The Maryland Medical Protocols for Emergency Medical Services Providers Effective July 1, 2005. Maryland Institute for Emergency Medical Services Systems The complete “Maryland Medical Protocols for Emergency Medical Services Providers” is also avail- able on the Internet. Check out the MIEMSS website www.MIEMSS.org. ii To All Health Care Provides in the State of Maryland: On December 14, 2004 the EMS Board approved the 2005 update of the Maryland Medical Protocols for EMS Providers. The update will be implemented on July 1, 2005 and contains many revisions, as well as a few new protocols that have direct impact on BLS and ALS providers. A two-hour formal update will be required for all EMT-Bs, CRTs, CRT-(I)s and EMT-Ps. A Protocol Update Summary spreadsheet has been developed to provide the reader with a detailed list of each individual protocol revision. The spreadsheet specifically outlines each revision by providing the protocol title with its page and line numbers, as well as the old and new text for each change. The updated material, the entire protocol with the 2005 update revisions, and the Protocol Update Summary can be found in PDF format on the MIEMSS web page at www.MIEMSS.org. The Protocol Review Committee (PRC) has been working diligently to update protocols based only on research or evidence that a revision/addition is warranted. The following are new protocols for 2005: • Apparent Life-Threatening Events (ALTE) • Pain Management Protocol • Universal Algorithm for Pediatric Cardiac Arrest • Procedure page for Tracheostomy Suctioning and Tracheostomy Re-Insertion • The Pediatric Pneumatic Antishock (MAST) have been removed from the Protocol. • Update of the Nerve Agent portion of the WMD treatment protocols In July 2004 the EMS Board approved a revision to the existing Pilot Program for Rapid Sequence Intubations that would allow participants in the Pilot Program to intubate children under the age of 10 years. This revision also included the addition of the medication Etomidate (Amidate) to the RSI protocol. As of January 2005, three jurisdictions (Cecil, Anne Arundel, and Howard counties) are participating in this program in addition to the Maryland State Police Aviation Division. Recommendations for new protocols are encouraged and should be directed to your EMS Operational Program Medical Director or to the Office of the State EMS Medical Director in writing with supporting documentation and/or justification for their implementation. Please send your recommendations by either email ([email protected]) or fax (410-706-0853). Remember it is the responsibility of each provider to review the enclosed material to ensure he/she is familiar with the revisions. If you have any questions regarding the additions or revisions contained in the update, please contact the Office of the State EMS Medical Director at 410-706-0880. Thank you for your continued efforts in making the Maryland EMS system a world leader in the delivery of emergency care. Richard L. Alcorta, M.D., FACEP Robert Bass, M.D., FACEP State EMS Medical Director Executive Director MIEMSS MIEMSS iii THIS PAGE IS INTENTIONALLY BLANK. iv TABLE OF CONTENTS I. GENERAL INFORMATION A. General Provisions 1 B. Important Numbers 3 C. Health Care Facility Codes 5 D. Maryland Trauma and Specialty Referral Centers 13 E. Protocol Key 15 F. Protocol Usage Flow Diagram 16 G. Protocol Variation Procedure 17 H. Inability to Carry Out Physician Order 19 I . Physician Orders for Extraordinary Care 21 J. Quality Review Procedure for Pilot Programs 23 II. GENERAL PATIENT CARE 25 III. TREATMENT PROTOCOLS Abuse/Neglect A. Abuse/Neglect 35 Altered Mental Status B. Seizures 37 C. Unresponsive Person 39 Apparent Life-Threatening Event (ALTE) D. Apparent Life-Threatening Event (ALTE) 41 Behavioral Emergencies E. Behavioral Emergencies 43 Cardiac Emergencies F. Cardiac Guidelines 45 Universal Algorithm for Adult Emergency Cardiac Care for BLS 46 Universal Algorithm for Adult Emergency Cardiac Care for ALS 47 Universal Algorithm for Pediatric Emergency Cardiac Care for BLS 48 Universal Algorithm for Pediatric Emergency Cardiac Care for ALS 49 G. Bradycardia 50 Adult Bradycardia Algorithm 51 Pediatric Bradycardia Algorithm 52 H. Cardiac Arrest 53 Adult Asystole Algorithm 54 Pediatric Asystole and Pulseless Arrest Algorithm 55 Pulseless Electrical Activity (PEA) Algorithm 56 VF Pulseless VT Algorithm 57 I. Chest Pain 58 J. Hyperkalemia 60 v TABLE OF CONTENTS K. Newly Born 62 Universal Algorithm for Newly Born for ALS 63 L. Premature Ventricular Contractions (PVCs) 65 M. ST Elevation Myocardial Infarction [STEMI] (Protocol to be Developed) 66 N. Sudden Infant Death Syndrome (SIDS) 68 O. Tachycardia 69 Adult Tachycardia Algorithm 71 Pediatric SVT Algorithm 72 Pediatric VT Algorithm 73 Do Not Resuscitate P. EMS/DNR Flowchart 74 Environmental Emergencies Q. Cold Emergencies (Frostbite) 75 R. Cold Emergencies (Hypothermia) 77 S. Depressurization 79 T. Hazardous Materials Exposure 80 U. Heat Related Emergencies 82 V. Near-Drowning 83 W. Overpressurization 84 Hyperbaric Emergencies X. Hyperbaric Therapy 85 Non-Traumatic Shock Y. Hypoperfusion 87 Obstetrical/Gynecological Emergencies Z. Childbirth Algorithm 89 AA. Vaginal Bleeding 91 Overdose/Poisoning BB. Absorption 92 CC. Ingestion 94 DD. Inhalation 97 EE. Injection 99 Pain Management FF. Pain Management 101 Respiratory Distress GG. Allergic Reaction/Anaphylaxis 103 HH. Asthma/COPD 106 I I. Croup 108 JJ. Pulmonary Edema/Congestive Heart Failure 110 KK. Stroke: Neurological Emergencies 112 vi TABLE OF CONTENTS Trauma Protocol LL. Burns 114 MM. Eye Trauma 116 NN. Hand/Extremity Trauma 118 OO. Multiple/Severe Trauma 120 Glasgow Coma Scale 122 PP. Sexual Assault 123 QQ. Spinal Cord Injury 124 RR. Trauma Arrest 126 SS. Trauma Decision Tree Algorithm 128 IV. APPENDICES A. Glossary 133 B. Procedures, Medical Devices, and Medications for EMS and Commercial Services 140 C. Rule of Nines 144 D. Normal Vital Signs and APGAR Chart 145 E. EMS/DNR (Do Not Resuscitate) 146 F. Presumed Dead on Arrival 156 G. Physician-Directed Termination of Unsuccessful, Non-Traumatic Field Resuscitation 158 H. Procedures 161 Airway Management Bag Valve Mask Ventilation 161 Combitube 163 Gastric Tube 164 Nasotracheal Intubation 165 Needle DecompressionThoracostomy (NDT) 167 Obstructed Airway Foreign Body Removal: Direct Laryngoscopy 168 Orotracheal Intubation 169 Tracheostomy Change 172 Tracheostomy Suctioning 174 Electrical Therapy Automated External Defibrillation 175 Cardioversion 177 Defibrillation 179 External Transcutaneous Cardiac Pacing 180 vii TABLE OF CONTENTS Hypoperfusion Adjunct PASG (Pneumatic Antishock Garment) 182 Intravenous Access and Maintenance External Jugular (EJ) 184 Glucometer Protocol 185 Intraosseous Infusion (IO) 187 Intravenous Maintenance Therapy for EMT-B 189 Peripheral Intravenous Access for CRT, CRT-(I), and EMT-P, and IV Access Option for EMT-B Approved by the EMS Operational Program 192 Personal Protective Equipment (PPE) 194 Physical and Chemical Restraints 195 I. BLS Pharmacology 199 Activated Charcoal (Without Sorbitol) 199 Albuterol 200 Epinephrine Auto-Injector 201 Nitroglycerin 202 Oral Glucose 203 Oxygen 204 J. ALS Pharmacology 205 Activated Charcoal (Without Sorbitol) 205 Adenosine 206 Albuterol 207 Aspirin 208 Atropine Sulfate 209 Atrovent 211 Benzocaine 213 Calcium Chloride 214 Dextrose 50% 215 Diazepam 216 Diltiazem 217 Diphenhydramine Hydrochloride 219 Dopamine Hydrochloride 220 Epinephrine 222 Furosemide 225 Glucagon 226 viii TABLE OF CONTENTS J. ALS Pharmacology(continued) Haloperidol (Haldol) 227 Lactated Ringer’s 229 Lidocaine 230 Morphine Sulfate 232 Naloxone 234 Nitroglycerin 235 Oxygen 236 Saline Nebulized 237 Sodium Bicarbonate 238 Terbutaline Sulfate 239 Inter-Facility K. Lidocaine Infusion for Inter-Facility Transport 241 L. Morphine Sulfate Infusion for Inter-Facility Transport 242 Pilot Programs M. Adult Rapid Sequence Intubation 245 RSI Pilot Program 245 Ventilatory Difficulty Secondary to Bucking or Combativeness in Intubated Patients 247 Pilot Protocol for Combitube 248 Protocol for Cricothyroidotomy (Surgical and Needle) 249 RSI Quality Assurance Process 251 N. Pediatric Rapid Sequence Intubation 252 RSI Pilot Program 252 Ventilatory Difficulty Secondary to Bucking or Combativeness in Intubated Patients 254 Protocol for Needle Cricothyroidotomy 255 RSI Quality Assurance Process 256 Etomidate 257 Midazolam 258 Succinylcholine 259 Vecuronium 260 V. JURISDICTIONAL OPTIONAL PROTOCOLS O. Continuous Positive Airway Pressure 261 P. Glycoprotein IIb/IIIa Antagonist Infusions 263 Q. Glycoprotein IIb/IIIa Antagonist 264 ix TABLE OF CONTENTS V. JURISDICTIONAL OPTIONAL PROTOCOLS (Continued) R. Heparin Infusion for Inter-Facility Transport 265 S. Heparin 266 T. Administration of MARK I Kits (Atropine and 2-PAM Auto-injectors) 267 U. Transport of Acute Ventilated Inter-Facility Patients 271 V. Transport of Chronic and Scene Ventilated Patients 273 W. Wilderness Emergency Medical Services Protocols 276 x I. GENERAL INFORMATION A. GENERAL PROVISIONS The goal of prehospital emergency medical services is to deliver a viable patient to appropriate definitive care as soon as possible. Optimal prehospital care results from a combination of careful patient assessment, essential prehospital emergency medical services, and appropriate medical consultation. The Maryland Medical Protocols were developed to standardize the emergency patient care that EMS providers, through medical consultation, deliver at the scene of illness or