2006 Protocol Update

1
2006 Protocol Update

• Central Shenandoah EMS Council

2
Background

• Release of the American Heart Association 2005
  Guidelines for CPR and ECC
• CSEMS Council Medical Control Review Committee
• Protocol Sub-committee
• Peer Review

3
Summary of Major AHA Changes

• 2006 Protocol Update

4
Basic Life Support

• Focus on providing high-quality CPR with special
  attention to chest compression depth and rate,
  permitting complete chest wall recoil and minimal
  interruptions to compressions.

5
Basic Life Support

• All rescuers acting alone should use a 302 ratio
  of compressions-to-ventilations for all victims
  except newborns.
• Health-care providers performing two-rescuer CPR
  for adults should use a 302 compression-to-ventil
  ation ratio when there is no advanced airway in
  place.
• Health-care providers performing two-rescuer CPR
  for infants and children should use a 152
  compression-to-ventilation ratio when there is no
  advanced airway in place.

6
Basic Life Support

• Compressions are given at a rate of 100 per
  minute with complete relaxation of pressure on
  the chest wall after each compression.
• Once an advanced airway is in place, continuous
  chest compressions are given at 100/minute with
  one ventilation every six to eight seconds (810
  ventilations per minute). The ventilations are
  given without pausing chest compressions.

7
Basic Life Support

• Each rescue breath should be given over one
  second.
• If a jaw thrust without head extension does not
  open the airway for an unresponsive trauma victim
  with suspected cervical spine injury, use the
  head tiltchin lift maneuver.
• Avoid over-ventilation too many breaths per
  minute or breaths that are too large or too
  forceful.

8
Basic Life Support

• Use a child dose-reduction system with AEDs (e.g.
  pediatric pads/cable), when available, for
  children from one to eight years old.
• When two or more health-care providers are
  present during CPR, rescuers should rotate the
  compressor role every two minutes.

9
Basic Life Support

• For victims of ventricular fibrillation (VF)
  cardiac arrest, use a single shock, followed by
  immediate CPR for two minutes, starting with
  compressions first.

10
Basic Life Support

• Actions for foreign body airway obstruction
  (FBAO) relief were simplified.
• For adult out-of-hospital cardiac arrest that is
  not witnessed by the EMS provider, rescuers give
  a period of CPR (about two minutes) before
  checking the rhythm and attempting defibrillation.

11
Advanced Life Support - Adults

• Therapy for acute coronary syndrome (ACS)
• Emphasis on 12-lead ECG acquisition by EMT-Bs and
  all ALS providers.

12
Learn More

• www.americanheart.org
• Click on
• CPR ECC ? AHA Guidelines for CPR ECC

13
2006 BLS Protocol Review

• CSEMS Council

14
Level Designation

• First Responder A
• EMT-Basic B
• EMT-Shock Trauma C
• EMT-Enhanced J
• EMT-Cardiac D
• EMT-Intermediate I
• EMT-Paramedic E

15
Table of Contents
3

• Each item is linked to the heading.

16
General Patient Management
7

• Scene size-up

17
Initial Assessment
8

• Breathing
• Breaths delivered over 1 second.
• Rescue breathing at 10 to 12 breaths/min (adult),
  12 to 20 breaths/min (infant/child).

18
BLS Maneuvers
9
19
General Patient Management
10-12

• History and Examination
• OPQRST-ASPN
• Associated symptoms
• Pertinent negatives
• On-going Assessment

20
Cardiac Arrest Adult
13
More
21
Cardiac Arrest Adult
13
22
Cardiac Arrest Adult
14

• Follow manufacturers recommendations for shock
  energies.
• Arrest witnessed ? defibrillate as soon possible.
• Arrest not witnessed ? 5 cycles of CPR ?
  defibrillation.
• Provide CPR while the defibrillator charges.
• Give the shock as quickly as possible.
• Immediately after shock delivery,
• Resume CPR (beginning with chest compressions)
• Continue for 5 cycles (about 2 minutes)
• Then check the rhythm.

23
Cardiac Arrest Adult
14

• Push hard and fast (100/min).
• Ensure full chest recoil.
• Minimize interruptions in chest compressions.
• One cycle of CPR 30 compressions then 2 breaths
  5 cycles ? 2 min.
• Rotate compressors every cycle.
• Resuscitation can be terminated by BLS or ALS
  providers under the direction of Medical
  Control.

24
Cardiac Arrest Adult
14

• Avoid hyperventilation.
• Secure airway and confirm placement.
• ?After an advanced airway is placed, rescuers no
  longer deliver cycles of CPR. Give continuous
  chest compressions without pauses for breaths.
• Give 8 to 10 breaths/minutes.
• Check rhythm every 2 minutes.
• Rotate compressors every 2 minutes with rhythm
  checks.

25
Cardiac Arrest Adult
14

• Search for and treat possible contributing
  factors
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo-/hyperkalemia
• Hypoglycemia
• Hypothermia

• Toxins
• Tamponade, cardiac
• Tension pneumothorax
• Thrombosis (coronary or pulmonary)
• Trauma

26
Cardiac Arrest - Child
25
More
27
Cardiac Arrest - Child
22
28
Medical Trauma Protocols

• 2006 Protocol Update

29
Altered Mental Status
37

• Most protocols contain introductory section with
  a background on the condition.
• AMS protocol directs provider to new sections.
• Hypoglycemia
• Hyperglycemia
• AEIOUTIPS

30
Burns
39

• Essentially unchanged.
• Classification of burn severity table.
• ABA burn unit referral criteria table.

31
Chest Pain (Non-traumatic)
43

• Nitroglycerin to a total of 3 doses.
• Emphasis on 12-lead acquisition.
• Notification of hospital.
• Patient disposition.

32
Environmental (Snake Bite)
49

• No constricting bands.
• Every 15 minutes, use a pen to mark the border of
  the advancing edema and document the time.

33
Obstetrics Normal Delivery
53

• Expanded, more detailed guidelines.

34
Obstetrics Normal Delivery
55

• Essentially unchanged.
• Ensure preservation of newborn warmth.
• APGAR score.

35
Obstetrics Newborn Resuscitation
56

• Respirations adequate, HR gt100, centrally
  cyanotic
• Blow-by oxygen.
• No response in 30 seconds ? BVM 40 to 60 breaths
  per minute.
• Respirations inadequate or HR lt100
• Ventilation with a BVM.
• Continue until HR gt100.
• HR lt60 after 30 seconds of BVM
• Chest compressions at a rate of 120/min.
• Compression to ventilation ratio of 31.
• Continue until HR gt60.

36
Respiratory Airway Obstruction
60

• ? 1 year of age
• Are you choking?
• Less than 1 year of age
• Deliver 5 back blows (slaps) followed by 5 chest
  thrusts

37
Respiratory Airway Obstruction
61

• Start CPR in all ages.
• No longer perform abdominal thrusts in age ?1
  year.
• Higher sustained airway pressures can be
  generated using the chest thrust rather than the
  abdominal thrust.
• Each time the airway is opened during CPR, look
  for an object and remove if found with a finger
  sweep.

38
Respiratory Pulmonary Edema
67

• Assist the patient with prescribed nitroglycerin,
  if available.

39
Spinal Immobilization
75

• New protocol.
• o indicates First Responders trained to perform
  spinal immobilization.
• Applies to patient 14 years of age or older.

40
Selective Spinal Immobilization
76
41
Toxicology
78

• 4.25.1 GENERAL
• No syrup of ipecac.
• No activated charcoal.
• Charcoal still in the Virginia OEMS Regulations.

42
Trauma Triage
83

• UN-ENTRAPPED PRIORITY PATIENTS
• Patient is located within 15 minutes of the
  closest hospital
• Transport the patient directly to the closest
  hospital.
• Summon a helicopter to rendezvous at the
  hospital.
• Patient is located more than 15 minutes from the
  closest hospital
• Attempt to rendezvous with a helicopter at a
  location between the incident scene and the
  closest hospital.
• Set the rendezvous site such that the ambulance
  does not have to wait on the helicopter.

43
Trauma Triage
83

• UN-ENTRAPPED PRIORITY PATIENTS
• Do not delay transport to wait on higher trained
  personnel.
• If a helicopter has been dispatched to the scene
  and the patient is ready for transport, divert
  the helicopter to the closest hospital and
  transport the patient to that hospital.
• If ALS support is en route for a rendezvous, do
  not wait on the ALS personnel.

44
Trauma Triage
83

• ENTRAPPED PRIORITY PATIENTS
• Provide care to the extent the entrapment
  permits.
• Request ALS personnel to the incident scene.
• Summon helicopter support to the scene.
• Notify Medical Control of the incident.
• As soon as the entrapped person is freed,
• Follow the protocol on for un-entrapped patients.
• Do not wait on ALS personnel or a helicopter
• Initiate transport and rendezvous if possible.

45
Trauma Triage
84

• CARDIAC ARREST IN TRAUMA PATIENTS
• Adult and pediatric patients found dead at the
  scene of a trauma are not to be resuscitated
  unless they are
• Hypothermic
• recently drowned
• Electrocuted
• BLS airway and ventilation procedures.
• Patients who lose vital signs while care is being
  administered. are to be resuscitated. Prompt
  consultation with Medical Control is mandatory.
• Blunt vs. penetrating trauma.

46
Trauma Triage
84

• LANDING ZONES
• Pre-designated landing zones are preferred.
• Landing zone should be selected in such a way
  that the helicopter would be expected to arrive
  before the ambulance that is transporting the
  patient.

47
Procedures

• 2006 Protocol Update

48
12-Lead ECG
85

• All levels of training except First Responder.
• Agency-based monitor-specific training.
• CSEMS will be working with Phillips Medical
  Systems to sponsor 12-lead classes in region.

49
Combitube
88

• Procedure now recognized the two Combitube sizes.
• 37 French
• 41 French

50
PASG
X
51
Suctioning, Adult/Pediatric
117

• Expanded procedure description.

52
Pharmacology

• 2006 Protocol Update

53
Aspirin
131

• Blood-thinning drugs, such as Coumadin, are no
  longer contraindications.

54
EpiPen?, EpiPen Jr.?
140
55
Metered Dose Inhaler
145
56
Nitroglycerin, Assisted
153
57
Nitroglycerin, Assisted
153
58
Oral Glucose
154
59
Abbreviations and Symbols
158

• Approved medical abbreviations.
• Limit use of abbreviations to those that appear
  on this list.

60
Abbreviations and Symbols
163

• Dangerous abbreviations and dosage designations
• DO NOT USE!
• Problem Term
• Intended meaning
• Reason for Problem(s)
• Suggested remedy

61
Deceased Patient Guidelines
165
62
Glasgow Coma Scale
167
63
Pediatric References
169
64
Telephone Numbers
170
65
Triage, JumpSTART
171
66
Triage, START
172
67
Appendix
173
68
References
176
69
Conclusion

• Protocols in two formats
• Field guide.
• Reference only.
• Text-like document available electronically.
• Complete protocol document.
• Field guides are being printed.
• Distribution of field guides.
• First part of August.
• Effective date will be announced when printing of
  the field guides is completed.

70
Questions