ema protocols

7/30/2019 EMA Protocols

1/14

Glyce mia Protoco llndic3tionIn the situation that trauma is not a primary cause for. and patient who has: Decreased level ofconsciousness, ORAcu te change in neurological functions in terms of speech ability, motor and/or cognitive status, OREvidence/reason that leads to suspicion of hypoglycemia or hyperglycemia. ANDThe reading ofblood glucose is: 4 mmol/L or less; OR > 20 mmol/LContraindica tionPatient under 12 years of age .Guid elines fo r Glvcc mi a Protoco lSpeeech disability (may include but not limited to the following): according to Paramedic Protoco lFS Manual (Operational) Part II - Ambulance ServicesGlycemia Protocol Flow Chart ~ I D C B A RBS Skin Oitygen I

I Secondary Survey: History, vital signs & capillary blood sample Decis ion Point ~ H'stiit > 20 mmoVL I I H'stix S4 mmoVL I II Transport I T HAS airway problems or swallowing Init iate IV NS at 200 ml/hr problems or risk of aspiration Continue with assessment +nd tm1tment Failure to establishInitiate IV glucose r+, preparation, 100 ml full rate IV infusion of glucosepreparationNO airway problems. NO risk of ... (Max . attempt shouldaspiration AND CAN swallow by Administer 50 mg be limited to 3)him/herself Th iamine JM to deltoid t+ muscle before dextrose Administer I mginfusion is completed glucagon IM/SCOral glucose drinks (e .g. 1OOml glucose preparation solution) I Transpo rt & con tinue with ...assessment and treatment Transport & continueIT with assessment andNo or incomplete treatmentimprovement of acutelyimpaired mental status

H epeart H'stix (2..i H'stiit) IImproved to former I usualbest mental status + ..H'stix S4 mmoVL I I H'stix >4 mmoVLAdminister 2" 100 ml glucosepreparation full rate IV infusion- Continue with assessment andAdminister IV glucose - treatmentprepiration I00 ml/hr . Continue with assessmentand treatment -


2/14

Glucagon ProtocolInd icntionDecreased level of consciousness and with signs and symptoms ofHypoglycemiaThe reading of blood glucose is 4 mmol/L or less, and3 attempts in establishing intravenous infusion ofD IOW have fail ed .Contra indicatfonPatient under 12 years of age.History of allergy to glucagon preparation3) Insulinoma4) Glucagonoma5) Phaeochromocytoma6) Contraindications for IM injection

Initiate Hypoglyce1nia Protocol

3 attempts in establishing IV infusion ofD1OW have failed

Administer 1mg glucagon hydrochloride IM to deltoid muscle

Initiate RAPID Transport

Continue with assessment and monitor ABC en -route

If patient regains FULL consciousness with GCS= 15,DIOW by mouth, max.200c.c..gives


3/14

Nitroglycerin Protocollnd ic3 ti onI) Patient whose presentation is chest pain/discomfort of cardiac origin; and2) Patient who has a history of heart disease and would normally take his/herprescribed Nitroglycerin (NTG) for chest pain/discomfort .Contra in di cationI) Patient has taken dn1gs alleged to increase sexpotency in the past 72 hourst e.g.

Phosphodiesterase 5 Inhibitor derivatives: Sildenafi l (Viagra), Tadala fil (Cialis).2) Patient whose SBP < 1OOmmHg.3) Hypersensit ivity to nitrates.

Acetylsalicylic Acid(ASA)Aspirin

::!: 12 years: AND Cardiac chest pain/discomfort

presentation < 12 years; or Inability to swallow; or Pregnant: orHypersensitive to ASA or

NSAIDs; or NSATDs include but not Jimite.d to:- Hx of Perforated Peptic Ulcer Ibuprofen (Brufen)confinned by OGD Naproxen (Naprosyn)(Oesophagogastroduodenoscopy) / lndomethacin (lndocid)G I Bleeding; or Mefenamic Acid (Ponstan) Curren tly on Warfarin Diclofenac (Voltaren/Cataflam) Methyl Salicylate (Analgesic balm)r econdary Survey: History & Vital ~

SBP < IOOmm Hg SBP ~ lOOmm Hg

RSE'Y

LOC I'Y

DCBA'Y

RBS'YSkin

IOxygen I'Y

I

I Decision Point I'Y

-Administer one dose ofNTG sprayI I

Load and transport-Continue with assessment and treatment-Reassess at eve 5 minutesSBP < IOOmm Hg SBP ~ IOOmm Hg and pain/discomfort isnot completely relieved

-Administer one dose ofNTG sprayI I

Continue with assessment and treatment-Reassess at every 5 minutesaximum 3 NTG doses


4/14

Respiratory Protocol-(MDI with spacer)Snlhulamol lndicalionChief complaint of shortness of breath (SOB)in a patient :Who has a history of asthma or chronic obstructive airway/ pulmonary disease (COAD/COPD) ORWho has a history of lung disease and is currently prescribed by doctor withP2 - agonist e.g. Salbutarnol ORWho has an exposu re history to ans/or has inhaled chemical agent and is presenting with signs and syptoms ofbtonchoconstric tion(i.c. lower airway obstruction)Contraind ication .,Known Salbu tamo l allergylpratropium Indica tionPat ient is ~ 12 years old; and Chiefcomplaint of SOB in a patjent who has history of lung disease or asthma orchronic obs tructive airway/pulmonary disease (COAD/COPD) AND is currently prescribed by doctor withIpratropium Bromide (Atrovent)Con traindicut ionPatient is in acute glaucoma attack; or RSEPatient is allergic to lpratropium Bromide/Atropine, or l'.-------.Patient is allergic to so ya lecithin orrelated products LOCe.g. soybean nndpeanut l'

(1) Salbutamol

DCBAl'

RBSl'

Skinl 'I Oxygenl '

Begin Secondary Survey- History-Vita si

l '!Decision Poinijl '

2to< 5 yr old : 200mcg (2 puffs)Sto< 12 yr old : 300mcg (3 puffs)

~ 12yr old : 400mcg (4 puffs)(2) lpratropium Bromide ,where applicable:

I f espiration is inadequate (lowRR and/or shallow respiration),support ventilation by BVMand high flow oxygen. ThenLOAD AND GO

add 40 mcg lpratropium Bromide (2 puffs)(3) Resume Oxygen therapy

Sa tisfactorily ImprovedContjnue oxygen therapy

...

TransportT

Continue with assessment

Notimprovingomotsatisfac torily improved-Consider administering 2nd 3rd or 4mdose ofSalbutamo l at 5 minutes apart(No lpratropium Bromidt In substqutnttreatment)

I


5/14

Suspected Narcotic Overdose ProtocolInd icationDecreased LOC in a patient wi th a history that suggests narcotic overdose,Respiratory rate < 10 per minute and I or shallow respiration, andDifficulty in maintaining the patient's airway(All three criteria must be met)Contra indicntionKnown na loxone allergyPatient und er 12 years of agePatient maintains bis/her own airway we ll.The EMA II ambulance supervisor bas no difficulty in maintaining the patient's airway(e.g. patients accepts OPA well and has no resistance to bagging)

RSE...

LOC...

DCBA...

RBS...

Skin...

Oxygen...

II

I Decision Point I...

Secondary Survey:H istory Vital Signs

Administer 0.4 mg naloxone hydrochloride IM to deltoid mu scleContinue with assessment

No improvement Improvement- Maintain ABC and assistventilation. Maintain ABC and 0 2- Haemoglucostix; if 4 mmol/L orless , follow the Hypog lycemia therapyProtoco l (even if history ofDMcannot be obtained).

I I..

TRANSPORT Continue with treatment and assessment


6/14

Hypovolemia ProtocolIndication1) Evidence of loss ofa significant quantity of blood.2) Presence of clinical signs of shock, OR shock is anticipated because of the mechanism

of injury, the nature and extent of the injuries, or the patient 's condition.ContraindicationPeripheral IVs.iare contra indicatedPatients under 12 years. RSE

II

...

LOC...

DCBA...RBS...

Skin...IOxygen I...I Decision Point I...

Transportr Secondary Survey: Hi story & Vital ~If SBP ~ 90 mmHg I I I f SBP < 90 mmHgObtain IV access

Administer IV N/S at lOOml/hr...

Obtain IV accessAdminister 500ml N/S rapid infusion

...

Continue with assessment and treatment Continue with assessment and trea tment

If SBP fa lls< 90 mmHg,Follow " IF SBP


7/14

Automated External Defihrillat ion (FR2+ AEO) ProtocolI.IndicationPatient in cardiac arrest not primarily due to trauma2.Contraindication2.1Traumatic arrest (Cardiac arrest primarily due to trauma)2.2 Newborn (Any infant at the time of birth in the pre-hospital setting).

RSELOCDCBA

WitnessedArrestCPR and immediately use I apply AED& defibrillation ads

Unwitnessed Arrest2-min CPR and prepare

AED & defibrillation ads

AED analysisEAD ECG rh thm

No

ShockIndicated

Check Pulse

Pulse Absent I I ulse present I

Shock indicatedPress to Shock

2-m in CPR(NopulsecheckAED analysis

READ ECG rh thm) .............Shock indicated

Press to Shock

Load and transport L oad and transport(:issist ven ti lation+AED monitoring+S 2 monitorin )

r - - - ~ - - - 1

(movin CPR) +'!Analyze every 2-3 minsWhen a licable

I Re-arrest ..--------


8/14

Paediatric Seizure ProtocolIn


9/14

Tramadol ProtocolIndi ca tionCo nsc ious and fully oriented patient suffering from acut severe pain arising from trauma to the trunkand.for limbs; AND\\ 'hen the use ofEntonx is contrnindicated,impracticable, ineffective or not feasible.ContrnindicntionPatient whose SBP < 90mmH g (Hypotension)Patient wi th history of Epilepsy or seizure.Patien t und er 12 years ofAge.Patient on any Drugs in the past 2 weeks.Pregnant Patient.Patient with history of drug/opioid Abuse.Patien t with acut Intoxication with alcohol.Kn own history of hypersensitivity to Narcotics.A mnemonic for easy memory of contraindications HEAD PAI N.

Spinal precaution as indicated

Control bemorrbage as indicated

Treat soft tissue and/or skeletal injuries as indicated

Secondary Survey: -e Critical History ofCICe Vital Signs

Pain Assessmente Rule out Contraindicationse Explain side-effects to patient

Administer Tramadol IMI< 50kg: 50 mg

~ 50kg: 75mg

Reassessment


10/14

Activated Charcoal ProtocolIndicationPatient has ingested toxic substance AND/OR medication exceeding the prescribed amountand the time of ingestion is within 2 hours.Patient is fully co,pscious. cooperative AND has no difficulties with self drinking and swallowing.Patient has clear airway and no choking or vomiting.ContraindicationPatient with history ofhypersensitivity to charcoal preparation.Patient with decreased level ofconsciousness. uncooperative, has difficulties with selfdrinking and swallowing, whose airway is not clear or has choking or vomiting.Patient has ingested the substance for more than 2 hours.Patient < 12 'l..ears of ~ .

RSE...

LOC...IDCBA I...I RB S I...I Skin I...

1ore 1Decision Point

Secondary Survey: History

Vital Signs

Administer 50g Activated Charcoal

Continue with assessment and treatment

;


11/14

Adrenaline for AnaphylaxisIndications Contraindications Side effects

I 1+2 < 12 years of age TachycardiaI l + 3 c present SIS of CHF Pa lpitation1+2+3 A Allergy to Adrenaline Intracrainial

Skin - urticaria , s Hx of Stroke (C VA) Haemorrhage1 generalized flushing HT at presentor angioedcma H (SBP> 180&/or Hypertension

DBP> l 10)2 Airway obstruction- M Hx of MI/ coronary artery Ml,Upper/ lower di sease ang inal pain

Hx of VF I life threateningArrhythmia requiring IV

Shock A medica tion I defibrillation/ VF / VT3 (SBP < 90 mmHg) cardioverson to tenninateDistributive I hypovolaemic

D Implantab le Cardioverter OtherDefibrillator arrhvthmiaIn dications Drug Dosage Max

I + 2 or I + 3 or Adrenaline 0 .3 mg (= 0.3 ml)SC l doseI + 2 + 3 & NO ( I: !OOO solution)contraindications Piriton !Omg(= l ml)IMl I doseLower airway Ventolin 2 to < 5 years of ageobstruction (enroute 5 to < 12 years of age 300 mcg 4 doses(wheezing or

rhonchi) by spacer) > 12 years o f age 400 mcgOn car if B P 9 0 = 100 ml/hr.

All anaphylactic On car ifSBP < 90 ' I 1 500 ml FR.patient (Shock: N/S After SBP < 90 =2'10 500 ml FR. 2 bolusSBP < 90 or (enroute I SI FR S B P 9 0 =500 ml/hr. of 500anticipitated via IV) ml

shock SBPf'.90) After 2"d FR = 500 ml/hr

Drug Adrenalineset Duration Elimination

5-10 m lns S-10 mlns Metabolized by enzymes in blood, liverAnd other tissues, and excreted in urine

SC Contraindications Local skin infection Existing local injurieslM I Contraindications Local skin in fection Existing local injuries

Coagulopathy Anti-coagulant


12/14

Anaphvlaxis FlowchartRSE _. Note MOI & clues of anaphylaxisLOC _. A / V / P / U

-! Dc -.f No radial pulse = low BP =shockB ~ 02 orBVM

~ Lower A obstnLction - wheezingA _. ~ Upper A obstruction-Stridor,

hoarseness, difficult swallowingRBS _. ~ Note any skin manifestation

(urticaria, generalized flushingSkin _. or angioedema)~ Remove allergen if any

DecisionBassline Vital

NO EpiPen EpiPen availableAvailable Self-injected 12 years, IMI Chlorpgenira mine : 1Omg (lml)(Rule out Chlorpheniramine allergy & IMI contraindication)If lower A obstruction

Reassess SOB, lung sound, RR & Sp02I f SOB not relieved, V entolin via spacer

max 4 doses with 5 mins in between .All anaphylactic patient, reassess SBP on carI f SBP < 90 If SBP f 90

IV N/S500 ml @ FRl st FR completed~ SBP f 90 - 500 ml/hr

~ SBP < 90 - 2"d 500 ml FR2 n FR completed - 5001nl/hr

IV N/S I00 ml/hr

Continue assessment &reassess as needed.


13/14

Adu lt Seizure Protocol (Important: This advancedprotocol is acluslvt!/y ust!d bytrained EMAiiambulanct! supt!rvisors who havt! bt!t!n authorh.ed to USt! Midarolam.)J.n\lg;at1onPatient has on-going generalized convulsion continuously for more than 5 minutes with loss ofconsciousness by witness or by a reliable history. ANDPatient who is > I2 years old (or, in case the age is NOT known, a patient whose height isgreater than 130 cm).Contraindication of Milia10la111Patient with history of hypersensitivity to Midazolam.Patient's convulsion bas stopped.Patient has received Benzodiazepines for termination ofconvulsion (e.g. IVIPR Diazepam, IV IMMidazolam, IV Lorazepam) in a period of less than 5 minutesConsideration to give treatment should be raised again after this S minute period has lapsed perpatient's condition.Anti-epileptic prophylactic agents (usually taken by the oral route on a regular basis) should notbe counted as drug for termination ofconvulsion.

Transport

RSELOC...IDCBA I...

I RBSI Skin

IDecision Point I...

2 survey:Critical Hx & vital signs

...

lMl MidazolamBW < 50 kg :7.5 mgB W ~ 50 kg: 10 mg

I Continue to assess vitals..______ (ABC I BP I P I RR I GC S I Sp02 / Skin)

Other paramedic protocols as necessaryContinue re-assessment


14/14

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ema protocols

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