1 2006 protocol update central shenandoah ems council

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2006 Protocol Update2006 Protocol Update

Central Shenandoah EMS CouncilCentral Shenandoah EMS Council

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BackgroundBackground

• Release of the American Heart Association 2005 Guidelines for CPR and ECC

• CSEMS Council Medical Control Review Committee

• Protocol Sub-committee• Peer Review

• Release of the American Heart Association 2005 Guidelines for CPR and ECC

• CSEMS Council Medical Control Review Committee

• Protocol Sub-committee• Peer Review

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Summary of Major AHA Changes

Summary of Major AHA Changes


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Basic Life SupportBasic 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.

• 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.

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• All rescuers acting alone should use a 30:2 ratio of compressions-to-ventilations for all victims except newborns.

• Health-care providers performing two-rescuer CPR for adults should use a 30:2 compression-to-ventilation ratio when there is no advanced airway in place.

• Health-care providers performing two-rescuer CPR for infants and children should use a 15:2 compression-to-ventilation ratio when there is no advanced airway in place.

• All rescuers acting alone should use a 30:2 ratio of compressions-to-ventilations for all victims except newborns.

• Health-care providers performing two-rescuer CPR for adults should use a 30:2 compression-to-ventilation ratio when there is no advanced airway in place.

• Health-care providers performing two-rescuer CPR for infants and children should use a 15:2 compression-to-ventilation ratio when there is no advanced airway in place.

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• 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 (8–10 ventilations per minute). The ventilations are given without pausing chest compressions.

• 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 (8–10 ventilations per minute). The ventilations are given without pausing chest compressions.

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• 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 tilt–chin lift maneuver.

• Avoid over-ventilation: too many breaths per minute or breaths that are too large or too forceful.

• 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 tilt–chin lift maneuver.

• Avoid over-ventilation: too many breaths per minute or breaths that are too large or too forceful.

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• 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.

• 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.

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

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

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• 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.

• 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.

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Advanced Life Support - AdultsAdvanced Life Support - Adults

• Therapy for acute coronary syndrome (ACS):– Emphasis on 12-lead ECG acquisition by EMT-Bs

and all ALS providers.

• Therapy for acute coronary syndrome (ACS):– Emphasis on 12-lead ECG acquisition by EMT-Bs

and all ALS providers.

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Learn More…Learn More…

• www.americanheart.org• Click on…

– CPR & ECC AHA Guidelines for CPR & ECC

• www.americanheart.org• Click on…

– CPR & ECC AHA Guidelines for CPR & ECC

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2006 BLS Protocol Review2006 BLS Protocol Review

CSEMS CouncilCSEMS Council

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Level DesignationLevel Designation

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

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

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Table of ContentsTable of Contents

• Each item is linked to the heading.• Each item is linked to the heading.

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General Patient ManagementGeneral Patient Management

• Scene size-up• Scene size-up

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Initial AssessmentInitial Assessment

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

12 to 20 breaths/min (infant/child).

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

12 to 20 breaths/min (infant/child).

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BLS ManeuversBLS Maneuvers 9

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General Patient ManagementGeneral Patient Management

• History and Examination– OPQRST-ASPN

• Associated symptoms• Pertinent negatives

• On-going Assessment

• History and Examination– OPQRST-ASPN

• Associated symptoms• Pertinent negatives

• On-going Assessment

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Cardiac Arrest – AdultCardiac Arrest – Adult13

More…More…

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Cardiac Arrest – AdultCardiac Arrest – Adult13

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Cardiac Arrest – AdultCardiac Arrest – Adult

• Follow manufacturer’s 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.

• Follow manufacturer’s 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.

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• 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].

• 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].

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• 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.

• 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.

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

• 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

– Toxins– Tamponade, cardiac– Tension pneumothorax– Thrombosis (coronary or

pulmonary)– Trauma

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Cardiac Arrest - ChildCardiac Arrest - Child25

More…More…

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Cardiac Arrest - ChildCardiac Arrest - Child22

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Medical & Trauma ProtocolsMedical & Trauma Protocols


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Altered Mental StatusAltered Mental Status

• Most protocols contain introductory section with a background on the condition.

• AMS protocol directs provider to new sections.– Hypoglycemia– Hyperglycemia

• AEIOUTIPS

• Most protocols contain introductory section with a background on the condition.

• AMS protocol directs provider to new sections.– Hypoglycemia– Hyperglycemia

• AEIOUTIPS

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BurnsBurns

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

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

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Chest Pain (Non-traumatic)Chest Pain (Non-traumatic)

• Nitroglycerin to a total of 3 doses.• Emphasis on 12-lead acquisition.

– Notification of hospital.– Patient disposition.

• Nitroglycerin to a total of 3 doses.• Emphasis on 12-lead acquisition.

– Notification of hospital.– Patient disposition.

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Environmental (Snake Bite)Environmental (Snake Bite)

• No constricting bands.• Every 15 minutes, use a pen to mark the

border of the advancing edema and document the time.

• No constricting bands.• Every 15 minutes, use a pen to mark the

border of the advancing edema and document the time.

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Obstetrics – Normal DeliveryObstetrics – Normal Delivery

• Expanded, more detailed guidelines.• Expanded, more detailed guidelines.

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Obstetrics – Normal DeliveryObstetrics – Normal Delivery

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

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

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Obstetrics – Newborn ResuscitationObstetrics – Newborn Resuscitation• Respirations adequate, HR >100, centrally

cyanotic:– Blow-by oxygen.– No response in 30 seconds BVM 40 to 60 breaths per

minute.

• Respirations inadequate or HR <100:– Ventilation with a BVM.– Continue until HR >100.

• HR <60 after 30 seconds of BVM:– Chest compressions at a rate of 120/min.– Compression to ventilation ratio of 3:1.– Continue until HR >60.

• Respirations adequate, HR >100, centrally cyanotic:– Blow-by oxygen.– No response in 30 seconds BVM 40 to 60 breaths per

minute.

• Respirations inadequate or HR <100:– Ventilation with a BVM.– Continue until HR >100.

• HR <60 after 30 seconds of BVM:– Chest compressions at a rate of 120/min.– Compression to ventilation ratio of 3:1.– Continue until HR >60.

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Respiratory – Airway ObstructionRespiratory – Airway Obstruction 1 year of age

– “Are you choking?”

• Less than 1 year of age– Deliver 5 back blows (slaps) followed by 5 chest

thrusts

1 year of age– “Are you choking?”

• Less than 1 year of age– Deliver 5 back blows (slaps) followed by 5 chest

thrusts

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Respiratory – Airway ObstructionRespiratory – Airway Obstruction• 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.

• 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.

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Respiratory – Pulmonary EdemaRespiratory – Pulmonary Edema

• Assist the patient with prescribed nitroglycerin, if available.

• Assist the patient with prescribed nitroglycerin, if available.

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Spinal ImmobilizationSpinal Immobilization

• New protocol.• “o” indicates First Responders trained to

perform spinal immobilization.• Applies to patient 14 years of age or older.

• New protocol.• “o” indicates First Responders trained to

perform spinal immobilization.• Applies to patient 14 years of age or older.

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“Selective Spinal Immobilization”“Selective Spinal Immobilization”

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ToxicologyToxicology

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

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

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Trauma TriageTrauma Triage

• 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.

• 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.

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• 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.

• 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.

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• 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.

• 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.

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• 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.

• 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.

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• 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.

• 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.

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ProceduresProcedures


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12-Lead ECG12-Lead ECG

• 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.

• 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.

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CombitubeCombitube

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

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

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PASGPASGX

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Suctioning, Adult/PediatricSuctioning, Adult/Pediatric

• Expanded procedure description.• Expanded procedure description.

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PharmacologyPharmacology


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AspirinAspirin

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

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

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EpiPen, EpiPen Jr. EpiPen, EpiPen Jr. 140

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Metered Dose InhalerMetered Dose Inhaler145

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Nitroglycerin, AssistedNitroglycerin, Assisted153

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Nitroglycerin, AssistedNitroglycerin, Assisted153

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Oral GlucoseOral Glucose154

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Abbreviations and SymbolsAbbreviations and Symbols

• Approved medical abbreviations. • Limit use of abbreviations to those that

appear on this list.

• Approved medical abbreviations. • Limit use of abbreviations to those that

appear on this list.

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Abbreviations and SymbolsAbbreviations and Symbols

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

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

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Deceased Patient Guidelines

Deceased Patient Guidelines

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Glasgow Coma ScaleGlasgow Coma Scale167

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Pediatric ReferencesPediatric References169

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Telephone NumbersTelephone Numbers170

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Triage, JumpSTARTTriage, JumpSTART171

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Triage, STARTTriage, START172

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AppendixAppendix173

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ReferencesReferences176

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ConclusionConclusion

• 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.

• 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.

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QuestionsQuestions

1 2006 protocol update central shenandoah ems council

Documents

ratio of compressions

advanced airway

ventilation ratio

continuous chest compressions

rescuer cpr

chest compression depth

healthcare providers

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