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Patient Care Protocols (Blue Book) and EMS Update 2007 Seattle—King County.

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Presentation on theme: "Patient Care Protocols (Blue Book) and EMS Update 2007 Seattle—King County."— Presentation transcript:

1 Patient Care Protocols (Blue Book) and EMS Update 2007 Seattle—King County

2 Seattle—King County EMS Introduction Indicates a change or update from the 2005 blue book (NOT necessarily a change or update to current protocols).

3 Seattle—King County EMS Alerts & After—Care Instructions EMTs will leave alerts or after—care instructions as indicated for the following patients: High blood pressure High blood sugar Low blood sugar You must document that an alert or after— care instruction was provided and verify the patient's home phone number. Page 63

4 Seattle—King County EMS Alerts & After—Care Instructions Inclusion Page 63 Diabetic with sugar ≥ 300 Non diabetic with sugar ≥ 175 Paramedic transported patient Nursing home patients Use judgment with trauma patients Exclusion Optional

5 Seattle—King County EMS Alerts & After—Care Instructions Inclusion Page 63 Any patient with a systolic ≥ 160 mmHg or diastolic ≥ 100 mmHg Paramedic transported patient Nursing home patients Use judgment with trauma patients Exclusion Optional

6 Seattle—King County EMS Alerts & After—Care Instructions Inclusion Page 63 Diabetic on insulin who responds fully to oral glucose and who is stable enough to remain at home Paramedic or EMT transported patient Exclusion

7 Seattle—King County EMS Personal Protective Equipment (PPE) Pages 104—105 Hand washing is the most effective way to prevent transmission of infectious disease. Wash hands: After patient contact Before eating, drinking, smoking, or handling food Before and after using the bathroom After cleaning or checking equipment

8 Seattle—King County EMS PPE, continued Pages 104—105 Gloves and eye protection should be worn for every patient. Gloves Eye protection (such as glasses, face shields and goggles) Fit-tested masks (such as N95 and N100 masks) Gowns (or suits) FULL PPE for possible infectious contacts:

9 Seattle—King County EMS PPE, continued Pages 104—105 Put on PPE before entering the patient area. The sequence for donning PPE is MEGG: 1.Mask 2.Eye protection 3.Gown 4.Gloves Mask patient if possible.

10 Seattle—King County EMS PPE, continued Pages 104—105 The sequence for doffing PPE is: 1.Gloves 2.Gown—hand washing min 20 sec. 3.Eye protection 4.Mask—hand washing min 20 sec. Handle equipment as contaminated waste. Decontaminate eye protection.

11 Seattle—King County EMS PPE, continued Pages 104—105 Febrile Respiratory Illness Dispatchers will notify units of infectious symptoms or locations. Dispatch info or fever w/ cough or illness or possible infectious disease Full PPE required. Limit patient contacts. Full PPE required. Limit patient contacts.

12 Seattle—King County EMS PPE, continued Pages 104—105 After patient contact: Remove PPE –- (approved sequence). Dispose of PPE as contaminated waste. On-scene decontamination: eye protection & equipment w/ germicidal cleaner. Hospital decontamination: eye protection, equipment and apparatus.

13 Seattle—King County EMS PPE, continued Pages 104—105 At station: Decontaminate affected equipment & contacts (kits, BP/steth, radios, clipboards, etc.). Wash hands before leaving apparatus floor.

14 Seattle—King County EMS Taser Dart Removal and Care See pages of the Blue Book (PCP) for a detailed description of Taser darts, Taser removal, EMS care and transport policies for all patients. Pages 126—127

15 Seattle—King County EMS All EMTs are now encouraged to incorporate the SICK/NOT SICK approach into patient assessment PCP provides a brief overview of SICK/NOT SICK Sick/Not Sick Pages 10—17

16 Seattle—King County EMS ALS Indicators PCP now has a two-page summary of all ALS Indicators — conditions that require a medic response Specific ALS indicators for some conditions have been changed and are listed under each condition below Pages 59-60

17 Seattle—King County EMS Cardiac Arrest For initial analyis After delivering one shock, immediately begin 2 minutes of CPR If no shock indicated, immediately begin 2 minutes of CPR After 2 minutes of CPR, reanalyze the rhythm If a shock is indicated, immediately deliver a single shock If no shock is indicated, immediately check pulse. If no pulse, then begin 2 minutes of CPR Pages 22—23

18 Seattle—King County EMS Anaphylaxis BLS Care Page 9 Any patient who receives an EpiPen (pre– or post—EMS arrival) should be transported and evaluated in a hospital. Mode of transport depends on clinical symptoms and findings. Any patient who receives an EpiPen (pre– or post—EMS arrival) should be transported and evaluated in a hospital. Mode of transport depends on clinical symptoms and findings.

19 Seattle—King County EMS Page 75 Epinephrine (EpiPen) EMTS may deliver epinephrine via an EpiPen injector for ANY case of suspected anaphylaxis (respiratory distress and/or hypotension must be present.

20 Seattle—King County EMS Page 75 EpiPen, continued Seattle EMTs Patient (any age) has a history of same and a prescription for epinephrine Patient is less than 18 years of age with no prescription but permission is obtained from parent or legal guardian. This may be written or oral.

21 Seattle—King County EMS King County EMTs There are no requirements for: Page 75 EpiPen, continued Age Having a prescription Written/oral permission (beyond standard consent)

22 Seattle—King County EMS Dosages Page 75 EpiPen, continued Adults and children over 30 kg or 66 lbs: EpiPen (0.3 mg) Child under 30 kg or 66 lbs.: EpiPen, Jr. (0.15 mg)

23 Seattle—King County EMS Blood glucometry is within EMT scope of practice EMTs must complete initial training in glucometry before applying this skill (see EMS Online) Optional protocol for individual EMS agencies Glucometry Pages 26—27

24 Seattle—King County EMS Pulse oximetry is within the scope of practice for EMTs EMTs must have initial training in pulse oximetry before applying this skill (see EMS Online) Optional to EMS agencies Pages 28—29 Pulse Oximetry

25 Seattle—King County EMS New section to provide more guidance on bloodborne exposures Definition of reportable exposure General steps to take following an exposure Page 30 Reportable Exposures

26 Seattle—King County EMS New ALS indicators Hypoglycemia with decreased LOC Drug or alcohol related seizures Other Changes Defined time period of 15 minutes or more in postictal period vs. “not regaining consciousness between seizures” Signs and symptoms of shock vs. “hypotension” Page 32 Altered Level of Consciousness

27 Seattle—King County EMS New ALS indicator for asthma Sustained tachycardia (persistent heart rate of or greater per minute depending on clinical setting) Page 35 Asthma

28 Seattle—King County EMS New section to give EMTs more guidance on assessment and treatment of burn injuries Page 38 Burns

29 Seattle—King County EMS ALS Indicators in this section have changed significantly including Use of nitroglycerin Signs and symptoms of shock such as poor skin signs Sustained tachycardia and hypotension ALS Indicators now emphasize Discomfort or unusual sensations for those 40 years old or greater or with a history of heart problems New Special Instructions section has been added that directs EMTs to be aware of atypical findings seen in the elderly, women and diabetics Pages 39—40 Chest Discomfort

30 Seattle—King County EMS Hypothermia cardiac arrest protocol has been eliminated Follow standard cardiac protocols for hypothermic cardiac arrest Page 44 Cold-Related

31 Seattle—King County EMS Added ALS indicator Unable to lie flat Page 46 Congestive Heart Failure

32 Seattle—King County EMS ALS Indicator added Sustained tachycardia Revised BLS indicator Gag reflex intact, as indicated by swallow Check gag reflex by asking patient if he or she can swallow DO NOT check a gag reflex by putting a tongue depresser against the back of the throat Page 48 Diabetic

33 Seattle—King County EMS New variation in BLS care If hypoglycemic and patient is unable to swallow, position on side, give oxygen, ventilation and await paramedics Revision of instructions for leaving patient at the scene Patients with hypoglycemia who have responded to oral glucose may be left at scene (see page 27). These patients must have a repeat glucose level documented and after-care instructions must be left with the patient. Page 49 Diabetic, continued

34 Seattle—King County EMS Revised BLS care for SCUBA-related injury Position patient flat (supine) to avoid cerebral edema Former treatment “Position patient on left side with head and chest lower than feet to prevent air bubbles from moving to lungs, heart and brain (heart down, head down).” Page 52 Drowning (Scuba Diving)

35 Seattle—King County EMS ALS Indicators added Sustained tachycardia (persistent heart rate or greater per minute depending on clinical setting) Possible ectopic pregnancy Page 52 Gynecologic

36 Seattle—King County EMS Revised care for suspected c-spine injury when wearing a helmet As long as the airway is not affected and remains patent AND the c-spine can be secured in an neutral, in-line position, leave football and motorcycle helmets on All other non-fitted helmets may be removed as soon as possible (e.g., bicycle helmets, skateboard helmets, rollerblade helmets) Page 57 Head and Neck

37 Seattle—King County EMS ALS Indicator added Sustained tachycardia Page 58 Heat - Related

38 Seattle—King County EMS New ALS indicators Open fractures except for hands and feet High index of suspicion based on MOI Contact medics for severe pain Refined realignment of long-bone fractures Long-bone fractures, which occur in the proximal or distal 1/3, that may or may not involve a joint, may be realigned if compromise of distal circulation or nerve function is detected and definitive care is delayed. New BLS care for pelvic fractures - “sheet splinting” Pages 65—67 Orthopedic

39 Seattle—King County EMS ALS Indicator added Sustained tachycardia Page 70 Respiratory

40 Seattle—King County EMS ALS Indicators added Multiple seizures (status seizures) Drug and alcohol associated seizures Defined a time frame for the postictal period of greater than 15 minutes Page 72 Seizures

41 Seattle—King County EMS Revised conditions for assisting with nitrogylcerin The patient should not have taken Viagra or Levitra within the past 24 hour or Cialis within the past 48 hours Page 83 Admin of Meds (Nitro)

42 Seattle—King County EMS FATS technique is now referred to as the One EMT Technique Page 92 Bag—Valve Mask

43 Seattle—King County EMS Revised BLS Care Cover eviscerated abdominal contents with a large multi-trauma dressing soaked with sterile saline. Then apply an occlusive dressing, if available, to retain heat and moisture. Former PCP directed EMTs to not moisten the dressing. Pages 96—97 Dressing and Bandaging

44 Seattle—King County EMS Two approved methods only: Firm earlobe pressure (Figure 1) Firm pressure behind earlobe (Figure 2) Page 91 Noxious Stimuli Figure 1 Figure 2

45 Seattle—King County EMS For King County COPD patients (non-Seattle FD) EMTs have the option of using a non-rebreathing mask if a nasal cannual at 4 L/min is inadequate Page 106 Oxygen Delivery

46 Seattle—King County EMS Change in technique One arm secured high above the head and the other low at the patient’s side and both secured to the backboard or stretcher Pages 113—114 Patient Restraint

47 Seattle—King County EMS Added contraindication Patient with suspected cardiac chest pain Check vital signs in two positions only: supine or sitting and standing (formerly 3: supine, sitting and standing) Positive findings have been redefined as follows: Increase in pulse of 20/minute or more and/or a 20 mmHg or more drop in systolic BP from supine to standing with associated symptoms OLD: “Decrease in systolic BP of 30 mm/Hg or more from supine to sitting or standing. Systolic BP of less than 90 mm/Hg in sitting or standing position.” Pages 115—116 Postural Vital Signs

48 Seattle—King County EMS Questions Dr. Mickey Eisenberg Medical Director Ask the Doc: EMS Online Guidelines and Standing Orders Mike Helbock, M.I.C.P., NREMT-P Training Division Manager support:


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