The Maryland Medical Protocols for Emergency Medical Services Providers Effective July 1, 2010 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 2010 PROTOCOL UPDATE SUMMARY MARYLAND MEDICAL PROTOCOLS FOR EMS PROVIDERS PROTOCOL TITLE CURRENT PAGE # LINE # ORIGINAL NEW INFORMATION New text has been added. The new text reads: Contents v III.J. J. Hyperkalemia J. Hyperkalemia: Renal Dialysis/Failure or Crush Syndrome Airway Management Contents vii This text has been deleted as Combitube has been removed from the protocols. Combitube The pilot protocol for Combitube has been removed. Combitube is no longer an approved airway Contents ix Pilot Protocol for Combitube device. General Information 17 I.G. The protocol variation procedure has been revised. General Information 19 I.H. The inability to carry out physician order protocol has been revised. This text has been revised. The text now reads: GPC 26 Chart (moderate hypoxia) Give 100% Oxygen Consider Assisting Ventilations Give 100% Oxygen, assisting ventilations. GPC 27 Chart The nasal cannula concentration has been changed. The new text reads: 24-44% (b) If patient is symptomatic with poor perfusion (unresponsive This text has been corrected. The new text reads: GPC 27 II.D.4.a)(2)(b) or responds only to painful stimuli) and pulse is greater than 60 ……and pulse is less than 60 bpm: bpm: Pediatric section of the treatment protocol will be used for New text has been added. The text now reads: GPC 31 II.F.3.a) children who have not reached their 15th birthday (trauma and Pediatric section of the treatment protocol will be used for children who have not reached their 15th medical). birthday (trauma and medical), except as otherwise stated in the treatment protocol. New text has been added and the remainder of the outline re-numbered. The new text reads: Providers should obtain on-line medical direction to administer other prescribed rescue medications GPC 31 II.F.3.C NEW not specifically mentioned in the Maryland Medical Protocols for EMS Providers (e.g. Solucortef for Adrenal Insufficiency). The rescue medication must be provided by the patient or caregiver and the label must have the patient's name and the amount of medication to be given. A new ALERT has been added. The new text reads: GPC 31 ALERT NEW Do not administer oral medications (except glucose paste) to patients with an altered mental status. New text has been added to the outline. The new text reads: d) Provide patient trauma Decision Tree Category (A-D). GPC 32 II.G.5. NEW e) Provide assigned patient priority (1 to 4). f) Pertinent patient signs and symptoms (e.g. HR, RR, BP, Pulse Ox, and GCS) If patient is a known diabetic, glucose paste (10-15 grams) New text has been added. The new text reads: Altered Mental Status: Seizures 37 III.B.3.b)(2) should be administered between the gum and cheek. …..Consider single additional dose of glucose paste if not improved after 10 minutes. A new ALERT has been added. The new text reads: Altered Mental Status: Seizures 37 ALERT (Bottom) NEW If patient is pregnant, continue with seizure protocol and use midazolam. Medical consultation required for pregnant patients who may require larger doses of midazolam to control seizures. If patient is a known diabetic, glucose paste (10-15 grams) New text has been added. The new text reads: Altered Mental Status: Seizures 38 III.B.g)(2) should be administered between the gum and cheek. …..Consider single additional dose of glucose paste if not improved after 10 minutes. Administer glucose paste (10-15 grams) between the gum and New text has been added. The new text reads: Altered Mental Status: Unresponsive Person 39 III.C.3.b) cheek. …..Consider single additional dose of glucose paste if not improved after 10 minutes. Administer glucose paste (10-15 grams) between the gum and New text has been added. The new text reads: Altered Mental Status: Unresponsive Person 40 III.C.3.j) cheek. …..Consider single additional dose of glucose paste if not improved after 10 minutes. The pacer age-related box has been added to the pediatric bradycardia algorithm for quick Pediatric Bradycardia Algorithm 51 Pacer age-related rates box NEW reference. (f) - Transcutaneous Pacing available for CRT-(I) & EMT-P This text has been revised. Medical consultation is no longer a requirement in the pediatric Pediatric Bradycardia Algorithm 51 Footnote (f) only. Medical consultation required. bradycardia algorithm.. New text has been added to the heading. The new text reads: Cardiac Emergencies: Hyperkalemia 59 III.J. Cardiac Emergencies: Hyperkalemia Cardiac Emergencies: Hyperkalemia (Renal Dialysis/Failure or Crush Syndrome) Suspected Hyperkalemia (e.g. crush syndrome) or renal dialysis This text has been revised. The new text reads: Cardiac Emergencies: Hyperkalemia 59 III.J.3.a)(1) patients (1) Suspected hyperkalemia patient Cardiac Emergencies: Hyperkalemia 59 III.J.3.a)(1)(a) NEW a) Renal dialysis/failure with poor or non-functioning kidneys or Cardiac Emergencies: Hyperkalemia 59 III.J.3.a)(1)(b) NEW b) Crush syndrome or patients with functional kidneys by history New text has been added and the outline has been re-lettered. The new text reads: Cardiac Emergencies: Hyperkalemia 59 III.J.3.f) Initiate Bradycardia protocol. h)……Consider sodium bicarbonate 50 mEq IV over 5 minutes. New text has been added and the remainder of the outline re-lettered. The new text reads: Cardiac Emergencies: Hyperkalemia 59 III.J.3.h) NEW i) Consider/administer albuterol (high dose) via nebulizer 20 mg (if available). A new ALERT has been added. The new text reads: Cardiac Emergencies: Hyperkalemia 59 ALERT NEW Flush IV with 5 mL of Lactated Ringer's between calcium and sodium bicarbonate administration. 2010 PROTOCOL UPDATE SUMMARY MARYLAND MEDICAL PROTOCOLS FOR EMS PROVIDERS PROTOCOL TITLE CURRENT PAGE # LINE # ORIGINAL NEW INFORMATION New text has been added and the remainder of the outline re-lettered. The new text reads: (j) Crush Syndrome or patients with functional kidneys by history; consider/administer sodium Cardiac Emergencies: Hyperkalemia 59 III.J.3.i) NEW bicarbonate 50 mEq SLOW IV over five minutes, then initiate drip of sodium bicarbonate 100 mEq in 1000 mL to run over 30-60 minutes. (Reserve for patients suspected of Crush Syndrome or with functional kidneys by history.) New text has been added and the outline re-lettered. The new text reads: Cardiac Emergencies: Hyperkalemia 60 NEW q) Consider/administer albuterol via nebulizer. (1) Patients 2 years of age or greater, administer albuterol 2.5 mg (2) Patients less than 2 years of age, administer albuterol 1.25 mg A new ALERT has been added. The new text reads: Cardiac Emergencies: Hyperkalemia 60 ALERT NEW Flush IV with 5 mL of Lactated Ringer's between calcium and bicarbonate administration. New text has been added and the outline re-lettered. The new text reads: (r) Crush Syndrome or patients with functional kidneys by history; consider/administer sodium Cardiac Emergencies: Hyperkalemia 60 NEW bicarbonate 1 mEq/kg IV over five minutes. Maximum dose 50 mEq. (Reserve for patients suspected of crush syndrome or with functional kidneys by history.) Acute coronary syndrome (ACS) is defined as patients presenting New text has been added to the ALERT. The new text reads: Cardiac Emergencies: ST Elevation Myocardial Infarction with angina or anginal equivalents such as chest, epigastric, arm, Acute coronary syndrome (ACS) is defined as patients presenting with angina or anginal 65 ALERT-top of page [STEMI] or jaw pain or discomfort and may be associated with equivalents such as shortness of breath, chest, epigastric, arm, or jaw pain or discomfort and may diaphoresis, nausea, shortness of breath or difficulty breathing. be associated with diaphoresis, nausea, shortness of breath, or difficulty breathing. c) If patient meets one of the above condition sets for STEMI This text has been revised. The new text reads: inclusion criteria, the patient shall be transported to the closest Cardiac Emergencies: ST Elevation Myocardial Infarction c) If patient meets one of the above condition sets for STEMI inclusion criteria, the patient shall be 65 III.M.3.c) Primary STEMI Center unless the transport time is more than 30 [STEMI] transported to the closest Cardiac Intervention Center by ground as long as the transport time is not minutes greater than the transport time to the closest STEMI more than 30 minutes greater than transport to the nearest ED. Transfer Center or Emergency Department. d) When indicated and based on the EMS provider's report, the This text has been revised. The new text reads: Cardiac Emergencies: ST Elevation Myocardial Infarction 65 III.M.3.d) Base Station physician at the receiving Primary STEMI Center d) When indicated and based on the EMS provider's report, the Base Station physician at the [STEMI] will activate its Cardiac Intervention Team. receiving Cardiac Intervention Center will activate its Cardiac Intervention Team. New text has been added. The text now reads: g) Patient who presents with inferior wall MI, clear lung sounds, g) Patient who presents with inferior wall MI, (perform right side V4r to rule out right and hypotension (90 systolic) (40% of inferior wall MI have right Cardiac Emergencies: ST Elevation Myocardial Infarction ventricular involvement-if ST elevation present in V4r withhold nitrates) clear lung sounds, 66 III.M.3.g) ventricular infarction) should be given a fluid bolus of 250-500 [STEMI] and hypotension (90 systolic) (40% of inferior wall MI have right ventricular infarction) should be mL of Lactated Ringers. For additional bolus, perform medical given a fluid bolus of 250-500 mL of Lactated Ringer's.