2008 maine ems protocol revision

2008 Maine EMS Protocol Revision

Provider EducationApril 10, 2008

Purple Section

Central Line Access• Central line access has been removed from

the MEMS protocols– Institute for Healthcare Improvement (IHI) found

extreme risk in this procedure and instituted recommendations that are nearly impossible for EMS.

On Line Medical Control Definition• “On Line Medical Control” (“OLMC”) refers to

the on-line physician, physician assistant or nurse practitioner who is licensed by the State and authorized by a hospital to direct emergency medical services persons consistent with the protocols developed by the MDPB.”

Adult Intraosseous Access• “IO” in these protocols, means intraosseous access. • IO may be used in any patient if an IV is not established within

two attempts or 90 seconds and that patient has one of the following:– Altered mental status (GCS less than or equal to 8)– Respiratory Failure (SaO2 less than or equal to 80% after appropriate

oxygen therapy, Respiratory rate less than 10 or greater than 40 breaths per minute) with alteration of mental status.

– Profound hypovolemia or hemodynamic instability (Systolic BP less than 90 mm Hg) with alteration of mental status

– Cardiac Arrest (Medical or Traumatic)

Adult Intraosseous Access• With discussion with OLMC, may consider IO

placement for the following conditions:– Profound hypovolemia (Systolic BP less than 90 mm Hg)– Burn patients with bilateral upper extremity burns

Adult Intraosseous Access• *IO is Contraindicated in the following conditions:

– Fracture of the tibia or femur – IO within 24 hours – Knee replacement– Tumor near site– Inability to locate landmarks– Excessive tissue at insertion site– IO access is not intended for prophylactic use.

Adult Intraosseous Access• Approved Sites (one per bone):

– Anterior/medial Tibia– Proximal Lateral Humerus

Brown Section

Hospital Destination Choice• Added to the Brown section

– Diversion is also non-binding• If a patient insists or if the crew deems that bypass is

not in the patient’s best interest, then going to a hospital “on diversion” is appropriate.

– Additionally, critical patients should not be diverted to hospitals further away.

Carbon Monoxide Monitors Approved

• Non-invasive CO monitoring devices are approved

On-Scene Medical Personnel

• Other health care providers in the home attending the patient (e.g. RN, LPN, CNA, Nurse Midwife, etc.) are bystanders who may be a valuable source of information.

On-Scene Medical Personnel

• Any aid or treatment they wish to give must be authorized by OLMC .

• Any dispute over treatment/transport should be settled by OLMC.

Home Health Care Devices and Appliances

• Many patients will, have devices and appliances (drains, ports, etc.). with which they are routinely discharged home.


• Patients (or their licensed care providers, or previously instructed family members), are expected to maintain them on their own.


• These devices have some risks associated with them, but are generally considered safe in the home environment.

• EMS providers are not restricted in the care or transfer of these patients based solely on the presence of these devices or appliances.


• Unfamiliarity with, or any questions concerning these devices that cannot be immediately resolved by the patient or caregivers, should be referred to OLMC.

Left Ventricular Assist Device (LVAD)

• Left Ventricular Assist Device (LVAD): – A surgically implanted

pump to assist left ventricular function.

– An LVAD can be a bridge to heart transplant (although used for chronic care as well).


• Inform OLMC as soon as possible when interacting with a patient with a LVAD, as diversion to a hospital with a higher level of care may be suggested.


• Direct contact with the cardiac service responsible for this patient is also suggested at the earliest possible moment.


• No cardiac arrhythmia should be treated if the LVAD is functioning, as judged by an audible sound or pulse, without medical control approval for any treatment.


• Be sure to bring the patient’s batteries (including the 24 hour battery) and the large battery charger.


• Local EMS services may receive specialized training and protocol exemptions to extend help to these patients by working with regional EMS medical directors and MEMS.

Taser Probes• The use of a TASER does not automatically

necessitate an EMS response or involvement.

Taser Probes• In assessing such patients, be cognizant of

the potential for underlying metabolic dysfunction

• TASER probes may be removed from the subject by the deploying officer.

Taser Probes

• Probes that are imbedded in a “sensitive area” (Face, neck, breast, and genitals) may need to be removed by medical personnel.

• In these cases, the subject should be transported to the hospital for examination and removal of the probes by medical personnel at the hospital.

Taser Probes

• Other adverse affects, if any, (e.g. respiratory difficulty, seizures, etc.) should be treated as appropriate by the applicable protocol(s).

“Rescue” or “Alternate” Airway Devices

• MEMS has divided “rescue” or “alternate” airway devices into 2 major classes:1. Periglottic devices2. Transglottic devices

Periglottic Devices

• E.g. LMA, Cobra PLA• Do not have a risk of obstructing the trachea.

Transglottic or Potentially Transglottic Devices

• E.g. Combitube, King LT• Devices that are designed to enter the

trachea or have the risk of entering the trachea.


• The Maine EMS airway algorithm calls for providers to use a rescue device if endotracheal intubation cannot be achieved.

• Any FDA approved device from these classes is approved for use.


• If an agency selects a transglottic / potentially transglottic device, end-tidal CO2, either colorimetric or continuous (waveform or capnometric) must be used to confirm placement.


• There are periglottic devices on the market that can be used to facilitate endotracheal intubation – ILMA, IMA.


– If these devices are placed without an attempt at endotracheal intubation, they may be treated as any other periglottic device.

– If they are used to assist in placing an endotracheal tube, that tube must be treated and confirmed as any other endotracheal intubation.


• It is recommended to have NO MORE THAN one device per class (periglottic and transglottic), and if a service elects to have multiple options per class, then training and maintenance in proficiency for all devices available is required.

Blue Section

Chronic

Concurrent History (CHF and COPD)

History of COPD, Asthma,

Pneumonia

History of CHF/APE

Physical Exam Lung Sounds

Acute

Rales Wheezes

Physical Exam Capnography

Box-like wave form

Shark fin wave form

No edema

Note: Asthma can have acute onset

Physical Exam Edema

Dependent Edema

Patient Medical History

History of illness, particularly fever/cough

Note: APE can present with

wheezes

Note: APE can present with

shark fin wave forms

Onset of Respiratory Distress

Note: The presence of edema only indicates a likely history of CHF, but

does not assure APE JVD

Note: in certain cases APE may occur concurrently with bronchospasm. In such cases it is appropriate to combine treatments. However, bronchodilators should only be utilized when

there is clear evidence of bronchspasm.

Indicating Acute Pulmonary Edema Unclear Etiology Indicating Bronchospasm

Airway Confirmation

• Transglottic or potentially transglottic airway device placement must be confirmed with end-tidal CO2, either colorimetric or continuous (waveform or capnometric) device.

• For pediatrics, continuous wave form capnography is required.

Auscultate to assist confirmation

1. Epigastrum

2. Apices and bases11

Confirm ET placement with absence of sounds over the epigastrium first and presence of bilateral symmetric breath sounds second.

Airway Algorithm Changes

• Both pediatric and adult airway algorithms have been updated to include:– New airway terminology (periglottic/transglottic)– Updated confirmation– OG Tubes for paramedics

Adult Airway Algorithm (Blue 2) Surgical airways for paramedic only!

Patient with respiratory distress and failure of therapy Trial of Oxygen Therapy If unable to maintain adequate oxygenation/ventilation

consider suctioning, assess for foreign body or tongue obstruction consider placing nasopharyngeal or oropharyngeal airway, and trial

of bag-valve-mask support if deemed appropriate If still unable to maintain adequate oxygenation/ventilation

consider orotracheal intubation or nasopharyngeal intubation if no facial trauma or other contraindications

If unable to intubate, again Reassess if maintaining adequate oxygenation/ventilation

consider changing tube size and/or laryngoscope blade

If still unable to intubate, again reassess if maintaining adequate oxygenation/ventilation

consider using facilitating device if available such as gum elastic bougie, intubating stylet, tube changer, or digital intubation

or If this fails, reassess if maintaining adequate oxygenation/ventilation

consider an attempt to place a periglottic device or If this fails, reassess if maintaining adequate oxygenation/ventilation

consider attempt to place a transglottic device or If this fails, reassess if maintaining adequate ventilation/oxygenation

In trauma only(head, face or neck) or unrelieved and complete upper airway obstruction, consider a surgical airway (cricothyrotomy). In general, a surgical airway is unlikely to benefit an adult patient without the aforementioned caveats.

If successful, confirm placement and continuous monitoring:

auscultation chest wall movement lack of air sounds over

the epigastrium capnography or end-tidal

CO2 pulse oximetry

*Paramedic may consider placing OG Tube

Pediatric Airway Algorithm (Blue 3) Surgical airways for paramedic only!

Patient with respiratory distress and failure of therapy Trial of Oxygen Therapy If unable to maintain adequate oxygenation/ventilation

consider suctioning, assess for foreign body or tongue obstruction consider placing nasopharyngeal or oropharyngeal airway, and trial

of bag-valve-mask support if deemed appropriate BVM IS THE PREFERRED METHOD OF AIRWAY SUPPORT IN THE PEDIATRIC PATIENT

If still unable to maintain adequate oxygenation/ventilation

consider orotracheal intubation If unable to intubate, again Reassess if maintaining adequate oxygenation/ventilation

consider changing tube size and/or laryngoscope blade

If still unable to intubate, again reassess if maintaining adequate oxygenation/ventilation or If this fails, reassess if maintaining adequate oxygenation/ventilation

consider an attempt to place a periglottic device or If this fails, reassess if maintaining adequate ventilation/oxygenation

In trauma only(head, face or neck) or unrelieved and complete upper airway obstruction, consider a surgical airway (cricothyrotomy). In general, a surgical airway is unlikely to benefit a pediatric patient without the aforementioned caveats.

Consider needle cricothyrotomy in patients that have epiglottis or unrelieved upper airway obstruction.

If successful, confirm placement and continuous monitoring:

auscultation chest wall movement lack of air sounds over

the epigastrium continuous waveform

capnography required pulse oximetry

*consider placing OG Tube in patient > 2 years of age

Orogastric Tubes

• Indications:– To perform gastric decompression in patients >2

years after endotracheal intubation has been performed and placement verified.

Orogastric Tubes

• Contraindications:– Suspected basilar skull fracture– Facial Trauma with suspected fractures or

penetrating neck trauma– Known esophageal varices– Known ingestion of caustic substances

Orogastric Tubes

• Complications:– Tracheal Insertion– Coiling of tube in the posterior hypopharynx

Orogastric Tubes

• Equipment:– Gastric evacuation tubes (Ewald, Salem Sump, or

other dual lumen tube)– Sizes: 16 french adult or appropriate pediatric size– Water soluble lubricant.– 60 ml irrigation syringe with catheter tip.– Tape or tube holder.– Stethoscope.

Orogastric Tubes

• Procedure:– Determine correct size:

• Pediatric Size: Refer to length based resuscitation tape• Adult Size: 16 french

– Restrain the patient, as necessary.

Orogastric Tubes

• Procedure (Cont.):– Measure length of OG tube from the corner of the

mouth to the earlobe and then to the xyphoid process.

– Mark the length of tube with a piece of tape.

Orogastric Tubes

• Oral insertion:– Direct tube to the back of the tongue and then

direct tube downward through the oropharynx• If patient is conscious or old enough to follow

instructions, instruct the patient to swallow to facilitate the placement of the tube in the stomach.

Orogastric Tubes

• Oral insertion:– Continue advancing tube until tape mark is at the lip.

• If tube meets resistance or the patient has respiratory distress, remove the tube.

• If the tube coils in the hypopharynx, direct laryngoscopy may be utilized to direct the tube into the esophagus.

• Fogging of the tube accompanied by cough or respiratory distress indicates tracheal intubation.

– If patient begins to vomit, suction around tube and leave in place.

Orogastric Tubes

• Confirm placement of tube by:– Aspirating gastric contents with a syringe. Assess

for cloudy, green, tan, brown, bloody, or off-white color contents consistent with gastric contents.

– Injecting 5 to 20cc of air while auscultating over the stomach for a “swoosh” or a “burp” indicating gastric placement.

– Auscultate lung sounds.

Orogastric Tubes

• If tube is not placed properly:– Remove immediately.– Reinsert following the same procedure.

**Do not attempt insertion more than three (3) times.

Orogastric Tubes

• If tube is properly placed:– Tape in place or apply a tube holder.– Leave tube open to allow passive decompression

Bronchospasm

Intermediate • 7. Contact OLMC to administer Albuterol, 2.5

mg by nebulization (use 3 ml premix or 0.5 ml of 0.5% solution mixed in 2.5 ml of normal saline) or…

• Levalbuterol 1.25 mg nebulizer if > 12 years of age.

Bronchospasm

CRITICAL CARE/PARAMEDIC8. Adult/Pediatric—

a. Albuterol 2.5 mg by nebulization. May repeat 1 time; or Levalbuterol 1.25 mg nebulizer if > 12 years of age; orb. Albuterol MDI (multi-dose inhaler), 5 puffs with spacer. May repeat 1 time; or Levalbuterol tartrate (Xopenex®) inhaler 5 puffs with spacer if > 4 years of age; or

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Levalbuterol hydrochloride (Xopenex®)

• Classification: Sympathomimetic, bronchodilator• Mechanism of Action: Sympathomimetic Beta 2

adrenergic receptor selective isomer of albuterol• MEMS Use: Treatment of bronchospasm as an

option to Albuterol Sulfate

Levalbuterol hydrochloride (Xopenex®)

• How Supplied: Solution for inhalation 0.31mg/3ml, 0.63mg/3ml & 1.25mg/3ml. MDI 45mcg/puff

• Contraindications: Tachycardia due to dysrhythmias, heart block caused by digitalis toxicity

Levalbuterol (Xopenex®)

• Precautions: Use with caution in patients with ischemic heart disease, coronary insufficiency and CAD.

• Side Effects: Tachycardia, palpitations, hypertension, anxiety, general CNS stimulation

Levalbuterol (Xopenex®)

• Dose:– Adults and adolescents >12 years old 1.25

mg nebulizer or if >4 years- Levalbuterol tartrate inhaler 5 puffs with spacer.

Bronchospasm

Paramedic Only (c and d):c. Consider Ipratropium Bromide 0.5 mg/ Albuterol Sulfate (Duo-Neb®) 3 mg nebulizer if > 1 year of age and more significant respiratory distress, and may repeat one time; or…

Bronchospasm

Paramedic Only (c and d):d. Ipratropium Bromide/Albuterol Sulfate (Combivent) Inhaler 2 puffs if greater than 1 year of age and may repeat one time in those with more significant respiratory distress

Patients receiving Combivent inhaler must be questioned regarding peanut allergies prior to inhaler administration as a peanut allergy is an absolute contraindication to

this medication.

Note:• Ipratropium Bromide and Albuterol is

available and allowed to be carried in two forms. 1. Duo-Neb® 3 ml nebulized solution and2. Combivent® inhalers.

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Ipratropium Bromide and Albuterol Sulfate (Duo-Neb®)

• Classification: Anticholinergic and sympathomimetic bronchodilator

• Mechanism of Action: Antagonism of cholinergic receptors


• MEMS Use: Treatment of bronchospasm as an option to Albuterol Sulfate

• How Supplied: 3 ml solution for nebulization


• Precautions: Use with caution in patients with coronary insufficiency, cardiac dysrhythmias and CAD.

• Side Effects: Tachycardia, palpitations, hypertension, anxiety, ECG changes including flattening of the T-wave and ST segment depression


• Dose:– Pt’s > 1 year of age- 3 mg nebulizer. May repeat

one time if more significant respiratory distress

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Ipratropium Bromide and Albuterol Sulfate (Combivent®)

• Classification: Anticholinergic and sympathomimetic bronchodilator

• Mechanism of Action: Antagonism of cholinergic receptors


• MEMS Use: Treatment of bronchospasm as an option to Albuterol Sulfate

• How Supplied: metered dose inhaler• Contraindications: Soybean or peanut allergy (soya

lecithin/ground nut hypersensitivity)


• Precautions: Use with caution in patients with coronary insufficiency, cardiac dysrhythmias and CAD.

• Side Effects: Tachycardia, palpitations, hypertension, anxiety, ECG changes including flattening of the T-wave and ST segment depression


• Dose:– Pt’s > 1 year of age- Inhaler 2 puffs. May repeat

one time in those with more significant respiratory distress

Acute Pulmonary Edema

Intermediate• 7. Contact OLMC for administration of

nitroglycerin 0.4 mg or 1 spray SL. Repeat nitroglycerin at 2 minute intervals if systolic BP greater than 100 mm Hg.


Intermediate• After initiation of SL nitroglycerin, may place 1

inch of nitroglycerine ointment 2% to the chest wall if BP greater than 115 mm Hg and remove nitroglycerine ointment 2% if BP less than 95 mm Hg.


Intermediate• 8. Consider use of CPAP (Note: CPAP use is

limited to those providers who have completed the MEMS CPAP training program).


Critical Care/Paramedic9.Nitroglycerin 0.4 mg or 1 spray SL. Repeat

nitroglycerin at 2 minute intervals if systolic BP greater than 100 mm Hg. After initiation of SL nitroglycerin, may place 1 inch of nitroglycerine ointment 2% to the chest wall if BP greater than 115 mm Hg and remove nitroglycerine ointment 2% if BP less than 95 mm Hg.


Critical Care/Paramedic9. Consider use of CPAP (Note: CPAP use is limited to

those providers who have completed the MEMS CPAP training program).

10.Furosemide (Lasix) 40 mg IV.Must contact OLMC for use of following OPTIONS:• Fentanyl 1 microgram/kg IV to a maximum dose of

100 micrograms

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Nitroglycerine Topical Ointment (Nitro-Bid®)

• Classification: Nitrate, Anti-anginal coronary vasodilator

• Mechanism of Action: Relaxation of vascular smooth muscle

• MEMS Use: Treatment of acute pulmonary edema following administration of sub-lingual nitroglycerine.

• How Supplied: 2% ointment 15, 30, 60 mg tube (generally with applicator patches)

Nitroglycerine Topical Ointment (Nitro-Bid®)

• Contraindications: Hypotension (SPB<95mmHg), patient use of erectile dysfunction medications within the last 24 hours.

• Side Effects: Hypotension, head ache• Dose:

– After initiation of SL nitroglycerin, may place 1 inch of nitropaste to the chest wall if B/P > 115 mm Hg and remove nitropaste if B/P < 95 mm Hg

Red Section

Chest Pain

BASIC4. If patient has not taken an aspirin and has no

allergy to aspirin: administer chewable aspirin 324 mg po if not contraindicated by allergy, bleeding/anticoagulant history, or ulcer disease.

• ALS back-up still mandatory despite use of aspirin

Chest Pain

INTERMEDIATE7.Cardiac monitor and 12 lead EKG if available

(see Red 4)8. Chewable aspirin, 324 mg PO, if not

contraindicated by aspirin allergy, bleeding/anticoagulant history, or ulcer disease.

Chest Pain

CRITICAL CARE / PARAMEDIC10. Obtain 12 lead EKG12. Chewable aspirin, 324 mg PO13. Contact OLMC for OPTIONS:

b. Additional nitroglycerin.c. Fentanyl 1 microgram/kg IV or IM to a maximum dose of 100 micrograms.

Chest Pain

PARAMEDIC• 14. If no CHF and BP greater than 140 systolic

and HR greater than 100 beats/min, then Metoprolol (Lopressor) 5 mg IV over 5 minutes x1 for target HR 70-80 beats/min.

• Call OLMC for option of repeating this once or twice more.

GUIDELINES TO THE PREHOSPITAL USE OF12-LEAD EKG BY THE ALS PROVIDER

1. Prehospital 12-lead EKG is now a standard of care for increasing diagnostic information regarding the chest pain/cardiac patient.


2. Acquisition of a 12-lead EKG should be done in all patients with chest pain or a potential cardiac complaint/diagnosis such as syncope or shortness of breath and have high index of suspicion in elderly patients.


3. Transmission of 12-lead EKG or presentation of pre-hospital 12-lead EKG to treating personnel at the receiving ED is intended to augment patient triage and facilitate rapid identification of a potential thrombolytic or PTCA candidate.

4. In the case of STEMI, notify receiving ED immediately.

12 Lead EKG Use for Intermediates

• The purpose of this is to get baseline data ASAP and acquire 12 lead EKG if available

• If trained, the intermediate should place 12 lead stickers and acquire 12 lead EKG

• This is intended to have Intermediate present this to the Paramedics or receiving facilities

• This must not modify the ALS response

V-Fib/Pulseless V-Tach Algorithm

• Adopt current ACLS standards– One shock vs. “stacked shocks”

• Replace Lidocaine with Amiodarone

V-Fib/Pulseless V-Tach AlgorithmBasic• Check Pulse, if no pulse then:

– CPR until AED is available– Analyze with AED, follow AED instructions*– If severe Hypothermia, go to Yellow 11– Manage Airway**

• 5 Cycles of CPR and then reassess with pulse check and AED check

• Call for Critical Care/Paramedic Back-up/Intercept

V-Fib/Pulseless V-Tach AlgorithmIntermediate• Continue cycle of CPR if no pulse (5 cycles), followed by pulse

and AED/manual defibrillator check—defibrillate as indicated• Manage Airway**• Establish IV/IO enroute• Call for Critical Care/Paramedic Back-up/Intercept and

contact OLMC

**See Airway Algorithm Protocol: Blue 2 and 3

V-Fib/Pulseless V-Tach AlgorithmCritical Care/Paramedic• Precordial thump if witnessed arrest• Continue CPR if no pulse—after 5 cycles of CPR, do rhythm and pulse

checks and consider next intervention listed in order—do one medication intervention at each 5 cycle re-assessment

• Rhythm Check– If VF or pulseless VT, then defibrillate X 1 at 360 J or equivalent biphasic

• Manage Airway**• Establish IV/IO• Epinephrine 1:10,000 1 mg IV/IO Push—repeat every 3-5 minutes

**See Airway Algorithm Protocol: Blue 2 and 3

V-Fib/Pulseless V-Tach AlgorithmCritical Care/Paramedic• Give 5 cycles of CPR, then do rhythm and pulse checks –

defibrillate X 1 at 360J or equivalent biphasic if VF or VT• Amiodarone 300 mg IV/IO push, then consider additional 150

mg IV/IO one time• Give 5 cycles of CPR, then do rhythm and pulse checks –

defibrillate X 1 at 360J or equivalent biphasic if VF or VT• Consider Magnesium 1-2 grams IV/IO push• Give 5 cycles of CPR, then do rhythm and pulse checks –

defibrillate X 1 at 360J or equivalent biphasic if VF or VT

V-Fib/Pulseless V-Tach AlgorithmCritical Care/Paramedic• Contact OLMC for OPTION of Sodium Bicarbonate and orders

on continuing ACLS or termination of resuscitation.• Upon successful conversion from V-Tach or V-fib (if no 2nd

degree Type II AV block of 3rd degree AV block is present) contact OLMC for options of:– Amiodarone bolus– Amiodarone drip

*If return of spontaneous circulation (ROSC) is established, contact OLMC and follow appropriate protocol for patient rhythm

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Amiodarone Hydrochloride (Cordarone®)

• Classification: Class III Antidysrythmic agent• Mechanism of Action: Blocks sodium channels

at rapid pacing frequency, causing an increase in the duration of the myocardial cell action potential and refractory period, as well as alpha- and beta-adrenergic blockade.


• MEMS Use: Anti-ventricular dysrhythmic for use in V-Fib/V-Tach cardiac arrest, wide complex tachycardia and symptomatic premature ventricular contractions


• How Supplied: 50 mg/ml as 150mg/3ml vial. • Contraindications: Bradycardia, high level heart

block, hypotension, cardiogenic shock• Side Effects: Hypotension, dyspnea, cough,

bradycardia/AV block, nausea, photophobia, blurred vision, dizziness


Dose: • As a primary anti-ventricular dysrhythmic in V-

Fib/V-Tach cardiac arrest: – 300 mg IV/IO push once then consider additional

150 mg IV/IO once. – If successful conversion occurs, providers should

contact OLMC for dosing information for additional bolus or infusion.


Dose: • For wide complex tachycardia (probable V-

Tach)- BP>100:– Contact OLMC for option of Amiodarone 150 mg

mixed with 50 ml D5W infused over 10 minutes.


Dose: • For symptomatic premature ventricular

ectopy:– If patient is hypotensive (blood pressure less than

90 mm Hg), with OLMC may consider Amiodarone 150 mg mixed with 50 ml D5W infused over 10 minutes along with a 500 ml NS IV fluid challenge.

Wide Complex Tachycardia (Probable V Tach)

• Chart added to better align MEMS with current AHA standards.

• Intermediate/Critical Care/Paramedic (up to level of training)

• Replace Lidocaine with Amiodarone• Remove Lorazepam for premedication of

cardioversion

Wide Complex Tachycardia (Probable V Tach)

• Amiodarone Dose for wide complex tachycardia (probable V-Tach)- BP>100:– Contact OLMC for option of Amiodarone 150 mg

mixed with 50 ml D5W infused over 10 minutes.

Narrow Complex Tachycardia

• Chart added to better align MEMS with current AHA standards.– Note: this algorithm replaces the former

“Supraventricular Tachycardia Protocol).

Narrow Complex Tachycardia

• Significant changes include:– Differentiating SVT from rapid A-Fib/A-Flutter– Addition of Metoprolol (Lopressor®) for rate

control (paramedic Only)– Removal of Lorazapam (Ativan®) for

premedication of cardioversion

Metoprolol Tartrate (Lopressor®)


• Classification: Beta-adrenergic blocking agent• Mechanism of Action:

– Combines with beta-adrenergic receptors to block the response to sympathetic nerve impulses.

– Acts as an anti-ischemic by combining with beta-adrenergic receptors to block the response to sympathetic nerve impulses resulting in reduced heart rate, blood pressure, and contractile force.


• MEMS Use: Rate control for narrow complex tachycardia (A-Fib/A-Flutter) or as a treatment option for symptomatic premature ventricular contractions.


• How Supplied: Generally 1 mg/ml• Contraindications: Sinus bradycardia, second

and third degree AV blocks, cardiogenic shock, CHF unless secondary to tachydysrhythmia, severe COPD or bronchospasm

• Side Effects: Bradycardia, hypotension


• Dose: – Rate Control for A fib or A flutter:

• Contact OLMC- 5 mg IV over 5 minutes• Repeat of therapy only after consult with OLMC

– For symptomatic PVC’s (In patient without bradycardia or hypotension):

• Contact OLMC-may consider 5 mg IV over five minutes. – DO NOT USE LOPRESSOR IF ANY EVIDENCE OF SHOCK!

Premature Ventricular Ectopy (PVC’s)

• Slight wording revision• This protocol has also been adjusted to

include Metoprolol as a rate control medication and Amiodarone as a ventricular anti-dysrhythmic.


• Contact OLMC if patient has chest pain suggesting MI and any one of the following:– PVCs more than 6/minute, or– Multifocal PVCs , or– Sequential (coupling) PVCs, or– PVCs near T wave (R on T), or– 3 or more PVCs in a row (ie, non-sustained VT).


• If patient without bradycardia nor hypotension, with OLMC may consider Metoprolol 5 mg IV over five minutes—only Paramedics may administer Metoprolol. DO NOT USE Metoprolol IF ANY EVIDENCE OF SHOCK!


• If patient is hypotensive with OLMC may consider Amiodarone 150 mg mixed with 50 ml D5W infused over 10 minutes along with a 500 ml NS IV fluid challenge.


• If pulse rate is less than 60 bpm, these may be “escape PVCs” from an irritable focus and with OLMC may want to consider the option of Atropine 0.5 mg IV.

Gold Section

Allergy/Anaphylaxis

• Addition of anteriolateral thigh as primary injection site for IM epinephrine

• Addition of IV epinephrine for severe reaction.

Anteriolateral Injection• Intramuscular injection

• Anteriolateral thigh midway between waist and knee

For Severe Anaphylaxis

Critical Care/Paramedic• Contact OLMC for repeat options of IM

Epinephrine and/or IV dosing of epinephrine for shock or cardiovascular collapse

• Typical IV dose:– 0.5 to 1 ml of Epinephrine 1:10,000 (0.1 mg) IV

every 10 to 20 minutes.

Adult Coma

• Glucometer blood glucose checks as an option for the Basic level.

• Addition of intranasal route and removal of ET route for Naloxone administration for intermediates and paramedics.

Adult Coma

Basic4. Option to perform finger stick to measure

blood glucose using MEMS approved technique/device limited to providers who have completed the MEMS BG monitoring training program.

Adult Coma

Intermediate9B. Naloxone (Narcan) 0.1-2 mg IV, IO, IM or Intranasal

(may opt to give 2mg as starting dose if using intranasal route)

Adult Coma

Critical Care/Paramedic– Only give Naloxone if respirations less than 12

per minute and you suspect narcotic overdose, titrate to improve respiratory drive; patients abruptly fully awakened may become combative, or suffer acute narcotic withdrawal symptoms. Some drugs such as Propoxyphene, Talwin, or Methadone may require high doses.

– Once intubated, do not give naloxone

Adult Coma

Critical Care/Paramedic– Naloxone (Narcan) 0.1 – 2 mg IV, IO, IM or

Intranasal (may opt to give 2 mg as starting dose if using intranasal route)

Intranasal Administration Route

Advantages:• Needleless system• Rapid absorbtion• Easy administration

Intranasal Medication Administration

MEMS Medications:• Naloxone

Precautions:• Beware damage to the nasal mucosa that may

effect absorbtion of medications – Vasoconstrictors (EG cocaine) prevent absorption– Bloody nose, nasal congestion, mucous discharge– Destruction of nasal mucosa from surgery or cocaine

abuse


Equipment• Small syringe • Atomizing device (prefferred)


Administration:• Draw up solution

– Be aware of IV vs. IN differences in dose.• Expel air from syringe.• Attach atomizing device if available• Insert in nostril and rapidly compress the syringe

plunger.– Brisk brief compression results in controlled atomization.– Gently pushing the plunger will not result in atomization.

Adult Diabetic Emergencies

Intermediate7A. If blood glucose is < 80 mg/dL, contact OLMC for

OPTION of administering Dextrose 25 gm (50 ml of 50% solution IV). Recheck blood glucose in 5 minutes.B. If blood glucose > 300 mg/dL, give 500 ml NS fluid challenge.

Adult Diabetic Emergencies

• “Guideline for Diabetic Patient Signoff” has been removed. – Although the MDPB considers these issues no less

important, it was felt that prior and current EMS education standards have made such a statement unnecessary to be included in the protocol book itself.

Adult Seizures

• Lorazapam (Ativan®) has been removed from the protocol.

• Language has been added to remind providers that Midazolam should be used for active seizures only.

Adult Seizures

CRITICAL CARE / PARAMEDIC• Use of benzodiazepines is for active seizures only.

Midazolam (Versed) 3 mg IV or IO. If IV or IO cannot be established, option of Midazolam (Versed) 3-5 mg IM

• Contact OLMC for the following OPTIONS:– If unable to establish IV or IO, or if repeat dose of

Midazolam (Versed) is necessary.

Stroke Checklist

• A new stroke checklist has been added to the protocol– Standardizes a diagnostic approach to a national

benchmark

Stroke ChecklistCheck if Abnormal

Level of Consciousness □Abnormal = lethargic, stuporous, comatose Speech □Have pt. state” “You can’t teach an old dog new tricks”Abnormal = wrong word, slurred or absent speech Facial droop when asked to show teeth or smile □ Abnormal = one side does not move as well as the other Motor: have pt. close eyes and hold out both arms □Abnormal = arm cannot move or drifts down when held out One new positive finding with abrupt onset = 70% chance of acute strokeThree new positive findings with abrupt onset = 85% chance of acute stroke

Green Section

Tension Pneumothorax

• Language change to assure appropriate length of catheter and note approval for “alternate devices”

Tension Pneumothorax

• “NOTE: Chest decompression will be performed on the involved side using an appropriate length, 14 guage IV catheter or approved alternate device at the second or third intercostals space on the mid-clavicular line, or fifth or sixth space on the mid-axillary line.”

Hemorhage Control/Amputations

• Previous Amputation protocol now changed to “Hemorrhage”

• Tourniquet use added/encouraged if direct pressure fails

• Contained Hemostatic Agent (dressings/sponges) added.


BASIC• Ascertain all sites of bleeding and control with pressure• Treat for shock if indicated and oxygen as appropriate• If bleeding is on extremity and uncontrolled with pressure,

apply a tourniquet proximal to the bleeding site


BASIC• If amputation, rinse severed part briefly and gently with

sterile saline to remove debris• Wrap severed part in sterile saline gauze, moisten with sterile

saline (do not soak), place in a water-tight container. Place container on ice (do not use dry ice). Do not put part directly on ice. If necessary, use ice packs to provide some level of cooling.


BASIC• If bleeding is coming from torso or scalp and uncontrolled

with pressure, apply contained hemostatic agent approved by Maine EMS. If it is coming from an extremity and there is continued bleeding despite tourniquet, apply hemostatic agent approved by Maine EMS.

• Apply pressure dressing over hemostatic agent approved by Maine EMS

• Request ALS if available

“Contained Hemostatic Agent

Z-Medica Corporation 4 Fairfield Blvd., Wallingford, CT 06492, Tel: 203.294.0000, Website: www.z-medica.com

Hypovolemic Shock

Changes:• Removal of Trendelenburg position as a treatment

for shock. • Addition of Pelvic Binders to treat hypovolemia

secondary unstable to unstable pelvic fractures.• Adjustment of fluid challenge guidelines (add

“permissive hypotension)

Hypovolemic Shock

INTERMEDATE / CRITICAL CARE / PARAMEDIC• IV en route• Cardiac monitor• If shock present, i.e. BP less than 90 mm Hg in an adult less

than 65 years of age, perform fluid challenge according to the following guidelines:

Hypovolemic Shock

INTERMEDATE / CRITICAL CARE / PARAMEDIC

• Controlled bleeding—in situations where the provider has controlled the hemorrhage, give 1-2 liters of NS or LR to restore normal vital signs

• Uncontrolled Bleeding (permissive hypotension)—for suspected internal bleeding or uncontrolled bleeding; fluid resuscitate to maintain SBP between 80-90 mm Hg.

• Suspected TBI/CNS injury—fluid resuscitate to maintain SBP greater than 90 mm Hg.

• Contact OLMC if patient is greater than 65 years of age for a fluid challenge order

Hypovolemic Shock

Additional Reminders:

• When dealing with a multisystem trauma patient or a potential multisystem trauma patient…– Early IV access in anticipation of possible fluid resuscitation is

extremely important– Regular and frequent monitoring of vitals and the patient’s condition

is critical to recognizing the need for fluid resuscitation– All ALS providers should remain diligent to strictly adhere to the idea

of keeping an uncontrolled bleeding patient’s systolic BP between 80-90 mmHg

Hypovolemic Shock

• If the cause of hypovolemic shock is felt to be secondary to acute unstable pelvic fracture, contact OLMC for consideration of using MAST as a pelvic stabilization device.

Pain Management

Changes:• Fentanyl dose change• Inclusion of 50% nitrous oxide/oxygen • Ondanzetron to replace Promethazine

(Phenergan®).

Pain Management

CRITICAL CARE / PARAMEDIC• For isolated extremity trauma in a stable patient,

consider the use of Fentanyl 1 microgram/ kg IV or IM initially with an initial maximum dose of 100 micrograms then 25-75 micrograms IV every 5- 10 minutes titrated to effect with cumulative maximum dose of 400 micrograms.

• Alternative Pain Control: 50% nitrous oxide/oxygen mixture self administered (such as Nitronox).

50% Nitrous Oxide (Nitronox®)

http://pediatrics.aappublications.org/content/vol105/issue4/images/large/pe0404178001.jpeg

50% Nitrous Oxide/Oxygen Mixture

• Classification: Analgesic• Mechanism of Action: Induces change in the basal

levels of the thalamic nuclei utilizing direct intraspinal anti-nociceptive action. In the brain stem, responses evoked by pain stimulation are variably depressed.

• MEMS Use: Alternative to Fentanyl for pain management

50% Nitrous Oxide/Oxygen Mixture

• How Supplied: Inhaled gas compound comprised of Nitrous oxide and 50% oxygen

• Contraindications: Pneumothorax, increased ICP, COPD, known bowel obstruction, known middle ear infection

• Precautions: High concentrations may cause hypoxia and respiratory depression

• Dose: Self administered to effect

Pain Management

CRITICAL CARE / PARAMEDIC• For nausea or vomiting, administer Ondansetron

(Zofran) 4 mg IV and may repeat once after 15 minutes if needed. For dosage question (such as in pediatrics), abnormal vital signs, coincident drug use (including alcohol) by patient, if cannot be established or if not isolated extremity trauma, contact OLMC before administering medication.

Nausea/Vomiting

CRITICAL CARE / PARAMEDIC

• When using narcotics for pain control or when pain alone seems to trigger vomiting, consider the use of antiemetics.– Ondansetron (Zofran) 4 mg IV/IO, may repeat in

15 minutes if needed.– Peds: 0.15 mg/kg IV/IO to a maximum dose of 4

mg, and contact OLMC if repeat dosing needed.

Ondansetron Hydrochloride (Zofran®)

• Classification: Antiemetic• Mechanism of Action: Seratonin receptor

antagonist. (Blocks vomiting reflex of serotonin release).

• MEMS Use: Treatment of nausea/vomitting• How Supplied: Generally 2mg/ml


• Contraindications: None• Precautions: Safety and effectiveness in

children <3 is unknown• Side Effects: May cause tachycardia,

hypotension


• Dose: – Adult- 4 mg IV/IO, may repeat in 15 minutes if

needed.– Peds: 0.15 mg/kg IV/IO to a maximum dose of 4

mg, and contact OLMC if repeat dosing needed.

Yellow Section

Antidotes for Specific Toxins-Cyclic Antidepressants

Intermediate/Critical Care/Paramedic• IV Fluid bolus if hypotensive

Antidotes for Specific Toxins- Organophosphate/Carbamate

Basic• O2 as appropriate and vigorous suctioning may be

necessary.Intermediate• Manage airway as appropriate. Ventilatory support

can be critical in these poisonings. “See Blue 1 & 2.”

Mild Hypothermia

• Moderate Hypothermia: Reduced core temperature greater than 93.2°F (>34°C) and patient’s…

• Cold, pale, beginning of cyanosis• Cold diuresis• Active external rewarming should be effective• Resuscitation efforts (such as CPR) follow

normothermic guidelines.• Medications may be given at temperatures greater

than 30◦C , but at increased intervals

Severe Hypothermia• Severe Hypothermia: Reduced core temperature below

82◦F (28◦C) and patient has no ability to rewarm without external heat source.

• Cold, frozen, pale, cyanotic skin, rigidity• Vital signs reduced or absent• Below 86◦F (30◦C) shivering stops• Loss of consciousness• Increased risk of mechanically stimulated ventricular

fibrillation/cardiac arrest in severe hypothermia• Withhold medication until temperature > 86° F (30◦C)• May require prolonged CPR and internal rewarming

Severe Hypothermia (Treatment)

Basic • Do not attempt to increase heat production with any

exercise.

Severe Hypothermia With No Signs Of Life

Assessment: • Check for pulse and respirations for 30 to 45

seconds.


Assessment: • If an Automated External Defibrillator (AED) is

available, then proceed with one shock if the machine deems that this is indicated. If the core temperature cannot be determined…normothermic. If the patient’s core temperature is below 86◦F (30◦C), discontinue use of AED after the initial shock until the patient’s core temperature has reached 86◦F (30◦C).


Assessment: • If contact with OLMC is not possible, consider

termination of resuscitative efforts after 30 minutes and contact OLMC as soon as possible.

Eye Pain from Chemical Exposure

Basic/Intermediate• Flush eye with sterile saline or clean water

source continuously

New Section-Combative Patient

Basic• Maintain crew safety, ask for law enforcement

assistance if available.• If altered mental status, check oxygen saturation and

option to perform finger stick to measure blood glucose using MEMS approved technique/device limited to providers who have completed the MEMS BG monitoring training program.


Intermediate• Consider blood glucose if patient with altered mental

status. If blood glucose is < 80 mg/dL, establish IV and contact OLMC for Option of administering Dextrose 25 gm (50 ml of 50% solution IV). Recheck blood glucose in 5 minutes.


Critical Care/Paramedic• A. Consider blood glucose if patient with altered

mental status. If blood glucose is < 80 mg/dL, establish IV and administer Dextrose 25 gm (50 ml of 50% solution IV). Recheck blood glucose in 5 minutes.

• B. If IV unavailable and blood glucose < 80 mg/dL, consider IO or administer Glucagon 1 mg IM.


Critical Care/Paramedic• Contact OLMC for OPTION of Midazolam 4 mg IM

for patient safety and comfort. Contact OLMC if dosing adjustment needed.

Midazolam (Versed®)

• Classification: Benzodiazepine• Mechanism of Action: Short acting

benzodiazepine with sedative-general anesthetic properties

• MEMS Use: Treatment of active seizures, premedication for cardioversion, combative patients


• How Supplied: 1 mg/ml or 5 mg/ml• Contraindications: Hypotension, severe alcohol

intoxication• Precautions: Respiratory depression and

sedation may be caused with doses as small as 1 mg. Careful monitoring of patient is essential in Midazolam administration. When possible, patients should have a running IV of NS or LR prior to administration of Midazolam.

• Side Effects: Respiratory depression, sedation, hypotension


Dose: • Combative patient

– Contact OLMC for OPTION of 4 mg IM for patient safety and comfort.

– Contact OLMC if dosing adjustment needed.

• Premedication for cardioversion– 3 mg IV bolus.


Dose: • Active Seizures (Adult)

– 3 mg IV or IO; or – (If IV or IO cannot be established) 3-5 mg IM.

• Active Seizures (Pediatric)– 0.02mg/kg IV to a maximum dose of 3 mg; or– 0.2 mg/kg IM (if IV cannot be established) to a

maximum dose of 5 mg

Known or Suspected Cyanide Exposure

Change: • Cyanide exposure algorithm has been added• Cyanokit antidote has been approved

Pink Section

Pediatric Coma

Narcan Dose Change:B. Naloxone (Narcan): if < 20 kg give 0.1 mg/kg

and if > 20 kg (> 5 years) give 2 mg IV, IO, IM or Intranasal (may opt to give 2mg as starting dose if using intranasal route)

Pediatric Seizures

• Ativan removed from the protocol• Maximum dose of Versed has been

decreased.– Midazolam IV dose to a maximum of 3 mg– Intramuscular dosing to a maximum dose of 5

mg.

Pediatric Seizures

CRITICAL CARE / PARAMEDIC• Administer:

– Midazolam (Versed) 0.02 mg/kg IV maximum 3 mg: or contact OLMC if repeat dosing is necessary.

– Alternate routes to IV dosing:– Intramuscular dosing – Midazolam (Versed) 0.2 mg/kg IM if IV cannot

be established to maximum dose of 5 mg. Buccal administration: Midazolam (Versed) 10 mg per buccal/mucosa. Rectal administration: Midazolam (Versed) 0.3 mg/kg to a maximum dose of 10 mg.

Pediatric Respiratory Distress

Basic/Intermediate• If the patient’s bronchodilator inhaler if

Albuterol (Proventil or Ventolin) or Levalbuterol HCl (Xopenex) – assist the patient in self-administering 5 puffs


Basic/Intermediate• If patient’s inhaler medication is not one listed in

the above, contact OLMC for permission to assist patient with self-administered bronchodilator (using spacer if available*). Inform OLMC of the name of the inhaler. OLMC will prescribe the number of puffs.

• *If spacer unavailable and Intermediate/Critical Care/Paramedic present, they should use nebulizer instead


Intermediate3. Contact OLMC to administer Albuterol, 2.5 mg by nebulization (use 3 ml premix or 0.5 ml of 0.5% solution mixed in 2.5 ml of normal saline); or Levalbuterol HCl 1.25 mg nebulizer if > 12 years of age.


Critical Care/Paramedica. Second dose of patient’s inhaler, as begun in #1

(above).or

b. Albuterol 2.5 mg by nebulization. May repeat 1 time; Levalbuterol HCl 1.25 mg nebulizer if > 12 years of age

orc. Albuterol MDI (multi-dose inhaler), 2-5 puffs with

spacer. May repeat 1 time; or Levalbuterol tartrate inhaler 2 puffs with spacer if > 4 years of age


Paramedic Only (d and e)d. Ipratropium Bromide 0.5 mg/ Albuterol Sulfate 3

mg nebulizer (Duo-Neb®) if > 1 year of age and more significant respiratory distress, and may repeat one time

or


Paramedic Only (d and e)e. Ipratropium Bromide/Albuterol Sulfate

(Combivent®) Inhaler 2 puffs if > 1 year of age and may repeat one time in those with more significant respiratory distress

• Patients receiving Combivent inhaler must be questioned regarding peanut allergies prior to inhaler administration as a peanut allergy is an absolute contraindication to this medication.

Pediatric Cardiac Arrest Dosages

Note that although Lidocaine is still listed in this chart, it has been removed from

the protocol

Questions?

2008 maine ems protocol revision

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