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2013 oems protocol_changes_gutman

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  • 1. 2013 OEMS Prehospital2013 OEMS PrehospitalProtocol UpdateProtocol UpdateAmy Gutman MDEMS Medical Directorprehospitalmd@gmail.com / www.teaems.comMay 2013
  • 2. ObjectivesObjectives• Inform Massachusettspre-hospital providers ofupdates to the OEMSPre-hospital Treatmentprotocols effective as ofJune 15, 2013• Review evidence-basedliterature rationale behindthe changeswww.mass.gov/dph/oems
  • 3. Medication ChangesMedication Changes• Majority of changes areroute-related or providealternatives duringmedication shortages• Updated wording reflectsnational standards, forexample removing “trailingzeros” from medicationdosing in all protocols,appendixes & drugreferenceswww.jointcommission.orgRationale: Joint Commission safety recommendation, consistent withnational patient care practices
  • 4. General Principles for Specific SkillsGeneral Principles for Specific Skills• EMS crews should not begin or administer interventions thatrequire further medical assessment if the patient is beingtransported to an environment where the intervention will notbe provided / monitored– i.e. Giving IV narcotics to patient not being transported to a medical facility• This principle does not apply to giving medications if thepatient is being transported to a facility where personnel areavailable to assess the patient, such as a physician’s office or askilled nursing facilityRationale: Clarification of role of EMS as medical providers
  • 5. General Principles for Specific SkillsGeneral Principles for Specific Skills• Recent advances in resuscitation science have increased potential forsurvival in out-of-hospital cardiac arrest (OOHCA)• Some MA EMS systems monitor their OOHCA survival rates withexcellent results comparable to national norms. Ideally every EMSsystem should monitor & strive to improve their OOHCA survival rates• For services not currently monitoring & taking steps to improve theirOOHCA outcomes the following is recommended:– EMD instructions to provide hands-only CPR if patient unconscious & notbreathing normally– Emphasis on continuous compressions to maintain 80% compression fraction– Delay intubation to after 1st8 minutes of CPR in primary cardiac arrest to avoidinterrupting compressions– Field initiated followed by in-hospital hypothermia for ROSC– Rapid 12-lead EKG after ROSC to determine if STEMI POE should be usedRationale: Monitoring out-of-hospital cardiac arrest care
  • 6. Ewy GA, Sanders AB. Alternative approach to improvingsurvival of patients with out-of-hospital primary cardiacarrest (OOHCA). J Am Coll Cardiol. 2013. Jan 15;61(2):113-8• Cardiocerebral resuscitation (CCR) significantly improved survival ofOOHCA patients in 2 Wisconsin counties from 15% to 39%, and in 60Arizona EMS departments to 38% over one year. Using CCR, over afive year period, survival from primary cardiac arrest in Arizonaincreased from 18% to 33%• Conclusions: Advocating bystander compression only CPR forpatients with primary OOHCA, and encouraging EMS CCR vs priorCPR guidelines which included emphasis on ventilations and earlyairway management
  • 7. Ewy GA, Kern KB. Recent advances in cardiopulmonaryresuscitation: cardiocerebral resuscitation. J Am CollCardiol. 2009 Jan 13;53(2):149-57• CCR advocates continuous compressions without mouth-to-mouthventilations for witnessed cardiac arrest• For bystanders with AED access & EMS arriving in electrical (1st4-5minutes) phase of VF, prompt defibrillation recommended• For EMS arriving in circulatory phase of VF arrest (>5 minutes) whenfibrillating myocardium has used up energy stores, compressionsmandatory prior to & immediately after defibrillation• Recommendations: delayed endotracheal intubation, avoid excessiveventilations, & utilize early epinephrine
  • 8. Clemmensen P, et al. Diversion of STEMI patients for primaryangioplasty (pPCI) based on wireless prehospital 12-lead ECGtransmission directly to cardiologists handheld computer: aprogress report. J Electrocardiol. 2005 Oct;38:194-8• Time to reperfusion critical in STEMI patients. Transfer from receivinghospital to a catheterization center can cause unacceptable delays• Prehospital ECGs transmitted for 408 CP patients (success 93%).Cardiologists receiving ECG recommended 113 patients (28%)diverted for pPCI• Results: EMS scene time increased by 7 minutes when ECGtransmitted to cardiologist compared to control group. Time from ECGto ED arrival 25 minutes. Hospital treatment time significantly reducedfor diverted patients - ED arrival to pPCI 40 minutes vs. 94 minutes incontrol group
  • 9. Wenzel V, et al. Comments on the 2010 guidelines oncardiopulmonary resuscitation of the EuropeanResuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23• Chest compressions minimum 100/min, 5 cm depth at ratio of 30:2with ventilation. Avoid interruptions in compressions to ventilate• After every defibrillation attempt (initially biphasic 120-200J,monophasic 360J, subsequently with respective highest energy),compressions immediately reinitiated for 2 minutes independent ofrhythm• ETI performed only by experienced providers during ongoingcompressions with a maximum interruption of 10 sec to pass ETTthrough vocal cords. Supraglottic airways are alternatives to ETI• Active compression-decompression & inspiratory threshold valve arenot superior to good standard CPR
  • 10. Wenzel V, et al. Comments on the 2010 guidelines oncardiopulmonary resuscitation of the EuropeanResuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23• Pediatric BLS:– Initially 5 rescue breaths, followed by compressions (100-120/min depth 1/3chest diameter), compression-ventilationratio 15:2– Foreign body airway obstruction with insufficient cough:alternate back blows & compressions (infants), orabdominal compressions (>1 yo)• Pediatric ALS:– Epinephrine 10 ug/kg IV or IO every 3-5 minutes.Defibrillation (4 J/kg) followed by 2 minutes CPR, then ECG& pulse check
  • 11. 1.5 ACS, 1.6 ROSC, 3.11 Acute Stroke1.5 ACS, 1.6 ROSC, 3.11 Acute Stroke• Added: Avoid hyperoxygenation, administeroxygen using the appropriate delivery deviceas clinically indicated• If pulse oximetry available, givesupplemental oxygen only if oxygensaturation level <94% on room airRationale: Hyperoxygenation causes coronary & systemicvasoconstriction, resulting in decreased coronary blood flow, increasedcoronary vascular resistance & free radical formation
  • 12. Ranchord AM, et al. High-concentration versus titratedoxygen therapy in STEMI: a pilot randomized controlledtrial. Am Heart J. 2012 Feb;163(2):168-75• Methods: 136 STEMI patients uncomplicated by cardiogenic shock orhypoxia randomized to receive high-concentration (>6 L/min) or titratedO2 (to achieve O2 saturation 93%-96%) for 6 hrs. Outcomes were 30-daymortality & infarct size assessed by troponin level at 72 hrs. Secondaryoutcomes: meta-analysis of mortality data from previous trials, &infarct size assessed by MRI at 4 - 6 weeks• Conclusions: No benefit or harm from high-concentration O2 comparedwith titrated O2 in uncomplicated STEMI. Because meta-analysis datahad a large confidence interval (meaning, data uncertainty) largerrandomized studies required to resolve any clinical uncertainty
  • 13. Shi J, et al. A new idea about reducing reperfusion injuryin ischemic stroke: Gradual reperfusion. Med Hypotheses.2013 Feb;80(2):134-6• Occlusion of intracranial arteries leads to direct cell death with cellfunctional impairment surrounding dead core (ischemic penumbra).Opening the occluded artery to limit ischemic penumbra size is aim ofthrombolysis therapy, but reperfusion induced injury counteractspotential benefits of thrombolysis• Conclusions: Gradual reperfusion reduces reperfusion injury byreducing free radical production; free radicals come from reperfusionpenumbra & respiration cycle which is unregulated during ischemia.Once reperfusion occurs, respiratory chain enzymes need only normalamount of O2 & glucose to avoid producing free radical intermediates.Gradual reperfusion reduces free radical production by limiting O2 &glucose provided to the respiratory chain
  • 14. 3.4 Bronchospasm/ Respiratory Distress3.4 Bronchospasm/ Respiratory Distress• Added to ALS-P Standing Orders:In patient with known asthma or COPD,without history or findings significant forCHF give Hydrocortisone 100 mg IV, IM, IOor Methylprednisolone 125 mg IV, IM or IO• In patients <40 yo Epinephrine 0.15-0.3 mgIM* by autoinjector only as 1 time dose,contact medical control for additionaldosing• Added to MCO: “BY AUTOINJECTORONLY” for additional dosingRationale: Therapy for severe distress by reducing inflammationassociated with bronchospasm; Effective treatment to patients <40 yoin treatment of bronchospasm/respiratory distress due to asthma;safety reminder regarding dosing devicewww.hubpages.com
  • 15. 4.2 Burns / Inhalation Injuries4.2 Burns / Inhalation Injuries• Added to ALS-P StandingOrders:In patient with hypotension,AMS, or indications ofcyanide toxicity who mayhave experienced smokeinhalation, considerHydroxocobalamin 5gm IVover 15 minutes (adult), or 70mg/kg (to max 5 gm) IV over15 minutes (pediatric)Rationale: Effective treatment for acute cyanide poisoningsanatate.bzi.ro
  • 16. O’Brien DJ, et al. Empiric management of cyanidetoxicity associated with smoke inhalation. PrehospDisaster Med. 2011. Oct;26(5):374-82• Closed-space smoke inhalation 5thmost common cause of USunintentional injury deaths. Cyanide is a toxin in many cases of smokeinhalation but it’s presence cannot be rapidly confirmed• Findings suggesting cyanide toxicity include: closed-space fire withlikely smoke inhalation; oropharyngeal soot or carbonaceousexpectorations; altered LOC, otherwise inexplicable hypotension• Prehospital studies demonstrate feasibility & safety of empirictreatment with FDA-approved hydroxocobalamin for patients withsuspected smoke inhalation cyanide toxicity. Based on literaturereview & on-site observation of the Paris Fire Brigade, prehospitalprotocols to guide empiric & early hydroxocobalamin administration insmoke inhalation victims with high-risk presentations recommended
  • 17. 4.3 Head Trauma &4.3 Head Trauma &4.7 Spinal Column / Cord Injuries4.7 Spinal Column / Cord Injuries4.3 Head Trauma• Removed: “Hyperventilation may helpbrain injury by reducing intracranialpressure. Hyperventilate patient insuspected cases of herniationsyndrome (e.g. decorticate posturing,decerebrate posturing, fixed, dilatedpupils, etc.)”• Removed: “Consider hyperventilationif clinically appropriate with asignificant closed head injury & signsof herniation syndrome”4.7 Spinal Column / Cord Injuries• Removed: “Consider hyperventilationwith 100% oxygen with BVM ifassociated with a significant closedhead injury & signs of herniationsyndrome”Rationale: Hyperventilation causes increased ICP & decreasedperipheral blood flow, worsening patient outcomes
  • 18. Dumont TM, et al. Inappropriate prehospital ventilation insevere traumatic brain injury increases in-hospitalmortality. J Neurotrauma. 2010. Jul;27(7):123-41• In traumatic brain injury (TBI), hyperventilation to reduce ICP may be life-saving. However, undue use of hyperventilation may increase incidence ofsecondary brain injury through direct reduction of cerebral blood flow• Methods: TBI patients with GCS <8 (n = 65) sorted into hypocarbic (Pco2<35 mmHg), normocarbic (Pco2 35-45 mmHg), & hypercarbic (Pco2 >45mmHg). Survival related to admission Pco2 in TBI patients requiring ETI.Patients with normocarbia had in-hospital mortality of 15%, significantlyimproved over patients presenting with hypocarbia (77% mortality) orhypercarbia (61% mortality).• Conclusions: Abnormal Pco2 on presentation after TBI correlated withincreased in-hospital mortality and advocate prehospital normoventilation
  • 19. 4.6 Soft Tissue / Crush Injury4.6 Soft Tissue / Crush Injury• Removed: under Basic Procedures words“direct pressure”, “pressure points”• Added: “If suspect severe crushing injury /compartment syndrome, if injury permits”Rationale: To avoid contradicting new changes for hemorrhage control(direct pressure followed by tourniquet). Allows use of tourniquet if noother way to stop hemorrhage
  • 20. 4.7 Spinal Column / Cord Injuries4.7 Spinal Column / Cord Injuries• Added: “Evidence of non-penetrating traumaabove the clavicles” when considering spinalimmobilizationNote: Patients with penetrating trauma whowere immobilized had worse overalloutcomesRationale: Immobilized patients with penetrating trauma have worseoutcomes than non-immobilized patients
  • 21. Paiva WS, et al. Spinal cord injury and its association withblunt head trauma. Int J Gen Med. 2011;4:613-5• What are risk factors for spine trauma plus traumatic brain injury (TBI)?• Results: 180 pts with moderate or severe TBI had cervical spine x-rayand CT. Most common causes of TBI were pedestrians struck byvehicles (31%), MVC (28%) & falls (25%). Systemic injuries found in 80(44%) patients. 53% had severe , & 47% had moderate head trauma. 14patients (8%) had a spinal cord injury (12 cervical, 1 lumbar, 1 thoracic).In the elderly, presence of systemic injuries & GCS <9 were significantrisk factors for spine injury• Conclusions: Spinal cord injury related to moderate & severe braintrauma usually affects the cervical spine
  • 22. 4.7 Spinal Column / Cord Injuries4.7 Spinal Column / Cord Injuries• Deleted: “including adult fall from standing”from the high risk factors for determiningpossible spinal injury• Age <8 years or >65 years still considered“high risk mechanisms”Rationale: Fall from standing only a risk in patients >65 years of age
  • 23. Lomoschitz FM, et al. Cervical spine injuries in patients 65years old & older: epidemiologic analysis regarding the effectsof age & injury mechanism on distribution, type, & stability ofinjuries. Am J Roentgenol. 2002 Mar;178(3):573-7• Methods & Results: 225 cervical spine injuries in 149 patients >65 yoretrospectively assessed. Mechanism (falls from standing or seatedheight vs higher energy mechanisms) & initial neurologic statusrecorded. 95 (64%) patients had upper cervical injuries. 59 (40%)patients had multilevel injuries. Main causes for cervical injuries wereMVCs in "young elderly" (65-75 yo; 61%) & falls from standing orseated height in "old elderly" (>75yo; 40%). Patients >75 yo(independent of mechanism), & patients falling from standing height(independent of age), more likely to injure the upper cervical spine• Conclusions: Elderly patients in general including those falling fromstanding height are more prone to injuries of the cervical spine
  • 24. 4.10 Traumatic Amputations4.10 Traumatic Amputations• Language Added to BasicProcedures:– Control/stop any lifethreatening hemorrhage– If other methods cannotcontrol bleeding applyappropriate tourniquet– Document exact time oftourniquet applicationRationale: ITLS recommends use of tourniquets to control lifethreatening bleeding; pressure points & elevation have been removedwww.thefreedictionary.com
  • 25. Kragh JF, et al. Survey of the indications for use ofemergency tourniquets. J Spec Oper Med. 2011Winter;11(1):30-8• Optimal tourniquet use in trauma appears to depend on device,doctrine, training, speedy evacuation, & performance improvement.Challenges remain in estimation of blood loss & injury lethality• Methods: Data on emergency tourniquet use analyzed from a clinicalstudy of 728 casualties with 953 tourniqueted limbs. Authors comparedknown prior datasets to this clinical study• Recommendations: Current indication for emergency tourniquet use isany compressible limb wound that provider assesses as havingpossibly lethal hemorrhage. This indication has shown good outcomesonly when devices, training, doctrine, evacuation & research optimized
  • 26. Appendix D Emergent AirwayAppendix D Emergent Airway• Appendix renamed “Difficult Airway Protocol”Rationale: More representative of when process should be utilized
  • 27. Appendix T Nerve Agent Dosing &Appendix T Nerve Agent Dosing &Reference TableReference Table• Added: Duodote to Appendix T• Mark I kits & Duodote not approvedfor routine pediatric use, howevershould be used as initial therapy forchildren with life-threatening nerveagent toxicity (in extremis) when IVtherapy not available• “Assumes” 0.8 inch needle insertiondepthRationale: Accepted treatment for children with severe life-threateningnerve agent toxicitywww.myfirefighternation.com
  • 28. 1.1 Asystole1.1 Asystole• Added to ALS-P StandingOrders:if Epinephrine 1:10,000unavailable due to drugshortage,Vasopressin 40 units may besubstituted & given every 20minutes IV or IORationale: Handle epinephrine shortageswww.drugline.org
  • 29. Wenzel V, et al. A comparison of vasopressin & epinephrinefor out-of-hospital cardiopulmonary resuscitation. NEJM.2004 Jan 8;350(2):105-13• Background: Vasopressin is an alternative to epinephrine forvasopressor therapy during CPR• Study Methods: Adults with OOHCA received 2 injections of either 40IU of vasopressin or 1 mg of epinephrine, followed by additionaltreatment with epinephrine if needed. Primary end point was survivalto admission; secondary end point was survival to discharge• Study Conclusions: Effects of vasopressin similar to those ofepinephrine in management of VF and PEA, but vasopressin superiorto epinephrine in patients with asystole. Vasopressin followed byepinephrine may be more effective than epinephrine alone inrefractory cardiac arrest
  • 30. Protocols / References Involving Morphine andProtocols / References Involving Morphine andFentanylFentanyl(1.2, 1.3, 1.4, 1.5, 1.9, 1.11, 3.7, 3.14, 4.2, 5.13)(1.2, 1.3, 1.4, 1.5, 1.9, 1.11, 3.7, 3.14, 4.2, 5.13)• Standing Orders:– Deleted “This is a one time dose option”; Replaced with“Medication dose may be given in divided doses up to themaximum”– This includes titrating to pain control for ACS (Protocol 1.5)• Added:– Fentanyl linked to drug reference page– IM route added for FentanylRationale: Allow pain control titration of under standing orders,technical fix to text, added administration route
  • 31. Protocols & References InvolvingProtocols & References InvolvingEpinephrine (1.4,1.6, 3.2, 5.1, 5.2, 5.3, 5.5)Epinephrine (1.4,1.6, 3.2, 5.1, 5.2, 5.3, 5.5)• Infusion:– Administer 1 mcg to 10 mcg /min IV or IO– For example: mix 1 mg of1:1000 Epinephrine in 250 mlNS– 15 micro drops/min = 1 mcg /minRationale: Standardized language, administration routes clarified byadding IV & IO routescommons.wikimedia.org
  • 32. 1.5 ACS1.5 ACS• NTG 0.3mg removedfrom MCO section• Standardized dosingremains the same of0.4mg under standingorderRationale: Standardized languagewww.webmed.com
  • 33. Protocols Involving Amiodarone (1.6 & 1.11Protocols Involving Amiodarone (1.6 & 1.11))• Added: “for example” todrip information– Amiodarone 1 mg/minIV drip for example:100mg/100ml - 1mg/minRationale: Standardize dosing option in ALS-P & MCOwww.rxprescriptionguide.org
  • 34. Allergic Reaction/AnaphylaxisAllergic Reaction/Anaphylaxis3.2 Adult• Added:– IO route to diphenhydramine• Added to ALS-P Standing Orders:– Hydrocortisone 100 mg IV, IM, IOor– Methylprednisolone 125 mg IV, IMor IO• Added to MCO Section:– Epinephrine “by autoinjectoronly” 1:1,000: 0.15-0.3mg IM5.2 Pediatric• Added:– IO route to diphenhydramine• Added to ALS-P Standing Orders:– Hydrocortisone 2 mg/k. tomaximum 100 mg IV, IM, IO or– Methylprednisolone 2 mg/kg tomaximum125 mg IV, IM or IORationale: Appropriate administration & therapy route to rapidly reduceinflammation; safety reminder
  • 35. 3.13 Toxicology / Poisoning / SA / OD3.13 Toxicology / Poisoning / SA / OD• Deleted:– EMT-B proceduresnaloxone 0.4mg– Protocol now reads“Administer naloxone2.0mg nasal via atomizer”Rationale: Correct dosing as under special project waiversstore.airwaycam.com
  • 36. Merlin MA, et al. Intranasal naloxone delivery is analternative to intravenous naloxone for opioid overdoses.Am J EM. 2010. Mar;28(3):296-303• Proposal that EMS intranasal (IN) naloxone administration preferableto intravenous (IV) naloxone without risk of needle exposure• Methods: retrospective chart review of ALS patients performed onconfirmed opioid overdose patients. Initial and final unassistedrespiratory rates & GCS used as indicators of naloxone effectiveness• Conclusion: IN naloxone statistically as effective as IV naloxone inreversing effects of opioid overdose with similar average increases inRR and GCS. IN naloxone is a viable alternative to IV naloxone whileposing less risk of needle stick injury
  • 37. 3.14 Adult Pain & Nausea Management3.14 Adult Pain & Nausea Management5.13 Pediatric Pain & Nausea Management5.13 Pediatric Pain & Nausea Management• Added: PO and ODT routesfor Odansetron as astanding order & treatmentoptionRationale: Reasonable treatment route & formulation without threat ofneedlestick injurywww.finlandpharmacyonline.com
  • 38. SeizuresSeizures3.9 Adult• Added To ALS-P Standing Orders:– Midazolam 2.5-5mg slow IVpush or IM5.7 Pediatric• Added To ALS-P Standing Orders:– Midazolam 0.05 mg/kg IV, IO, IMto max single dose of 4 mgRationale: An option for benzodiazepine therapy shown to work fasterin some studies; addresses medication shortages
  • 39. 5.4 Pediatric Bronchospasm / Respiratory5.4 Pediatric Bronchospasm / RespiratoryDistressDistress• Added to ALS-P Standing Orders :– For >2 yo with known diagnosis of asthma;Hydrocortisone 2 mg/kg to maximum 100 mg IV,IM, IO or– Methylprednisolone 2 mg/kg to maximum 125 mgIV, IM, IORationale: Therapy reduces inflammation associated with bronchospasm
  • 40. Knapp B, Wood C. The prehospital administration of IVmethylprednisolone lowers hospital admission rates formoderate to severe asthma. PEC. 2003 Oct-Dec;7(4):423-6• Compare hospital admission rates for patients with moderate to severeasthma who receive prehospital vs ED methylprednisolone• Results: 31 moderate to severe asthmatics received prehospitalmethylprednisolone. 33 asthmatics transported by EMS & later receivedIV methylprednisolone in the ED. Only 13% (4) of patients receivingprehospital solumedrol were admitted to the hospital vs 33% (11)receiving solumedrol in the ED• Conclusions: Patients with moderate to severe asthma receivingprehospital methylprednisolone have 3 times fewer hospital admissions
  • 41. Summary of Medication ChangesSummary of Medication Changes• Vasopressin 40 units every 20minutes IV or IO if Epinephrine1:10,000 shortage• Morphine & Fentanyl may be givenin divided doses to the maximum• IM route added for Fentanyl
  • 42. Summary of Medication ChangesSummary of Medication Changes• NTG 0.3mg removed from MCO• IO route added forDiphenhydramine• Added Hydrocortisone 100 mg IV,IM, or IO or Methylprednisolone125 mg IV, IM or IO
  • 43. Summary of Medication ChangesSummary of Medication Changes• “By autoinjector only” added toMCO for Epinephrine 1:1,000, 0.15-0.3mg IM• Midazolam 2.5-5mg slow IVP or IM• Midazolam 0.05 mg/kg IV, IO or IMto max single dose of 4 mg(pediatrics)
  • 44. Summary of Medication ChangesSummary of Medication Changes• PO / ODT as Odansetronroute as a standing order &a treatment option
  • 45. SummarySummaryprehospitalmd@gmail.com• This review serves as notification ofthe changes to the MA Pre-hospitalTreatment Protocols effective June 15,2013• Provide evidence-based informationregarding why changes occurred

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