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transcript
Patient Care Protocols (Blue Book)
andEMS Update 2007
Seattle—King County
Seattle—King County EMSSeattle—King County EMS
Introduction
Indicates a change or update from the 2005 blue book (NOT necessarily a change or update to current protocols).
Seattle—King County EMSSeattle—King County EMS
Alerts & After—Care Instructions
EMTs will leave alerts or after—care instructions as indicated for the following patients: High blood pressure
High blood sugar Low blood sugar
You must document that an alert or after—care instruction was provided and verify the patient's home phone
number.
You must document that an alert or after—care instruction was provided and verify the patient's home phone
number.
Page 63
Seattle—King County EMSSeattle—King County EMS
Alerts & After—Care Instructions
Inclusion
Page 63
Diabetic with sugar ≥ 300Non diabetic with sugar ≥ 175
Paramedic transported patientNursing home patients
Use judgment with trauma patients
Exclusion
Optional
Seattle—King County EMSSeattle—King County EMS
Alerts & After—Care Instructions
Inclusion
Page 63
Any patient with a systolic ≥ 160 mmHg or diastolic ≥ 100 mmHg
Paramedic transported patientNursing home patients
Use judgment with trauma patients
Exclusion
Optional
Seattle—King County EMSSeattle—King County EMS
Alerts & After—Care Instructions
Inclusion
Page 63
Diabetic on insulin who responds fully to oral glucose and who is stable enough to remain at home
Paramedic or EMT transported patient
Exclusion
Seattle—King County EMSSeattle—King County EMS
Personal Protective Equipment (PPE)
Pages 104—105
Hand washing is the most effective way to prevent transmission of infectious disease. Hand washing is the most effective way to prevent transmission of infectious disease.
Wash hands:
After patient contactBefore eating, drinking, smoking, or handling foodBefore and after using the bathroomAfter cleaning or checking equipment
Seattle—King County EMSSeattle—King County EMS
PPE, continuedPages 104—105
Gloves and eye protection should be worn for every patient.
Gloves and eye protection should be worn for every patient.
• Gloves • Eye protection (such as glasses,
face shields and goggles)• Fit-tested masks (such as N95
and N100 masks)• Gowns (or suits)
FULL PPE for possible infectious contacts:
Seattle—King County EMSSeattle—King County EMS
PPE, continuedPages 104—105
Put on PPE before entering the patient area.
The sequence for donning PPE is MEGG:1. Mask2. Eye protection3. Gown4. Gloves
Mask patient if possible.Mask patient if possible.
Seattle—King County EMSSeattle—King County EMS
PPE, continuedPages 104—105
The sequence for doffing PPE is:
1. Gloves2. Gown—hand washing min 20 sec.3. Eye protection4. Mask—hand washing min 20 sec.
Handle equipment as contaminated waste.
Decontaminate eye protection.
Handle equipment as contaminated waste.
Decontaminate eye protection.
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PPE, continuedPages 104—105
Febrile Respiratory Illness
• Dispatchers will notify units of infectious symptoms or locations.
• Dispatch info or fever w/ cough or illness or possible infectious disease
Full PPE required.
Limit patient contacts.
Full PPE required.
Limit patient contacts.
Seattle—King County EMSSeattle—King County EMS
PPE, continuedPages 104—105
After patient contact:
• Remove PPE –- (approved sequence).• Dispose of PPE as contaminated waste.
On-scene decontamination:• eye protection & equipment w/
germicidal cleaner.
Hospital decontamination:
• eye protection, equipment and apparatus.
Seattle—King County EMSSeattle—King County EMS
PPE, continuedPages 104—105
At station:
• Decontaminate affected equipment & contacts (kits, BP/steth, radios, clipboards, etc.).
• Wash hands before leaving apparatus floor.
Seattle—King County EMSSeattle—King County EMS
Taser Dart Removal and Care
See pages 126-128 of the Blue Book (PCP) for a detailed description of Taser darts, Taser removal, EMS care and transport policies for all patients.
Pages 126—127
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All EMTs are now encouraged to incorporate the SICK/NOT SICK approach into patient assessment
PCP provides a brief overview of SICK/NOT SICK
Sick/Not SickPages 10—17
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ALS Indicators
PCP now has a two-page summary of all ALS Indicators — conditions that require a medic response
Specific ALS indicators for some conditions have been changed and are listed under each condition below
Pages 59-60
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Cardiac Arrest
For initial analyis After delivering one shock, immediately begin
2 minutes of CPR If no shock indicated, immediately begin 2
minutes of CPR After 2 minutes of CPR, reanalyze the
rhythm If a shock is indicated, immediately deliver a
single shock If no shock is indicated, immediately check
pulse. If no pulse, then begin 2 minutes of CPR
Pages 22—23
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Anaphylaxis
BLS Care
Page 9
• Any patient who receives an EpiPen (pre– or post—EMS arrival) should be transported and evaluated in a hospital.
• Mode of transport depends on clinical symptoms and findings.
• Any patient who receives an EpiPen (pre– or post—EMS arrival) should be transported and evaluated in a hospital.
• Mode of transport depends on clinical symptoms and findings.
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Page 75
Epinephrine (EpiPen)
EMTS may deliver epinephrine via an EpiPen injector for ANY case of suspected anaphylaxis (respiratory distress and/or
hypotension must be present.
EMTS may deliver epinephrine via an EpiPen injector for ANY case of suspected anaphylaxis (respiratory distress and/or
hypotension must be present.
Seattle—King County EMSSeattle—King County EMS
Page 75
EpiPen, continued
Seattle EMTs
Patient (any age) has a history of same and a prescription for epinephrine
Patient is less than 18 years of age with no prescription but permission is obtained from parent or legal guardian. This may be written or oral.
Seattle—King County EMSSeattle—King County EMS
King County EMTs
There are no requirements for:
Page 75
EpiPen, continued
Age
Having a prescription
Written/oral permission (beyond standard consent)
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Dosages
Page 75
EpiPen, continued
Adults and children over 30 kg or 66 lbs: EpiPen (0.3 mg)
Child under 30 kg or 66 lbs.: EpiPen, Jr. (0.15 mg)
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Blood glucometry is within EMT scope of practice
EMTs must complete initial training in glucometry before applying this skill (see EMS Online)
Optional protocol for individual EMS agencies
GlucometryPages 26—27
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Pulse oximetry is within the scope of practice for EMTs
EMTs must have initial training in pulse oximetry before applying this skill (see EMS Online)
Optional to EMS agencies
Pages 28—29
Pulse Oximetry
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New section to provide more guidance on bloodborne exposures
Definition of reportable exposure General steps to take following an
exposure
Page 30
Reportable Exposures
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New ALS indicators Hypoglycemia with decreased LOC Drug or alcohol related seizures
Other Changes Defined time period of 15 minutes or more in
postictal period vs. “not regaining consciousness between seizures”
Signs and symptoms of shock vs. “hypotension”
Page 32
Altered Level of Consciousness
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New ALS indicator for asthma Sustained tachycardia (persistent heart rate of
100-120 or greater per minute depending on clinical setting)
Page 35
Asthma
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New section to give EMTs more guidance on assessment and treatment of burn injuries
Page 38
Burns
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ALS Indicators in this section have changed significantly including Use of nitroglycerin Signs and symptoms of shock such as poor skin signs Sustained tachycardia and hypotension
ALS Indicators now emphasize Discomfort or unusual sensations for those 40 years old
or greater or with a history of heart problems New Special Instructions section has been added
that directs EMTs to be aware of atypical findings seen in the elderly, women and diabetics
Pages 39—40
Chest Discomfort
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Hypothermia cardiac arrest protocol has been eliminated
Follow standard cardiac protocols for hypothermic cardiac arrest
Page 44
Cold-Related
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Added ALS indicator Unable to lie flat
Page 46
Congestive Heart Failure
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ALS Indicator added Sustained tachycardia
Revised BLS indicator Gag reflex intact, as indicated by swallow
Check gag reflex by asking patient if he or she can swallow
DO NOT check a gag reflex by putting a tongue depresser against the back of the throat
Page 48
Diabetic
Seattle—King County EMSSeattle—King County EMS
New variation in BLS care If hypoglycemic and patient is unable to
swallow, position on side, give oxygen, ventilation and await paramedics
Revision of instructions for leaving patient at the scene Patients with hypoglycemia who have
responded to oral glucose may be left at scene (see page 27). These patients must have a repeat glucose level documented and after-care instructions must be left with the patient.
Page 49
Diabetic, continued
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Revised BLS care for SCUBA-related injury Position patient flat (supine) to avoid cerebral
edema Former treatment
“Position patient on left side with head and chest lower than feet to prevent air bubbles from moving to lungs, heart and brain (heart down, head down).”
Page 52
Drowning (Scuba Diving)
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ALS Indicators added Sustained tachycardia (persistent heart rate
100-120 or greater per minute depending on clinical setting)
Possible ectopic pregnancy
Page 52
Gynecologic
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Revised care for suspected c-spine injury when wearing a helmet As long as the airway is not affected and
remains patent AND the c-spine can be secured in an neutral, in-line position, leave football and motorcycle helmets on
All other non-fitted helmets may be removed as soon as possible (e.g., bicycle helmets, skateboard helmets, rollerblade helmets)
Page 57
Head and Neck
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ALS Indicator added Sustained tachycardia
Page 58
Heat - Related
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New ALS indicators Open fractures except for hands and feet High index of suspicion based on MOI Contact medics for severe pain
Refined realignment of long-bone fractures Long-bone fractures, which occur in the proximal or
distal 1/3, that may or may not involve a joint, may be realigned if compromise of distal circulation or nerve function is detected and definitive care is delayed.
New BLS care for pelvic fractures - “sheet splinting”
Pages 65—67
Orthopedic
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ALS Indicator added Sustained tachycardia
Page 70
Respiratory
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ALS Indicators added Multiple seizures (status seizures) Drug and alcohol associated seizures Defined a time frame for the postictal period of
greater than 15 minutes
Page 72
Seizures
Seattle—King County EMSSeattle—King County EMS
Revised conditions for assisting with nitrogylcerin The patient should not have taken Viagra or
Levitra within the past 24 hour or Cialis within the past 48 hours
Page 83
Admin of Meds (Nitro)
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FATS technique is now referred to as the One EMT Technique
Page 92
Bag—Valve Mask
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Revised BLS Care Cover eviscerated abdominal contents with a
large multi-trauma dressing soaked with sterile saline. Then apply an occlusive dressing, if available, to retain heat and moisture.
Former PCP directed EMTs to not moisten the dressing.
Pages 96—97
Dressing and Bandaging
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Two approved methods only: Firm earlobe pressure (Figure 1) Firm pressure behind earlobe (Figure 2)
Page 91
Noxious Stimuli
Figure 1 Figure 2
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For King County COPD patients (non-Seattle FD) EMTs have the option of using a non-
rebreathing mask if a nasal cannual at 4 L/min is inadequate
Page 106
Oxygen Delivery
Seattle—King County EMSSeattle—King County EMS
Change in technique One arm secured high above the head and the
other low at the patient’s side and both secured to the backboard or stretcher
Pages 113—114
Patient Restraint
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Added contraindication Patient with suspected cardiac chest pain
Check vital signs in two positions only: supine or sitting and standing (formerly 3: supine, sitting and standing)
Positive findings have been redefined as follows: Increase in pulse of 20/minute or more and/or a 20 mmHg
or more drop in systolic BP from supine to standing with associated symptoms
OLD: “Decrease in systolic BP of 30 mm/Hg or more from supine to sitting or standing. Systolic BP of less than 90 mm/Hg in sitting or standing position.”
Pages 115—116
Postural Vital Signs
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Questions
Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp
EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp
Mike Helbock, M.I.C.P., NREMT-PTraining Division ManagerEmail support: help@emsonline.net