HARTFORD HOSPITAL SPONSORED EMS SERVICE

2016 STATE PROTOCOL ROLL-OUT

Note: CCR/CPR and Wound Packing Updates are Separate

Hartford Hospital Sponsored Service Implementation of State Protocols

• State goal – implement no later than 12/31/2016• Don’t use new protocols until Sponsor Hospital

gives your agency the green light• Before HH-sponsored agency goes live, all

agency personnel must:– Complete the State online presentation– Complete HH Sponsor Hospital Roll-Out (what we are

doing now)– Successfully complete the protocol exam

Today’s Roll-Out

• This presentation highlights some major changes

• Not all changes will be presented here• Providers are responsible to read and

familiarize themselves with protocols

Many “Considers” in the Protocols• “Consider” = medical judgment• Remember - EMS functions as an extension of the

Medical Director and his or her medical judgment• In some cases, medications or treatments will not be

available based on Medical Director judgment• If you don’t fully understand the reasons to “consider”

in choosing a treatment option, contact OLMC and/or discuss later with EMS Coordinator/Medical Director

• The sponsor hospital will continue to issue guidance to direct and assist in this medical decision making

Routine Patient Care

• IV fluid for dehydration w/o shock still OK– Now in increments of 250 ml

• “Only apply topical hemostatic agents in a gauze format that supports wound packing”– Will get back to wound packing in a bit

Exception Protocol

• Rare circumstance• Need to do something not in protocols but IS

in paramedic scope of practice– MUST call OLMC for permission – MUST notify Sponsor Hospital and OEMS in

writing within 48 hours

Adult Allergic Rxn/Anaphylaxis

• Pepcid– Only useful for skin reaction– HH services will not be carrying

• Removes steroid• IV epi only after 3 doses IM epi– IV epi now only as infusion 2-10 mcg/min

• Albuterol neb increased up to 4 doses

Pediatric Allergic Rxn/Anaphylaxis

• PO diphenhydramine dosing increased to 1.25 mg/kg– IV diphenhydramine remains 1 mg/kg

• IV epi change to infusion 0.1 – 2 mcg/kg/min (max 10 mcg/min)

Pedi Asthma/Bronchiolitis/Croup

• Pedi CPAP for asthma– Start at 5 cmH2O– Need pedi CPAP mask

• Does not specify Solumedrol rate of admin but still dilute and give slow (over ~15 min)

• Adds dexamethasone (0.6mg/kg PO/IV/IM with PO preferred to max 10mg)– Croup or asthma– Parenteral formulation can be used PO (just tastes yucky)

Hyperthermia

• Mentions “immersion cooling” if “proper resources are available”

• Probably the best thing for the patient with true exertional heat stroke– Minutes till cooled actually make a difference in

outcome• So…If an athletic trainer has someone in an ice

bath and it appears indicated, consider keeping the patient in the ice bath but…

Hyperthermia• Some immersion cooling concerns to considerer:– Is this something else and not actually heat stroke?– Continuous temperature monitoring being used?

• Should be flexible rectal or esophageal probe– How much cooling is enough?

• Ideally by core temp (<101.5 deg F)• Maybe at 20 minutes if core temp is not available

– Ability to manage patient during immersion?• Airway• Seizures common

– Should contact OLMC for direction in these cases• Further guidance is being developed – Stay tuned!

Hypoglycemia Adult/Pedi

• D10 Only (no more option for D25 or D50)• Hypoglycemia with altered mental status:– If unable to give oral glucose and ALS

interventions are not available, stop or disconnect insulin pump

Nausea Vomiting

• Must call OLMC for second line anti-emetic• Metoclopramide (Reglan)– Now 5mg dose IV (previously 10mg); IM not listed– Note: Reglan has a more rapid onset of action than

ondansetron (3 minute vs ~30 minute onset)• OK to consider IV fluid for dehydration, even if

VS are normal– 500ml adult– 10-20ml/kg pedi

Pain Management

• Allows repeat opioids every 5 minutes– Morphine takes longer to reach its peak; consider

waiting longer than 5 minutes to repeat• IN fentanyl now at same doseing (1mcg/kg) as

other routes• For pedi, cut repeat opioid doses in half• Ketamine…

Ketamine

• Dissociative agent– Induces a trance-like state

• Bad side effects (especially with rapid admin):– Tachycardia– Hypertension– Resiratory depression– Laryngospasm

• Good side effect: causes Bronchodilation – May be a good choice in patients with asthma

• Will be supplied as either 50 mg/ml or 100 mg/ml

Ketamine

• Onset of action: – IV: Within about 30 seconds– IM: 3 to ~15 minutes

• Duration:– Full dissociative effect lasts about 20 minutes– Patient then very gradually transitions back to

baseline

Ketamine for Pain

• Pain management – 0.3 mg/kg IV/IO/IM– Be careful – MUCH LOWER dose than for behavioral

• Non-dissociative dose• Patients may become confused/uncomfortable if approaching

but not fully in dissociative state• Best to dilute and give slowly IV

• Alternative analgesic to opiates– May be good choice in nerve pain or opioid dependence– Also, when combined with opiates, shown to lower opiate

dose required for pain control• Call OLMC if wishing to add an opiate after ketamine (i.e.

ketamine is not adequately addressing pain)

Ketamine for Pain continued

• If Severe Emergence Reactions – 2.5 mg midazolam IV or IM– Emotional distress– Anxiety/agitation– Hallucinations

• If it looks like the patient is uncomfortable and emergence reaction is developing, generally best to get ahead of it and administer midazolam

Ketamine for Restraint

• Violent patient restraint (excited/agitated delirium or extreme agitation)– 1-2 mg/kg IV– 3-4 mg/kg IM

• Give full dose – cutting the dose may result in partial dissociation which is extremely uncomfortable for the patient

• If you choose ketamine in these cases, need to call OLMC for additional doses or to add midazolam for restraint

Midazolam• Seizures: all adults as 10mg IM (be ready with BVM)• Restraint: 5mg dose may repeat x1 in 5 min

– Haloperidol ONLY if violent after 2nd midazolam• Alcohol withdrawal: Use restraint protocol/dosing of

midazolam (and IV hydration per routine care)• Post-intubation: 2-5mg midazolam AND 50-100mcg

fentanyl• Also see TBI, Hypothermia, cardioversion• Pacing: Midazolam listed – working on change back to

fentanyl• Ketamine Emergence Reactions: 2.5 mg

Orogastric Tubes

• Indication: Decompress the stomach in intubated patients

• Contraindications: – Known esophageal varices– Caustic ingestion

• Complications:– Tracheal insertion– Coiling in posterior pharynx– Localized trauma

Orogastric Tubes

• Dual lumen tube– Large lumen can connect to suction– Small lumen is an air vent to reduce negative

pressure and prevent gastric mucosa from being drawn into the catheter

Orogastric Tubes• Equipment– Gastric evacuation tube (Ewald, Salem, Sump or other double

lumen tube)– Water soluble lubricant– 60 ml syringe with catheter tip– Tape or tube holder– Stethoscope

• Sizing– Adult – 16 or 18 french– Pediatric – Use length based tape for appropriate size (8, 10 or

12 french)

Orogastric Tube Insertion• Measure length from nostril to earlobe to xiphoid process –

mark with tape• Insert orally to marked depth. If resistance is met, stop, adjust

direction and re-attempt• Confirm placement

– Aspirate gastric content with 60ml catheter tipped syringe– Inject air auscultating over stomach for ‘swoosh’ or burp

• Adult: 20ml air• Pedi: 10ml air

• Secure with tape• Leave tube open to allow passive decompression

– Apply intermittent suction if required (then disconnect/leave open)• Suction around tube if vomiting occurs

Bougie Assisted Surgical Cric

• Not new – have been training providers on this for the last year

• Now should be the standard cric method• Simple process using familiar equipment• Very fast and reliable with relatively minimal

training• Yearly skill validation

Spinal Motion RestrictionPositioning

• NOT “position of comfort”• SUPINE and FLAT on STRETCHER– Secure “firmly” with straps– Limited elevation of stretcher if needed for

respiratory function– Lateral recumbent if needed for nausea/vomiting

Vassopressor AdministrationPumps OR Flow Restricting Devices Required

• Safety concern of:– Inaccurate dosing– Runaway IV lines

• Some states are requiring IV pumps for EMS if administering vasopressors

• Option of flow-restricting devices was a compromise due to fiscal impact of requiring pumps– These devices DO NOT provide the level of safety pumps

do

Pressor Administration

• What everyone would like to see:

What Most Will See

Flow Restricting IV Device

• Sets flow at ml/hr• NOT exact– Affected by vein, gravity, etc.– MUST confirm rate by counting drops/min

• Upper and lower limits– Lower usually around 12-15 ml/hr– Upper around 250 ml/hr then unrestricted setting

Questions