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Region X SOP Review

Changes and Rationales

ECRN CE Mod IV 2011Condell Medical Center

EMS System

Objectives and preparation by Sharon Hopkins, RN, BSN, EMT-PRevised 2.1.12

WATCH FOR INFORMATION ON

CRITICAL MEDICATION SHORTAGES

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Objectives

Upon successful completion of this module, the ECRN will be able to:

Discuss changes to the Region X SOP’sDiscuss changes in drug administration

based on the 2010 AHA guideline changesAcknowledge changes in oxygen

administrationReview the SOP drugsAcknowledge resources in the SOP’s for

medication information

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Objectives

Review the indications for EMS treatments

Review contents in the skills sectionReview contents in the reference

sectionReview case scenariosSuccessfully complete the quiz with a

score of 80% or better

Critical Shortage Medications

• Nation-wide issue

• Will need to flexible in responding to alternatives

• Critical shortage:Diazepam (Valium)EtomidateFentanylOndansetron (Zofran)

Contingency Plan – Med Shortage

Diazepam (Valium) currently unavailableMidazolam (Versed) to be used

Fentanyl is in limited supplyConsider use of Morphine

In absence of Etomidate, reserve field intubation attempts to unconscious/unresponsive patients without a gag reflex (can check for a blink reflex – if present still has a gag reflex)

ECRN must consult ED MD for orders not stated in the SOP’s

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Credible Source for Changes• AHA

– Every 5 years scientific assembly meets with worldwide representation• Research results affect changes to BLS,

ACLS, PALS, NALS programs• Illinois Emergency Medical Services for Children

(EMSC)– Oversees policies, procedures and care of the

pediatric population• International Trauma Life Support

– International representation for trauma care

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Region X SOP Formatting

• Where applicable, if there is an adult protocol, there is generally a matching pediatric protocol

• Multiple reference pages: • - skills/charts for quick access• - pediatric normal vital signs• - Wong-Baker pain scale• - 2010 AHA CPR guidelines• -12 lead placement

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Formatting cont’d

• Drug dosing charts based on weights– Pediatric chart

• 1 table for cardiac medications• 2 tables for general medications• Pediatric weight ranges 2 Lbs to 98 Lbs

–1 Kg to 44 Kg• Lists mL for drawing up the medications at

the patient’s side• Lists mg for aid in documentation

Broselow Tape

• Broselow tape available and used as a reference tool

• Benefit– Guides in choosing equipment sizes

• Limitations– Not all meds in ml which is information

needed when at the beside– May not be as familiar with drug name used

• Diazepam for Valium; Naloxone for Narcan; crystalloids for normal saline

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Formatting cont’d

– Adult chart• Lists medications that must be given by

weight–Etomidate–Fentanyl–Lidocaine for drug assisted intubation

• Adult weight ranges 88 Lbs to 300 Lbs–40 kg – to 136 Kg

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Abbreviations for Documentation

• Last 2 pages list out abbreviations, acronyms, symbols– Common and medically accepted list

• Hospital and EMS resources

• Watch use of abbreviations for misinterpretation– ie: MSO4 is morphine (MgSO4 is mag sulfate and

sounds similar!!!)

• Whenever possible, words should be fully spelled out to avoid confusion

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Global Change

• Oxygen administration– Patient must be assessed for need before

automatically administering oxygenBreathlessnessSigns of heart failureSigns of shockSpO2 <94%

– O2 not required/not found useful • Uncomplicated acute MI (AMI) or ACS

patient without signs of hypoxemia or heart failure

Pulse Oximetry vs Capnography

• Capnography gives an instant and current snapshot of patient’s ventilation status– Measures exhaled CO2– Changes immediately if perfusion returns

(ROSC) or if ventilation drops

• Pulse oximetry change is delayed in time from the actual incident– Can also be falsely elevated in carbon

monoxide exposure giving false sense of security

Capnography

• Departments that have the device will use the device

• Normal readings (patient perfusing and ventilating self) are 35-45 mmHg– Just like a blood gas result

• Readings during effective CPR are >10 mmHG• Reading <8 mmHg during CPR require

reevaluation of technique, equipment and patient

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Global Reinforcement

• Fluid challenges– Global formula is 20 mL/kg all ages

• Adults receive fluid in increments of 200 mL – Move toward total goal (usually 1 – 2L)– Reassess as you move past each 200 mL

increment• Pediatric total calculated at 20 mL/kg

– As you move toward total goal, reassess every 200 mL

• Example: Pediatric patient to get 480 mL of fluid– Reassess at 200 mL; 400mL; then 80mL

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Securing the Airway

• A vague term: - indicates to do what is necessary to ventilate and oxygenate the patient after your assessment of the situation Question: The patient has snoring respirations

– What would be done initially for the airway?• Reposition the patient

–One of the least attempted maneuvers –Often most overlooked technique

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Question - Securing the Airway• The patient is unresponsive and breathing

4 times per minute– What would be the initial response for airway?

• Begin to support ventilations via BVM– 5-6 breaths per minute

• EMS is working a full arrest– They have performed CPR, defibrillated, secured

IV access, and started medications– What can now be done to secure the airway?

• Intubate the patient (ETT, King airway, combitube)• Apply cervical collar to keep tube in place

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Predicting Difficult Intubation

• A tool: Mallampati score • The pharynx is viewed (the oral cavity)

– Scoring• I – Entire tonsil or tonsillar bed visible• II – Upper half of tonsil or tonsil bed seen• III – Soft and hard palates are clearly visible• IV – Only hard palate is visible

– The higher the score, the higher the degree of potential intubation difficulty, the more likely an alternate airway device is used

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Mallampati Score

• EMS can use Mallampati Score as a tool but not obligated to

• Do not expect report to include this score!

Alternative to Endotracheal Intubation

• EMS may place the King airway - more likely if failure with ETT

• Some EMS may place the combitube- rare• If unable to place a device, may assist

ventilations via BVM– Non-intubated patient with a pulse

• Ventilate once every 5-6 seconds– Intubated patient with any device

• Ventilate once every 6-8 seconds

Alternate Airway Devices

• King Airway • Combitube

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Global Additions

• Pain is considered the 5th vital sign– All trauma patients and many medical patients

need pain evaluated and documented

• Time of onset• EMS to be as specific as possible

– Most important to obtain and communicate to ED staff in presence of suspected acute stroke

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CPR Changes

• Change from A-B-C to C-A B– After assessing responsiveness, begin

compressions • Add 2 ventilations after the initial compressions

– There was too long of a delay in starting compressions

– There is always residual oxygen left in the lungs

• Immediately resume compressions after each defibrillation attempt

• Change compressors every 2 minutes during 10 second pause to check rhythm

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CPR changes cont’d

• Pulse checks performed ONLY if there is a rhythm viewed that should produce a pulse– So NO pulse check for VF or asystole

• ROSC - If patient is resuscitated from cardiac arrest, remains unconscious, and pulse is maintained for a minimum of 5 minutes, start to cool the patient– Ice packs in areas with superficial blood

vessels• Back of neck, axilla (armpits), groin, over IV

site

Withdrawing Resuscitation

• Medical Control consultation for an order– Patient normothermic adult– Unwitnessed arrest– Airway secured and IV/IO placement – Patient remains in asystole– No response to at least 20 minutes ALS care

• EMS needs time of order and name of MD authorizing withdrawal– Will continue efforts in pediatric population

• An exception may be extenuating circumstances

Medication Additions

• Etomidate – Drug Assisted Intubation

• Fentanyl – pain control

• Atrovent (Ipratropium Bromide) – bronchodilator & dries secretions

• Zofran (Ondansetron)– nausea/vomiting

– New SOP for adult and peds

Medication Deletions

• Benzocaine – replaced with Etomidate

• Lidocaine – for any cardiac patient; replaced with Amiodarone– Still use for head insult with Drug Assisted

Intubation and comfort with infusion via IO site

• Lidocaine drip – no use for a drip now

• Any Albuterol dose will be mixed with Atrovent for 1st time (Duoneb); repeats just Albuterol alone

Medication Changes

• Etomidate replaces Benzocaine, Versed and Morphine for Drug Assisted Intubation

• Adenosine attempted once in stable adult monomorphic VT before Amiodarone

• Adenosine as a trial in STABLE peds probable VT with adequate perfusion prior to Amiodarone

• Amiodarone started sooner in adult unstable VT requiring cardioversion

Medication Changes cont’d

• Versed 1st line med for active seizures and behavioral situations – can be given IN (intranasally) avoiding needle stick potential

• Fentanyl – 1st pain med over Morphine– Morphine still 1st for Acute Coronary

Syndrome and burns if IV line is established

SOP Revisions

• The following are SOP revisions effective February 1, 2012– Affects Condell and Highland Park EMS

System paramedics– Vista System paramedics will follow previous

version SOP until March 1, 2012

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Drug Assisted Intubation

• Name change to SOP– Better reflects what is being done

• Lidocaine necessary if head insult - medical or trauma (1.5 mg/kg IVP/IO)– Eliminates cough reflex to prevent ICP

• Etomidate (0.3 mg/kg IVP/IO; max 20mg)– As hypnotic, sedative

• Replaces initial Versed, Morphine, Benzocaine

• Versed (2 mg IVP/IO every 2 min to max 20mg)– To keep patient sedated

Peds Drug Assisted Intubation

• NEW!!!

• Similar to adult process

• Added Atropine as a pre-medication– Avoid potential bradycardia from stimulation

during intubation attempts

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Peds Drug Assisted Intubation

• Lidocaine necessary if head insult medical or trauma (1.5 mg/kg IVP/IO)– Eliminates cough reflex to prevent ICP

• Atropine (0.02 mg/kg IVP/IO – max 0.5 mg)– To blunt a bradycardic response when introducing

equipment into the airway• Etomidate (0.3 mg/kg IVP/IO; max 20mg)

– As hypnotic, sedative• Replaces Versed, Morphine, Benzocaine

• Versed (0.1 mg IVP/IO to max 10mg)– To keep patient sedated after intubation– Contact Medical Control if additional sedation is

required

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Asystole/PEA• Atropine eliminated

– Not found to be of any benefit in asystole or PEA

• Lots of CPR, CPR, CPR• No pulse checks for asystole• DO perform pulse check with each rhythm check

for PEA– Maybe some intervention reestablished a pulse

• Search for causes – H’s and T’s• If ROSC, cool patient• If sustained asystole, consider withdrawing effort

– With Medical Control approval in adult patient

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Adult Bradycardia & AV Blocks

• Determine stability of patient– What is their mental status?

• Altered level of consciousness first indicator to change when circulation diminished

– What is the blood pressure?• Feel for a radial pulse

–What is the quality and rate?– If they have a radial pulse, they have at least

a minimal blood pressure• B/P is the last compensation factor to change in

decreased perfusion states

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Adult Bradycardia• Administer Atropine while reaching out

and applying the TCP– “When their alive, give them 0.5” (mg IVP/IO)– If no response to Atropine (response not likely

in second degree Type II or 3rd degree heart blocks)

• Begin pacing– Valium is relatively longer acting than Versed

» Used for sedation– Fentanyl is for pain associated with pacing

• Dopamine is to support B/P

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Adult Acute Coronary Syndrome

• Obtaining a 12 lead as soon as possible will help direct patient care– To give or hold Nitroglycerin

• Held in presence of ST elevation in II, III, aVF (inferior wall MI)

• Held if Viagra type drug use past 24-48 hours• Held if systolic B/P <90

– Results determine activation of hospital cardiac alert • Aspirin is important to inhibit platelet aggregation

– Better to get an extra dose than to not have a dose

– Can hold if patient reliable and DID take ASA• Per AHA, Morphine is the preferred drug in AMI

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Adult Cardiogenic Shock• EMS starts at 5 mcg/kg/min• Expanded dose ranges added for dopamine

5 mcg/kg/min10mcg/kg/min15mcg/kg/min20mcg/kg/min

• Easy way to calculate 5 mcg/kg/min– Determine patient weight in pounds– Take first 2 numbers– Subtract 2– That’s where to start the minidrip– (Ex: 180 # 18 – 2 = 16 mini drips per minute)

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Adult SVT/Rapid A Fib/Flutter

• Determine if the patient is stable or notCheck level of consciousnessCheck blood pressure

• Patient determined to be unstable or relatively stable

–Remember that patients will have symptoms if pulse rapid

»Having symptoms doesn’t necessarily make someone unstable, just symptomatic

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Valsalva Maneuvers if Stable

• Need to stimulate the vagus nerve to slow down the impulses in rapid heart rates– Have patient bear down (carefully) for 10

seconds– Have patient blow through a straw

• Can’t blow through a straw?–Have patient stick their thumb in their

mouth and blow against the thumb–Effective for pediatric population

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Managing Sedation & Pain with Cardioversion

• Cardioversion is a painful procedure

• Versed used to sedate/relax the patient and act as a hypnotic– Not something you want to have memory of!

• Fentanyl can be used to manage any complaints of pain after the procedure– There may be residual discomfort in the chest

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Adult VF/Pulseless VT

• Begin CPR (C-A-B) until defibrillator ready• Biphasic joules amount is based on brand

of defibrillator • Resume CPR immediately after each

shock is delivered• Alternate Epinephrine 1:10,000 with 2

rounds of Amiodarone (300mg 1st dose, then 150 mg 2nd dose in 3-5 minutes)– Amiodarone more effective and

studied/effects reviewed more than Lidocaine

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Adult VT with Pulse

• Stable monomorphic– From beat to beat the complexes have same

shape and form– Trial dose of Adenosine

• Trying to determine if rhythm is SVT with aberrancy or VT

• Relatively safe for diagnosis and treatment• NOT okay if irregular or polymorphic VT

– May deteriorate to VF

• If SVT with aberrancy, may transiently slow down or convert to sinus rhythm

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Monomorphic vs Polymorphic VT

• Polymorphic – complexes change beat to beat

•Monomorphic – complexes appear the same

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Adult VT with Pulse

• Polymorphic VT – Complexes vary from beat to beat– If stable, treatment with Amiodarone

• Amiodarone must be administered slowly in the non-arrested patient (over 10 minutes)

– Watch for hypotension

• Unstable patient with any tachycardia– Losing consciousness– Poor perfusion (B/P <90 mmHg)

• Need to cardiovert

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Cardioversion

• Start at relatively low doses/joules• Increase joules as needed• This is a painful procedure

– Versed used to sedate patient and as amnesic• Relatively short acting• Benefit – it can be given IN via MAD

– Manage pain with Fentanyl

• Will want/need an IV in this population at some time – more unstable patient

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Adult & Peds Seizures

• Why is Versed used?

– Shorter acting than Valium

• Both are Benzodiazepines

– Versed can also be given via the IN route via MAD

• Reduces exposure to inadvertent needle sticks

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Adult & Peds Seizures• Need to determine cause of seizure activity

– If epileptic, head injury, brain tumor type causes, patient will most likely respond to a Benzodiazepine (i.e.: Versed)

– If seizure due to lowered blood sugar level, the patient needs glucose• The brain is starving for sugar, needs

Glucose• Glucagon is a hormone to release sugar

stores if available; it is not sugar– Given IM/IN in absence of IV access

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Adult & Peds Burns

• Why is Morphine used for pain for the patient with burns?– Morphine is longer acting than Fentanyl

• Therefore, less doses should have to administered in the field

– In burns, we know why the patient is having pain; don’t need it “worn off” for assessment at hospital

• In absence of IV access, Fentanyl can be given

IN via MAD

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Adult & Peds Pain Management

• Fentanyl 0.5 mcg/kg (adult & peds)– Synthetic narcotic– Relatively short acting– If respiratory depression, can be reversed

with Narcan• Support respirations via BVM if needed

– Can be given variety of routes• IVP/IN/IO

– Dose calculated by patient weight• FYI - A 875 pound patient would get 198 mcg

(max is 200 mcg)

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Adult & Peds Nausea Management• Zofran (ondansetron) is a frequently used

medication– Adults & peds >40kg – 4mg– Peds <40 kg 0.1mg/kg

• If nausea is relieved, the patient may not need other medication for a secondary problem (i.e.: abdominal pain with nausea)

• Often causes drowsiness– Watch airway for aspiration

precautions

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Peds Bradycardia

• The pediatric etiology of bradycardia is different than the adult population

• First drug is Epinephrine 1:10,000– 0.01 mg/kg IVP/IO– Repeated every 3-5 minutes if no response

• Medical Control to be contacted to consider Atropine order– Most peds patients do not have sick hearts so

usually do not respond to Atropine

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Peds VF/Pulseless VT

• Begin CPR (C-A-B) until defibrillator ready• Defibrillation is 2 joules/kg; then 4j/kg • Resume CPR immediately after each

shock is delivered• Alternate Epinephrine 1:10,000 with 2

rounds of Amiodarone (5mg/kg 1st dose, then 5 mg/kg 2nd dose in 3-5 minutes)– Amiodarone more effective and

studied/effects reviewed more than Lidocaine

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SOP Skill References

• Placed in the SOP’s as a quick “how-to” reference

• Step by step detail to complete a skill

• Located at the back of the SOP’s

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King Airway• New to the Region

• Alternative airway adjunct

• Used as a backup when intubation with the endotracheal tube cannot be accomplished

• Cannot be used in presence of a gag reflex– Check for the blink reflex, if present then gag is

still present– Etomidate used to sedate the patient

• Will control the gag reflex

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King Airway• Contraindications

– Height less than 4 feet• Our tubes sizes are #3, #4, #5

– Sizes match up with heights» #3 for 4-5' heights (yellow tip) (think 3-4-5)» #4 for 5-6' heights (red tip) (think 4-5-6)» #5 for >6' heights (purple tip) (think 5-6)

– Do not want to insert with diseased/damaged esophagus

• Could tear through esophageal wall

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King Airway

• Distal cuff sits in and seals esophagus• Proximal cuff seals oropharynx• Air enters trachea between the cuffs• King does NOT fully protect the airway from

potential aspiration following vomiting – ETT is superior in aspiration protection– Decision by ED MD to extubate King airway and

replace with ETT prior to admission

• No meds administered thru King airway• Ventilate once every 6-8 seconds via King

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Endotracheal Tube vs King Airway

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Assessing Placement of Advanced Airway Devices

• Usual steps– Chest rise and fall– 5 point auscultation

– ETCO2 detector

• Look for yellow

– If capnography, reading 35-40 mmHg

Removing King Airway

• Prepare alternate airway equipment• Deflate cuffs

– One pilot used for both cuffs– Can hold 45-90 ml air depending on size tube

• Extubate similar to removing an ETT• Prepare to oxygenate and ventilate patient

as needed• Secure airway with appropriate alternate

method

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MADD

• Used for medications that can be given intranasally (IN)– Fentanyl IN/IVP/IO– Glucagon IN/IM

• IN works as slowly as IM injection

– Narcan IN/IVP/IO– Versed IN/IVP/IO

• Max volume per nares is 1 mL– Can use divided doses if necessary– If dose <0.5 mL, place in one nostril

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Intraosseous Infusions

• Regardless of site used, equipment is the sameSite preparation material / cleanserDrillNeedlePrimed EZ connect tubingPrimed IV tubing spiked to IV fluid bagPressure bagMethod to secure the site

• Lidocaine useful for pain control during infusion

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Humeral IO Site

• Used as a backup to a peripheral IV site

• Situation in which you NEED IV access

• Proximal humeral site a backup in the adult patient population– Primary site should be the proximal tibial area

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Sizing an IO Needle

• Assess patient to determine the size needle to use for the site used– Palpate over your wrist in line with the thumb

• Do you feel the bone?• If you feel the child’s tibia like this, use the shorter pink

needle

– Palpate the inside crook of your elbow• Do you feel the meatiness?• If you feel the child’s tibia like this, use the middle sized blue

needle

– Humeral site for the adult• Always use the long yellow needle

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Adult Humeral

Head Site

Need to keep arm

immobilized after needle placement

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Tibial Insertion Site

• Palpate over site to determine length needle required

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Inserting the IO Needle

• Needle inserted until resistance is felt– You are touching bone

• Look to see at least one black line – If no black lines are visible the needle is too

short

• Then drill to seat the needle in the bone

Removing an IO Needle• Establish an alternate IV site• Stop IO infusion system• Remove IV tubing and EZ connect extension

tubing• Connect a syringe to needle hub

– Gives you something to hold onto

• As you turn syringe clockwise, exert steady, gentle pull– Turning counter clockwise just disconnects the syringe– It takes quite a few turns to remove the needle

• As the needle is removed, place bandaid over site

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Needle Decompression• Site remains the 2nd intercostal site,

midline of the clavicle

• Flutter valve not necessary– Air will enter the larger diameter (trachea vs

needle in the chest)

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2010 AHA CPR Guidelines • You should have been updated in the

2010 AHA guidelines by now or heard of the changes

• Key points– Push hard, push fast (rate at least

100/minute)– Ventilate slower

• 1 breath every 6 seconds

• Immediately resume CPR after each defibrillation attempt

• Switch compressors every 2 minutes

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ROSC & Cooling

• Return of spontaneous circulation– Following cardiac arrest– Patient remains unconscious & unresponsive– Pulse is present at least 5 minutes– B/P able to be maintained >90

• Not recommended for respiratory arrest• Remember – if patient is able to complain about

the coldness of the ice packs, they don’t need to be cooled

• Ice packs used by EMS

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SOP References

• Placed in the SOP’s to be immediately available for review as needed

• Are adjuncts to the SOP’s• Useful information available that can be

referenced – Nice to have available when you are not sure of a

process– Contains reference tables of norms

• Vital signs• Equipment

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Pain Scales

• Wong-Baker FACESTM Pain Rating Scale– Useful for 3 year-old and older– Useful for non-English speaking patients– Point to the face and read the description– Ask the patient to point to the face that describes their

pain• FLACC Pain Scale

– An observer related method to assess for pain– Evaluates the face, legs, activity, crying, and

consolability

• Copyright 1983, Wong-Baker FACESTM Foundation, www.WongBakerFACES.org. Used with permission.

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Peds Cardiac Medication Chart

• Provides information in a quick reference format• Includes information on:

– Adenosine (Adenocard)– Amiodarone (Cordarone)– Atropine– Epinephrine 1:10,000– Versed (midazolam)– Cardioversion joules– Defibrillation joules

• Great reference for drawing up medication and documenting the mg administered

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Peds Medical Medication Chart

• Provides information in a quick reference format• Includes dosing information on:

– Dextrose 25%– Dextrose 12.5%– Glucagon– Narcan (Naloxone)– NS IV fluid challenge– Valium (Diazepam)– Epinephrine 1:1000

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Peds Medical Medication Chart cont’d

• On additional sheet:– Etomidate– Fentanyl– Lidocaine (Xylocaine)– Ondansetron ( Zofran)– Morphine – Benadryl (Diphenhydramine)

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Adult Weight Based Medication Chart

• Provides information in a quick reference format

• Includes dosing information on:– Etomidate 0.3 mg/kg IVP/IO– Fentanyl 0.5 mcg/kg IN/IVP/IO– Lidocaine 1.5 mg/kg IVP/IO (DAI)

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Drug Information List

• Reference guide listing information on medications used in the Region X SOP’s– Information not all inclusive

• Supplement to other drug reference material

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Region X Drug Route Options

• Lists routes appropriate for the list of medications used in the Region x SOP’s

• Choice of drug route is based upon patient assessment at the time of need

• If any question of the appropriateness of the route, Medical Control will be contacted and consulted

• For ANY orders from Medical Control, the ECRN MUST consult with the ED MD

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Region X SOP Medications

• The following are medication guidelines

• Each medication lists the SOP it is associated with– Currently, there are shortages for

manufacturing of some medications– Note, substitutions may need to be

considered

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Adenosine in Region X SOP’s(Adenocard)

• To slow the ventricular response

• Can be a diagnostic tool Adult stable SVT Adult stable monomorphic Ventricular

Tachycardia Pediatric Tachycardia with Adequate

Perfusion (probable stable SVT or stable VT) Pediatric Tachycardia with Poor Perfusion –

probable SVT

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Albuterol in Region X SOP’s

• As a bronchodilator

Adult Asthma/COPD with Wheezing Peds Asthma Adult & Peds Allergic Reaction, Anaphylaxis if

wheezing Croup if wheezing

• First dose only mixed with Atrovent (duo-neb treatment)

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Amiodarone in Region X SOP’s

• Antidysrhythmic

Adult and Pediatric Ventricular Fibrillation(VF) / PulselessVentricular Tachycardia

Adult stable/unstable Ventricular Tachycardia or Wide Complex Tachycardia with a pulse

Pediatric Tachycardia with Adequate Perfusion – probable VT

Pediatric Tachycardia with Poor Perfusion – with orders from Medical Control

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Aspirin in Region X SOP’s

• To block platelet aggregation/clumping

Acute Coronary Syndrome

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Atropine in Region X SOP’s

• To increase the heart rate

Adult symptomatic bradycardia Pediatric bradycardia not responsive to

Epinephrine 1:10,000 and under Medical Control orders

In Pediatric Drug Assisted Intubation• To blunt the reflexive bradycardia from

vagal stimulation during intubation attempts

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Atrovent® in Region X SOP’s(Ipratropium Bromide)

• Ih-prah-trow-pea-um

• Bronchodilator, to reduce bronchospasm– Dries secretions

• Mixed with first dose Albuterol only Adult Asthma/COPD with Wheezing Pediatric Asthma Adult and Pediatric Allergic Reaction /

Anaphylaxis if wheezing Croup if wheezing

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Benadryl in Region X SOP’s(Diphenhydramine)

• Antihistamine to stop the release of histamines and stop the resultant signs and symptoms that occur

Adult and Pediatric Allergic Reaction and Anaphylaxis

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Dextrose in Region X SOP’s

• To replace low sugar levels Adult and Pediatric Altered Mental Status if

blood sugar <60 Stroke if blood sugar <60 Diabetic Emergencies if blood sugar <60 Adult and Pediatric Seizures if blood sugar

<60 Head Injuries if blood sugar <60

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Dopamine in Region X SOP’s

• To support failing blood pressures by improving contractility

Adult Bradycardia when Atropine ineffective Cardiogenic Shock

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Epinephrine 1:1000 in Region X SOP’s

• Bronchodilator, vasoconstrictor Adult Asthma/COPD with Wheezing

For severe distress; Medical Control order only Adult and Pediatric Allergic Reaction and

Anaphylaxis with airway involvement (FYI: IM route faster than SQ absorption in shock states)

Pediatric Asthma with Medical Control orders Pediatric Croup and Epiglottitis if not

improving with initial treatments

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Epinephrine 1:10,000 in Region X SOP’s

• Vasoconstrictor to support perfusion

Adult and Pediatric Asystole and PEA Adult and Pediatric Ventricular Fibrillation (VF)

/ Pulseless Ventricular Tachycardia (VT) Adult and Pediatric Anaphylaxis with Medical

Control orders for worsening condition Pediatric Bradycardia

Peds patients do not respond to Atropine as they generally do not have diseased hearts

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Etomidate in Region X SOP’s

• Short acting hypnotic

Adult Drug Assisted Intubation Pediatric Drug Assisted Intubation

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Fentanyl in Region X SOP’s

• For pain relief• Can be given a variety of routes (IN, IVP, IO)

Adult and Pediatric Pain Management Adult Bradycardia with TCP application Adult Supraventricular Tachycardia if cardioverted Adult Rapid Atrial Flutter / Fibrillation (Narrow

Complex Tachycardia) if cardioverted Adult Ventricular Tachycardia or Wide Complex

Tachycardia (Patient with a Pulse) if cardioverted Adult & peds Burns if no IV access

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Glucagon in Region X SOP’s

• Hormone to stimulate the release of sugar stores (is not a sugar) Adult and Pediatric Altered Mental Status if no

IV access and blood sugar <60 Stroke if no IV access and blood sugar <60 Diabetic if no IV access and blood sugar <60 Adult and Pediatric Seizures if no IV access

and blood sugar <60 Head Injury if no IV access and blood sugar

<60

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Lasix in Region X SOP’s

• Diuretic

Pulmonary Edema Hypertensive Emergency

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Lidocaine in Region X SOP’s

• To blunt the cough reflex to prevent an increase in intracranial pressure during intubation Adult Drug Assisted Intubation Pediatric Drug Assisted Intubation

• For pain relief during infusion of fluids via IO sites Adult EZ IO insertion Pediatric EZ IO insertion

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Morphine in Region X SOP’s

• Opioid, narcotic, pain relief, reduces preload via vasodilation

Acute Coronary Syndrome Pulmonary Edema Adult and Pediatric Burns if IV access

available

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Narcan in Region X SOP’s(Naloxone)

• Narcotic antagonist to reverse respiratory depression

Adult and Pediatric Altered Mental Status Adult and Pediatric Pain Management if

respiratory depression occurs following Fentanyl

100

Nitroglycerin in Region X SOP’s

• Venodilator to reduce the preload and reduce the work load of the heart

Acute Coronary syndrome Pulmonary Edema Hypertension Emergency with orders from

Medical Control

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Valium in Region X SOP’s(Diazepam)

• Benzodiazepine

• Relax the patient, reduce anxiety, amnesic Adult Bradycardia when the TCP is used Adult and Pediatric Heat Emergencies if the

patient begins to shiver during the cooling process

Behavioral Emergencies – if additional sedation required after Versed

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Verapamil in Region X SOP’s

• To slow down rapid atrial fibrillation and flutter Adult Supraventricular Tachycardia (Narrow

Complex Tachycardia (SVT) - stable Adult Rapid Atrial Flutter / Fibrillation (Narrow

Complex Tachycardia) - stable

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Versed in Region X SOP’s(Midazolam)

• Benzodiazepine• Relax the patient, reduce anxiety, amnesic

Adult and Pediatric Drug Assisted Intubation Cardioversion with unstable rapid Atrial Fibrillation /

flutter, unstable SVT, unstable VT Adult and Pediatric Seizures Head Injuries if seizure activity Hypertensive OB if actively seizing Pediatric Tachycardia requiring cardioversion Behavioral Emergencies – Adult

Medical Control order for peds patient

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Zofran® in Region X SOP’s(Ondansetron)

• On-dan-sah-tron

• Antinausea, antiemetic

Adult and Pediatric Nausea

Case Scenario Practice

• Read the cases

• Determine the appropriate ECRN response

• Click on the slide / press “page down” and the answer will appear

Case Scenario #1

• EMS arrives to the ED with a patient that has been intubated

• Report did not indicate any trauma• Why would the patient have a cervical collar in

place?– Applying a cervical collar after intubation minimizes

neck movement– The distal tip of the ETT is less likely to slip out of

place if a cervical collar is applied along with the usual methods of securing the airway in place

Case Scenario #2• EMS is on the scene of a full arrest• The adult patient has remained in asystole• What medications would have been

given?– Epinephrine 1:10,000 1 mg every 3-5 minutes

• Can EMS withdraw resuscitative efforts?– After Medical Control is contacted for an order

• If EMS must transport the body, can they bring the patient to the hospital?– Yes, the hospital may have to take the body

that cannot be left at the scene

Case Scenario #3

• EMS calls with an adult patient with symptomatic bradycardia

• What drug and dose has been given?– Atropine 0.5 mg IVP/IO– May be repeated every 3-5 minutes to a max

of 3mg

• When should a TCP be applied?– If the patient is unresponsive to Atropine

Case Scenario #3

• What is different about treatment for a symptomatic pediatric bradycardia?– Initial medication is Epinephrine 1:10,000

0.01 mg/kg IVP/IO– Epi repeated every 3-5 minutes if no response– For persistent bradycardia with hypotension,

Medical Control contacted for orders• Medical Control may consider

Atropine 0.02 mg/kg IVP/IO

Case Scenario #4

• EMS calls with report of a patient with chest pain• 12 lead EKG reveals ST elevation in II, III, aVF• What medications are given; which are held?

– Aspirin should be given (324 mg chewed)• Can be held if patient reliable and Ems sure dose

was taken– Consult with ED MD regarding nitroglycerin

• Can cause hypotension• Patient should also be screened for Viagra type

drug use past 24-480 (causes hypotension resistant to treatment)

Case Scenario #5

• When would EMS begin to cool a patient who had been worked as an arrest?– Patient suffered a cardiac arrest (not

respiratory arrest)– After the patient has pulses for at least 5

minutes– Blood pressure maintained >90 systolic– Patient remains unresponsive

Case Scenario #6• How can Fentanyl be administered for Region X

EMS? IN via MAD IVP IO

• What are additional/alternative methods to address pain control?Positioning ImmobilizationElevation IceDistraction

Case Scenario #7• EMS is on the scene of a patient in

pulmonary edema• What treatment/medications are you

anticipating have been given if the patient is relatively stable?– Nitroglycerin repeated every 5 minutes x3– CPAP started after first NTG given– Lasix 40 mg IVP (80 mg if on med at home)– Morphine 2 mg IVP; repeated every 2 minutes

to max of 10 mg if B/P remains >90

Case Scenario #8

• EMS calls with a patient from a minor MVC

• The 15 year-old female wants to sign a release; she has no complaints/injuries– This patient is pregnant– Can she sign a release/refusal?

• Yes, she is emancipated due to the pregnancy

• If she remains the parent after delivery, she remains emancipated regardless of where she is living

Case Scenario #9

• EMS calls for a conscious, alert, cooperative patient who refuses transport

• The patient’s Durable Power of Attorney for Healthcare is also present– The DPOA wants the patient transported

• Who gets to speak for the patient?– The DPOA gets to speak when the patient is

no longer able to speak for themselves• Follow the wishes of the patient at this point

Case Scenario #10

• EMS calls from the scene for an imminent delivery

• If report includes a non-delivered breech birth or a prolapsed cord, what specific information do you want to hear in report?– Confirm that someone has fingers inserted

into the vagina during transport• For a stuck breech, create an airway for the infant• For a prolapsed cord, push against the presenting

part to allow blood flow through the cord

Case Scenario #11• In what circumstances would the King

airway be used?– Difficult/challenging intubation

• 2 failed attempts via endotracheal tube (ETT)• Poor visibility of anatomy• Short, thick necks

• SOP skill reference:– “Cardiac or respiratory arrest, unresponsive

medical or trauma patient without a gag reflex in which endotracheal intubation is unable to be established.”

Case Scenario #12

• In which cases is EMS mandated reporters?– Suspected child abuse– If release signed, then domestic violence

reported to local police• Local community informational brochure to be

offered to patient that signs a release

– Suspected elder abuse/neglect

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Bibliography

• 2010 American Heart Association Guidelines for CPR and ECC

• ITLS 6th Edition• Illinois Emergency Medical Services for Children.

Pediatric Prehospital Protocols. January 2008.• Region X EMS Standard Operating Procedures 2011

Teaching Document• CMC EMS System November 2011 CE• CMC EMS System October 2011 CE• CMC EMS System September 2011 CE• www.Kiingsystems.com/wp-contact/uploads/2010/09/

INFM-63-KLTSS.pdf• www.WongBakerFACES.org