2009 ALS/BLSPROTOCOL INSERVICE : 2009 ALS/BLSPROTOCOL INSERVICE County of San Diego
July 1, 2009 S-102 Abbreviation List : S-102 Abbreviation List EpiPen: brand name for Epi auto-injector
MCI: Mass Casualty Incident
MPI: Multiple Patient Incident
ODT: Oral Dissolving Tablet
POLST: Physician Orders for Life-Sustaining Treatment www.epipen.com/epipen_main.aspx POLST : POLST Legally recognized “request regarding resuscitation”.
Addresses not just end of life, but intensity of care.
Healthcare providers required to honor POLST requests.
Standardized color (pink).
http://www.finalchoices.calhealth.org S-120: Abdominal Discomfort : S-120: Abdominal Discomfort Title change: Abdominal Discomfort/GI/GU
A suspected AAA should be transported to a facility with immediately available surgical resources – the word “consider” has been removed. S-120 and IV Fluids : S-120 and IV Fluids The second fluid bolus to maintain a blood pressure of >90 has been removed.
IV 500cc can be given one time on SO for systolic BP <90. ALS: Ondansetron (Zofran) : Ondansetron (Zofran) Medication added to ADULT Protocol:
Ondansetron 4mg IV given slowly, or IM.
Ondansetron 4mg PO (Oral-Dissolving Tablet – ODT), if available.
Base Hospital Order Ondansetron(Zofran) : Ondansetron(Zofran) Indications:
Severe nausea and/or vomiting
Has been used extensively in chemotherapy & post-op patients with good success.
Known sensitivity to Ondansetron or similar: Granisetron (Kytril), Dolasetron (Anzemet), Palonosetron (Aloxi). Ondansetron IV/IM(Zofran) : Ondansetron IV/IM(Zofran) IV route - administer slowly, over >30 seconds
Does not typically cause sedation
Peak concentrations: 10 minutes after IV administration. 40 minutes after IM. Ondansetron Oral (optional inventory)(Zofran) : Ondansetron Oral (optional inventory)(Zofran) Oral-Dissolving Tablet (ODT) administration:
Remove just prior to administration
Do not push tablet through, peel foil back to remove.
Place tablet on tongue.
Tablet dissolves quickly and can be swallowed with saliva. Adverse Effects : Adverse Effects Usually well tolerated
Side effects are rare
(some tachycardia and hypotension reported) www.themedguru.com Ondansetron (Zofran) : Ondansetron (Zofran) As with any new medication added to our Protocols, calls involving the use of Zofran will be reviewed.
What effect did it have on the patient? Documentation : Documentation Indication: Vomiting and/or severe nausea
Vital signs prior and after each dose
Effect: Worse? Better? No change?
Any adverse effects? S-121 Airway Obstruction : S-121 Airway Obstruction If patient becomes unconscious or is found unconscious
Look in mouth with each rescue breath and remove object if it is seen.
Once obstruction is removed:
High flow O2, ventilate prn Slide 15: S-122 Allergic Reaction/Anaphylaxis
First dose of IM Epi 1:1000, 0.3mg in the patient with known cardiac history and/or >65 y/o is SO (previously BHO).
Atrovent removed from this protocol – Use Albuterol alone in nebulized treatment. Slide 16: S-123 Altered Neurologic Function:
Intranasal route added for Narcan and Versed – SO
Give Narcan IN prior to IV or IM in suspected overdose.
Direct IVP has been deleted from all protocols. Intranasal Medication Administration : Intranasal Medication Administration Advantages:
Easy and convenient
Nose: easy access point for medication delivery
Eliminates risk of a needle stick Intranasal Medication Administration: Advantages : Intranasal Medication Administration: Advantages Drugs absorbed via the nasal mucosa:
Nasal offers rich vascular area and directly enters the circulation.
Intranasal compared to IV medications:
Comparable blood levels depending on the drug and dose. Intranasal Medication Administration : Intranasal Medication Administration If there is something wrong with the nasal mucosa it may not absorb medications effectively.
Vasoconstrictors (e.g. cocaine) prevent absorption.
Bloody nose, nasal congestion, mucous discharge all prevent mucosal contact of drug.
Destruction of nasal mucosa from surgery or cocaine abuse – no mucosa to absorb the drug. Intranasal Medication Administration: Factors Affecting Bioavailability : Intranasal Medication Administration: Factors Affecting Bioavailability Volume and concentration:
Too large a volume or too weak a concentration may lead to failure because the drug cannot be absorbed in high enough quantity to be effective.
Volumes over 1 ml per nostril are likely too dilute and may result in runoff out of the nostril. Mucosal Atomization Device (MAD) : Mucosal Atomization Device (MAD) MAD - Mucosal Atomization device:
Device designed to allow emergency personnel to deliver nasal medications as an atomized spray.
Broad 30-micron spray ensures excellent mucosal coverage. Intranasal.net Prehospital IN : Prehospital IN Mucosal Atomizer Device (MAD)
Fits on standard syringe Intranasal.net Slide 23: 1. 2. 3. Slide 24: Denver Health Paramedics Naloxone (Narcan) : Naloxone (Narcan) Intranasal naloxone:
83% response in the field
Dose and volume:
higher concentration preferred so use 1mg/ml IV solution. Naloxone(Narcan) : Naloxone(Narcan) Intranasal naloxone:
Delivery – immediately on decision to treat inject naloxone into nose with MAD, then begin standard care.
Awakening is gradual, but adequate respiratory efforts occur as fast or faster than IV naloxone due to no delays with IV start.
Not 100% effective so failures with IN naloxone need to be followed with IV/IM naloxone. IN Midazolam (Versed) : IN Midazolam (Versed) Why intranasal midazolam for seizures?
No needles, no need for an IV start in an actively seizing patient.
Rapid delivery – No delays in IV attempts. IN Midazolam (Versed) : IN Midazolam (Versed) Seizures
Lahat et al, BMJ, 2000.
Prospective study: IN midazolam versus IV diazepam for prolonged seizures (>10 minutes) in children.
Similar efficacy in stopping seizures (app. 90%).
Time to seizure cessation:
IV Valium: 8.0 minutes.
IN Versed: 6.1 minutes. IN Midazolam(Versed) : IN Midazolam(Versed) Dose and volume: Higher concentration required - use 5mg/ml IV solution.
Dosing calculations: Versed 0.2mg/kg IN SO to max of 5mg. (d/c if seizure stops) SO MR x1 in 10“ SO
Pediatric: Versed per drug chart IN SO. MR x1 in 10" SO S-124: Burns : S-124: Burns BLS:
Wording change, under chemical burn section: now reads “brush off dry chemicals” “flush with copious water.”
Atrovent deleted from nebulized treatment.
If respiratory distress with bronchospasm give Albuterol only, via nebulizer. S-126: Discomfort/Pain of Suspected Cardiac Origin : S-126: Discomfort/Pain of Suspected Cardiac Origin BLS:
Deleted “One time only” and “Base Hospital contact required prior to any repeat dose” of patient’s own prescribed medications.
BLS can now encourage patient to take own NTG SL x3. S-126: Discomfort/Pain of Suspected Cardiac Origin : Note added to bottom of page:
*12-Lead EKG: Report STEMI: ***Acute MI*** or ***Acute MI Suspected***. Also report Left Bundle Branch Block, paced rhythm, atrial fibrillation or atrial flutter for exclusion from STEMI determination.
Please label field 12-Lead with patient identifier S-126: Discomfort/Pain of Suspected Cardiac Origin S-127: Dysrhythmias : S-127: Dysrhythmias Change:
“Perform no more than 10 second rhythm check, and pulse check if rhythm is organized.”
Added: “The timing of the drug delivery is less important than is the need to minimize interruptions in chest compressions.” S-127: Dysrhythmias : S-127: Dysrhythmias Lidocaine:
Deleted from VFib/Pulseless VTach Protocol. (Deleted from both adult & pediatric).
Can give Lidocaine after ROSC, especially if ectopy noted.
Change to Post Conversion: Lidocaine administration after firing of AICD – Must be witnessed and occur 2 or more times. S-127: Dysrhythmias : S-127: Dysrhythmias Added:
IO route, where appropriate.
Obtain 12-Lead EKG after return of pulses.
Note to bottom of protocol: “For patients with an EtCO2 reading of less than 10mm/Hg or patients in non-perfusing rhythms after resuscitative effort, consider early Base Hospital contact for disposition/pronouncement at scene. S-129: Envenomation Injuries : S-129: Envenomation Injuries BLS:
Added: “Remove pre-existing constrictive device.” http://medicalppt.blogspot.com/2009/03/snake-bite-management-powerpoint.html S-130: Environmental Exposure : S-130: Environmental Exposure BLS
Wording change: “Fanning, sponging with tepid water. Avoid shivering.”
Deleted: Note regarding fluid resuscitation in high heat situations. S-131: Hemodialysis : S-131: Hemodialysis ALS:
“Determine time of last dialysis”
In symptomatic patient “Obtain 12-Lead” S-131: Hemodialysis : S-131: Hemodialysis ALS:
Changed order of treatment with additional comment, “If >72 hours since last dialysis”:
Continuous Albuterol via nebulizer SO
CaCl2 250 mg IVP SO (NOTE DOSE CHANGE)
NaCO3 1mEq/kg IVP SO S-132: Near Drowning/Diving : S-132: Near Drowning/Diving Naval Hyperbaric Chambers:
Deleted North Island Air Station and Naval Special Warfare-Coronado. http://www.globalsecurity.org/military/facility/san-diego-navsta.htm S-133: Obstetrical Emergencies : S-133: Obstetrical Emergencies BLS:
Added: “Document name of person cutting cord, time cut & address.”
Added: Third trimester bleeding transport “to facility with OB services.”
Intranasal route added for Versed in seizures S-134: Poisoning/Overdose : S-134: Poisoning/Overdose ALS:
Deleted: Direct IVP of Narcan (from all protocols).
Added: Intranasal Narcan SO
IN route for Versed in severe agitation SO
Deleted: ET route for Atropine. Give IM. S-136: Respiratory Distress : S-136: Respiratory Distress Added: “May assist patient to self medicate own prescribed MDI ONE TIME ONLY. Base Hospital contact required prior to any repeat dose.” BLS: stevethechamp.vox.com S-139: Trauma : S-139: Trauma BLS:
Added: Tourniquets, both adult and pediatric trauma protocols.
For severely injured extremities. BHPO unless it is a mass casualty, then it is SO.
“Apply tourniquet in severely injured extremity when direct pressure or pressure dressing fails to control hemorrhage.” Tourniquets : Tourniquets Attempt to control hemorrhage with direct pressure or pressure dressing prior to tourniquet application.
In mass casualty direct pressure failure not required prior to tourniquet application. Tourniquet : Tourniquet Apply just proximal to the bleeding wound.
Apply tight enough to block arterial flow. (Photo Jeffrey Kalish) S-140: Triage, Multiple Patient : S-140: Triage, Multiple Patient Renamed: Triage, Multiple Patient Incident/Mass Casualty Incident/Annex D
Only one Base Hospital should be contacted during entire incident for all communication.
Multiple Patient Incident: MPI
Mass Casualty Incident: MCI S-142: Psychiatric/Behavioral : S-142: Psychiatric/Behavioral ALS:
Intranasal route for Versed added to Severe Agitation portion of the protocol.
Versed 0.2mg/kg IN SO to max of 5mg. SO MR x1 in 10“ SO
For severely agitated patient IN or IM Versed is preferred route to decrease risk of injury to patient and personnel. S-161: Pediatric Altered Neurological : S-161: Pediatric Altered Neurological BLS:
Changed wording: Hypoglycemia section now reads “Hypoglycemia (suspected) or patient’s glucometer results read <75mg/dL.”
Direct IVP Narcan deleted from all protocols.
Added: Intranasal route for Narcan and Versed, dose per drug chart. S-162: Pediatric Allergic Reaction : S-162: Pediatric Allergic Reaction BLS:
Changed: May assist patient to self medicate with own prescribed MDI or EpiPen.
Deleted: Atrovent to first dose of Albuterol. (Atrovent used only in asthma) S-163: Pediatric Dysrhythmias : S-163: Pediatric Dysrhythmias BLS:
When heart rate indicates and patient is unstable ventilate per BVM for 30 seconds, reassess HR and begin compression if indicated:
<9 yrs HR <60 bpm
9-14yrs HR <40bpm S-163: Pediatric Dysrhythmias : S-163: Pediatric Dysrhythmias ALS:
Deleted: Age restriction (>30 days) for Atropine. Okay to give. S-163: Pediatric Dysrhythmias : S-163: Pediatric Dysrhythmias ALS:
Deleted: Intubate SO
Added: Bag-Valve-Mask (BVM), if unable to adequately ventilate via BVM intubate SO. S-166: Newborn Deliveries : S-166: Newborn Deliveries BLS:
Deleted: “additional vigorous suctioning and BVM may be necessary” - meconium delivery.
Added: “Additional suctioning if baby is not vigorous” - meconium delivery. S-167: Pediatric Respiratory Distress : S-167: Pediatric Respiratory Distress ALS:
Deleted: Intubate SO
Added: BVM, if unable to adequately ventilate via BVM intubate SO
Epinephrine 1:1000 for severe respiratory distress changed from SC to IM S-168: Shock : S-168: Shock ALS:
Deleted: BP goal for fluid bolus in non-cardiogenic shock. S-169: Trauma Added: An <15 y/o trauma patient who is pregnant should be transported to UCSD. S-170: Burns : S-170: Burns Deleted: Atrovent
Atrovent deleted from nebulized treatment.
If respiratory distress with bronchospasm give Albuterol only, via nebulizer. P-104: ALS Skills : P-104: ALS Skills CPAP:
Specific indications listed:
Age > 15 years
Respiratory Distress: CHF, COPD or Asthma.
Moderate to severe respiratory distress. Retractions/accessory muscle use AND
SpO2 <92% Added: additional contraindication “BP<90” P-104: ALS Skills : P-104: ALS Skills 12-Lead:
Changed: under comments, “Report STEMI”…deleted “SVT” and added “Atrial Fibrillation” and “Atrial Flutter.”
Added to indications:
“suspected hyperkalemia and >72 hours since last dialysis.”
ROSC after cardiac arrest
ALWAYS label 12-Lead with patient identifier P-104: ALS Skills : P-104: ALS Skills EtCO2:
Quantitative EtCO2 now mandatory in advanced airway.
Monitor continuously after ET / ETAD/ Perilaryngeal Airway Adjunct insertion
Use early in cardiac arrest EtCO2 : EtCO2 Capnography:
Only method to continuously monitor and document CO2 production. EtCO2 : EtCO2 Verification of ET tube placement.
Monitoring and detection of ET tube dislodgement. (immediate detection).
Loss of circulatory function.
Determination of adequate CPR compressions. EtCO2 : EtCO2 Sudden loss of EtCO2 is immediate indication of a problem.
tube dislodged, kinked or obstructed.
Loss of circulatory function. ETCO2 and Cardiac Output : ETCO2 and Cardiac Output 35-45
8 No CPR POOR GOOD GREAT Check Pulse Alive &
Intubation (Cardiac Output)
Effectiveness of compressions ZERO CO2 EtCO2 Waveforms : EtCO2 Waveforms The shape is identical in all humans with healthy lungs. Jems
Capnography in EMS
Reading Low or Zero EtCO2 : Low or Zero EtCO2 Troubleshooting:
Remove detection device from ETT and BLOW into it.
Does monitor show presence of CO2?
Verify tube placement
Breath sounds? Epigastric sounds?
Deeper compressions – increase cardiac output. TROUBLESHOOTING : TROUBLESHOOTING Wet Device?
Do not withhold ventilations while troubleshooting. Troubleshooting : Troubleshooting If EtCO2 remains at zero pull the tube and begin bagging. Ventilation : Ventilation Goals
Maintain SpO2 > 90%
Maintain ETCO2 approx. 35 *
* Asthma patients excepted – they retain CO2 and trying to ventilate then down to 35 could cause pneumothorax. P-104: ALS Skills : P-104: ALS Skills External Cardiac Pacemaker:
Reworded indications to clarify that Atropine 1mg is not required prior to pacing in wide complex bradycardia. P-104: ALS Skills : P-104: ALS Skills Intubation:
Pediatic patient: Intubate only if unable to adequately ventilate via BVM.
Apply c-collar to all intubated patients – both adult and pediatric. P-104: ALS Skills : P-104: ALS Skills Intraosseous – Adult & Pediatric
With the exception of LOC the indications & contraindications are the same for adult & pediatric patients:
Fluid/medication administration in acute status patient when unable to establish other IV
Peds can only receive fluid, epi, atropine and lido via IO. Adults can receive any med via IO (except hypertonic saline—was in scope for ROC previously) P-104: ALS Skills : P-104: ALS Skills Intraosseous:
Tibial site only, adult & pediatric.
Don’t delay trauma patients on scene for IV or IO access—do en route if needed!!!
Added: In conscious adult patient slowly infuse 40mg Lidocaine 2% (preservative free) IO prior to fluid administration. (one time administration). LIDO FOR ADULT ONLY!!!!! P-104: ALS Skills : P-104: ALS Skills ETAD:
Use Small Adult size for all patients under 6’. The Large Adult should be used only in patients over 6 feet tall.
Perilaryngeal Airway (King): ? replace ETAD over the year with King Airway.
Can give meds via ETT or ETAD
or King but IV and IO strongly
preferred. www.kingsystems.com P-104: ALS Skills : P-104: ALS Skills Perilaryngeal airway (King):
Indications and contraindications same as ETAD.
Use Capnography for placement verification, limited Toomey experience reported
Use Size 3 (yellow) for patients 4’ – 5’ tall
Use Size 4 (red) for patients 5’ – 6’ tall
Use Size 5 (purple) for patients >6’ tall P-104: ALS Skills : P-104: ALS Skills Spinal stabilization:
Pregnant patients (>6 months) tilt 15 degrees (was 30 degrees) left lateral decubitus.
Apply c-collar to all intubated patients – adult and pediatric. 5150 : 5150 Transport of:
5150 patients may be transported to ANY Emergency Department for medical clearance. Transporting patients to the correct facility : Transporting patients to the correct facility Questions to ask:
Where do you primarily receive your medical care?
Have you been admitted to a hospital? Which hospital?
Do you know which hospital your doctor admits patients? CEMSIS : CEMSIS National Association of State EMS Directors and NHTSA created National Emergency Medical Services Information System (NEMSIS).
State of California Emergency Medical Services Authority developed CEMSIS. CEMSIS : CEMSIS As a result, there will be changes to our patient documentation requirements.
Updates to the bubble form and QCS currently in progress to comply with CEMSIS. Questions? : Questions? References : References State of California, Health and Human Services Agency. Emergency Medical Services (EMS) Specific Guideline #2. (2009, April) Guidance and Recommendations for Local EMS Agencies and EMS providers for Swine Flu Response. Retrieved April 28, 2009, from http://www.emsa.ca.gov/about/files/EMSSpecificSwineFluRec2_4-27.pdf
Doyle GS., & Taillac PP. (2008). Tourniquets: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care. 2008 Apr-Jun; 12(2):241-56.
Mobsy Inc. (2007). Prehospital Trauma Life Support (Sixth Edition). Military Version.
Wayne, M. A., Levine, R. L., & Miller, C. C. (1995, June). Use of End-Tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest. Annals of Emergency Medicine, 25(6), 762-767.
Kodali, B. S. (2004, January). Capnography. Retrieved April 2004, www.capnography.com
Oregon EMS powerpoint. Nasal Drug Delivery in EMS. Retrieved April 2009, http://www.oregonems.org/Downloads/NasalDrugDeliveryinEMS.ppt Fair Use : Fair Use Graphics included in this presentation used for academic and educational purposes under the Fair Use principle.