sign in sign up
<<
Home , ABC (medicine)

PARAMEDIC UPDATE

2020 AGENDA

Protocol format New medications Base contact requirements Against Medical Advice Pediatric King Airway Protocol changes New Policies Determination of death Online Certifications- Image trend NEW PROTOCOL FORMAT

Public safety, EMT, and Public safety personal can Adults and Pediatric are on protocols are in only perform skills in the top the same page. one document. canary yellow section

Anything listed in the yellow EMT’s can perform any skills will start with ALS section is a standing in the green BLS section the BLS section (BLS before order. Base contact must be located below the public ALS!) and move down into attempted for anything in the safety area. the ALS section as needed. red “base hospital contact required” section. NEW PROTOCOL FORMAT

Adults Pediatrics (13 years and under) Public Safety Procedures: Only Public Safety First Aid Procedures: Only • Remove nearby objects to prevent injury to Patient. Place • Remove nearby objects to prevent injury to Patient. Place patient in on left side patient in recovery position on left side • Give Oxygen if available • Give Oxygen if available • Request Fire/EMS • Request Fire/EMS • Public safety will start here BLS Procedures: EMT’s and Paramedics start here BLS Procedures: EMT’s and Paramedics start here • Support ABC’s • Support ABC’s • Give Oxygen only if Spo2 < 94% or if in Respiratory Distress • Give Oxygen only if Spo2 <94% or if in Respiratory Distress • Blood Glucose Check, if hypoglycemic enter appropriate • Glucose check, if hypoglycemic enter appropriate protocol protocol • EMT and Paramedic start here • If Focal seizure, place patient in position of comfort, rapid • If Focal seizure, place patient in position of comfort, rapid transport or ALS Rendezvous transport or ALS Rendezvous • If full body tonic/clonic seizure, prepare to support • If full body tonic/clonic seizure, prepare to support respirations, provide cooling measures if febrile respirations. • Spinal motion restriction if trauma is suspected • If febrile seizure, start cooling techniques. Acetaminophen 15 • Rapid transport or ALS rendezvous for repetitive or prolonged mg/kg PO after seizure has ended and patient can safely seizure activity swallow. • Spinal motion restriction if trauma is suspected • Rapid transport or ALS rendezvous for repetitive or Paramedics move down as needed prolonged seizure activity • ALS Prior to Base Hospital Contact: Paramedic only ALS Prior to Base Hospital Contact: Paramedic only

• Monitor/Spo2/Blood Glucose Check. IF ACTIVELY SEIZING • Monitor/Spo2/Blood Glucose check IF ACTIVELY SEIZING GIVE VERSED PRIOR TO BLOOD GLUCOSE CHECK GIVE VERSED PRIOR TO BLOOD GLUCOSE CHECK, if • If patient actively seizing and is PREGNANT give Magnesium hypoglycemia or narcotic overdose enter appropriate Sulfate 4-6 GM IV if patient continues to seize give Versed If > protocol 40 kg Give 10 mg IV/IO/IM/I.N. If < 40 kg Give 5 mg. or 1 mL • Versed 0.2 mg/kg IM/IN ONLY For first dose. Repeat doses Max per Nare if given IN may be IM/IN/IV/IO MAX dose 5 mg/ 1 mL per Nare if given • Versed 10 mg if >40 kg 5 mg if < 40 kg IM/IN ONLY For the first IN. dose. Repeat doses may be IM/IN/IV/IO. MAX 1 mL per Nare. • If Versed not available give Valium 0.3 mg/kg IV/IO MAX dose • If active seizure lasts longer than 10 minutes may repeat dose 5 mg Rectal 0.5 mg/kg MAX dose 10 mg 1 time, BASE for further direction • If seizure lasts longer than 10 minutes may repeat dose 1 • If Versed not available give Valium 5 mg/IV/IO if seizure lasts time. BASE for further direction longer than 10 minutes may repeat dose 1-time BASE for • Anything in the red line section requires further direction

base contact Base Hospital Contact Required Base Hospital Contact Required Versed beyond 2 doses Versed beyond 2 doses NEW MEDICATIONS NEW MEDICATIONS

ACETAMINOPHEN KETAMINE TRANEXAMIC PUSH DOSE ACID (TXA) EPINEPHRINE Acetaminophen Protocol 116 (Tylenol) Classification Analgesics (pain relievers) and Antipyretics (fever reducers) Actions Pain reliever and fever reducer. Indications • Used for fevers > 100.4 to prevent increase of fever and to lower body temperature. • Can be used post-febrile seizure as long as patient is responsive. • Pain relief

Contraindications Unable to swallow Adverse Effects • Diarrhea • Sweating • Nausea or • Stomach cramps or pain Adult Dose 650 mg PO.

Pediatric Dose 15 mg/kg. PO Use a disposable syringe to inject liquid medication into check area of mouth. (No sharp attached) Then dispose of syringe. Onset PO 15 - 20 minutes Duration 4-6 hours Pregnancy Safety Category B Comments Use with caution in patients with liver disease. Protocol 108 Ketamine 116 Classification Hypnotic analgesic

Actions A rapid-acting nonbarbiturate hypnotic analgesic agent characterized by normal pharyngeal-laryngeal reflexes, normal or enhanced skeletal muscle tone, and possible cardiovascular and respiratory stimulation.

Indications Moderate to severe pain Contraindications • Age <4 years • GCS 14 or less • Known allergy to ketamine • Known or suspected alcohol or drug intoxication • Known or suspected pregnancy Adverse Effects • Nausea/Vomiting • Tachycardia • Increased salivation • Laryngospasm, Occurs mostly at higher doses Adult Dose 15 mg IV infusion –Inject Ketamine into a 100mL bag of normal saline. Infuse 100mL bag containing Ketamine as IV/IO drip over 5 minutes Repeat in 15 minutes prn x1

25mg (0.5mL) IN – do not dilute Repeat in 15 minutes prn x1, maximum total dose 50mg Pediatric Dose 0.3mg/kg IV infusion –Inject Ketamine into a 100mL bag of normal saline. Infuse 100mL bag containing Ketamine 0.2mg/kg as IV/IO drip over 5 minutes. Do not exceed adult dose. Repeat in 15 minutes prn x1, maximum 2 total doses 0.5mg/kg (50mg/mL) IN– do not dilute. Repeat in 15 minutes prn x1, maximum 2 total doses Onset IV/IO 5-10 Minutes IN 15-20 Minutes Duration Pregnancy Safety Category C Comments • The likelihood of respiratory depression and undesired pressor effects is increased by too rapid IV administration. • For pediatric trauma IN route is preferred. Protocol 124 Tranexamic Acid (TXA) 127 Classification Anti-fibrinolytic Actions Forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis; it also inhibits the proteolytic activity of plasmin.

Indications • Trauma associated with significant hemorrhage • Must administer within 3 hours of injury • SBP <90 mm Hg, HR > 110 or both • Tachycardia > 120 beats per minute with sighs of hypoperfusion (confusion, altered metal status, cool extremities, etc.) • Patients > 65 years of age with systolic BP < 110 mmHg. • (PPH) Post-Partum Hemorrhage (blood loss from the birth canal in excess of 500mL during the first 24 hours after delivery) • Epistaxis not controlled by BLS measures Contraindications • Hypersensitivity to medication • Suspected CVA, MI, or PE • Injuries > 3 hours old (Shock protocol) • Patients < 14 years of age • Hypotension (with rapid IV injection) • nausea Adverse Effects • vomiting • Giddiness • blurred vision • allergic dermatitis • diarrhea Adult Dose Trauma: MUST BE ADMINISTERED WITHIN 3 HOURS OF INJURY 1 gram administered over 10 minutes for the initial dose. Mix 1 gram (10 ml) in 100 ml of NS and infuse via: Macro 10 gtts/mL over 10 minutes @ 110 gtts. Epistaxis: MAD 1ml (100mg) per nare Immediately compress or clamp nares after administration of Tranexamic Acid Repeat in 5 minutes if continues. Pediatric Dose Not recommended for patients < 14 years of age. Onset 5-15 minutes Duration 3 hours

Pregnancy Safety Category B Comments Should only be used in life threating cases for patients taking anticoagulants or female patients taking birth control. Female patients taking birth control containing estrogen or progestin are at risk for blood clots, and TXA significantly increases that risk. TXA is NEVER administered at a “wide open” rate. Base contact required for TXS in PPH treatment Protocol Epinephrine 103 104 106 115 117 119 120 124 125 Classification Sympathomimetic agent (Catecholamine)

Actions Acts directly on Alpha & Beta receptors of the SNS. Beta effect is more profound than Alpha effects. Effects include: • Increased HR (chronotropy) • Increased cardiac contractile force (inotropy) • Increased electrical activity with in myocardium (dromotropy) • Increased systemic vascular resistance • Increased blood pressure • Increased automaticity • Increased bronchial smooth muscle dilation • Increases coronary perfusion during CPR by increasing aortic diastolic pressure

Indications • Cardiopulmonary arrest: -Asystole -Pulseless electrical activity (PEA) • Allergic reaction/anaphylaxis • Respiratory compromise w/ bronchospasm • Bradycardia • Hypoperfusion

Contraindications Hypertension

Adverse Effects • Hypertension-tachycardia • Increases myocardial oxygen demand and potentially increases myocardial ischemia

Adult Dose Cardiopulmonary arrest: IV Drip rate 2-8 mcg Allergic reaction/anaphylaxis: 0.3 mg of 1:1,000 IM, may repeat in 20-minute intervals. If severe: IV Drip rate 2-8 mcg/min OR push dose 0.5 ml every 1-5 minutes Bronchospasm: 0.3 mg of 1:1,000 IM OR IV drip 2-8 mcg/min Bradycardia: Push Dose 0.5 ML every 1-5 minutes OR IV drip if 2-8 MCG/Minute Hypoperfusion: Push Dose 0.5 ML every 1-5 minutes OR IV drip if 2-8 MCG/Minute Protocol 103 104 106 115 117 119 Epinephrine: 120 124 125

Pediatric Dose : IV/IO: IV drip 0.1-1mcg/kg/min IV drip Allergic Reaction/anaphylaxis: 0.01mg/kg max 0.3 mg 1:1000 IM. If severe distress initiate drip 0.1-1 mcg/kg/min OR push dose 1mL IV/IO every 2 minutes to Systolic B/P age 1-10 > 70 mmHg, over 10 years > 90mmHg. Bronchospasm: 0.01 mg/kg max. 0.3 mg of 1:1,000 IM, may repeat in 10-20 minutes for a total of 2 doses. Bradycardia: IV drip 0.1-1 mcg/kg/min OR push dose 1 ml every 3-5 minutes. Severe Croup: Nebulized 1:10,000 0.5mg Hypotension: IV drip 0.1-1 mcg/kg/min

Onset Immediately if given IVP 5-10 minutes if given SQ/IM

Duration 3-5 minutes if given IVP 20 minutes if given SQ/IM

Pregnancy Safety Category C

Comments High dose epinephrine is no longer recommended (except in adult patients in anaphylaxis related cardiac arrest). High doses do not improve survival or neurologic outcome and may contribute to post resuscitation myocardial dysfunction. Recommended method for mixing infusion is to mix 2 mg in a 250 mL bag of NS or 4 mg in a 500 bag of NS and infuse via microdrip at a rate of 15-60 gtts/min. for a rate of: 2 mcg/min.=15 gtts/min. 4 mcg/min.=30 gtts/min. 6 mcg/min.=45 gtts/min. 8 mcg/min.=60 gtts/min Adult and Pediatric Push dose Epinephrine Begin with 1 mg of 0.1 mg/mL preparation (cardiac epinephrine) and waste 9 ml of epinephrine. Into that syringe withdraw 9 mL of normal saline from the patient’s IV bag. Shake well. Mixture now provides 10 mL of epinephrine at a 10 mcg/mL concentration. Push Dose: 0.5 ml (5 mcg) IV/IO, every 1-5 minutes. PUSH DOSE EPINEPHRINE

Adult/ Pediatric Push dose Epinephrine • Begin with an empty 10mL syringe and apply a medication label to indicate push dose epinephrine. • Withdraw 1 mg of 0.1 mg/mL preparation (cardiac epinephrine) • Withdraw 9 mL of normal saline. Shake well. • Mixture now provides 10 mL of epinephrine at a 10 mcg/mL concentration. • Push Dose: 0.5 mL (5 mcg) IV/IO, every 1-5 minutes. BASE CONTACT

WHEN SHOULD YOU CALL FOR ORDERS OR MEDICAL DIRECTION BASE CONTACT REQUIRED

Bradycardia (106) Pediatric ROSC (117) Seizure (121) Tachycardia with a (123) •Adults & Pediatrics: pain control •If suspected cardiogenic shock •Adults & Pediatrics: Versed •Pediatric: Lidocaine for beyond initial dosing for TCP Epinephrine infusion 0.1-1 after the First 2 doses tachycardia that fails to respond mcg/kg/min IV/IO titrate to to cardioversion effect.

Shock / Hypoperfusion (124) Epistaxis (127) Excited Delirium (128) Combative Patient Restraint •Trauma •Bleeding longer than 3 hours •Adult: Beyond initial dose for (205) •Adult & Pediatric: Fluid bolus and is NOT controlled by BLS agitation control •Adult: Beyond initial dose for •Post-Partum Hemorrhage procedures consider TXA •Pediatrics: Administer Versed agitation control •Consider TXA for agitation control •Pediatrics: Beyond initial dose for agitation control BASE CONTACT REQUIRED

Bradycardia (106) • Adults: pain control beyond initial dosing for TCP • Pediatrics: pain control beyond initial dosing for TCP BASE CONTACT REQUIRED

• Pediatric ROSC (117) – If suspected cardiogenic shock Epinephrine infusion 0.1-1 mcg/kg/min IV/IO titrate to effect. BASE CONTACT REQUIRED

• Seizure (121) – If active seizure lasts longer than 10 minutes may repeat dose 1 time – Adults & Pediatrics: Versed beyond 2 doses BASE CONTACT REQUIRED

• Tachycardia with a pulse (123) – Pediatric: Lidocaine for tachycardia that fails to respond to cardioversion. – 1 mg/kg IV/IO. If rhythm persists, repeat dose in 10 minutes. BASE CONTACT REQUIRED

• Shock / Hypoperfusion (124) – TRAUMA • Adult: Fluid bolus • Give 250 ml fluid bolus to maintain Systolic B/P >80 mmHg • Pediatric: Fluid Bolus • Give 5 mL/kg fluid bolus to maintain Systolic B/P. • 1-10 years old >70 mmHg 10 + years old >80 mmHg – POST-PARTUM HEMORRHAGE • Consider Tranexamic Acid 1 gram administered over 10 minutes for the initial dose. Mix 1 gram (10 mL) in 100 mL of NS BASE CONTACT REQUIRED

Epistaxis (127) • Adult: If bleeding has lasted more than 3 hours and is not controlled by BLS procedures, consider administration of Tranexamic Acid. BASE CONTACT REQUIRED

• Excited Delirium (128) – Adult: Beyond initial dose for agitation control BASE CONTACT REQUIRED

Combative patient restraint (205) • Adult and pediatric: Versed for agitation control beyond initial dosing. BASE CONTACT REQUIRED

• A paramedic may transfer patient care authority to a BLS transport only after base contact has been made – Base contact shall be made with MICN and must concur with handoff. AGAINST MEDICAL ADVICE AMA PROTOCOL

• PURPOSE: – To provide guidelines for EMS personnel to determine which patients who do not wish to be transported to the hospital have the decision-making capacity to refuse EMS treatment and/or transport, and to identify those who may be safely released at scene. • DEFINITIONS – Adult: A person at least eighteen years of age. – Minor: A person less than eighteen years of age. – Minor Not Requiring Parental Consent is a person who: • Is 12 years or older and in need of care for a reportable medical condition or substance abuse • Is pregnant and requires care related to the pregnancy • Is in immediate danger of suspected physical or sexual abuse • Is an emancipated minor AMA PROTOCOL

• If the patient has an emergency medical condition as defined below and a BLS unit is alone on scene, an ALS unit shall be requested for evaluation prior to AMA. – Extremes of age (≤12 months or ≥70 years old) – Abnormal vital signs or high-risk chief complaints including: • Chest pain • • Abdominal pain • Gastrointestinal • Vaginal bleeding • Syncope • These patients are more challenging to fully evaluate in the field and, in general, shall be transported to the . AMA PROTOCOL

• EMS personnel may contact the base hospital physician to discuss patient refusals, obtain guidance, and/or assistance in educating patients on the risks and benefits. • This must be done prior to leaving the patient. • EMS personnel shall not make base contact for documentation purposes only AFTER leaving the patient. PEDIATRIC KING LTD CONTRAINDICATIONS:

Caustic ingestion or Unresolved complete Known esophageal Intact gag reflex extensive airway airway obstruction disease burns

Distorted anatomy that prohibits proper Laryngectomy with Adequate BVM Oral trauma placement (e.g. stoma ventilations oropharyngeal mass or abscess). COMPLICATIONS:

• Regurgitation leading to aspiration of gastric contents • Unable to obtain an adequate seal leading to air leakage Casualty Casualty Criteria LT Size Color Newborn <5kg 0 Clear Infant 5kg – 12kg 1 White Child 12kg – 25kg 2 Green Child 125cm – 150cm 2.5 Orange Adult <155cm 3 Yellow Adult 155cm – 180cm 4 Red Adult >180cm 5 Purple

KING LT SIZES PROCEDURE

• Choose the correct size King airway based on the patient's height or weight. • Test the cuff inflation system by injecting the maximum recommended volume of air into the cuffs. • Remove all air from the cuffs prior to insertion. • Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube taking care to avoid the introduction of lubricant in or near the ventilator openings. • Pre-oxygenate the patient. • Positioned the head: The ideal head position for insertion of the King Airway is the sniffing position; tube can also be used with the head in the neutral position. PROCEDURE CONTINUED

• Hold the King Airway at the connector end with the dominate hand. With the non-dominate hand hold the mouth open and apply a chin lift unless contraindicated due to suspected spinal injury. • With the King Airway rotated laterally 45-90 degrees such that the blue orientation line is touch the corner of the mouth, introduce the tip of the tube into the mouth and advance behind base of . Never force the tube into position. • As the tube tip passes under the tongue rotate the tube back to midline (blue orientation line faces the chin). • Without exerting excessive force, advance the King Airway until the base of the connector aligns with the teeth or gums. PROCEDURE CONTINUED

• Fully inflate the cuffs using the maximum volume of the syringe (see chart). • Attach the device to the 15mm connector of the King Airway and gently start bagging the patient to assess ventilation, is easy and free flowing (large tidal volume with minimal airway pressure). • Note the depth markings to give an approximate distance in cm’s to the vocal cords. • Confirm proper position by , chest movement, and verification of CO2 using waveform Capnography. If failure of the Capnography device a end tidal CO2 color metric device may be used. • Readjust cuff inflation to just seal the airway. • Secure the King Airway to the patient using an accepted method. Use care not to place tape over the proximal opening of the gastric access device. PROTOCOL CHANGES FLUID IN TRAUMA PATIENTS

RESEARCH SHOWS OVERLOADING TXA IS GIVEN IN A 100ML IV BAG. BASE CONTACT IS REQUIRED FOR OUR TRAUMA PATIENTS WITH FLUID THIS SHOULD BE THE ONLY FLUID ANY ADDITIONAL FLUID THE CAN INCREASE MORTALITY. TRAUMA PATIENTS RECEIVE. PARAMEDIC WANTS TO ADMINISTER. VS LIDOCAINE

Amiodarone has been removed Lidocaine will now be used in its from the Paramedic protocols. place. ADMINISTRATION OF

Adenosine is no longer given IVP followed by a normal saline flush. Adults: 6 mg in a 20ml syringe with 18ml of normal saline, rapid IVP. Repeat 12 mg mixed in a 20ml syringe with 16ml normal saline, if needed. May repeat a third time if needed. (Total dose 30 mg) Pediatric: 0.1 mg/kg mixed in a 10ml syringe with enough normal saline to equal 10ml, rapid IVP. (Max dose 6 mg). May repeat in 3 minutes at 0.2 mg/kg in a 10ml syringe with enough normal saline to equal 10ml, rapid IVP (Max dose 12 mg.) **Always withdraw the normal Saline first, followed by the Adenosine. NAUSEA TREATMENT

Inhaled Isopropyl alcohol is shown to be effective in the treatment of nausea. For EMT’s or Paramedics with a nauseated patient open a alcohol prep pad, have the patient hold it below their nares, and breath through their nose. REMOVAL OF

• Dopamine will no longer be carried. • For vasopressors utilize; – BLS procedures. – Fluid challenge for medical patients only. Titrate to a bp of 80 mmHg systolic. – Push dose Epi or Epi drip. CARDIAC ARREST CHANGES

Use of Epinephrine in cardiac arrest – If the patient is in PEA or Asystole: • Give Epinephrine as a drip @ 2-8 mcg/min. – If the patient is in VFIB or VTACH: • Withhold administration of Epinephrine. CARDIAC ARREST CHANGES

As stated earlier Lidocaine will be replacing Amiodarone. For patients in VFIB or VTACH administer Lidocaine at: Adult: • Lidocaine 1-1.5 MG/KG IV/IO first dose then 0.5-0.75 MG/KG every 5-10 minutes Max 3 doses or 3 MG/KG. First Lidocaine dose should be given at the 2nd shock. Pediatric: • Lidocaine 1mg/kg IV/IO first dose then 0.5-0.75 mg/kg may repeat dose X 2 in 3-5 minutes with 1 mg/kg for 3 mg/kg MAX. First Lidocaine dose should be given at the 2nd shock. ALS TO BLS HANDOFF

We have added a more defined definition of “REASONABLE TIME”

“The BLS ambulance is available within a reasonable time. A reasonable time is defined as the time it would take the ALS crew to transport to hospital or 20 minutes, whichever is less.” NEW POLICIES EMS ABUSER POLICY 911 ABUSER POLICY

Kern County EMS has developed a policy on an excessive caller abuse policy. We hope to be able to identify chronic 911 callers and provide them with alternate resources to lessen their frequency in calling. IDENTIFICATION OF 911 ABUSER

• Inappropriate system users may come to the attention of EMS by direct report from provider agencies, hospitals, the CQI system, law enforcement, or analysis of system data.

• An inappropriate system user will be defined as an individual who has accessed the EMS system an average of two times per month over a period of three months (e.g., six or more responses within a 90 day period)

• Public drunkenness is not a and will not be treated as such in the policy. Law enforcement initiated responses will not exempt patient from revocation of EMS system.

• Inappropriate users who appear to have psychiatric or medical conditions which make them incapable of caring for themselves will be referred to the appropriate agency to assess the patient’s competency or ability to care for themselves. If it is determined that the patient is competent to make their own decisions or has the ability to care for themselves, this policy will be in effect in evaluating EMS usage. COUNSELING Once an EMS inappropriate user is identified pursuant to Section IV.A.2 of this policy, the following agencies will be notified, if possible, to assist with management of the individual: a) Kern County Public Health b) Kern County Behavioral c) Kern County Department d) The patient’s primary care e) Appropriate law Nursing Health & Recovery Services of Human Services physician (if possible) enforcement agency

The inappropriate user will be engaged by one of the aforementioned agencies on at least one occasion prior to suspension of ambulance transport services.

EMS, or its designee, will counsel the patient regarding the purpose, and appropriate use, of the EMS system

The inappropriate user will be provided a copy of this policy. This policy will be discussed with the user, and questions will be answered by EMS staff or their designee. REVOCATION OF EMS TRANSPORT • FIRST WARNING – During the initial counseling period, the inappropriate user will be given a first written warning of impending cancelation of ambulance transport services. This warning will be mailed by certified mail or hand- delivered. • SECOND WARNING – After 15 days, if the trend of use of the 911 system continues to be excessive, a second written notice shall be mailed by certified mail or hand-delivered. • FINAL DEMAND – After 30 days, if the trend of use of the 911 system continues to be excessive, a third and final written notice shall be hand-delivered. • REVOCATION OF TRANSPORT – After a minimum of 40 days (or 10 days after the Final Demand is delivered), if the trend of use of the 911 system continues to be excessive, a written notice shall be hand-delivered advising the user that ambulance transport privileges have been discontinued, and they will no longer receive an ambulance transport. RESPONDER RESPONSIBILITY

• If the patient is not ambulatory, cannot sit unassisted, meets 5150 criteria, meets specialty care center criteria, or the paramedic recognizes a medical condition that requires immediate medical treatment, normal policies and procedures for patient assessment, treatment and transport shall be initiated. • If the patient does not meet the above criteria EMS crew will advise the patient of the following

– “You have been identified as an inappropriate user of the 911 system. The EMS Medical Director has suspended ambulance transport for you. You need to consider alternative transportation. If you feel this is in error, you can contact EMS at (661) 321-3000. We are not transporting you to the hospital.” EPCR POLICY • Remember your PCR and narrative is a reflection of your care. • There has not been approved abbreviations in Kern County for several years. During Qi of PCRs we are coming across a lot of abbreviations that are not widely known, are used incorrectly, or are being used to mean two different things in the same narrative. • Be sure to document any medication administration performed in the flow chart and specify prior to arrival and who administered – i.e. Aspirin PROTOCOL UPDATE POLICY

• Policy 1013 – This policy details the process and timeline we use for putting out new protocols. – It also allows you as a provider to make suggestions to add or change protocols. DETERMINATI ON OF DEATH DETERMINATION OF DEATH

There has been NO change to this policy, however, we have noticed issues following this policy. • A lot of patients are having CPR started that should not. • A lot of patients are being transported that should be left or worked on scene. • A lot of medics are making base contact when it is not needed. DETERMINATION OF DEATH

• Obvious Death Criteria: – A patient may be determined obviously dead by Prehospital Care Personnel if, in addition to the absence of respiration, cardiac activity, and fixed pupils, one or more of the following physical or circumstantial conditions exists: • Decapitation • Massive crush injury to the head, neck, or trunk • Penetrating or blunt injury with evisceration of the heart, or brain • Decomposition • Incineration • Rigor Mortis • Post-Mortem Lividity DETERMINATION OF DEATH

When not to initiate CPR: • Primary assessment reveals a pulseless, non- patient who has signs of prolonged lifelessness in accordance with obvious death criteria or confirmed pulseless for 10 minutes. This does not apply to drownings, and barbiturate overdoses. • Blunt trauma patient, who on the arrival of EMS personnel, is found to be apneic, pulseless and with fixed pupils. – When the mechanism of injury does not correlate with the clinical condition, suggesting a medical cause of cardiac arrest, standard resuscitative measures should be followed. DETERMINATION OF DEATH

• Penetrating trauma patient who on the arrival of BLS EMS personnel shall initiate resuscitation until arrival of ALS personnel. ALS EMS personnel, if patient is found to be pulseless, apneic, and there are no other signs of life, including spontaneous movement, electrocardiographic activity, or pupillary response. If resuscitation initiated by BLS, cease resuscitative efforts. • A patient with an approved “Do-Not-Resuscitate” (DNR) document in accordance with Division policy. DETERMINATION OF DEATH

Termination of CPR by Paramedic Personnel: Paramedic personnel may discontinue resuscitative efforts as outlined below: • Any case in which information becomes available that would have prevented initiation of CPR had that information been available before CPR was initiated, CPR should be terminated. • If patient does not meet above criteria, initiate CPR. Consider termination of resuscitation after 30 minutes of resuscitation without ROSC. DETERMINATION OF DEATH

• Personnel may consider further resuscitative efforts in the following situations: • Persistent PEA with End Tidal Carbon Dioxide >20 or trending upwards. • Persistent shockable rhythm • Paramedic judgement • Termination of resuscitation and determination of death should be considered for witnessed traumatic cardiopulmonary arrest patients with a fifteen (15) minute or greater transport time to an ED or with effective (effective bag valve mask ventilations with OPA and NPA (unless contraindicated) successful intubation, or supraglottic airway, thoracic needle decompression (if appropriate), and IV therapy. – Does not apply to lightning strike injuries or drownings – If transport time to an ED or Trauma Center is less than fifteen (15) minutes, transport should be initiated immediately. Resuscitation while in transport. TRANSPORTING CARDIAC ARREST

• EMS personnel shall initiate transport and continue resuscitation ONLY when one of the following factors are present: – ROSC occurs following cardiac arrest – Hypothermia – Barbiturate overdose – Drownings – Patient age <18 years (Patient is a minor) – Extreme, unusual or dangerous social or scene situations. – Provider discretion with base order. KERN COUNTY EMS ONLINE NEW ONLINE CERTIFICATION PLATFORM

Kern County EMS is now 100% online. • We no longer accept walk-ins for certification or recertification. • Everyone that is currently certified in Kern County already has an account. – If logging in for the first time do not create a new account. Click on “forgot username”. You will be asked a few questions, after you answer them it will send you an email with your username and a link to reset your password. NEW ONLINE CERTIFICATION PLATFORM NEW ONLINE CERTIFICATION PLATFORM NEW ONLINE CERTIFICATION PLATFORM NEW ONLINE CERTIFICATION PLATFORM NEW ONLINE CERTIFICATION PLATFORM NEW ONLINE CERTIFICATION PLATFORM PARAMEDIC PROTOCOL EXAM

The paramedic protocol exam will still be administered at public health. After you finish the online process for initial or reaccreditation you will receive a message instructing you to call Kern County EMS and schedule your exam. The exam will be offered Tuesday – Thursday from 0900 to 1500 by appointment only. Excluding county holidays. THANK YOU QUESTIONS? PARAMEDIC UPDATE

2020