Clark County EMS 2003 Protocol Revisions

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Clark County EMS 2003 Protocol Revisions

• Lynn Wittwer, MD, MPD
• Clark County EMS

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Topics for Discussion

• New Medications
• Diltiazem
• Lorazepam
• Etomidate
• Other Medication Changes
• Revisions to Protocol
• New Protocol
• Gastric Decompression

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Diltiazem (Cardizem)

• Class
• Calcium Channel Blocker
• Actions
• Coronary artery vasodilitation
• Systemic vasodilitation
• Less effect than Nifedipine
• Slows AV nodal conduction
• ?ventricular rate w/ Afib Aflutter
• Interrupts reentry circuit in PSVT

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Diltiazem (Cardizem)

• Indications
• Increased ventricular response w/ Afib/flutter
• Refractory PSVT

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Diltiazem (Cardizem)

• Dosing/Administration
• 0.25 mg/kg over 2 minutes
• Avg. bolus for normal sized adult 20mg
• May repeat w/ 0.35 mg/kg over 2 minutes
• Avg. bolus 35mg
• If successful conversion
• 10 mg/hr infusion

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Diltiazem (Cardizem)

• Contraindications
• Wide Complex Tachycardia
• Precautions/Side Effects
• Hypotension
• Treat w/ fluid bolus
• Extreme/refractory hypotension may require
  Calcium infusion
• AV block
• Other side effects
• Angina, palpitations
• bradycardia, asystole, PVCs
• Flushing, peripheral edema

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Lorazepam (Ativan)

• Class/Actions
• Benzodiazepine
• CNS depressant
• Anxiolytic
• Sedative
• Indications
• Seizures
• Longer duration of action than Valium

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Lorazepam (Ativan)

• Dosing/Administration (adults and peds)
• Adults
• 2mg/min
• May repeat 2mg/min to max 8mg
• Peds
• 0.05 mg/kg slow IVP
• May repeat 0.05 mg/kg
• IV/IM
• Precautions/Side effects
• Respiratory depression
• Extravasation at insertion
• Myasthenia gravis

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Etomidate

• Class
• Non-barbiturate hypnotic
• Action
• Has no analgesic activity
• Does not blunt sympathetic response to intubation
• Slight decrease in ICP
• Produces hypnosis rapidly (
• Duration 3-5 min

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Etomidate

• Indications
• Sedation prior to Succinylcholine during RSI
• Dosing/Administration
• 0.3 mg/kg IV to 20 mg max dose
• Precautions/Side Effects
• Myoclonus
• Local irritation at injection site
• Can cause nausea and vomiting

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Summary of Medication Changes

• Diltiazem (Cardizem)
• CA channel blocker
• Indicated for Afib/flutter w/ rapid ventricular
  response
• Contraindicated in WCT
• Dosing regimen
• 0.25 mg/kg (typical dose 20mg)
• May repeat at 0.35 mg/kg (typical 35 mg)

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Summary of Medication Changes

• Lorazepam (Ativan)
• Benzodiazepine
• Longer duration than Versed/Valium
• Has relatively same CNS depressive, anxiolytic,
  sedative properties
• Not as good an amnestic as the above
• Seizures
• 2 mg/min
• repeat 2 mg/min to max 8 mg prn
• 0.05 mg/kg peds x 2 prn

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Summary of Medication Changes

• Etomidate
• Hypnotic
• Rapid onset w/ short duration
• May help decrease ICP in head injury
• Sedation during RSI prior to SUX
• 0.3 mg/kg Max 20mg
• If used w/o paralytic, may cause NV

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Other Medication Changes

• Versed
• Indications
• Sedation prior to cardioversion and pacing
• Post RSI intubation sedation
• Control of muscle spasm for pain control
• Sedation of psych pt. if Haldol ineffective or
  inappropriate
• Atropine
• Administer during RSI for HR
• Hx of COPD/CHF and pt. hypoxic
• Elevated CO2 decreased O2 sat
• Succinylcholine
• Max dose 200 mg

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Protocol Revisions
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Page 14
RECEIVING HOSPITAL II. Diversion Criteria
A. Medical Diversion - Diversion by SWMC Medical
Control to Portland area hospitals may occur due
to availability of resources, equipment, and/or
facilities at SWMC. Destination hospital will
generally be determined by closest facility.
B. Trauma Diversion - The final decision for
diversion to Emanuel or OHSU rests with Medical
Control at SWMC. Contact Medical Control as
soon as possible with patient information if
directed to divert, contact Medical Resource
Hospital (MRH) at OHSU for further
instructions. 1. Criteria for diversion
may include a) Penetrating or severe
injuries to the mid thorax and in
shock. b) Major burns (patients requiring
burn center intervention). c) Pregnancy with
multi-system trauma in shock,
unresponsive to aggressive resuscitation or
immediate surgery anticipated. d)
Pediatric trauma patient with shock/respiratory
distress e) SWMC Medical Control advised
diversion.
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Summary of Changes for Trauma Diversion

• Revised
• Multi-system trauma in shock (BPunresponsive to aggressive resuscitation, or
  where surgery is anticipated immediately.
• Penetrating or severe injuries to the thorax.
• Removed
• Head injury in shock.

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Page 20
DO NOT RESUSCITATE ORDERS I. Definitions A. A
DNR (DO NOT RESUSCITATE OR NO CODE) Order is an
order issued by a physician directing that
in the event the patient suffers a
cardiopulmonary arrest, (i.e., clinical death)
cardiopulmonary resuscitation will not be
administered. DNR orders are only valid
when a patient is under the care of skilled
nursing personnel. B. A Living Will is a
legally executed document expressing the
patient's wish to not undergo ALS
resuscitation. C. Physician Orders for Life
Sustaining Treatment (POLST) Legal document
signed by patient and physician indicating
patient preference for life sustaining
treatment. Includes preference for
resuscitation, replaces EMS No-CPR.
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WASHINGTON STATE EMS PROVIDER'S PROTOCOLS FOR
EMS-NO CPR and POLST FORM 3. After confirming
that the patient has a valid EMS-No CPR or POLST
form, the EMS provider should carry out these
standard EMS-No CPR orders a) POLST a.
Provide resuscitation based on patients wishes
identified on the form b. Provide
medical interventions identified on the form
c. Always provide comfort care b) EMS-No CPR
a. Do Not begin resuscitation measures
b. Provide comfort care c. Contact
patients physician or MC with questions or
problems c) Other DNR Orders a. Follow
specific orders in the DNR based on your
certification level and communications
with Medical Control
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WA STATE EMS PROVIDER'S PROTOCOLS FOR EMS-NO CPR
AND POLST FORM (CONT'D) 7. Comfort Care
Measures a) Comfort care measures for the dying
patient may include a. Manually open the
airway (do not provide positive pressure
ventilation with a bag valve mask, pocket
mask or endotracheal tube). b. Clear the airway
(including stoma) of secretions with
appropriate suction. c. Provide oxygen via
nasal cannula at 2-4lpm d. Place patient in
position of comfort e. Splint and control
bleeding as necessary f. Treat pain as per
protocol g. Provide emotional support to
patient and family
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Summary of Changes to DNR Protocols

• Add
• Definition of POLST
• Comfort Care Measures
• Should remove any confusion regarding when/not to
  intubate!
• Removed
• Liability for EMS Provider

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DYSRHYTHMIAS (CONTINUED) D. Supraventricular
Tachycardia 1. SINUS TACHYCARDIA a) consider
cause (e.g., hypovolemia, etc.). b) treat
shock. 2. ATRIAL FIBRILLATION/FLUTTER stable
with rapid ventricular rate
a) Diltiazem 0.25 mg/kg (typically 20
mg) b) may repeat at 0.35 mg/kg (typically
30-35 mg) c) If conversion, 10mg/hr
drip 3. ATRIAL FIBRILLATION/FLUTTER - unstable
with rapid ventricular rate
a) Cardiovert synchronized at 100,200,300,360
J. ? Peds 0.5 j/kg, 1 j/kg prn (Versed
sedation as needed).
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Summary of Changes to Dysrhythmia Protocol

• Add
• Atrial Fibrillation/Flutter Stable with rapid
  ventricular rate
• Diltiazem for above

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Page 63
SEIZURES (MAJOR MOTOR GRAND MAL) II.
Treatment/Drug Therapy A. If seizure has
persisted more than 5-10 minutes or if
repetitive 1. I.V. TKO. 2. Draw
blood for laboratory use Glucoscan.
3. EKG 4. Dextrose 25 grams, if
hypoglycemic may repeat x 2 every 5 minutes,
prn. Child 0.5-1 gm/kg may repeat x 2 every 5
minutes, prn. 5. Ativan 2mg/min IV, IM
until seizure stops max 8 mg Child 0.05 mg/kg
IV/IM slow IVP. May repeat prn 6. Thiamine
100 mg I.V. for Adult, if alcoholism suspected.
7. Magnesium Sulfate 2 grams I.V. over
5-10 minutes for possible alcohol withdrawal
seizure.
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Summary of Changes to Seizure Protocol

• Ativan substitutes Versed in the following
  protocols
• Seizures
• Toxemia of Pregnancy
• Pediatrics Fever
• Quick Reference Medication List
• Heat Syndromes
• Hypertensive Emergencies
• Poisons and Overdosages

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Page 79
ENDOTRACHEAL INTUBATION WITH SUCCINYLCHOLINE
"SUX" II. Management A. 100 O2 assisted
ventilations, BVM, hyperventilate patient prior
to SUX if possible. 1. Suction as needed.
2. I.V. secured. Surgical equipment
available. 3. Cardiac monitor.
B. Pretreatment medications
1. Lidocaine 1 mg/kg I.V. All patients.
2. Atropine 0.5 mg I.V. - Adults with pulse

O2sat and increased CO2 All children
old, 0.01 mg/kg I.V. 3. Etomidate
0.3 mg/kg max 20 mg (adult) for sedation.
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Summary of Changes to RSI Protocol

• Add
• Etomidate for initial sedation
• Versed remains for post intubation sedation and
  with all Vecuronium use
• Atropine for hypoxic patients
• Elevated PCO2 with decreased O2 saturation

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New Protocol Gastric Decompression

• Indications
• Inability to adequately ventilate due to gastric
  distension
• Gastric distension in an unresponsive patient
• Usually done in intubated patient
• Contraindications
• Head/face injured trauma patient
• Anatomic anomalies preventing correct placement

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New Protocol Gastric Decompression

• Procedure NG Intubation
• Size age appropriate
• Newborn/infant 8 fr.
• Toddler/pre sch. 10 fr.
• School age 12 fr.
• Adolescent/Adult 14-18 fr.
• Tube depth
• Measure top of nose to tip of Xyphoid

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New Protocol Gastric Decompression

• Procedure (cont.)
• Lube tube and pass along floor of nasal cavity
  into stomach
• DO NOT FORCE
• Auscultate over epigastrium while instilling air
  via syringe

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New Protocol Gastric Decompression

• Procedure (cont.)
• Aspirate stomach contents
• Achieve adequate ventilations
• Secure tube

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New Protocol Gastric Decompression

• Complications with NG placement
• Epistaxis
• Intracranial placement
• Bronchial placement
• Pharyngeal perforation
• Esophageal obstruction or rupture
• Bronchial or alveolar perforation
• Pneumothorax
• Gastric or duodenal rupture

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New Protocol Gastric Decompression

• Techniques for identifying correct placement
• Gastric placement
• Auscultation of air over epigastrium
• Aspiration of recognizable GI contents
• Tracheobronchial placement
• Absence of above
• Coughing or choking
• Inability to speak
• Air bubbles when proximal end of tube placed in
  water

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Other Protocol Considerations

• Trauma System Issues
• Trauma patient to Portland
• ALWAYS activate through Trauma Resource Hospital
  (MRH at OHSU)
• They will provide you w/ destination (usually
  Emanuel)
• Prevents inappropriate destination for trauma
• ALWAYS notify Medical Control at SWMC of
  diversion to Portland
• If necessary, contact receiving hospital AFTER MRH

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Other Protocol Considerations

• Trauma System Issues
• Know changes to triage tool
• Current changes mirror diversion criteria at SWMC
• Other Protocol Changes
• CVA protocol
• Stroke sx changed to 5 hours
• RSI protocol
• 200 mg max single SUX dose