PROTOCOL UPDATE ALABAMA EMS PROTOCOLS PARAMEDIC EDITION 5 JUNE, 2010 UPDATE 1

PROTOCOL UPDATE IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES IF YOU IDENTIFY MISTAKES IN THE PROTOCOLS OR IF YOU HAVE SUGGESTIONS FOR PROTOCOL CHANGES 2

PURPOSE OF PROTOCOLS IMPROVE PATIENT CARE IMPROVE PATIENT CARE PROVIDE OFF-LINE MEDICAL DIRECTION PROVIDE OFF-LINE MEDICAL DIRECTION REPRESENT STANDARD OF CARE REPRESENT STANDARD OF CARE PROVIDE QI STANDARDS PROVIDE QI STANDARDS PROVIDE EDUCATION STANDARDS PROVIDE EDUCATION STANDARDS 3

TITLE PAGE & TABLE OF CONTENTS TABLE OF CONTENTS UPDATED WITH CHANGES TABLE OF CONTENTS UPDATED WITH CHANGES –Added two new Patient Care Protocols 4.26 Respiratory Illness/Influenza 4.27 Respiratory Illness – Mass Casualty Emergency Renumbered: –4.28 Seizures –4.29 Shock –4.30 Stroke –4.31 Suspected Spinal Injury –4.32 Syncope –4.33 Vaginal Bleeding –4.34 Vomiting and Nausea 4

SECTION 4 TREATMENT PROTOCOLS 5

ALLERGIC REACTION 4.4 Because it is more rapidly absorbed and reaches higher blood levels, IM epinephrine for allergic reactions is now preferred to SQ epinephrine Because it is more rapidly absorbed and reaches higher blood levels, IM epinephrine for allergic reactions is now preferred to SQ epinephrine IV epinephrine has been associated with iatrogenic overdoses and cardiac complications and its use for allergic reactions is discouraged except for anaphylactic shock where the 1:10,000 solution can be given but is Category B IV epinephrine has been associated with iatrogenic overdoses and cardiac complications and its use for allergic reactions is discouraged except for anaphylactic shock where the 1:10,000 solution can be given but is Category B The 1:1000 solution is NEVER given IV The 1:1000 solution is NEVER given IV The Epipen can still be used but its needle may be too short to reach the muscle in some obese patients The Epipen can still be used but its needle may be too short to reach the muscle in some obese patients 6

CARDIAC ARREST 4.8 Under “Physical Assessment, Part B” changed “closed chest massage” to “chest compressions” to reflect current terminology Under “Physical Assessment, Part B” changed “closed chest massage” to “chest compressions” to reflect current terminology 7

CARDIAC ARREST 4.8 Treatment of adult VFib/Pulseless Vtach, Part J: Treatment of adult VFib/Pulseless Vtach, Part J: –Added that if you substitute vasopressin for the first dose of epinephrine, you can give subsequent doses of epinephrine –Because of the current shortage of 1:10,000 epinephrine this may temporarily have to be the preferred medication for Vfib/Pulseless Vtach in adults 8

CARDIAC MEDICATIONS 4.9 Corrected category of Amiodarone (Cat. A) Corrected category of Amiodarone (Cat. A) 9

CARDIAC SYMPTOMS/ACUTE CORONARY SYNDROME 4.10 Added wording to stress that women, diabetics, and all adult medical patients over the age of 50 years have an increased risk of coronary artery disease. Added wording to stress that women, diabetics, and all adult medical patients over the age of 50 years have an increased risk of coronary artery disease. Also stressed that all adult patients complaining of epigastric pain should have an ECG performed Also stressed that all adult patients complaining of epigastric pain should have an ECG performed Noted that all Ambulance services must have the capability to perform 12-lead ECGs on patients by June of 2013 Noted that all Ambulance services must have the capability to perform 12-lead ECGs on patients by June of

CONGESTIVE HEART FAILURE 4.14 Changed dose of Furosemide from Changed dose of Furosemide from 20-40mg to 40mg to simplify the dosage 11

4.26 Respiratory Illness/Influenza NEW PROTOCOL For Routine Use During a Flu Epidemic 12

4.26 Respiratory Illness/Influenza 1. Follow General Patient Care Protocol Be sure you are using appropriate standard precautions A. If Dispatch advises of the potential for acute febrile respiratory illness symptoms on scene, you should don PPE for suspected cases of influenza prior to entering the scene. This includes disposable N-95 mask, eye protection (shield or goggles), and disposable non-sterile gloves. B. If Dispatch has not identified individuals with symptoms of acute febrile respiratory illness symptoms on scene, you should stay more than 6 feet away from the patient and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of influenza. If patient has signs or symptoms of influenza, you should don the PPE described above before coming in close contact with the patient. 13

4.26 Respiratory Illness/Influenza 3. Signs and Symptoms of Influenza : a. Rapid onset of symptoms b. Difficulty breathing with exertion c. Doctor has already diagnosed influenza d. Cough e. Fever f. Shaking Chills g. Pleuritic chest pain h. Sore throat (no difficulty breathing or swallowing) i. Nasal congestion j. Runny nose k. Muscle aches l. Headache 14

4.26 Respiratory Illness/Influenza 4. All EMS personnel engaged in aerosol generating activities (e.g. endotracheal intubation, bag-mask ventilation, nebulizer treatment, or CPAP [use expiratory filter]) should wear the PPE described in 2.a. 5. All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient. 6. Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. 15

4.26 Respiratory Illness/Influenza TRANSPORT OF PATIENTS TO HEALTHCARE FACILITIES When transporting a patient with symptoms of acute febrile respiratory illness, you should notify the receiving healthcare facility so that appropriate infection control precautions may be taken prior to patient arrival. Patients with febrile respiratory illness should wear a surgical mask, if tolerated. When transporting a patient with symptoms of acute febrile respiratory illness, you should notify the receiving healthcare facility so that appropriate infection control precautions may be taken prior to patient arrival. Patients with febrile respiratory illness should wear a surgical mask, if tolerated. 16

4.26 Respiratory Illness/Influenza INTERFACILITY TRANSPORT EMS personnel involved in the transfer of patients with confirmed influenza or suspected infectious respiratory illness should use standard droplet and contact precautions for all patient care activities. This should include wearing disposable N-95 mask, eye protection [shield or goggles], disposable non-sterile gloves and gown. If the transported patient can tolerate a surgical mask, its use can help to minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. Any nonessential equipment that can be removed from the patient compartment of the ambulance before transport will hasten the time needed to disinfect and return to service. EMS personnel involved in the transfer of patients with confirmed influenza or suspected infectious respiratory illness should use standard droplet and contact precautions for all patient care activities. This should include wearing disposable N-95 mask, eye protection [shield or goggles], disposable non-sterile gloves and gown. If the transported patient can tolerate a surgical mask, its use can help to minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. Any nonessential equipment that can be removed from the patient compartment of the ambulance before transport will hasten the time needed to disinfect and return to service. 17

4.26 Respiratory Illness/Influenza CLEANING VEHICLE AFTER TRANSPORTING AN INFLUENZA PATIENT After the patient has been removed and prior to cleaning, the air within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment. After the patient has been removed and prior to cleaning, the air within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment. Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can reduce the chance of hand transfer of virus particles. Influenza viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial sources. Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can reduce the chance of hand transfer of virus particles. Influenza viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial sources. 18

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY NEW PROTOCOL Not for Routine Use 19

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY This protocol is designed to be implemented only when there is a significant respiratory disease that has impacted the health care system to the extent that hospital beds are full, few or no ventilators are available for new patients with respiratory failure, the EMS/Dispatch work force is significantly depleted due to absenteeism, and the calls for EMS support overwhelm resources to manage all calls. When the Governor proclaims a state of emergency, the Alabama Public Health Department (ADPH) Office of EMS & Trauma (OEMS&T) will activate this protocol to provide authorization for the adjustment in the prehospital standard of care. Depending upon the Governor’s proclamation, ADPH OEMS&T may activate this protocol statewide or on a regional or local basis. This protocol is designed to be implemented only when there is a significant respiratory disease that has impacted the health care system to the extent that hospital beds are full, few or no ventilators are available for new patients with respiratory failure, the EMS/Dispatch work force is significantly depleted due to absenteeism, and the calls for EMS support overwhelm resources to manage all calls. When the Governor proclaims a state of emergency, the Alabama Public Health Department (ADPH) Office of EMS & Trauma (OEMS&T) will activate this protocol to provide authorization for the adjustment in the prehospital standard of care. Depending upon the Governor’s proclamation, ADPH OEMS&T may activate this protocol statewide or on a regional or local basis. 20

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY 1.Follow General Patient Care Protocol Be sure you are using appropriate standard precautions A. If Dispatch advises of the potential for acute febrile respiratory illness symptoms on scene, you should don PPE for suspected cases of influenza prior to entering the scene. This includes disposable N-95 mask, eye protection (shield or goggles), and disposable non-sterile gloves. B. If Dispatch has not identified individuals with symptoms of acute febrile respiratory illness symptoms on scene, you should stay more than 6 feet away from the patient and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of influenza. If patient has signs or symptoms of influenza, you should don the PPE described above before coming in close contact with the patient. 21

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY 3.Signs and Symptoms of Influenza Rapid onset of symptoms Rapid onset of symptoms Difficulty breathing with exertion Difficulty breathing with exertion Doctor has already diagnosed influenza Doctor has already diagnosed influenza Cough Cough Fever Fever Shaking Chills Shaking Chills Pleuritic chest pain Pleuritic chest pain Sore throat (no difficulty breathing or swallowing) Sore throat (no difficulty breathing or swallowing) Nasal congestion Nasal congestion Runny nose Runny nose Muscle aches Muscle aches Headache Headache 22

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY 4. If patient has critical vital signs, immediately transport to Emergency Department a.Critical Vital Signs: Adult If present, immediately transport to an Emergency Department Pulse: equal or greater than 130 beats per minute Pulse: equal or greater than 130 beats per minute Respiratory Rate: equal or greater than 30 breaths per minute Respiratory Rate: equal or greater than 30 breaths per minute Systolic Blood Pressure: Less than 90 mm/Hg Systolic Blood Pressure: Less than 90 mm/Hg Pulse Oximeter: Less than 92 on room air Pulse Oximeter: Less than 92 on room air Temperature: Febrile Temperature: Febrile Level of Consciousness: Responds only to Pain or is Unresponsive Level of Consciousness: Responds only to Pain or is Unresponsive Lung sounds: Rales or Wheezing Lung sounds: Rales or Wheezing 23

24 Capillary refill:> 2 seconds Resp. rate: 45 or increased work of breathing 45 or increased work of breathing 45 or increased work of breathing Systolic Blood pressure< 60 mmHg< 70 mmHgUnder age 10 < 70 + (2 X age in years) Pulse Oximeter< 92 on room air TemperatureFebrile Level of Consciousnessresponds only to pain or is unresponsive Lung soundsRales or Wheezing Critical Vital Signs: Pediatric: If present, immediately transport to Emergency Department Vital Signs Neonates Infants Children

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY 5. If patient has “normal” vital signs, then evaluate for signs and symptoms of influenza. a. “Normal” Vital Signs Adult with respiratory illness Pulse: Less than 130 beats per minute Pulse: Less than 130 beats per minute Respiratory Rate: Less than 30 breaths per minute Respiratory Rate: Less than 30 breaths per minute Systolic Blood Pressure: equal or greater than 91 mmHg Systolic Blood Pressure: equal or greater than 91 mmHg Pulse Oximeter equal or greater than 92 Pulse Oximeter equal or greater than 92 Temperature: Afebrile Temperature: Afebrile Level of Consciousness: Alert or responds to verbal stimuli Level of Consciousness: Alert or responds to verbal stimuli Lung sounds: Clear Lung sounds: Clear 25

26 Capillary refill:< 2 seconds Unlabored breathing or resp. rate: Systolic Blood pressure> 60 mmHg> 70 mmHgUnder age 10 > 70 + (2 X age in years) Pulse Oximeter> 92 TemperatureAfebrile Level of ConsciousnessAlert or responds to verbal stimuli Alert Lung soundsClear b. “Normal” Vital Signs Pediatric Patient with Respiratory Illness Vital Signs Neonates Infants Children

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY 6. If patient has three (3) or more signs or symptoms of influenza, transport patient to alternate care facility (if available). 7. If patient has two (2) or fewer signs or symptoms of influenza, call On-line Medical Direction (OLMD) to determine if patient may be left on-scene, self quarantine, and refer to nurse/public health hotline (insert phone number here) for further assistance. 8. Endotracheal intubation should not be performed on any patient except by direct order of the OLMD physician (Cat. B). 9. Because of the danger of EMS personnel becoming infected, aerosol-generating procedures such as advanced airway procedures, use of bag-mask, and nebulizer treatments should not be performed on patients with acute febrile respiratory illness except by direct order of the OLMD physician (Cat. B). CPAP with expiratory filter is still Category A. 27

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY 10.If OLMD orders advanced airway procedures, use of bag-mask, or nebulizer treatments on a patient with acute febrile respiratory illness, EMS personnel must be in PPE as described in 2.a above. 11.All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient. 12.Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. 28

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY TRANSPORT OF PATIENTS TO HEALTHCARE FACILITIES When transporting a patient with symptoms of acute febrile respiratory illness, you should notify the receiving healthcare facility so that appropriate infection control precautions may be taken prior to patient arrival. Patients with febrile respiratory illness should wear a surgical mask, if tolerated. When transporting a patient with symptoms of acute febrile respiratory illness, you should notify the receiving healthcare facility so that appropriate infection control precautions may be taken prior to patient arrival. Patients with febrile respiratory illness should wear a surgical mask, if tolerated. 29

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY INTERFACILITY TRANSPORT EMS personnel involved in the transfer of patients with confirmed influenza or suspected infectious respiratory illness should use standard droplet and contact precautions for all patient care activities. This should include wearing disposable N-95 mask, eye protection [shield or goggles], disposable non-sterile gloves and gown. If the transported patient can tolerate a surgical mask, its use can help to minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. Any nonessential equipment that can be removed from the patient compartment of the ambulance before transport will hasten the time needed to disinfect and return to service. EMS personnel involved in the transfer of patients with confirmed influenza or suspected infectious respiratory illness should use standard droplet and contact precautions for all patient care activities. This should include wearing disposable N-95 mask, eye protection [shield or goggles], disposable non-sterile gloves and gown. If the transported patient can tolerate a surgical mask, its use can help to minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment vehicle airflow/ventilation (turn on exhaust fan) to reduce the concentration of aerosol accumulation when possible. Any nonessential equipment that can be removed from the patient compartment of the ambulance before transport will hasten the time needed to disinfect and return to service. 30

4.27 Respiratory Illness/Influenza MASS CASUALTY EMERGENCY CLEANING VEHICLE AFTER TRANSPORTING AN INFLUENZA PATIENT After the patient has been removed and prior to cleaning, the air within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment. After the patient has been removed and prior to cleaning, the air within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment. Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can reduce the chance of hand transfer of virus particles. Influenza viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial sources. Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can reduce the chance of hand transfer of virus particles. Influenza viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial sources. 31

STROKE 4.30 Added that the EMS personnel should attempt to bring a knowledgeable friend or family member with the stroke patient Added that the EMS personnel should attempt to bring a knowledgeable friend or family member with the stroke patient Added that if the patient with stroke symptoms has no signs of CHF then they should receive a 500cc IV bolus of Normal Saline Added that if the patient with stroke symptoms has no signs of CHF then they should receive a 500cc IV bolus of Normal Saline Added under SPECIAL PRECAUTIONS: Many patients with stroke are taking diuretics and are volume depleted. Administer one bolus of fluid as noted above, unless there are obvious signs of acute heart failure. This may improve cerebral circulation. Added under SPECIAL PRECAUTIONS: Many patients with stroke are taking diuretics and are volume depleted. Administer one bolus of fluid as noted above, unless there are obvious signs of acute heart failure. This may improve cerebral circulation. 32

4.34 VOMITING AND NAUSEA Changed name to Vomiting and Nausea Changed name to Vomiting and Nausea Under “Specific Information Needed” added: Under “Specific Information Needed” added: B. Is the patient nauseated? C. If vomiting, is the cause known? K. History of vomiting when receiving narcotics? 33

4.34 VOMITING AND NAUSEA Under “NOTES:” added: Under “NOTES:” added: 1. Ondansetron may be used in cases of nausea to prevent vomiting 2. Ondansetron may be used to prevent nausea when administering morphine, especially if there is a history of vomiting after receiving narcotics 34

SECTION 5 MEDICATIONS 35

5.10 DIPHENHYDRAMINE Changed :”dystonic reaction” to “extrapyramidal symptoms” or “extrapyramidal reaction” to reflect current terminology in EMS texts Changed :”dystonic reaction” to “extrapyramidal symptoms” or “extrapyramidal reaction” to reflect current terminology in EMS texts 36

5.12 EPINEPHRINE Changed administration to IM for allergic reaction except for anaphylactic shock where it can be given IVP if the doctor orders (CAT B) Changed administration to IM for allergic reaction except for anaphylactic shock where it can be given IVP if the doctor orders (CAT B) Stressed that the 1:1000 solution (vial) is never given IV Stressed that the 1:1000 solution (vial) is never given IV 37

5.13 FUROSEMIDE Changed dose from 20-40mg to 40mg to simplify the dose Changed dose from 20-40mg to 40mg to simplify the dose 38

SECTION 6 PROCEDURES 39

6.5 ENDOTRACHEAL INTUBATION Under “PROCEDURE” added: Under “PROCEDURE” added: 7. Monitor tube placement with qualitative CO2 detector or preferably a quantitative waveform CO2 monitor (Use of one or the other is MANDATORY) After June 2013 the waveform capnography will be required. After June 2013 the waveform capnography will be required. 40

6.5 ENDOTRACHEAL INTUBATION Under “NOTES” added: Under “NOTES” added: 6. BY June 2013 all ALS services must have the ability to monitor patients with waveform capnography 41

SECTION 9 ACCEPTABLE EMS EQUIPMENT AND DEVICES 42

9.1 BLIND INSERTION AIRWAY DEVICES Noted that the King Airway may be used if the service medical director approves Noted that the King Airway may be used if the service medical director approves 43

ALERT! BEFORE USING NEW PRTOTOCOLS: EACH SERVICE MUST NOTIFY AND PROVIDE YOUR SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF THE 5 TH EDITION PROTOCOLS (June 2010 edition) AND A COPY OF THIS UPDATE PRESENTATION EACH SERVICE MUST NOTIFY AND PROVIDE YOUR SERVICE OFF-LINE MEDICAL DIRECTOR A COPY OF THE 5 TH EDITION PROTOCOLS (June 2010 edition) AND A COPY OF THIS UPDATE PRESENTATION –It is OK for the medical director to download the material instead EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS ARE AWARE THAT THE PROTOCOLS HAVE BEEN UPDATED AND WHERE TO GET THE MATERIAL EACH SERVICE MUST BE SURE THE ON-LINE MEDICAL DIRECTORS AT YOUR MEDICAL DIRECTION HOSPITALS ARE AWARE THAT THE PROTOCOLS HAVE BEEN UPDATED AND WHERE TO GET THE MATERIAL –The service is not responsible for furnishing copies of the protocols or update slide presentation 44

NEW PROTOCOLS CAN BE USED WHEN EVERYONE IN A SERVICE HAS BEEN UPDATED WHEN EVERYONE IN A SERVICE HAS BEEN UPDATED –TURNED ON SERVICE BY SERVICE NOT INDIVIDUAL BY INDIVIDUAL –TURN IN ROSTER TO REGIONAL EMS AGENCY NOT TO OFFICE OF EMS & TRAUMA Also acknowledge that you have updated your off-line medical director and provided copy of protocols Also acknowledge that you have updated your off-line medical director and provided copy of protocols –REGIONAL EMS AGENCY WILL NOTIFY YOU WHEN YOU CAN START USING NEW PROTOCOLS –EVERY SERVICE MUST BE UPDATED BY OCTOBER 1 ST,

QUESTIONS? 46