2019 Protocol Roll - OUT

Transcription

1 2019 Protocol Roll - OUT

2 Objectives Discuss participation in the Regional EMS Protocol Outline changes, and discuss how UH will implement Review changes from last year that carry over into this protocol

3 Regional Protocol UH has been participating in regional protocol standardization 2-year process Cleveland Clinic, Metro, and Southwest Collaboration Contents of this year's protocol is the regional protocol contents Format and flow same as UH previous protocol releases low learning curve

4 Regional Protocol New items will be noticed throughout Not all will be adopted by all participating hospital systems Multiple items may be listed but not all supplied by UH This roll out will highlight what will and will not be available to UH departments

5 Medication Nomenclature Medications that have look-alike names or easily confused have Tall-Man lettering This is a Pharmaceutical industry standard practice Probably have seen before on medication packaging / constrainers Helps differentiate the medications DOPamine Examples HYDROmorphone diphenhydramine LORazepam Medications that are not easily confused with others do not have Tall- Man lettering

6 Changed Section Only 1 protocol has moved to another location in the document. Neonatal resuscitation is now in section 12 OB Emergencies. Was previously in Pediatric Cardiac section

7 Multiple Medication Listings Some medications have 2 similar medications listed in protocol. These are agents that other departments are using for other reasons / their Medical Director preference. You will use what's available to you from UH. UH will not provide the other medication unless there is shortage. Supplied

8 Multiple Medication Listings UH Supplied UH Supplied

9 Pain Management Multiple options both opioid and non-opioid Ketorolac (Toradol) is back - review the many contraindications Ketamine (Ketalar) can be used for pain in small doses Low dose ketamine (LDK)

10 Multiple Medication Listings - Pain UH Supplied UH Supplied UH Supplied UH Supplied

11 Very effective NON- OPIOD analgesic Correct concentration must be MADE prior to use Push One Pull One Waste 1 ml from a 10 ml flush Pull up 1 ml of Ketamine (Ketalar) from the 100 mg / ml concentration (Supplied as 500 mg in 5 ml) Shake Concentration now 10 mg / ml 5-10 mg at a time up to 30 mg Low Dose Ketamine 100kg X 0.1 = 10mg

12 Pain Management - Ketamine Remember Ketamine similar to PCP, Pay attention to dosing Very high or very low, stay out of NO go (Recreation Dosing) Pain mg / kg Analgesia Recreational Zone NO - GO AIRWAY 1 2 mg / kg IV / IO Amnestization + Analgesia VIOLENT mg IM Amnestization + Analgesia Major Tranquilization 0 mg 30 mg 100 mg 250 mg 500 mg Disassociation Occurs

13 Another NON-Opioid Option 15 mg IV 30 mg IM Is a Non-Steroidal Anti- Inflammatory (NSAID) Useful in minor / moderate pain inflammatory processes Sprains / Strains / Over extensions / Soft tissue injury / Kidney stones Toradol Contraindications Allergies / Hypersensitivity to NSAIDS >65 Years Bleeding (GI / Stroke) Pregnancy / Nursing Mothers Asthma

14 Review Backup Medications If Fentanyl (Sublimaze) or HDROmorohne (Dilaudid) unavailable MORPHINE Not routinely supplied unless shortage IF Midazolam (Versed) or LORazepam (Ativan) unavailable DiazePAM (Valium) Not routinely supplied unless shortage Reference both in Medication section for dosing

15 New (OLD) Backup Medication Lido s back baby 2018 AHA midstream release allows for Lidocaine (Xylocaine) to be used in place of Amiodarone (Cordarone) Similar outcomes with either UH will use Lidocaine (Xylocaine) as a backup to Amiodaorone (Cordarone) Same dosing as always (Review) Still used with IO insertion

16 Lidocaine Dosing

17 Non-Invasive option for behavioral Agitation cases where IM agents are not warranted ODT tablet Let dissolve in mouth Patient cooperative enough or knows they are highly anxious NOT for Violent or Combative patients New Medication OLANZapine (Zyprexa)

18 OLANZapine (Zyprexa) Med Page

19 OLANZapine (Zyprexa)

20 REVISED ANAPHYLAXIS Pediatric and Adult Anaphylactic Shock / Reaction now same layout Now only 3 columns Merged Moderate and Severe, practically the same info in both columns

21 REVISED ANAPHYLAXIS Anaphylactic REACTION 2 Columns IM Epinephrine Anaphylactic SHOCK 1 Column Orange Hashes IV Epinephrine

22 REVISED PEDS ANAPHYLAXIS Anaphylactic REACTION 2 Columns IM Epinephrine Anaphylactic SHOCK 1 Column Orange Hashes IV Epinephrine

23 PEDS STEROIDS MethylPREDNISolone (Solu-Medrol) is now approved for is pediatric breathing protocols Better mimics adult protocols Both upper airway (croup) as well as lower airway

24 Stroke UH Not participating in Mobile Stroke UH Not participating in Pre- Hospital use of Labetalol (Trandate) for Stroke BP management Disregard these boxes UH Believes access to stroke centers is faster and more diagnostic than mobile units UH Follows AHA recommendation not to modify BP of stroke patients out of hospital

25 Replaces State of Ohio triage pages since this is followed locally Both in adult and peds trauma sections NOTS Hospital Triage

26 NOTS FIELD TRIAGE ADULT

27 NOTS FIELD TRIAGE PEDS

28 PEDS Pages Weight in Kg, Lbs, and Height also referenced in Weight Based color Charts

29 Same concept as ADULT SMR Move patient SPINE IN LINE C-Collar or cervical immobilization still required Backboard NOT required Vacuum mattress preferred, but cot mattress or reeves fine PEDS SMR Spinal Motion Restriction now approved for PEDIATRICS and ADULTS

30 Previous Protocol Review Lets review some of the changes we made along the way that have been part of the Regional Meetings that UH has already changed along the way prior to the release of the regional document

31 Epi Ratio Expressions USP No longer permits the use the ratio expressions for Epinephrine Will grey out ratio in 2018 to begin to de-emphasize Medications in both expressions out there EPI 1:1000 1mg/ml EPI 1:10, mg/ml 2017 Current Epinephrine 1 mg IV / IO 0.1 mg/ml (1:10,000) 2018 Epinephrine 1 mg IV / IO of 0.1 mg / ml (1:10,000) Concentration 2020 (Potential) assuming AHA follows suit Epinephrine 1 mg IV / IO of 0.1 mg / ml

32 D10 Should be all you are using at this point D10 only referenced in protocol pages 2018 D50 listed as backup if D10 unavailable No D50 routinely in drug box

33 D5 for MIXING Pharmacy recommendation from regional group for MIXING Amiodarone Poor evidence for mixing and administering in NS For post-arrest or wide complex perfusing rhythms 150 mg Amiodarone in 100 ml D5 over 10 min TXA Can be mixed in D5 EPI Can be mixed in D5

34 TXA

35 TXA What tranexamic acid is; Preserves clot structure, prevents clot breakdown What tranexamic acid is NOT; A clot promoter Who is TXA for? Current or previous uncontrolled bleeding trauma patients in the first hour DO NOT DELAY TRANSPORT TO TRUAMA CENTER FOR TXA ADMIN

36 TXA How is TXA prepared? Mix 1 gram (10ml) into 100 ml D5 Run in over 10 mins With a 10gtt set = 2gtt / second With a 15gtt set = 3gtt / second

37 Epinephrine Drips No backup for Dopamine in protocol 2017 Shortage likely Must make Epi drip in it place real time NO premixed Epi drips Dear lord, MATH

38 Epinephrine Drips Determine what available to mix in, 100ml, 250ml, or 500ml Last resort remove volume from larger container to make 100ml, 250ml, or 500ml Mix Do math based on chart in med section for Epinephrine

39 Epinephrine Drips Med Page

40 Replaces Fentanyl from 2017 Poor choice if arrest caused by narcotic OD Only if interfering with arrest management SEE NEW FOR 2019 Ketamine Option Arrest Interference

41 Replaces Lorazepam / Midazolam prior to attempt if patient responds to pain 100mg average dose Already in RSI protocol Disassociates the patient; provides analgesia, sedation, while causing amnesia Ketamine - Airway

42 Agitation, Combative (reasonably controlled), Violent Would you use a Tazer on this patient? If violent and extreme risk to EMS or other healthcare providers Ketamine warranted Tell PHYSICIAN if you ever give Ketamine as tranquilizer or at dissociative doses so their presentation is not confused with other medical etiology Ketamine Behavioral

43 County group would like to go in this direction UH will be attempting to provide these in 2018 Single dose packet w/ 2- year shelf life Traditional NTG bottles are supposed to be retired after opening wasting numerous tablets Specially lined packet assures no powder left behind Go Nitro

44 Opiates and Ticagrelor (Brilinta) Opiates slow uptake of the PO med as currently carried No good IV replacement for prehospital care, needs to be a PO option Re-order the protocol to prioritize the Ticagrelor and limit concurrent use of opiates with this therapy All about timing for therapeutic effect with the PCI procedure improving outcomes This is for patients with STEMI on EKG and Ticagrelor (Brilinta) use is planned or indicated (Left protocol column) Does not prohibit is use, reserve for severe cases 7-10 / 10 unresolved with other measures This does NOT apply to patients without STEMI on EKG (Right protocol column) No change in process here

45 OLD Protocol Re-ordering of ACS protocol to prioritize Ticagrelor (Brilinta) for improved therapeutic effect Fentanyl Ticagrelor NEW Protocol Ticagrelor Fentanyl

46 Cautions associated with the protocol Protocol Verbiage CONSIDER FENTANYL (SUBLIMAZE) mcg IV / IM / IN / IO SLOW IV Max 100 mcg Routine use of opiate pain control discouraged if TICAGRELOR (Brilinta) being utilized interferes with absorption

47 HYPERTENSIVE EMERGENCIES IN PREGNANCY Gestational(>140/90 no proteinuria or edema) Preeclampsia(>140/90 with proteinuria and edema) 7% of pregnancies. Eclampsia(preeclampsia with onset of seizures)

48 Key Changes The Magnesium is still the same for eclampsia. Magnesium over minutes IV for preeclampsia, symptoms and vitals as documented. Labetalol for HTN emergencies in pregnancy. These are third trimester and may be up to 6 weeks post partum.

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50 Questions