MWLC EMS Continuing Education

January 2017

Cindy Amore R.N. John Pacini D.O. EMS System Coordinator EMS Medical Director

Objectives for this Class:

• Identify the major changes in the SOPs – We will not be reviewing every single language change

– It is your responsibility to review, understand and appropriately utilize the entire document

• Reinforce some SOPs as part of the QI process

New SOPs will go into effect as of March 1, 2017 at 0700

• The BLS next to skills and medications throughout the document means that our system EMTs will be able to perform these items AFTER we complete the skills check offs.

About this document…

Levels of acuity redefined:

• Lower Acuity = Low probability of progression to something more serious

• Emergent = Symptoms may progress to something more severe or result in complications

• Critical = Symptoms of a life threatening illness/injury with high probability of mortality if immediate intervention is not begun

Introduction pg. 1

• EMTs will have an expanded scope of practice and will be able to perform all skills listed

• Paramedics will also have an expanded scope

• We will need to teach all skills on the list

Scopes of Practice pg. 2

New skills for BLS:

Capnography Monitoring

Tracheal-bronchial suctioning

CPAP/PEEP

Alternate extraglottic airways

4L and 12L acquisition and transmission to OLMC

Spiking IV Fluids and setting up tubing for IV

New Medications for BLS:

Albuterol nebulized

Aspirin

Diphenhydramine PO/IM

Ipratropium bromide nebulized

Epinephrine (1mg/1mL) IM from ampule or vial

Glucagon IM or IN

Mark I or DuoDote autoinjector

Naloxone IN & IM

NTG per SOP (opt)

Ondansetron ODT

• New Medications ALS:

• D10

• Naloxone (Dose Change)

• Document total amount of IV fluid infused

• Expanded secondary assessment section in alignment with current EMS standards – please review on your own

• For pain management: pharmacologic and non-pharmacologic options (distraction, cold packs)

• Vital signs: – What is MAP? What does it tell you? – First BP should be manual – why? – Last set should be taken shortly before arrival at

facility

• MAP= diastolic (systolic-diastolic) /3

or

• MAP = SBP + (2 * DBP) 3

• Automatically shows on your monitors when you use auto B/P.

General Patient Assessment/IMC pg. 3 & 4

Pain management alternatives:

If fentanyl is not available, we will go to either morphine or ketamine

Emergency Drug Alternatives pg. 5

• DEXTROSE 10% (25 g/250 mL) IVPB – primary – Alternate will be D50

• Midazolam alternative: Diazepam (valium)

• Dopamine alternate: – Norepinephrine 0.03 mg IVSP with caution

(1mg/10ml) = 0.3 ml dose

Emergency Drug Alternatives (cont’d) pg. 5

• Vasopressor replacing dopamine

• Acts on alpha 1 and alpha 2 receptors

• Causes vasoconstriction and increased peripheral vascular resistance

• Also beta 1 stimulant: increased HR and cardiac output; dilates coronary arteries

Norepinephrine

• Administered IVSP into large vein – watch infusion carefully – causes tissue necrosis if extravasation occurs

• Mixed 1 mg in 10 mL 0.9 NS or D5W

• Adult use only: 0.03mg/0.3ml

• Target SBP > 90 (MAP > 65)

• VERY potent vasoconstrictor – must be administered at correct dose!

• Can lead to limb ischemia/death, organ damage, or loss of fingers and toes

• Contact OLMC – ASAP if infiltration occurs!

Norepinephrine Dosing

• Outlines radio report and ED bedside report

• Under #8: “An EMS “time-out” to allow for uninterrupted report to hospital staff is useful to ensure continuity of care”

• Handoff report – Changes since radio report – Must be given to higher level of care

• DR, PA, NP, RN • not first person in the room (PCT, HUC,

Reg.)

New: OLMC Handover Reports pg. 6

• Under POLST section, further explanation of Section B care

• Outlines components of a valid POLST/DNR Form, #5

Withholding/Withdrawing Resuscitative Efforts pg. 7

“Patient has remained in continuous monitored asystole or cardiac arrest with a non-shockable rhythm with no ROSC after full ALS resuscitation in the field for at least 30 minutes”

Capnography (if available) has remained ≤ 10 for 20 minutes

Mechanical CPR: Should shorten scene time and allow transport before 30 minutes

Termination of Resuscitation pg. 8

Remember to print a strip for the Coroner

• Advanced age should lower threshold for field triage directly to a trauma center, see page 41

• #2: Generally hypertensive, thus normal BP may reflect hypotension

• Also under #2: IV NS up to 1 L: Do not volume overload

• #6: Handle gently: with bone density changes they are predisposed to fractures

• #7: Reminder: Fentanyl dose lower

0.5 mcg/kg up to 50 mcg

Elderly Patients (65 and older) pg. 9

• This protocol applied to those who have a BMI of > 35

• Positioning of Patient should be considered

• Use appropriate sized equipment

• Understand differences to pt. “normal”

Extremely Obese Patients Pg. 10

• Lower Acuity/Mild Systemic Reaction: Diphenhydramine PO added

• Epinephrine changes: – 1:1000 = 1 mg/1mL – 1:10,000 = 1 mg/10 mL

• Picture of vastus lateralis for IM injection - for all IM administration

• For anaphylactic shock: total dose of epinephrine increased to 2 mg reassessing after each 0.1 mg

• If no IV/IO, may repeat 0.5 mg epi in 5 min

• Albuterol/Ipratropium neb may be repeated x 1

• Dopamine removed

Allergic Reactions/ Anaphylactic Shock pg. 13

• Vastus lateralis – Typical injection is 5 mL – Range is 1 to 5 mL – Only EMT-B access site

• Deltoid – Typical injection is 0.5 mL – Range is 0.5 to 2 mL

• Depends on person’s size

Adult Intramuscular (IM) Injection Sites

• Water-based medications = 20 g to 25 g needles

• Length depends on patient size and amount of subcutaneous fat covering the muscle

• Obese patients may need 1½ “ or longer

• Thin patients may need ½” – 1” long

Adult IM Injections: Needle Sizes

• Albuterol/Ipratropium neb may be repeated x 1

• Magnesium: same dose but different delivery method Start 0.9 NS IV first Magnesium Sulfate 2 gms in 40 mL NS

(pre-mix) IVPB using mini-drip tubing (60 drops/mL) to infuse over 5-10 minutes

Asthma/COPD pg. 14

• If aspirin administration prior to EMS arrival can be confirmed then no aspirin administration is required

• Serial 12 leads if initial 12 lead is normal – Repeat at least once or at 10 minutes

• 12 leads should be transmitted and printout brought in with Patient

Acute Coronary Syndrome pg. 16

• Additional descriptions under SOP title

• DOPAMINE IVPB: 5 mcg/kg/min – may titrate up to 20 mcg/kg/min

• Maintain SBP > 90 (MAP > 65)

If Norepi (Alternative) is being used: Proper dosage is critical

Bradycardia with a Pulse pg. 17

• More rhythms listed in title

• Under Low Acuity Section: more rhythms listed in monomorphic section – WPW, irregular wide complex

tachycardia, AF w/aberrancy, AF w/WPW (short PR, delta wave)

• Polymorphic: Magnesium IVPB pre-mix drip 2 gms/40 mL over 10 min

• Under Critical section clarified cardioversion vs. defibrillation

Wide Complex Tachycardia pg. 19

• Use Pit Crew approach

• With EMS witnessed arrest that is a shockable rhythm, before ventilating:

– Do 3 cycles (200 continuous compressions)

– Place NRM at 15 L/min on patient – After above completed, ventilate with BVM,

continue with compressions and treat per SOP

• Unwitnessed arrest: BLS airway, ventilate with BVM and CPR 30:2

• Advanced airway management moved to after vascular access

• BVM at 10 breaths/min; NO hyperventilation

Ventricular Fibrillation & Asystole/PEA pg. 20 & 21

• Drugs for V-fib: epinephrine 1mg/10 mL and amiodarone

• Drugs for Asystole/PEA: epinephrine 1 mg/10 mL

• For persistent/refractory V-fib (after 5 shocks still in V-fib): – Change pad location: A/P & anterior-lateral – Consider dual-sequential defibrillation

• Do not move patient with CPR in progress unless dangerous circumstances. Continue resuscitation for at least 30 min (non-trauma) before moving – Consider Mechanical CPR device

• Arrest due to Drug Overdose: – Follow Cardiac Medications – Naloxone should not be moved up before

cardiac drugs

Ventricular Fibrillation & Asystole/PEA (cont’d) pg. 20 & 21

• 2 sets of monitor pads: one set placed anterior/posterior and one set placed anterior/lateral

• Each set attached to a different monitor/defibrillator

• Each defibrillator is set at 360 joules or biphasic equivalent

• Energy is discharged simultaneously

• Immediately resume CPR

Dual-Sequential Defibrillation

• Do not hyperventilate even if increased EtCO2; BVM at 10 breaths/min

• Maintain SBP > 90 (MAP > 65): – IV wide open – Dopamine removed; norepinephrine

added

• Once ROSC is achieved: monitor femoral pulse, rhythm, SpO2 and EtCO2 – watch for PEA for a minimum of 5 minutes

• If Patient remains unconscious/unresponsive: – Ice packs to cheeks, palms, & soles of

feet; if additional available then also neck, lateral chest, groin, axillae, temples, and/or knees.

• Ideally, Pt should be transported to PCI Center

Ventricular Fibrillation and Asystole: ROSC pg. 20 & 21

• If respiratory distress and CPAP contraindicated, not tolerated or unavailable: consider need for advanced airway

• Cardiogenic Shock: if clear lungs and ventilations unlabored, fluid up to 1 L

Heart Failure pg. 22

• Algorithm removed

• Call LVAD Coordinator and follow their instructions

• Many different devices on the market

Left Ventricular Assist Device (LVAD) pg. 23

For hyperkalemia:

– Administer sodium bicarbonate 50 mEq

slow IVP over 5 min followed by 20 mL saline flush

– Administration of albuterol 5mg continuous neb up to 20 mg

– If no IV, administer the above neb

Dialysis/Chronic Renal Failure pg. 24

*Seizure treat with Midazolam 2mg increments slow IVP every 2 min up to 10 mg titrated to patient response

Withdrawal symptoms added: – May appear within 8 hrs of last drink – Peaks 1-2 days – Lasts for 5 days – Nausea/vomiting – Tachycardia – Tremors – Diaphoresis – Anxious – Agitated/irritable – Tactile, auditory and visual

disturbances – Disorientation & clouded sensorium – Headache

Alcohol Intoxication/Withdrawal pg. 25

Up to 50% Mortality!

• List of differential diagnoses added

• Reminder: narcan is administered to get patient to breath on their own, not to wake them up!

• Narcan for altered mental status and < 12 respiratory rate/respiratory arrest

• Narcan dosing for Opiate Overdose: – If spontaneously breathing: 0.4mg; may

repeat every 30 seconds until ventilations increase up to 4 mg

– If apneic: 1 mg. May repeat every 30 seconds until breathing resumes up to 4 mg. All additional doses per OLMC only

Altered Mental Status pg. 26

• Anxiety or serotonin syndrome: Midazolam 2mg increments slow IVP every 2 min (0.2 mg/kg IN) up to 10 mg titrated to patient response

• Seizures: Midazolam 2mg increments IVP/IO every 30-60 seconds (0.2 mg/kg IN)up to 10 mg IV/IO/IN titrated to patient response

• For both of above: may repeat to total of 20 mg as needed if SBP > 90 (MAP > 65)

Drug Overdose/Poisoning pg. 27 & 28

• Serotonin is a chemical neuro transmitter effecting mood, behavior, sleep, memory, appetite/digestion and sexual drive.

• Caused by too much serotonin in the system

• Therapeutic medication use, inadvertent interaction between drugs and intentional self-poisoning

• Occurs with taking more than one serotonin drug or increasing the dose of one serotonin drug. SSRI drugs include: Paxil, Prozac, Zoloft, Lexapro, Luvox, and Celexa.

• Most present within 6 hours of event but can be up to 24 hrs

• Anxiety, agitation, delirium, diaphoresis, tachycardia, hypertension, vomiting, diarrhea, tremors, & muscle rigidity

Serotonin Syndrome

• Transport lower acuity/stable patients to nearest hospital

• Severely confused but hemodynamically stable patients: consider transport directly to LGH

• Critical patients in respiratory or cardiac arrest or without an airway should be transported to nearest hospital

• In certain industrial scenarios, Cyanokit may be provided in anticipation of a cyanide exposure

Carbon Monoxide pg. 28

Reading on RAD 57

• D10 replaces D50. – Dextrose 50% is alternate

• After dextrose 10% administration, close clamp of dextrose and open 0.9 NS TKO; reassess patient

• After blood glucose has normalized patient can sign refusal if decisional

(OLMC contact is required while with patient)

• Advise patient to call their physician and eat before EMS leaves the scene

Glucose/ Diabetic Emergencies pg. 32

• Additions to SOP title

• Violent or Severe agitation: Midazolam

Psych/Behavioral/Agitated/Violent pg. 34

Centegra Psychiatric Emergency Service (PES) Diversion Decision Matrix pg. 35

• Additional assessment parameters added to identify large vessel occlusions

• IV: – Not necessary at scene unless need to

administer dextrose – Avoid multiple IV attempts – IF an IV is initiated, please start an 18

gauge antecubital to facilitate time to CT

• Last known well is imperative!

• Obtain reliable historian name and phone number – bring to ED and provide to bedside staff

• Scene time < 10 minutes

• Patient’s name and DOB can be given over the phone.

Stroke pg. 36

Stroke Transport Algorithm pg. 37

CSC = Comprehensive Stroke Center PSC = Primary Stroke Center

• Sepsis and septic shock definition

• Suspect septic shock if EtCO2 < 25

• Criteria (qSOFA) 2 or more must be present: – Altered mental status (GCS < 15), – RR > 22, – SBP < 100

• 200 mL NS boluses in rapid succession up to 30 mL/kg to SBP > 90 (MAP > 65); reassess after each bolus

• If hypotension persists after 500 mL, start 2nd IV line for Dopamine

• Continue IV fluids with via 1st IV line

Shock Differential/Hypovolemic – Septic pg. 39

• Breathing: – EtCO2 number and waveform if

possible ventilatory, perfusion, metabolic problem

– Target 92% for COPD unless hyperoxia contraindicated

• Circulation: specific information about tourniquet placement

• EMS “time out” for ED report

• Limb w/ uncontrolled bleeding: Tourniquet 2-3 cm proximal to wound – If bleeding continues, place 2nd

proximal to 1st

Initial Trauma Care (ITC) pg. 40 & 41

• Trauma patients should be taken directly to the most appropriate trauma center using these guidelines

• Hemodynamic stability: Sustained hypotension < 70, pediatrics added

• Anatomic criteria: – Head/Neck section: Skull/eyes/neck added – Chest/Back and Abd/Groin/Pelvis: Superficial

or deep added

Trauma Triage/Transport Criteria pg. 42

• Name revisions – Traumatic Arrest – Conducted electrical weapon: Post-TASER

Care

POST TASER CARE:

• For suspected excited delirium, violent or severe agitation: Midazolam

• Excited delirium, violent or severe agitation: Midazolam 2mg increments IVP/IO every 30-60 seconds (0.2 mg/kg IN)up to 10 mg IV/IO/IN titrated to patient response. Do not give to schizophrenia, psychosis or bipolar mania

Cardiac Arrest due to Trauma Post-TASER Care pg. 43

Excited Delirium

Increased levels of dopamine in the brain

Often due to cocaine use or psychiatric drugs

The elevated levels of dopamine cause agitation, paranoia, and violent behavior

Heart rate, respiration and temperature control are also affected causing tachycardia, tachypnea and hyperthermia

Hyperthermia is a hallmark sign of excited delirium

Treatment: IMC including pulse oximetry

and capnography Use least amount of physical

restraint necessary to subdue the patient

Midazolam per SOP for sedation

IV fluids and cooling (Heat Emergencies/Hyperthermia SOP) as needed

• Airway: – HOB elevated – Secure advanced airway with ties,

no tape to burned skin – If circumferential torso burn,

monitor chest expansion closely

• Indications for IV: – May start through burned skin – Warm fluid if possible – use hot

pack taped to IV – Not in shock – specific fluid rates – Shock = follow Trauma protocols – Document all fluids administered

Burns pg. 44 & 45

• Assess Depth – more information added here

• Calculate % TBSA: – Rule of 9’s OR – Rule of Palms: Patient’s palm and

fingers for irregular shaped burns up to 10% TBSA

– Include only partial and full thickness burns in calculation

– Superficial burns do not cause fluid shift & do not require fluid resuscitation

Burns (Cont’d) pg. 44 & 45

• Thermal Burns – Reason for plastic wrap added – Smaller burns < 5% and eye lids may

have moist dressings – Wrap digits individually – Keep warm

• FYI only: Burn Center Referral Criteria added with list of Burn Centers

• The MWLC System does not ground transport patients directly to a Burn Center.

• FFL to fly to Burn Center

• If they can’t be flown, transport all burns to the appropriate level Trauma Center for evaluation and stabilization

Burns (Cont’d) pg. 44 & 45

• “Deadly Dozen” added

• Tension Pneumothorax: Needle decompression takes priority over airway (OLMC must be called)

• Open Pneumothorax: vented occlusive dressing preferred

• Pericardial Tamponade: Permissive hypotension SBP 80

• Blunt Aortic and Cardiovascular Injury: Aortic information added

Chest Trauma pg. 46

• Nose, ears, midface, mandible, and dentition (teeth)

• Spine precautions, control bleeding

• Do not allow patient to blow their nose

• Vomiting/aspiration precautions: Ondansetron

• Fentanyl for pain

• Avulsed tooth: – Do not touch root – Do not wipe off – May rinse in cold water x 10 secs – Place in milk, saline or commercial

solution – If GCS = 15, may hold tooth in mouth

for transport

New: Facial Trauma pg. 47

• Reminder: No permissive hypotension in multi-system trauma

• If GCS < 8: Keep head of bed flat

• SBP = 110 -120 or higher to maintain cerebral perfusion pressure

• MAP 85-90

• NS IVF boluses 200 mL increments up to 1 L

• DO NOT OVERVENTILATE: Assist/ventilate at 10 BPM prn; maintain ETCO2 at 35-40

Head Injury/Traumatic Brain Injury pg. 48

Suspension Injury

• Reflux Flow Syndrome- Keep Legs flexed even after rescue

• Observe for signs of Hyperkalemia

• Cardiac Monitor

• Position-sitting up-not flat!

• IV TKO- to Wide Open – 1Liter

Crush Injury

• Cardiac Monitor- IV TKO prior to release /Wide Open post release

• Assess for Hyperkalemia

- Sodium Bicarb 50mEq IVSP -5min

or

- Albuterol 5mg continuous neb

Musculo-Skeletal Trauma p. 49

• Prevent hypothermia with SNS disruption: poikilothermia

• Pain management/fentanyl - judicious use of opiates; 0.5 mcg/kg up to 50 mcg. Contact OLMC for additional orders.

• NOTE: This is ½ our normal Fentanyl dose.

Spine Trauma pg. 50 & 51

• Recommendations for Protective Equipment Removal: – Decision to remove equipment should be made

by athletic trainer (if available), EMS and OLMC – Minimum 3 person procedure – Remove equipment if airway cannot be otherwise

secured – If left on, pad around helmet, neck and shoulders

filling any gaps while maintaining axial alignment

• Full face motorcycle helmets: EMS should remove – may cause forward flexion on BB and airway cannot be observed with helmet in place

• Contraindications for removal: Paresthesias or neck pain during removal OR healthcare providers have minimal skills in removal

Protective Equipment Removal pg. 51

• More information in title

• Pediatric dosing for atropine added, 0.2 mg/kg IV/IO min dose 0.1 mg, max adult dose

Neurogenic Shock pg. 51

MCI/Multi Pt scene pg. 52-53

Review of Small Incident vs. Medium/Large Incident Review Specific Divisions (Triage, Treatment, Transport under Medical/EMS (Branch) Review START Triage and JUMP START

• Definitions on page 55

• Guidelines on page 56

• Please review with your department for any procedural questions

New: Active Shooter Response pg. 56-57

• Page re-organized

• Physiological changes during pregnancy added middle of the page, please review on your own

Trauma in Pregnancy pg. 60

• Acrocyanosis definition added

• Periviable birth added (20-26 wks.) – information added with information

to assist with pre-term deliveries

• Contact OLMC for further direction

• Targeted Sp02 After Birth- considerations in your ongoing assessment

• Transport CHH, CHM or GSH

Newborn Resuscitation pg. 64

Magnesium 2 gms/40 mL pre-mix IVPB over 10-15 min

Pre-Eclampsia or Hypertension of Pregnancy pg. 65

• Page 67/Peds ECG: – Consider need for peds 12 lead ECG

based on chief complaint or PMH: same criteria as adults

• Page 68/Vital Signs: Obtain 1st BP manually using size-appropriate cuff (2/3 size of upper arm)

• Page 67/Review of Systems: information added – review on your own

• Page 68/Pain and sedation information added: kids < 6 years old at greater risk for adverse reaction

Pediatric Initial Medical Care pg. 66 - 69

• Children < 12 years of age shall have their airways secured using BLS adjuncts and interventions

• If unable to secure airway with BLS interventions: May make 1 attempt at advanced airway per OLMC only

• Adolescents > 12 years old: manage airway per adult SOPs

• BVM is primary Airway

• Select King Airway based on the child's size not age.

Pediatric Airway Adjuncts pg. 71

• Formerly ALTE

• Definition in SOP: sudden, brief episode of changes in color, breathing, tone or LOC

• Obtain full history

• Perform full assessment including mental status exam, vital signs

• Blood sugar

• All should be transported

New: Brief Resolved Unexplained Events (BRUE) pg. 73

• Epinephrine: – 1mg/1mL – 1 mg/10 ML

• Ipratropium added for pediatrics

• Critical: Albuterol/Ipratropium nebulizer may be repeated x 1

Peds Allergic Reaction/Anaphylactic Shock pg. 74

Always use the vastus lateralis site

Vastus lateralis – Range is 1 to 5 mL

When selecting the volume for a child's intramuscular (IM) injection, consider the: – Child's age – Size of the muscle – Thickness of adipose tissue at the

injection site

Intramuscular Injections for Pediatric Patients

• For neonates and preterm infants: – 5/8” needle – 22G to25G

• Infants younger than 12 months: – 1” needle – 22G to 25 G

• Toddlers 12 months and older: – At least 1” needle – 22G to 25G

Peds IM Injections: Needle Sizes

22 G 25 G

• Ipratropium added

• May repeat Albuterol/Ipratropium nebulizer x 1

• Severe distress: Magnesium 25 mg/kg up to 2 gms in 40 mL IVPB over 10-15 minutes

Peds Asthma pg. 75

• Use EtCO2 for ventilatory, perfusion or metabolism deficit

• Croup – signs/symptoms added

• Epi 1:1000 nebulizer removed

• Epi 1mg/10 mL, 0.5 mg (5 mL) nebulizer added -EMTP skill only

• RSV and Bronchiolitis added with signs/symptoms and management: Epinephrine 1mg/10mL nebulizer, 0.5 mg (5 mL)

Croup/Epiglottitis/RSV/Bronchiolitis pg. 76

• Epi 1mg/10mL

• Dopamine removed

Peds Bradycardia pg. 77

• Magnesium 2 grams/40 mL IVPB

• 25 mg/kg up to 2 grams with mini drip IV tubing over 10 minutes

Peds Wide Complex Tachycardia w/Pulse pg. 79

• Epinephrine 1mg/10mL, 0.01mg/kg = 0.1 ml /kg every 3-5 min during CPR

• Amiodarone: – 1st dose: 5mg/kg up to 300 mg

• 1st dose is same volume as Epi – 2nd dose: 2.5mg/kg up to 150 mg

• 2nd dose is ½ the volume as the 1st

• ROSC: Monitor femoral pulse, EtCO2 and

SpO2 for PEA

Cold packs to cheeks, palms, soles of feet (neck, lateral chest, groin, axillae, temples, and/or behind knees)

Peds Ventricular Fibrillation/Pulseless Ventricular Tachycardia & Asystole pg. 80 & 81

• Follows adult SOP changes

• Under IMC: monitor ECG and consider need for 12 lead ECG

Peds Altered Mental Status pg. 82

• All Dextrose 10%

• Dextrose 25% and 12.5% removed

• For bG < 60: dose remains 0.5g/kg up to 25 g (5 mL/kg)

• For bG 60-70: half the above dose

• If no IV/IO: Glucagon dosing clarified: – < 20 kgs: 0.03 mg/kg (0.5mg) IM/IN – > 20 kgs: 1 mg IN • DKA- IV NS at 10ml/kg over 1 hour

Peds Glucose/Diabetic Emergencies pg. 83

• Follows adult meds with pediatric dosing: – Midazolam

• For suspected Opiate Overdose – Narcan dosing: 0.1 mg/kg up to

0.4mg single dose with repeat dosing every 30 seconds until ventilations increase up to 4 mg

Peds Drug Overdose/Poisoning pg. 84 & 85

• Febrile Seizures

• Assess Hydration- IV attempt x 1

• Passive cooling- prevent shivering

• Don’t forget to check blood glucose!

• Definitions of Generalized Seizures

• Midazolam

• Intrarectal - Diastat

• Don’t forget to check blood glucose !

Peds Seizures Pg. 86

• Definition added: Temporary Protective Custody

• Allows physician to take temporary protective custody if it seems that the child is at risk for harm; allows transport

Suspected Child Abuse or Neglect pg. 89

• CPR Guidelines (page 90) – Updated to current AHA standards

• Drug Appendix (pages 91 – 100) – Updated

• Peds Cardioversion, Dextrose 10% and Ketamine Information (page 101)

• Pediatric Drug Dosing (page 102 & 103)

• Adult Fentanyl, Ketamine, Temperature conversions, and approved drug routes (page 103 & 104)

• QT Intervals, 12 lead placement & interpretation (page 105)

• Approved abbreviations (page 106 – 107)

• Differential for Shortness of Breath & CPAP Information (page 108)

Resource Pages pg. 90 - 111

• Biologic, Nuclear, Incendiary and Chemical Agents (page 109)

• Bioterrorist Agents (pages 110-111)

• Hospital Designations (page 112)

• Pain Scales (page 113)

Resource Pages pg. 90 - 113

• SOP take home exam is posted to the web page – www.centegra.org/emseducation

• Separate ALS and BLS exams and one universal answer sheet

• Open book exam will reference our SOP’s

• All exams are due to the EMS Office by February 28th!

• Two learning packets will be due to the office by March 31st! – Active Shooter Kit – EMS Medication Review

• February session will be implementing SOP’s through scenarios.

For all EMT-B, EMT-P and PHRN’s

Thanks To: ALGH EMS System for the original PowerPoint presentation!

Robyn Mazzolini, BSN, RN, TNS David Hassard, MD EMS System Coordinator EMS Medical Director

This concludes the SOP revision review…