Regional Protocol Update

1
Regional Protocol Update

• The General Airway Protocol has been updated. The
  following slides will summarize the changes, then
  continue to the updated protocol.

2
Summary of Changes

• Supraglottic Airway Device (added language)
• Supraglottic Airway Device (SAD) as approved by
  local MCA protocol
• A SAD is the accepted secondary device for
  Specialist and Paramedic.
• In cardiac arrest patients, a SAD should be
  considered early in patients whom oral
  intubation is perceived to be technically
  difficult.

3
General Airway Protocol

• Pre-Radio
• MFR/EMT/SPECIALIST/PARAMEDIC
• 1. Supplemental Oxygen
• When indicated, administer oxygen at the
  highest flow tolerated by the patient.
• 2. Oropharyngeal and Nasopharyngeal Airways
• When indicated, oral and nasal airways are to
  be used to assist in maintaining a patent
  airway.
• Use of one of these devices should be
  considered when ventilatory support by bag valve
  mask is provided.
• 3. Artificial Ventilation (BVM)
• Using a bag valve mask (BVM) is the recommended
  means of providing ventilatory assistance. The
  use of positive pressure ventilation (demand
  valve) is not allowed.

4

• EMT/SPECIALIST/PARAMEDIC
• 4. Intubation (Oral and Nasal)
• Intubation may be attempted two (2) times prior
  to utilizing a Supraglottic Airway Device, unless
  otherwise indicated in the protocol.
• Nasal intubation may be performed pre-radio.

5

• 5. Supraglottic Airway Device (SAD) as approved
  by local MCA protocol
• A SAD is the accepted secondary airway device for
  Specialist and Paramedic.
• BLS agencies may use these devices if they have
  met the criteria and been approved by the
  appropriate Medical Control Authority.
• If ALS care becomes available at the scene where
  a BLS unit has placed a SAD, the ALS unit will
  take over care of the patient.
• In cardiac arrest patients, a SAD should be
  considered early in patients whom oral intubation
  is perceived to be technically difficult.

6

• PARAMEDIC
• 6. Medications via the Endotracheal Tube
• ALTHOUGH SOME MEDICATIONS MAY BE GIVEN VIA THE
  ENDOTRACHEAL TUBE, IV OR IO ROUTES OF
  ADMINISTRATION ARE PREFERRED.
• The following medications may be given via the
  endotracheal tube
• Atropine, Epinephrine
• Adults Dosages given via this route need to be 2
  to 2.5 times that of the IV dosage.
• Children Dosages given via this route need to be
  2 to 3 times that of the IV dosage. All dosages
  for pediatric epinephrine administered ET are
  11000 concentration.
• 7. Cricothyrotomy
• Cricothyrotomy may be performed, as indicated,
  utilizing protocols for pediatric needle
  cricothyrotomy or adult surgical cricothyrotomy.

7
Regional Protocol Update

• The General IV/IO Protocol has been updated. The
  following slides will summarize the changes, then
  continue to the updated protocol.

8
Summary of Changes

• Attempts (added language)
• For a patient in cardiac arrest, if the IV
  attempts are unsuccessful or are determined,
  after initial attempts, to be technically
  difficult proceed to IO infusion
• Removed
• (Optional)
• Where Intraosseous infusions are allowed,
  use the guidelines approved by your local Medical
  Control Board for initiating an Intraosseous
  Infusion.
• Added
• Use the guidelines approved by your local
  Medical Control Board for initiating an
  Intraosseous Infusion.

9
Indications

• Removed
• Life threatening situations where venous
  access using peripheral veins has been
  unsuccessful
• Added
• Adult and pediatric life threatening situations
  where venous access using peripheral veins has
  been unsuccessful.

10
General IV/IO Protocol

• Southeast Michigan Regional Protocol
• Genesee, HEMS (Wayne), Lapeer, Macomb, Oakland,
  and Washtenaw/Livingston MCAs

11
Solutions Used

• NS (Normal Saline, 0.9 Sodium Chloride)

12
Sites

• The following sites may be used for establishing
  a peripheral IV (not necessarily in this order)

13
Sites

• Forearm
• Hand
• Antecubital Fossa
• Intraosseous
• Ankle
• Foot
• External Jugular
• Scalp Vein

• Large veins should be used in priority 1
  patients, or patients that are unstable
• If IV is placed in the vicinity of a joint, the
  joint should be immobilized

14
Attempts

• Once the equipment is set up, three (3) attempts
  to cannulate the vein may be made prior to
  contacting medical control. After three (3)
  attempts, contact medical control and additional
  attempts may be ordered. For patients in cardiac
  arrest, if the IV attempts are unsuccessful or
  are determined, after initial attempts, to be
  technically difficult proceed to IO infusion.

15
Attempts

• In situations where rapid transport is indicated,
  IV attempts should be done enroute

16
Catheter Size

• Adult trauma patients / patients needing fluid
  administration if possible, use at least an 18
  gauge catheter
• Other adult patients if possible, use at least
  a 20 gauge catheter for all other IV
  administrations
• Pediatric patients use the most appropriate
  size catheter for the size of the patients veins

17
Flow Rates

• Unless otherwise indicated in the protocol, the
  flow rate for IV/IO will be Keep Vein Open (KVO).

18
Saline Locks (ALS only)

• For adult patients in which the need for IV fluid
  is not anticipated, but for which medications
  might be needed, start an IV saline lock. A
  saline lock can be substituted for an IV of
  normal Saline, KVO.

19
Intraosseous (IO)

• Use the guidelines approved by your local
• Medical Control Board for initiating an IO
• infusion.
• In the Regional Medical Treatment Protocols,
  where it is listed that a drug is administered
  IV, it may be administered IO instead if an IO is
  indicated and has been established.

20
Intraosseous (IO) Continued

• Drugs administered IO should be followed by a NS
  flush of 5 ml.
• Fluids must be administered under pressure or
  with manual injection using a syringe.

21
Indications

• Venous access via peripheral veins should be
  attempted prior to attempting intraosseous
  placement.
• Adults and pediatric life threatening situations
  where venous access using peripheral veins has
  been unsuccessful. Situations include

22
Indications to Start an IO

• Cardiac Arrest
• Shock
• Status epilepticus
• Severe burn injury with shock
• Severe multiple trauma with shock

23
Contraindications

• Osteogenesis imperfecta
• Osteoporosis
• Fracture of the bone
• If possible, placement at or near sites of
  infection or burns should be avoided.

24
Site

• Proximal tibia
• Follow the manufactures recommendations for I/O
  insertion.