1. Boulder County Protocol Updates 2015 Revision

2. General Changes Formatting  Certification levels  Flow chart appearance of treatment protocols  New numbering system Chapter 2 changes and scope of practice  CPAP for EMTs  Cricothyrotomy no long requires a waiver Careful! Does mandate specific training and MD approval  More throughout the document

3. General Changes Certification Levels  Designated by color and box Teaching points  Those deemed sufficiently important to be included in the protocol are separated into grey- filled boxes with a double line border: EMT-I Paramedic FR/EMR OEC EMT EMT-IV

4. General Changes Alogrithmic Format

5. General Changes New Numbering System  0001 General Guidelines  0100 Procedures  1000 – 6000: Protocols 1000 – General Principles 2000 – ACS 3000 – 4000: Medical, Environment, OD/Poisoning and OB 5000 – Trauma 6000 – Pediatrics  7000 Medication

6. Changes in Specific Protocols Old Protocol Syncope Epistaxis Spinal injury and immobilization Spinal Injury with athletic equipment present Change Now “Hypotension/altered mental status” Look under “procedures”

7. Changes in Specific Protocols Old Protocol Pediatric dyspnea Pedi allergy/anaphylaxis, altered mental status, dehydration, hypo- and hyper-glycemia Change Replaced with “Pediatric universal respiratory distress” All redundant – see adult versions

8. Changes in Specific Protocols Old Protocol General respiratory distress Antabuse and withdrawal Vaginal bleeding Hyperglycemia, HHNK/C HELLP and PIH Lightning Strikes/electrical burns Change “Gen. principles of airway mgmt” “Alcohol intoxication” “Medical hypotension/shock” “Altered mental status” “Obstetrical complications” General trauma care/ burns

9. New Protocols 4061 – Adrenal Insufficiency 5002 – General Trauma Care 5040 – Face and Neck Trauma 6025 – Neonatal Resusciation

10. Old Protocol You contacted the ‘base hospital’ New protocol You contact the ‘receiving hospital’

11. Boulder County’s airway protocol…

15. 2000 – Cardiac No changes

16. 3000 – Respiratory

17. 3050 CHF/Pulmonary Edema

18. 4000 – Medical (includes OB)

19. 4013 – Adult Seizure Old Protocol “Valium” “Ativan” “Versed” New protocol All names replaced with “benzodiazepine” Allows for manufacturer drug shortages when a specific benzo is on backorder

20. 4013 – Adult Seizure

21. 4015 – Alcohol Intoxication Old Protocol Protocol for antabuse reaction Protocol for withdrawal New protocol Both protocols have been removed

22. 4020 – Allergy/Anaphylaxis Denver Denver Metro does not place a systolic BP number as a trigger for administering an epi drip Boulder County Boulder County requires a systolic BP of 70 or less prior to initiating an epi drip

23. 4030 – Abdominal Pain and Vomiting Old Protocol EMTs could not give an anti- emetic New protocol EMTs can now give Ondensatron (Zofran) ODT PO Requires verbal order

24. 4030 – Abdominal Pain and Vomiting

25. 7010 - Antiemetics

26. 4040 – Overdose/Poisoning New protocol Calcium Chloride and Pralidoxime added as antidotes

27. 4054 – Hyperthermia New protocol Benzos added for shivering, seizures, and tremors

28. 4060 – Medical Hypotension and Shock Old Protocol CHF with low BP used to be in the “respiratory section” “Syncope” had its own protocol New protocol It now lives here instead This protocol replaces the old “syncope” protocol Position statement on lactate measuring Addition of renal insufficiency protocol

29. 4060 – Medical Hypotension and Shock

30. 4061 – Adrenal Insufficiency New protocol to the county since the 2013 revision Addresses the need for timely steroid administration during life-threatening Addisonian Crisis Paramedics may administer methylprednisolone from their kit, if criteria are met EMTs may administer the patient’s prescribed steroids WITHOUT CALLING IN FOR A VERBAL ORDER in adrenal crisis

31. 4061 Adrenal Insufficiency

33. 4070 – Psychiatric/behavioral Mental health (M1, or “72 hour” or “psych”) holds, can now only be initiated by verbal order from the receiving hospital

34. 4070 – Psychiatric/behavioral

35. 4076 – Handcuffed patients Newly added protocol that addresses the safety of the EMS provider when transporting a handcuffed patient

37. 4080 - Childbirth Change to the protocol regarding the suctioning of the neonatal airway Now reflects current neonatal resuscitation guidelines It is not always necessary to suction the neonatal airway

38. Old ProtocolNew protocol

39. 4081 – OB Complications Originally, prolapsed cord = “knee to chest position” for mom We added two alternative positions

40. Old ProtocolNew protocol

41. 5000 - Trauma

42. 5002 – General Trauma Care Completely new to the Boulder County Protocols Consolidates the key points from a number of other trauma protocols which have been taken out

43. 5002 – General Trauma Care

45. 5010 – Trauma Arrest Old ProtocolNew protocol New trauma arrest protocol is streamlined into a flowchart

46. 5040 – Face and Neck trauma New protocol for 2015 We just didn’t have one until now

47. 5040 – Face and Neck trauma

49. 5090 - Burns Old – no fluid recommendations New – fluid guidelines

50. 6000 - Pediatrics General guidelines are new Specific considerations are also new

51. 6000 – General Guidelines

52. 6000 – Specific Considerations

53. 6005 Pediatric seizure Now recommends calling receiving facility if the third round of benzodiazepines fails to break the seizure activity

54. 6010- Pediatric cardiac arrest Old Go straight to pacing in symptomatic bradycardia Pediatric bradycardias often respond well to O2 and epi New Pacing still listed, but subsequent to O2/BVM and epi Added emphasis on BVM for patients <8 years old Added pedi King airway if authorized by medical director

55. 6010- Pediatric cardiac arrest Old New

56. 6010 – Pediatric Cardiac Arrest

57. Neonates Boulder County has no dedicated neonatal protocols We have added a neonatal resuscitation protocol (6025) and general principles (6026) for the 2015 revision

58. 6025 – Neonatal Resuscitation

60. 6040 Special Needs Children Providers at all levels can administer prescribed medications to the patient so long as the access route (e.g. oral, IV, etc) is within their scope of practice Providers must receive a verbal order to administer these prescription medications Providers do NOT have to receive a verbal order to administer prescription steroids in situations of adrenal (Addisonian) crisis

61. 6040 Special Needs Children The use of central venous (CV) lines by EMS personnel is now discouraged under the 2015 protocol If the EMS provider believes that use of a CV line is necessary during an emergency, they must call in to the receiving hospital prior to doing so

62. 6040 Special Needs Children

64. 6050 – Pedi Universal Respiratory Distress Replaces the 2013 pediatric dyspnea protocol Adds consideration of methylprednisolone for the pediatric patient suffering from croup Per Chapter 2, EMTs can now administer nebulized albuterol (non-prescription) with a VO from the receiving hospital

65. 6050 – Pedi Universal Respiratory Distress

66. 6060 - Alte ALTE is a new protocol to Boulder County It mirrors the Denver Metro ALTE protocol Useful guideline when we are called to a disturbing occurrence in a pediatric patient who now presents without apparent complaint

67. 6060 - Alte

69. 6070 – Pediatric Trauma General guidance for the injured pediatric patient Significant emphasis on spinal stabilization

70. 6070 – Pediatric Trauma

72. 7000 - Medications Medications allowed for EMT-IV by Chapter 2RouteMedical Control ASA – AspirinOralStanding Order DextroseIVStanding Order Epi Pen – auto injectIMStanding Order Naloxone (Narcan)IN/IVStanding Order OxygenINStanding Order Albuterol (NO Atrovent – Ipratroprium)NebulizerVerbal Order Bronchodilator MDI (pt assist)MDIVerbal Order Nitroglycerine (pt assist)OralVerbal Order Ondansetron (Zofran)ODTVerbal Order Specialized Meds to address acute crisesWithin scopeVerbal Order* Exception is adrenal crises

73. Albuterol

74. Amiodarone

75. Aspirin Old New

76. Benzodiazepines

77. Calcium Gluconate - NEW

79. Ipratropium Old Protocol New Protocol

80. Naloxone Old: New:

81. Oxygen Old New

82. Sodium Bicarbonate Formerly, there were no contraindications… Now…

83. Topical Opthalmic Anesthetics Now specifies the only two acceptable drug choices

84. Questions?