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The Maryland Medical Protocols for Emergency Medical Services Maryland Institute for Emergency Medical Services Systems

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The Maryland Medical Protocols for Emergency Medical Services Maryland Institute for Emergency Medical Services Systems The Maryland Medical Protocols for Emergency Medical Services Maryland Institute for Emergency Medical Services Systems Effective August 1, 2020 The complete “Maryland Medical Protocols for Emergency Medical Services ” is also available on the Internet at www.MIEMSS.org. Protocols are occasionally amended during the year. Please check the MIEMSS website to be sure you have the most up-to-date version. The edition date appears on the lower portion of the page. This text was produced from materials from the Division of State Documents (DSD), Office of the Secretary of State, State of Maryland. Only text obtained directly from the DSD is enforceable under Maryland law. For copies of the official text, call the DSD at 1-800-633-9657. Edition Date August 1, 2020 ii To All EMS Clinicians in the State of Maryland: Re: 2020 revisions, updates, and additions to The Maryland Medical Protocols for Emergency Medical Services EMS clinicians will be able to download the full document from the MIEMSS website at www.miemss.org and will receive a single copy of the 2020 pocket protocols. The EMS Board has approved these protocols for implementation on August 1, 2020. Prior to August 1, all EMS must complete the Maryland EMS Update: 2020 (visit the Online Training Center) that will highlight the new material. Of note, the implementation was delayed from July 1 to August 1, 2020 for this year due to COVID-19. Some major protocol additions, deletions, and changes have been made this year. The list of these changes is for reference only, and the information located in the full protocol book is the official medical reference for EMS clinicians. Protocol changes: • Epinephrine Administration: The administration of epinephrine in cardiac arrest has been modified to limit dosing during resuscitation based on findings of survival with good neurologic outcome. In addition, epinephrine is now the drug of choice for treating hypotension secondary to shock, replacing dopamine. • Pediatric Termination of Resuscitation (TOR): The indication for TOR has been expanded to include considerations for patients who have not yet reached their 18th birthday when meeting specific criteria. The protocol was approved after research and statewide focus groups were conducted by the Pediatric Emergency Medical Advisory Council (PEMAC). • Adult Rapid Sequence Intubation (RSI): Adult RSI has been moved from a pilot protocol to an optional supplemental protocol which continues to require a jurisdictional application for approval to be submitted to the State EMS Medical Director. The RSI procedure and program educational requirements have been updated with contributions from jurisdictions participating in the protocol. • Heat Emergencies: Language has been added to allow for a team management approach of care with EMS clinicians and team/event physicians on the scene specifically allowing for the continuation of active cooling measures. • Ketamine: The use of ketamine has been expanded to allow for use in the ventilatory difficulty secondary to bucking or combativeness protocol as well as allowing for treatment of CPR- induced awareness for all ALS clinicians. • Fluid Resuscitation: Dosing recommendations have been modified to target more specific volumes and blood pressures in trauma patients based on literature review and current best practices. The updated recommendations come from work conducted by members of the protocol review committee and subject matter experts from area trauma centers. • Ketorolac: This medication has been added to the formulary as an optional non-opioid medication for treatment of acute pain. Interested jurisdictions should submit an OSP application to the State EMS Medical Director if they wish to carry this medication. Timothy P. Chizmar, MD, FACEP Theodore R. Delbridge, MD, MPH State EMS Medical Director, MIEMSS Executive Director, MIEMSS iii Edition Date August 1, 2020 THIS PAGE IS INTENTIONALLY BLANK Edition Date August 1, 2020 iv TABLE OF CONTENTS I. GENERAL INFORMATION ���������������������������������������������������������������������������������������������������� 1 A. General Provisions ������������������������������������������������������������������������������������������������������1 B. Important Numbers ......................................................................................................3 C. Maryland Trauma and Specialty Referral Centers �������������������������������������������������������5 D. Protocol Key ............................................................................................................. 10 E. Protocol Usage Flow Diagram ...................................................................................11 F. Protocol Variation Procedure ������������������������������������������������������������������������������������ 12 G. Inability to Carry Out Physician Order ...................................................................... 13 H. Physician Orders for Extraordinary Care Not Covered by Maryland Protocol (NEW ’20) ................................................................................... 14 II. GENERAL PATIENT CARE �������������������������������������������������������������������������������������������������� 15 Age-Related Normal Vital Signs ..................................................................................... 20 III. TREATMENT PROTOCOLS................................................................................................. 33 Abuse/Neglect A. Abuse/Neglect ���������������������������������������������������������������������������������������������������������� 33 Altered Mental Status B. Altered Mental Status: Seizures ������������������������������������������������������������������������������� 35 C. Altered Mental Status: Unresponsive Person ........................................................... 38 Apparent Life-Threatening Event (ALTE) D. Apparent Life-Threatening Event (ALTE) ����������������������������������������������������������������� 40 Behavioral Emergencies E. Behavioral Emergencies ������������������������������������������������������������������������������������������� 41 Cardiac Emergencies F. Non-Arrest Cardiac Guidelines ................................................................................ 43 Universal Algorithm for Adult Emergency Cardiac Care for BLS ........................ 44 Universal Algorithm for Adult Emergency Cardiac Care for ALS ....................... 45 Universal Algorithm for Pediatric Emergency Cardiac Care for BLS .................. 46 Universal Algorithm for Pediatric Emergency Cardiac Care for ALS .................. 47 G. Bradycardia ............................................................................................................... 48 Adult Bradycardia Algorithm ������������������������������������������������������������������������������� 49 Pediatric Bradycardia Algorithm .......................................................................... 50 H. Tachycardia .............................................................................................................. 51 Adult Tachycardia Algorithm ............................................................................... 53 Pediatric Tachycardia Algorithm ......................................................................... 54 v Edition Date August 1, 2020 TABLE OF CONTENTS I. Cardiac Arrest ���������������������������������������������������������������������������������������������������������� 55 Adult Asystole Algorithm ������������������������������������������������������������������������������������������ 58 Pediatric Cardiac Arrest Algorithm ........................................................................... 59 Pulseless Electrical Activity (PEA) Algorithm ........................................................... 60 VF and Pulseless VT Algorithm ............................................................................... 61 J. Return of Spontaneous Circulation (ROSC) ������������������������������������������������������������ 62 K. Termination of Resuscitation ................................................................................... 66 Adult Termination of Resuscitation Algorithm Medical Arrest (NEW ’20) ���������� 68 Adult Termination of Resuscitation Algorithm Trauma Arrest (NEW ’20) ........... 69 Pediatric Termination of Resuscitation Algorithm Medical Arrest (NEW ’20) ..... 70 Pediatric Termination of Resuscitation Algorithm Trauma Arrest (NEW ’20) ..... 71 L. Pronouncement of Death in the Field ����������������������������������������������������������������������� 72 M. EMS DNR/MOLST ���������������������������������������������������������������������������������������������������� 73 N. EMS DNR Flowchart ������������������������������������������������������������������������������������������������� 83 O. Chest Pain/Acute Coronary Syndrome ..................................................................... 84 P. Hyperkalemia: Renal Dialysis/Failure or Crush Syndrome ....................................... 86 Q. Implantable Cardioverter Defibrillator (ICD) Malfunction .......................................... 88 R. ST Elevation Myocardial Infarction (STEMI) ������������������������������������������������������������� 90 S. Sudden Infant Death Syndrome (SIDS) �������������������������������������������������������������������� 93 Environmental Emergencies T. Cold Emergencies (Frostbite) ..................................................................................
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