pacing.

REMS Note

• Just a reminder, hypoglycemia is now considered a glucose level below 60mg/dL.

• Dr. Dailey wants to stress the use of your clinical judgment. Diabetics with a baseline glucose of 200mg/dL may show signs of hypoglycemia at 80 or 90mg/dL. Also, chronically hypoglycemic people may have no symptoms with a glucose level of 50mg/dL.

REMS Note

• This protocol had a typo: • 4mg magnesium should be given over 20

minutes, not 2 minutes for pregnant seizure patients.

REMS Note

• Same change as the cardiogenic shock protocol.

• Norepinephrine may be given only AFTER 2L saline bolus.

REMS Note

• Dr. Dailey wanted to stress the Cincinnati Stroke Scale. When you report and document this, do not simply state “positive” or “negative” but rather report and document the INDIVIDUAL aspects of the assessment (i.e. facial droop, arm drift, and speech)

REMS Note

• For septic shock, Physician Contact is required for norepinephrine administration.

• More likely, the physician will order additional saline boluses.

REMS Note

• Dr. Dailey wants to stress the use of epinephrine for severe asthma. He actually said that ephinephrine is UNDER utilized for severe asthma in this region.

• Same thing with anaphylaxis. If there is respiratory involvement, epinephrine should be given, then benadryl.

REMS Note

• For acute pulmonary edema, CPAP has been added for AEMTs (no significant relevance to us)

REMS Note

• BLS Narcan on an agency-by-agency basis. (no significant relevance to us)

• Remember to titrate narcan IV and administer it slowly.

REMS Note

• Dr. Dailey wanted to stress that needle decompression is for suspected TENSION pneumothorax, not any pneumothorax.

REMS Note

• Dr. Dailey wanted to stress the importance of bleeding control in major trauma. All other interventions mean nothing when your patient dies of blood loss.

REMS Note

• For traumatic hypoperfusion, norepinephrine is a Medical Control option. Remember, “squeezing the pipes” does very little when the “pipes need to be filled.”

REMS Note

• Once again, the typo has been fixed to read 4mg over 20 minutes.

REMS Note

• Same as adult asthma, consider epinephrine for severe pediatric asthma.

REMS Note

• Same as adult anaphylaxis, consider epinephrine for severe pediatric allergic reactions.

REMS Note

• INTRANASAL fentanyl is now standing order for pediatric pain management.

• Even if IV access has been established, fentanyl may NOT be administered IV without Physician Contact.

REMS Note

• Reminder on titration of oxygen.• Again, Dr. Dailey wanted to stress clinical

judgment. If a patient is having distress at 95%, they may need the extra oxygen. If a patient (with COPD history) has no distress at 90%, they probably don’t need supplemental.

REMS Note

• Dosing for norepinephrine.

Thanks.

REMS Note

Once again, the start date for protocol has not been set yet. When it is, we’ll probably be the first to know from Dean.

Questions/Comments

Questions? Comments? Concerns?

Please direct them to me at dhexel@gmail.com