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2008 Maine EMS Protocol Revision

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  • Providers are no longer allowed to access central lines. The Institute for Healthcare Improvement (IHI) ( www.ihi.org ) found extreme risk in this procedure and instituted recommendations that are nearly impossible for EMS. These recommendations included gowns and full sterile draping and thus create unrealistic probabilities for use in EMS. Furthermore, the introduction of adult IO has given EMS a safer alternative. Instructors may also advise learners that typically a patient has had a central line placed so as to avoid routine IV catheterizations and therefore providers should utilize good clinical judgment when deciding whether or not to place an IV in a “routine ALS” patient.
  • This change is primarily a wording change not a significant deviation from existing protocol
  • This change is not new. The IO protocol was modified to include adults in 2006. The 2008 update will include this protocol for clarification purposes. Instructors should note that adult IO training is a separate training class and must be taught by a MEMS IC. That said, instructors of this program should use this update to review the requirements of the adult IO protocol.
  • Diversion is a difficult and often times challenging subject. It will be easy to spend a great deal of time here debating the legality and merits of hospital diversion. However, in the interest of time, it is suggested that this course focus on simply the patient’s right to override diversion and the provider’s requirement not to divert a critical patient to a further away hospital. Those two elements should be the focus of discussion.
  • It is not intended for this course to teach the use of carbon monoxide detectors. In fact, it should be pointed out that before a service utilizes such a device, steps should be taken to provide their personnel with the specific training necessary to safely utilize their monitor of choice.
  • This change is primarily a wording change not a significant deviation from existing protocol. However, the role of the MDPB in approving on scene health care provider treatment or mediating on scene health care provider disputes should be reviewed with the learners.
  • This change is primarily a wording change not a significant deviation from existing protocol. However, the role of the MDPB in approving on scene health care provider treatment or mediating on scene health care provider disputes should be reviewed with the learners.
  • This new section has been added to address the increasing number of patient centric devices being found in the home environment. The specific criteria necessary to consider an appliance a “home health care device” is that it is intended to be maintained solely by the patient or their licensed care providers, or previously instructed family members. . If a device must be maintained by the EMS provider, it should NOT be considered a home health care device.
  • This new section has been added to address the increasing number of patient centric devices being found in the home environment. The specific criteria necessary to consider an appliance a “home health care device” is that it is intended to be maintained solely by the patient or their licensed care providers, or previously instructed family members. . If a device must be maintained by the EMS provider, it should NOT be considered a home health care device.
  • The intention of the MDPB was that home health appliances, that is, those maintained by the patient, should not impact treatment of transfer under usual circumstances. If the device is to be maintained solely by the patient (or their licensed care providers, or previously instructed family members), any provider is free to transfer this device.
  • The intention of the MDPB was that home health appliances, that is, those maintained by the patient, should not impact treatment of transfer under usual circumstances. If the device is to be maintained solely by the patient, any provider is free to transfer this device.
  • The MDPB has included this section to clarify questions regarding the increasing number of various “rescue airway devices” coming on the market. Periglottic and transglottic should be clarified for the students.
  • The MDPB has included this section to clarify questions regarding the increasing number of various “rescue airway devices” coming on the market. Periglottic and transglottic should be clarified for the students.
  • The MDPB has included this section to clarify questions regarding the increasing number of various “rescue airway devices” coming on the market. Periglottic and transglottic should be clarified for the students.
  • We will discuss intubation confirmation in the airway algorithm section, however, it would be appropriate to note that any device that has the potential for entering the trachea should be confirmed via end tidal CO2.
  • The intention of the MDPB was that home health appliances, that is, those maintained by the patient, should not impact treatment of transfer under usual circumstances. If the device is to be maintained solely by the patient, any provider is free to transfer this device.
  • The intention of the MDPB was that home health appliances, that is, those maintained by the patient, should not impact treatment of transfer under usual circumstances. If the device is to be maintained solely by the patient, any provider is free to transfer this device.
  • The inclusion of this chart was designed as a quick reference to aid the diagnosis of respiratory distress. The instructor might consider utilizing this chart as part of a larger respiratory distress class, separate from the protocol revisions.
  • The MDPB has required all devices that potentially enter the trachea (transglottic or endotracheal) to be confirmed with end tidal CO2 monitoring; colormetric, or capnographic. Neither of these techniques are new to the protocol revision (refer to the 2005 airway update class), but rather it is the requirement that is new. It is however, very important that the instructor indicate that continuous wave form capnography is REQUIRED in pediatric intubation. In other words, if the service does not have the capability of capnography, they cannot intubate pediatric patients.
  • In this section the instructor should review the slight wording changes: changing rescue airways to periglottic and transglottic devices.
  • The point of inserting an OG tube in MEMS is to decompress air from the stomach (alleviate gastric insufflation) and thereby increase functional residual capacity of the lungs.
  • In this section the instructor should review the slight wording changes: changing rescue airways to periglottic and transglottic devices.
  • Providers should refer to a length based resuscitation tape for sizing in pediatric patients.
  • Providers should refer to a length based resuscitation tape for sizing in pediatric patients.
  • Note: the tube should be left open to allow passive decompression.
  • This section will primarily focus upon familiarizing the learner with the new medications. The medication fact sheet (see attached) should be reviewed, and the overall protocol should be discussed. Note that Levalbuterol was designed as an option to Albuterol. Services are not required to carry both. Note that Combivent inhalers are an option to the nebulized solution (Duoneb). Services are not required to carry both.
  • This section will primarily focus upon familiarizing the learner with the new medications. The medication fact sheet (see attached) should be reviewed, and the overall protocol should be discussed.
  • Levalbuterol is quite similar in mechanism of action and effect to Albuterol. Providers should note that Levalbuterol should be used as an optional substitute for Albuterol.
  • Levalbuterol is quite similar in mechanism of action and effect to Albuterol. Providers should note that Levalbuterol should be used as an optional substitute for Albuterol.
  • Levalbuterol is quite similar in mechanism of action and effect to Albuterol. Providers should note that Levalbuterol should be used as an optional substitute for Albuterol.
  • Levalbuterol is quite similar in mechanism of action and effect to Albuterol. Providers should note that Levalbuterol should be used as an optional substitute for Albuterol.
  • This section will primarily focus upon familiarizing the learner with the new medications. The medication fact sheet (see attached) should be reviewed, and the overall protocol should be discussed. It is particularly important in this section that the peanut allergy contraindication to Ipratromium Bromide is discussed.
  • This section will primarily focus upon familiarizing the learner with the new medications. The medication fact sheet (see attached) should be reviewed, and the overall protocol should be discussed. It is particularly important in this section that the peanut allergy contraindication to Ipratromium Bromide is discussed.
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients.
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients.
  • Note: Duo-Neb solution does not have the same peanut/soy contraindication
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients. Soybean/Peanut ground nut allergies are a very important contradiction to emphasize.
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients. Soybean/Peanut ground nut allergies are a very important contradiction to emphasize.
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients.
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients.
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients. Soybean/Peanut ground nut allergies are a very important contradiction to emphasize.
  • Combivent can be used refractory to Albuterol or as a substitute for Albuterol alone in more severe respiratory distress patients. Soybean/Peanut ground nut allergies are a very important contradiction to emphasize.
  • In this section, the instructor should review the change in interval of NTG administration to 2 minute intervals. Additionally, the use of NTG paste should be reviewed. Correct application, dosing and precautions should be reviewed per the medication fact sheet.
  • In this section, the instructor should review the change in interval of NTG administration to 2 minute intervals. Additionally, the use of NTG paste should be reviewed. Correct application, dosing and precautions should be reviewed per the medication fact sheet.
  • Because CPAP is an optional protocol, specific learning objectives will be included in the designated CPAP education program. CPAP administration is not intended to be included in this class.
  • In this section, the instructor should review the change in interval of NTG administration to 2 minute intervals. Additionally, the use of NTG paste should be reviewed. Correct application, dosing and precautions should be reviewed per the medication fact sheet Although it will be discussed later, the Fentanyl dose change should be mentioned in this section as the protocol references it. The instructor should note the change to 1 microgram per kilogram. (see medication fact sheet). Because CPAP is an optional protocol, specific learning objectives will be included in the designated CPAP education program. CPAP administration is not intended to be included in this class.
  • Although it will be discussed later, the Fentanyl dose change should be mentioned in this section as the protocol references it. The instructor should note the change to 1 microgram per kilogram. (see medication fact sheet).
  • 1 inch of NTG paste = approximately 15 mg of NTG. Onset of action = 20-60 minutes Duration of action = 2-12 hours Ointment should be applied directly to skin of the chest wall (avoid distal extremities or areas where the skin may not be intact) and then covered by patch or other plastic type dressing.
  • 1 inch of NTG paste = approximately 15 mg of NTG. Onset of action = 20-60 minutes Duration of action = 2-12 hours Ointment should be applied directly to skin of the chest wall (avoid distal extremities or areas where the skin may not be intact) and then covered by patch or other plastic type dressing.
  • ASA is not a new drug to the protocols. The MDPB has now identified a specific dose rather than a range. Instructors should note that ASA is commonly recommended by emergency medical dispatchers and therefore patients should be questioned as to pre-arrival instructions prior to administration of ASA.
  • Instructors should emphasize that 12-lead acquisition is recommended for intermediates (but not required) but is in fact a standard of care for the critical care/paramedic level. That means it is expected of those levels to obtain a 12-lead ECG
  • Instructors should emphasize that 12-lead acquisition is recommended for intermediates (but not required) but is in fact a standard of care for the critical care/paramedic level. That means it is expected of those levels to obtain a 12-lead ECG Instructors should cover the dose change of Fentanyl, but note that the specifics will be covered later in this class. Note that the Chest Pain Protocol was not designed to be linear in nature. That is, it was not the intent of the MDPB that 12-lead ECG must be obtained prior to other interventions. As with any protocol, providers should use sound clinical judgment to determine the order and or urgency of interventions.
  • Lopressor is given here in relation to cardiac chest pain and not necessarily for rate control. However, paramedics should be aware of the lower limit of heart rate for administration. Instructors should emphasize that Lopressor is a paramedic level drug only.
  • Instructors should emphasize that 12-lead acquisition is recommended for intermediates (but not required) but is in fact a standard of care for the critical care/paramedic level. That means it is expected of those levels to obtain a 12-lead ECG
  • Although access to 12-lead ECG is an important component of the protocol revision, the instructor should make it clear in this section that ALS response may not be altered by intermediates utilizing 12-lead.
  • These changes are not new. Many services adopted the new ACLS changes in 2006. However, time should be taken to familiarize those students who are unfamiliar with the changes. Primarily, the changes focus on a single defibrillation rather than “stacked” shocks, the elimination of an immediate pulse check following defibrillation and the addition of Amiodarone. Instructors should refer to the 2005 AHA guidelines (add link here) and to the medication fact sheet for specific detail.
  • These changes are not new. Many services adopted the new ACLS changes in 2006. However, time should be taken to familiarize those students who are unfamiliar with the changes. Primarily, the changes focus on a single defibrillation rather than “stacked” shocks and the elimination of an immediate pulse check following defibrillation. Instructors should refer to the 2005 AHA guidelines (www.aha.org) for specific detail.
  • Instructors should refer to the 2005 AHA guidelines (www.aha.org). Instructors should also note that the AHA has de-emphasized the immediate need for intubation in the cardiac arrest patient.
  • These changes are not new. Many services adopted the new ACLS changes in 2006. However, time should be taken to familiarize those students who are unfamiliar with the changes. Primarily, the changes focus on a single defibrillation rather than “stacked” shocks, the elimination of an immediate pulse check following defibrillation and the addition of Amiodarone. Instructors should refer to the 2005 AHA guidelines (add link here) and to the medication fact sheet for specific detail.
  • These changes are not new. Many services adopted the new ACLS changes in 2006. However, time should be taken to familiarize those students who are unfamiliar with the changes. Primarily, the changes focus on a single defibrillation rather than “stacked” shocks, the elimination of an immediate pulse check following defibrillation and the addition of Amiodarone. Instructors should refer to the 2005 AHA guidelines (add link here) and to the medication fact sheet for specific detail.
  • These changes are not new. Many services adopted the new ACLS changes in 2006. However, time should be taken to familiarize those students who are unfamiliar with the changes. Primarily, the changes focus on a single defibrillation rather than “stacked” shocks, the elimination of an immediate pulse check following defibrillation and the addition of Amiodarone. Instructors should refer to the 2005 AHA guidelines (add link here) and to the medication fact sheet for specific detail.
  • Amiodarone has replaced lidocaine as the single anti-ventricular dysrhythmic. Provider should refer to the MEMS V-Fib/V-Tach cardiac arrest algorithm Provider should refer to the MEMS Wide Complex Tachycardia (probable V-Tach) algorithm Amiodarone is only one aspect of the symptomatic premature ventricular ectopy protocol. Providers should refer to all aspects of this protocol before treating.
  • Amiodarone has replaced lidocaine as the single anti-ventricular dysrhythmic. Provider should refer to the MEMS V-Fib/V-Tach cardiac arrest algorithm Provider should refer to the MEMS Wide Complex Tachycardia (probable V-Tach) algorithm Amiodarone is only one aspect of the symptomatic premature ventricular ectopy protocol. Providers should refer to all aspects of this protocol before treating.
  • Amiodarone has replaced lidocaine as the single anti-ventricular dysrhythmic. Provider should refer to the MEMS V-Fib/V-Tach cardiac arrest algorithm Provider should refer to the MEMS Wide Complex Tachycardia (probable V-Tach) algorithm Amiodarone is only one aspect of the symptomatic premature ventricular ectopy protocol. Providers should refer to all aspects of this protocol before treating.
  • Amiodarone has replaced lidocaine as the single anti-ventricular dysrhythmic. Provider should refer to the MEMS V-Fib/V-Tach cardiac arrest algorithm Provider should refer to the MEMS Wide Complex Tachycardia (probable V-Tach) algorithm Amiodarone is only one aspect of the symptomatic premature ventricular ectopy protocol. Providers should refer to all aspects of this protocol before treating.
  • Amiodarone has replaced lidocaine as the single anti-ventricular dysrhythmic. Provider should refer to the MEMS V-Fib/V-Tach cardiac arrest algorithm Provider should refer to the MEMS Wide Complex Tachycardia (probable V-Tach) algorithm Amiodarone is only one aspect of the symptomatic premature ventricular ectopy protocol. Providers should refer to all aspects of this protocol before treating.
  • Amiodarone has replaced lidocaine as the single anti-ventricular dysrhythmic. Provider should refer to the MEMS V-Fib/V-Tach cardiac arrest algorithm Provider should refer to the MEMS Wide Complex Tachycardia (probable V-Tach) algorithm Amiodarone is only one aspect of the symptomatic premature ventricular ectopy protocol. Providers should refer to all aspects of this protocol before treating.
  • These changes are not new. Many services adopted the new ACLS changes in 2006. However, time should be taken to familiarize those students who are unfamiliar with the changes. Primarily, the changes focus on the addition of Amiodarone as the first line anti-ventricular dysrythmic. . Instructors should distribute the MEMS Wide Complex Tachycardia protocol and refer to the 2005 AHA guidelines (www.aha.org) and to the medication fact sheet for specific detail. Further it should be noted here that Lorazepam has been removed from the protocols in the interest of having a single sedative medication (Midazolam will be used in its place).
  • Note: the low volume dose (3 ml) of Amiodarone will be difficult to push over 3 minutes. Services should consider mixing 150mg of Amiodarone in 50 ml of D 5 W to ease slow infusion rate.
  • These changes reflect current AHA ACLS guidelines for narrow complex tachycardias. Instructors should distribute a copy of the Narrow Complex Tachycardia Protocol.  
  • The addition of Metropolol (Lopressor®) gives the Critical Care/Paramedic level a second option (beyond Adenocard) for rate control. Instructors should note that the remainder of the protocol has not changed. Therefore, the focus should be on the aspects of the new drug, Lopressor. Specific detail can be found on the Medication Fact Sheet.  
  • Lopressor is paramedic only medication Onset = 15 minutes
  • Lopressor is paramedic only medication Onset = 15 minutes
  • Metoprolol is paramedic only medication Onset = 15 minutes
  • Onset = 15 minutes
  • Bradycardia is defined here as pulse<90mmHg
  • Lopressor and Amioderone will henceforth replace Liodocaine to control PVC’s. The basic principles of symptomatic ventricular ectopy have not changed. Emphasis here should include the OLMC decision making process and the contraindications of hypotension for Lopressor and rate for Amiodarone.
  • Lopressor and Amioderone will henceforth replace Liodocaine to control PVC’s. The basic principles of symptomatic ventricular ectopy have not changed. Emphasis here should include the OLMC decision making process and the contraindications of hypotension for Lopressor and rate for Amiodarone.
  • Bradycardia is defined here as pulse<90mmHg Instructor should note that Lopressor is a paramedic only medication
  • Hypotension = SBP<90mmHg
  • IM Thigh injections should not be a new concept, but the instructor should take time to be sure providers understand that this is the preferred location for epinephrine administration.
  • Epinephrine is not a new drug to the protocols. However, the IM administration site has changed (anterolateral thigh) and the option of IV epinephrine for extreme anaphylaxis (with OLMC consultation) has been added. Discussion of IV epinephrine should include a strong word of caution that this is considered the last resort in a critical patient (life threatening respiratory compromise or BP less than 100 mm Hg) and only should be administered after consultation with OLMC. Providers should note that the concentration for IV epinephrine for anaphylaxis is 1:10,000 and this route should only be used in the most dyer situations. Instructors should caution learners about the danger of medication errors (particularly concentration errors) surrounding the administration of IV epinephrine. Extreme caution should be taken to assure the correct concentration is administered.
  • Epinephrine is not a new drug to the protocols. However, the IM administration site has changed (anterolateral thigh) and the option of IV epinephrine for extreme anaphylaxis (with OLMC consultation) has been added. Discussion of IV epinephrine should include a strong word of caution that this is considered the last resort in a critical patient and only should be administered after consultation with OLMC. Providers should note that the concentration for IV epinephrine for anaphylaxis is 1:10,000 and this route should only be used in the most dyer situations.
  • Because EMT-B blood glucose monitoring is an optional protocol, specific learning objectives will be included in the designated EMT-B blood glucose monitoring education program.
  • This section should review the steps necessary for administering medications via the intranasal route. Instructors should note that the ET route has been removed as its efficacy has been proven questionable.
  • Instructors should emphasize the precautions about giving Narcan.
  • Instructors should emphasize the precautions about giving Narcan.
  • This section should review the steps necessary for administering medications via the intranasal route. Instructors should note that the ET route has been removed as its efficacy has been proven questionable.
  • This section should review the steps necessary for administering medications via the intranasal route. Instructors should note that the ET route has been removed as its efficacy has been proven questionable.
  • This section should review the steps necessary for administering medications via the intranasal route. Instructors should note that the ET route has been removed as its efficacy has been proven questionable.
  • This section should review the steps necessary for administering medications via the intranasal route. Instructors should note that the ET route has been removed as its efficacy has been proven questionable.
  • The changes identified in this section do not represent significant treatment alterations. Rather, they serve as important reminders for certain aspects of diabetic patient treatment that have thus far not been noted. Time elements were added to glucose re-checks to assure accuracy of the readings and a fluid challenge was added as it is the appropriate course of action for severely hyperglycemic patients (BG>300). Note that the “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.
  • Instructors should make students aware that Ativan is no longer included in the protocols. This change reflects the MDPB’s decision to utilize only one medication per class (one med. per category of use).
  • Instructors should make students aware that Ativan is no longer included in the protocols. This change reflects the MDPB’s decision to utilize only one medication per class (one med. per category of use).
  • The previous stroke checklist has been updated to reflect a neurologic assessment that will give providers a more accurate indication of the presence (or lack their of) of acute stroke. Instructors should note that this is simply an assessment tool and a lack of positive findings does not necessarily rule out stroke. On the other hand, positive findings do indicate a higher probability of stroke. Providers should be encouraged to follow the adult stroke protocol anytime stroke is suspected, regardless of the checklist findings.
  • Instructors should make students aware that Ativan is no longer included in the protocols. This change reflects the MDPB’s decision to utilize only one medication per class (one med. per category of use).
  • There are no real learning objectives in this section other than to remind providers that evidence of failed penetration of the chest wall during attempted chest decompression is becoming more and more common. Providers should be reminded that a 2 inch catheter is a minimum length. (Britten S; Palmer SH; Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure.) It should also be noted that there are viable alternate devices suitable for use in chest decompression.
  • There are no real learning objectives in this section other than to remind providers that evidence of failed penetration of the chest wall during attempted chest decompression is becoming more and more common. Providers should be reminded that a 2 inch catheter is a minimum length. (Britten S; Palmer SH; Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure.) Under ideal circumstances a catheter of 4” length is recommended for chest decompression. It should also be noted that there are viable alternate devices suitable for use in chest decompression.
  • The PHTLS curriculum has updated tourniquet use for at least a year and therefore many providers will already be familiar with these changes. However, the expectation is that all providers will be comfortable with the notion that tourniquets are now considered the next linear step in the event direct pressure fails to control bleeding. (see McSwain, et al. PHTLS . Mosby. 2003 and Campbell, J. International Trauma Life Support , Brady 2007).
  • The MDPB approved “contained hemostatic agents to assist in uncontrolled hemorrhage. In this case, contained means agents contained within a dressing, sponge or packet and not in a powder form. As with any product, manufacturer’s recommendations should be followed. Although there are other available contained hemostatic agents, Z-Medica Corporation (4 Fairfield Blvd., Wallingford, CT 06492, Tel: 203.294.0000, Website: www.z-medica.com) is an excellent source of specific product training information.  
  • Numerous studies have demonstrated that Trendelenburg position has little impact on hypovolemic patients. In fact, the change in position may even make respiration more difficult. Providers should be made aware of this change and instructed to concentrate on other aspects of trauma care in lieu of shock position. (See: CL Ostrow, et al. The Effect of Trendelenburg and Modified Trendelenburg Positions on Cardiac Output, Blood Pressure, and Oxygenation: a Preliminary Study . A.J. of Crit. Care. 3/5 382-386. Or Johnson S, Henderson SO. “Myth: The Trendelenburg position improves circulation in cases of shock.” Canadian Journal of Emergency Medicine . 2004;6(1):48-49.
  • This change does not represent necessarily new thinking, but rather defines an end point to fluid resuscitation in head injured shock patients.  
  • PHTLS/ITLS have also revised the criteria for aggressive fluid resuscitation. Providers should be clear that aggressive fluid resuscitation should only be considered in those patients with controlled bleeding. Patients with uncontrolled bleeding should be allowed “permissive hypotension” or a state of allowed, relative hypotension that allows the body opportunity to self control bleeding. Aggressive fluid resuscitation in patients with uncontrolled bleeding has been found to be counterproductive and my even make hemorrhage worse. (see McSwain, et al. PHTLS . Mosby. 2003 and Campbell, J. International Trauma Life Support , Brady 2007). When restoring normal vital signs with a fluid challenge (under controlled bleeding), normal vital signs are generally considered to be a pulse 100.
  • Instructors should also note in this section that the MDPB has allowed the introduction of pelvic binders to help treat hypovolemia secondary to acute, unstable pelvic fractures. OLMC should be consulted prior to application and services wishing to use such devices should follow manufacturer’s recommendations for training.
  • This change does not represent necessarily new thinking, but rather defines an end point to fluid resuscitation in head injured shock patients.  
  • The Fentanyl dose has increased and a maximum initial dose has been added. Instructors should note the change and caution learners that although the ceiling has been raised, caution should still be used when administering any narcotic. (See the Medication Fact Sheet for further detail).
  • Nitronox is not a change as it has been utilized in certain regions for years. That said the instructor should take time to review the pertinent information.
  • Nitronox is not a change as it has been utilized in certain regions for years. That said the instructor should take time to review the pertinent information. Nitronox is optional. Nitronox is meant as an option to Fentanyl
  • Nitronox is not a change as it has been utilized in certain regions for years. That said the instructor should take time to review the pertinent information. Nitrous oxide easily diffuses into air filled spaces in the body. As a result, extreme caution should be taken to avoid patients with potential pressure related problems such as pneumothorax or bowel obstruction.
  • The Fentanyl dose has increased and a maximum initial dose has been added. Instructors should note the change and caution learners that although the ceiling has been raised, caution should still be used when administering any narcotic. (See the Medication Fact Sheet for further detail).
  • Note: Although Ondansetron appears initially in the Pain Management Protocol, it also has been updated in the Nausea/Vomiting Protocol.
  • Zofran will replace Phenergan as the protocol anti-emetic. The instructor should take time to review the pertinent information for this medication as well.
  • Zofran will replace Phenergan as the protocol anti-emetic. The instructor should take time to review the pertinent information for this medication as well.
  • Zofran will replace Phenergan as the protocol anti-emetic. The instructor should take time to review the pertinent information for this medication as well.
  • There is no specific learning objective here as this treatment is fairly self explanatory and theoretically already consistent with the standard of care. Instructors should none the less emphasize its inclusion.
  • There is no specific learning objective in this section as these treatments are fairly self explanatory and theoretically already consistent with the standard of care. Instructors should none the less emphasize their inclusion.
  • These changes to the moderate hypothermia protocol are relatively minor. The temperature reference has been adjusted and in this case, certain protocol wording has been adjusted. Although this course is not intended to be a hypothermia treatment class, emphasis should be placed on active external warming in moderate hypothermia and medications are to be given only after the core temperature reaches 30° C in moderate to severe hypothermia patients.
  • These changes to the moderate hypothermia protocol are relatively minor. Again, the temperature reference has been adjusted and in this case, certain protocol wording has been adjusted. Although this course is not intended to be a hypothermia treatment class, emphasis should be placed on active external warming in moderate hypothermia and medications are to be given only after the core temperature reaches 30° C in moderate to severe hypothermia patients.
  • instructors should remind learners that there is no place for exercise in severe hypothermia patients.
  • These changes are mostly wording changes designed to better define the assessment and treatment of the Severe Hypothermia Patient with no signs of life. Emphasis should be placed on appropriate pulse check timing (30-45 seconds)
  • These changes are mostly wording changes designed to better define the assessment and treatment of the Severe Hypothermia Patient with no signs of life. Emphasis should be placed on appropriate pulse check timing (30-45 seconds)
  • Emphasize the guideline for termination of CPR when not in contact with OLMC (30 minutes).
  • There is no specific learning objective in this section as this treatment is fairly self explanatory and theoretically already consistent with the standard of care. Instructors should none the less emphasize the addition to this protocol and reinforce the need for continuous flush.
  • There is no specific learning objective in this section. Treatments listed here are either current standards of care or listed in other sections of existing protocols. Instructors should however emphasize safety and awareness of the new protocol.
  • There is no specific learning objective in this section. Treatments listed here are either current standards of care or listed in other sections of existing protocols. Instructors should however emphasize safety and awareness of the new protocol.
  • Although Midazolam exists in the current protocol, use in the combative patient is theoretically a new usage. Instructors should review the details of Midazolam per the medication fact sheet and note the difference in dose from the active seizure protocol.
  • Although Midazolam exists in the current protocol, use in the combative patient is theoretically a new usage. Instructors should review the details of Midazolam per the medication fact sheet and note the difference in dose from the active seizure protocol.
  • Although Midazolam exists in the current protocol, use in the combative patient is theoretically a new usage. Instructors should review the details of Midazolam per the medication fact sheet and note the difference in dose from the active seizure protocol.
  • Although Midazolam exists in the current protocol, use in the combative patient is theoretically a new usage. Instructors should review the details of Midazolam per the medication fact sheet and note the difference in dose from the active seizure protocol.
  • Although Midazolam exists in the current protocol, use in the combative patient is theoretically a new usage. Instructors should review the details of Midazolam per the medication fact sheet and note the difference in dose from the active seizure protocol.
  • Although Midazolam exists in the current protocol, use in the combative patient is theoretically a new usage. Instructors should review the details of Midazolam per the medication fact sheet and note the difference in dose from the active seizure protocol.
  • Note that there is a separate MEMS approved training program for the cyanokit treatment protocol.
  • The pediatric dose of Narcan has truly not changed, but rather been revised to include a weight based approach to dosing. (See Medication Fact Sheet for further detail). Providers should be made aware of this change.
  • Emphasis here should be on the decrease of the maximum dose of Versed (NTE 3mg IV or 5mg IM).
  • Emphasis here should be on the decrease of the maximum dose of Versed (NTE 3mg IV or 5mg IM).
  • This is not a significant change to the protocol. Rather, more detail has been added to assist the basic in assisting with patient self administration of inhaled medications
  • This is not a significant change to the protocol. Rather, more detail has been added to assist the basic in assisting with patient self administration of inhaled medications. Instructors should note the preference for nebulized medications in the presence of advanced providers
  • Note that Levalbuterol is not to be administered in patients<12 years
  • Note addition of Levalbuterol option in patients >12 years
  • Options d. and e. (Ipratropium Bromide) are limited to paramedics
  • Options d. and e. (Ipratropium Bromide) are limited to paramedics
  • Options d. and e. (Ipratropium Bromide) are limited to paramedics

2008 Maine EMS Protocol Revision Presentation Transcript

  • 1. 2008 Maine EMS Protocol Revision Provider Education April 10, 2008
  • 2. Purple Section
  • 3. 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.
  • 4. 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.”
  • 5. 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 (SaO 2 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)
  • 6. 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
  • 7. 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.
  • 8. Adult Intraosseous Access
    • Approved Sites (one per bone):
      • Anterior/medial Tibia
      • Proximal Lateral Humerus
  • 9. Brown Section
  • 10. 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.
  • 11. Carbon Monoxide Monitors Approved
    • Non-invasive CO monitoring devices are approved
  • 12. 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.
  • 13. 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.
  • 14. Home Health Care Devices and Appliances
    • Many patients will, have devices and appliances (drains, ports, etc.). with which they are routinely discharged home.
  • 15. Home Health Care Devices and Appliances
    • Patients (or their licensed care providers, or previously instructed family members), are expected to maintain them on their own .
  • 16. Home Health Care Devices and Appliances
    • 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.
  • 17. Home Health Care Devices and Appliances
    • Unfamiliarity with, or any questions concerning these devices that cannot be immediately resolved by the patient or caregivers, should be referred to OLMC.
  • 18. 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).
  • 19. Left Ventricular Assist Device (LVAD)
    • 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.
  • 20. Left Ventricular Assist Device (LVAD)
    • Direct contact with the cardiac service responsible for this patient is also suggested at the earliest possible moment.
  • 21. Left Ventricular Assist Device (LVAD)
    • 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.
  • 22. Left Ventricular Assist Device (LVAD)
    • Be sure to bring the patient’s batteries (including the 24 hour battery) and the large battery charger.
  • 23. Left Ventricular Assist Device (LVAD)
    • 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.
  • 24. Taser Probes
    • The use of a TASER does not automatically necessitate an EMS response or involvement.
  • 25. 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.
  • 26. 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.
  • 27. Taser Probes
    • Other adverse affects, if any, (e.g. respiratory difficulty, seizures, etc.) should be treated as appropriate by the applicable protocol(s).
  • 28. “ Rescue” or “Alternate” Airway Devices
    • MEMS has divided “rescue” or “alternate” airway devices into 2 major classes:
      • Periglottic devices
      • Transglottic devices
  • 29. Periglottic Devices
        • E.g. LMA  , Cobra PLA 
        • Do not have a risk of obstructing the trachea.
  • 30. 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.
  • 31. “ Rescue” or “Alternate” Airway Devices
    • 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.
  • 32. “ Rescue” or “Alternate” Airway Devices
    • If an agency selects a transglottic / potentially transglottic device, end-tidal CO 2 , either colorimetric or continuous (waveform or capnometric) must be used to confirm placement.
  • 33. “ Rescue” or “Alternate” Airway Devices
    • There are periglottic devices on the market that can be used to facilitate endotracheal intubation
      • ILMA  , IMA  .
  • 34. “ Rescue” or “Alternate” Airway Devices
      • 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.
  • 35. “ Rescue” or “Alternate” Airway Devices
    • 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.
  • 36. Blue Section
  • 37.  
  • 38. Airway Confirmation
    • Transglottic or potentially transglottic airway device placement must be confirmed with end-tidal CO 2 , either colorimetric or continuous (waveform or capnometric) device.
    • For pediatrics, continuous wave form capnography is required.
  • 39. Auscultate to assist confirmation
    • Confirm ET placement with absence of sounds over the epigastrium first and presence of bilateral symmetric breath sounds second.
    1. Epigastrum 2. Apices and bases 1
  • 40. 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
  • 41.  
  • 42.  
  • 43. Orogastric Tubes
    • Indications:
      • To perform gastric decompression in patients >2 years after endotracheal intubation has been performed and placement verified.
  • 44. Orogastric Tubes
    • Contraindications:
      • Suspected basilar skull fracture
      • Facial Trauma with suspected fractures or penetrating neck trauma
      • Known esophageal varices
      • Known ingestion of caustic substances
  • 45. Orogastric Tubes
    • Complications:
      • Tracheal Insertion
      • Coiling of tube in the posterior hypopharynx
  • 46. 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.
  • 47. Orogastric Tubes
    • Procedure:
      • Determine correct size:
        • Pediatric Size: Refer to length based resuscitation tape
        • Adult Size: 16 french
      • Restrain the patient, as necessary.
  • 48. 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.
  • 49. 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.
  • 50. 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.
  • 51. 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.
  • 52. Orogastric Tubes
    • If tube is not placed properly:
      • Remove immediately.
      • Reinsert following the same procedure.
    • ** Do not attempt insertion more than three (3) times.
  • 53. Orogastric Tubes
    • If tube is properly placed:
      • Tape in place or apply a tube holder.
      • Leave tube open to allow passive decompression
  • 54. 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.
  • 55. Bronchospasm
    • CRITICAL CARE/PARAMEDIC
    • 8. Adult/Pediatric—
    • a. Albuterol 2.5 mg by nebulization. May repeat 1 time ; or Levalbuterol 1.25 mg nebulizer if > 12 years of age; or
    • b. 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
  • 56. www.epocrates.com
  • 57. 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
  • 58. 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
  • 59. 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
  • 60. Levalbuterol (Xopenex®)
    • Dose:
      • Adults and adolescents >12 years old 1.25 mg nebulizer or if >4 years- Levalbuterol tartrate inhaler 5 puffs with spacer.
  • 61. 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…
  • 62. 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.
  • 63.
    • Note:
    • Ipratropium Bromide and Albuterol is available and allowed to be carried in two forms.
      • Duo-Neb® 3 ml nebulized solution
      • and
      • Combivent® inhalers.
  • 64. www.epocrates.com
  • 65. Ipratropium Bromide and Albuterol Sulfate (Duo-Neb®)
    • Classification: Anticholinergic and sympathomimetic bronchodilator
    • Mechanism of Action: Antagonism of cholinergic receptors
  • 66. Ipratropium Bromide and Albuterol Sulfate (Duo-Neb®)
    • MEMS Use: Treatment of bronchospasm as an option to Albuterol Sulfate
    • How Supplied: 3 ml solution for nebulization
  • 67. Ipratropium Bromide and Albuterol Sulfate (Duo-Neb®)
    • 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
  • 68. Ipratropium Bromide and Albuterol Sulfate (Duo-Neb®)
    • Dose:
      • Pt’s > 1 year of age- 3 mg nebulizer. May repeat one time if more significant respiratory distress
  • 69. www.epocrates.com
  • 70. Ipratropium Bromide and Albuterol Sulfate (Combivent®)
    • Classification: Anticholinergic and sympathomimetic bronchodilator
    • Mechanism of Action: Antagonism of cholinergic receptors
  • 71. Ipratropium Bromide and Albuterol Sulfate (Combivent®)
    • 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)
  • 72. Ipratropium Bromide and Albuterol Sulfate (Combivent®)
    • 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
  • 73. Ipratropium Bromide and Albuterol Sulfate (Combivent®)
    • Dose:
      • Pt’s > 1 year of age- Inhaler 2 puffs. May repeat one time in those with more significant respiratory distress
  • 74. 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.
  • 75. Acute Pulmonary Edema
    • 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.
  • 76. Acute Pulmonary Edema
    • Intermediate
    • 8. Consider use of CPAP (Note: CPAP use is limited to those providers who have completed the MEMS CPAP training program).
  • 77. Acute Pulmonary Edema
    • Critical Care/Paramedic
    • 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.
  • 78. Acute Pulmonary Edema
    • Critical Care/Paramedic
    • Consider use of CPAP (Note: CPAP use is limited to those providers who have completed the MEMS CPAP training program).
    • 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
  • 79. www.epocrates.com
  • 80. 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)
  • 81. 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
  • 82. Red Section
  • 83. Chest Pain
    • BASIC
    • 4. 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
  • 84. Chest Pain
    • INTERMEDIATE
    • 7.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.
  • 85. Chest Pain
    • CRITICAL CARE / PARAMEDIC
    • 10. Obtain 12 lead EKG
    • 12. Chewable aspirin, 324 mg PO
    • 13. Contact OLMC for OPTIONS:
    • b. Additional nitroglycerin.
    • c. Fentanyl 1 microgram/kg IV or IM to a maximum dose of 100 micrograms.
  • 86. 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.
  • 87. GUIDELINES TO THE PREHOSPITAL USE OF 12-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.
  • 88. GUIDELINES TO THE PREHOSPITAL USE OF 12-LEAD EKG BY THE ALS PROVIDER
    • 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.
  • 89. GUIDELINES TO THE PREHOSPITAL USE OF 12-LEAD EKG BY THE ALS PROVIDER
    • 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.
  • 90. 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
  • 91. V-Fib/Pulseless V-Tach Algorithm
    • Adopt current ACLS standards
      • One shock vs. “stacked shocks”
    • Replace Lidocaine with Amiodarone
  • 92. V-Fib/Pulseless V-Tach Algorithm
    • Basic
    • 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
  • 93. V-Fib/Pulseless V-Tach Algorithm
    • Intermediate
    • 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
  • 94. V-Fib/Pulseless V-Tach Algorithm
    • Critical 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
  • 95. V-Fib/Pulseless V-Tach Algorithm
    • Critical 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
  • 96. V-Fib/Pulseless V-Tach Algorithm
    • Critical 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 2 nd degree Type II AV block of 3 rd 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
  • 97. www.epocrates.com
  • 98. 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.
  • 99. Amiodarone Hydrochloride (Cordarone®)
    • MEMS Use: Anti-ventricular dysrhythmic for use in V-Fib/V-Tach cardiac arrest, wide complex tachycardia and symptomatic premature ventricular contractions
  • 100. Amiodarone Hydrochloride (Cordarone®)
    • 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
  • 101. Amiodarone Hydrochloride (Cordarone®)
    • 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.
  • 102. Amiodarone Hydrochloride (Cordarone®)
    • 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.
  • 103. Amiodarone Hydrochloride (Cordarone®)
    • 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.
  • 104. 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
  • 105. 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.
  • 106. Narrow Complex Tachycardia
    • Chart added to better align MEMS with current AHA standards.
      • Note: this algorithm replaces the former “Supraventricular Tachycardia Protocol).
  • 107. 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
  • 108. Metoprolol Tartrate (Lopressor®)
  • 109. 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.
  • 110. Metoprolol Tartrate (Lopressor®)
    • MEMS Use: Rate control for narrow complex tachycardia (A-Fib/A-Flutter) or as a treatment option for symptomatic premature ventricular contractions.
  • 111. Metoprolol Tartrate (Lopressor®)
    • 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
  • 112. Metoprolol Tartrate (Lopressor®)
    • 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!
  • 113. 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.
  • 114. Premature Ventricular Ectopy (PVC’s)
    • 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).
  • 115. Premature Ventricular Ectopy (PVC’s)
    • 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!
  • 116. Premature Ventricular Ectopy (PVC’s)
    • 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.
  • 117. Premature Ventricular Ectopy (PVC’s)
    • 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.
  • 118. Gold Section
  • 119. Allergy/Anaphylaxis
    • Addition of anteriolateral thigh as primary injection site for IM epinephrine
    • Addition of IV epinephrine for severe reaction.
  • 120. Anteriolateral Injection
    • Intramuscular injection
    • Anteriolateral thigh midway between waist and knee
  • 121. 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.
  • 122. 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.
  • 123. Adult Coma
    • Basic
    • 4. 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.
  • 124. Adult Coma
    • Intermediate
    • 9B. Naloxone (Narcan) 0.1-2 mg IV, IO, IM or Intranasal ( may opt to give 2mg as starting dose if using intranasal route )
  • 125. 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
  • 126. 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)
  • 127. Intranasal Administration Route
    • Advantages:
    • Needleless system
    • Rapid absorbtion
    • Easy administration
  • 128. 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
  • 129. Intranasal Medication Administration
    • Equipment
    • Small syringe
    • Atomizing device (prefferred)
  • 130. Intranasal Medication Administration
    • 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.
  • 131. Adult Diabetic Emergencies
    • Intermediate
    • 7A. 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.
  • 132. 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.
  • 133. 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.
  • 134. 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.
  • 135. Stroke Checklist
    • A new stroke checklist has been added to the protocol
      • Standardizes a diagnostic approach to a national benchmark
  • 136. Stroke Checklist
    • Check 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 stroke
    • Three new positive findings with abrupt onset = 85% chance of acute stroke
  • 137. Green Section
  • 138. Tension Pneumothorax
    • Language change to assure appropriate length of catheter and note approval for “alternate devices”
  • 139. 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.”
  • 140. Hemorhage Control/Amputations
    • Previous Amputation protocol now changed to “Hemorrhage”
    • Tourniquet use added/encouraged if direct pressure fails
    • Contained Hemostatic Agent (dressings/sponges) added.
  • 141. Hemorhage Control/Amputations
    • 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
  • 142. Hemorhage Control/Amputations
    • 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.
  • 143. Hemorhage Control/Amputations
    • 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
  • 144. “ Contained Hemostatic Agent Z-Medica Corporation 4 Fairfield Blvd., Wallingford, CT 06492, Tel: 203.294.0000, Website: www.z-medica.com
  • 145. 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)
  • 146. 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:
  • 147. 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
  • 148. 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
  • 149. 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.
  • 150. Pain Management
    • Changes:
    • Fentanyl dose change
    • Inclusion of 50% nitrous oxide/oxygen
    • Ondanzetron to replace Promethazine (Phenergan®).
  • 151. 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).
  • 152. 50% Nitrous Oxide (Nitronox®)
  • 153. 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
  • 154. 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
  • 155. 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.
  • 156. 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.
  • 157. 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
  • 158. Ondansetron Hydrochloride (Zofran®)
    • Contraindications: None
    • Precautions: Safety and effectiveness in children <3 is unknown
    • Side Effects: May cause tachycardia, hypotension
  • 159. Ondansetron Hydrochloride (Zofran®)
    • 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.
  • 160. Yellow Section
  • 161. Antidotes for Specific Toxins-Cyclic Antidepressants
    • Intermediate/Critical Care/Paramedic
    • IV Fluid bolus if hypotensive
  • 162. 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.”
  • 163. 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
  • 164. 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
  • 165. Severe Hypothermia (Treatment)
    • Basic
    • Do not attempt to increase heat production with any exercise.
  • 166. Severe Hypothermia With No Signs Of Life
    • Assessment:
    • Check for pulse and respirations for 30 to 45 seconds.
  • 167. Severe Hypothermia With No Signs Of Life
    • 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).
  • 168. Severe Hypothermia With No Signs Of Life
    • Assessment:
    •   If contact with OLMC is not possible, consider termination of resuscitative efforts after 30 minutes and contact OLMC as soon as possible.
  • 169. Eye Pain from Chemical Exposure
    • Basic/Intermediate
    • Flush eye with sterile saline or clean water source continuously
  • 170. 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.
  • 171. New Section-Combative Patient
    • 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.
  • 172. New Section-Combative Patient
    • 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.
  • 173. New Section-Combative Patient
    • Critical Care/Paramedic
    • Contact OLMC for OPTION of Midazolam 4 mg IM for patient safety and comfort. Contact OLMC if dosing adjustment needed.
  • 174. 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
  • 175. Midazolam (Versed®)
    • 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
  • 176. Midazolam (Versed®)
    • 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.
  • 177. Midazolam (Versed®)
    • 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
  • 178. Known or Suspected Cyanide Exposure
    • Change:
    • Cyanide exposure algorithm has been added
    • Cyanokit antidote has been approved
  • 179. Pink Section
  • 180. 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)
  • 181. 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.
  • 182. 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.
  • 183. 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
  • 184. Pediatric Respiratory Distress
    • 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
  • 185. Pediatric Respiratory Distress
    • Intermediate
    • 3. 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.
  • 186. Pediatric Respiratory Distress
    • Critical Care/Paramedic
      • a. 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
    • or
      • c. 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
  • 187. Pediatric Respiratory Distress
    • 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
  • 188. Pediatric Respiratory Distress
    • Paramedic Only (d and 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.
  • 189. Pediatric Cardiac Arrest Dosages
    • Note that although Lidocaine is still listed in this chart, it has been removed from the protocol
  • 190. Questions?