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 Paramedic 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 Paramedics 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 First Aid 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 recovery position 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 • Blood 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 vomiting • 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 bleeding 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 Cardiac Arrest: 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.