SAN LUIS OBISPO COUNTY HEALTH AGENCY

Transcription

1 SAN LUIS OBISPO COUNTY HEALTH AGENCY Prtcl & Drug Frmulary Revisins / Additins Nvember 15, 2013 Public Health Department Emergency Medical Services Agency 2156 Sierra Way, San Luis Obisp, CA FAX MEETING DATE EMCC Nvember 21, 2013 STAFF CONTACT SUBJECT SUMMARY REVIEWED BY RECOMMENDED ACTION(S) Heather Tucker, EMS Directr htucker@c.sl.ca.us Prtcl revisins, new prtcl and drug frmulary changes The fllwing is a summary f the prpsed prtcl revisins, new prtcl. and changes t the drug frmulary (all prtcls are presented in ur new frmat that as we review/revise prtcls, we will mve t this lk): 1) Behaviral emergencies: the change t this prtcl includes a change in the benzdiazepine (frm Diazepam t Midazlam) and allws fr a Paramedic t administer the medicatin t an extremely agitated patient prir t base cntact. 2) The fllwing prtcls are being revised t include BLS Optinal Scpe skills: Universal Algrithm will have the additin f Pulse Oximetry and will necessitate the purchase f Pulse Oximetry and training n the equipment by BLS agencies. Adult Cardiac Chest Pain/Acute Crnary Syndrme will have the additin f Aspirin (chewable nn-enteric cated) and will als necessitate the purchase f Aspirin and training n its use by BLS agencies. 3) End-Tidal CO2 Mnitring/Detectin (capngraphy) this is a new prtcl and was intrduced t imprve ALS patient care as a clinical best practice fr assessment and mnitring f bth intubated (using in-line capngraphy) and nn-intubated (using sidestream capngraphy) patients. 4) Drug Frmulary changes: Changing Benzdiazepine frm Diazepam t Midazlam. Midazlam will be the nly Benzdiazepine carried by ALS prviders but Diazepam will remain in the Drug Frmulary t be used by rder f the Medical Directr in cases where Midazlam is nt available. Diazepam will als remain in the cunty disaster caches. If there is an authrized mve t Diazepam as mentined abve, a prtcl will be issued with the directive. The fllwing prtcls will have an administrative update nce Midazlam is apprved: Adult Seizures and Pediatric Seizures. Thmas Rnay, Medical Directr and EMSA Staff Steve Lieberman, EMS Divisin Directr Apprve prtcls as presented and apprved by the Clinical Advisry Cmmittee ATTACHMENT(S) Behaviral Emergencies, Universal Algrithm, Adult Chest Pain/Acute Crnary Syndrme, End-Tidal CO2 Mnitring/Detectin (Capngraphy), Midazlam (Versed), and Diazepam (Valium) Drafts. K:\PublicData\COMMITTEES\EMCC\Meetings\2013\Nvember 21, 2013\Staff Reprt Summary_EMCC_NOV_13.dcx

2 San Luis Obisp Cunty Emergency Medical Services Agency UNIVERSAL ALGORITHM MEDICAL BLS PROCEDURES Evaluate Scene Safety / Persnal Prtective Equipment Assess, establish and maintain airway Evaluate breathing and circulatin Assess chief cmplaint Fcused physical exam and vital signs: Pulse Bld pressure Respiratry rate Lung sunds Skin signs Plicy N XXX TRAUMA Evaluate Scene Safety / Persnal Prtective Equipment Establish C-Spine cntrl Assess, establish and maintain airway Evaluate breathing and circulatin Cntrl life-threatening bleeding Full spinal precautins as indicated BLS Treatment Prtcl BLS OPTIONAL SCOPE Pulse Oximetry Pulse Oximetry Cnsider 12-lead ECG early Capngraphy (if available/applicable) Glucse Measurement ALS Treatment Prtcl Transprt Determinatin Effective Date: XXXXXXXXXXXXXX Next Review Date: 2013 ALS PROCEDURES ALS Treatment Prtcl(s) Transprt Determinatin Thmas Rnay, MD, EMS Medical Directr

3 Midazlam (Versed ) Classificatin: Actins: Indicatins: Benzdiazepine 1. Hypntic, amnesiac, sedative, anticnvulsant 2. Ptent but shrt-acting, 3-4 times mre ptent than diazepam 3. Has NO effect n pain 1. Active, cntinuus seizure 2. Status epilepticus 3. Sedatin prir t cardiversin 4. Acute behavir disrder (agitated patient danger t self r thers) 5. Severe muscle spasms (base physician rder nly) Cntraindicatins (Relative): 1. Histry f hypersensitivity t benzdiazepines 2. Shck with depressed vital signs 3. ALOC f unknwn etilgy / plypharmacy ingestin 4. Narrw-angle glaucma 5. Eclampsia (base physician rder nly) Adverse Effects (Precautins, Side Effects and Ntes): Midazlam may cause respiratry depressin and/r hyptensin especially if administered rapidly. Mnitr patient clsely. 1. Cmmn side effects include drwsiness, hyptensin, respiratry depressin and apnea. These are mre likely t ccur in the very yung and the very elderly. Rarely, patients may experience paradxical agitatin. 2. Respiratry depressin is mre likely in patients wh have taken ther CNS depressant drugs such as piids, alchl, ther benzdiazepines r barbiturates, r when given rapidly. 3. Midazlam is metablized in the liver and excreted by the kidneys. Dses shuld be adjusted accrdingly in patients with underlying hepatic r renal diseases r cardiac diseases with lw flw states such as CHF. 4. GI effects include nausea, vmiting, hiccugh/hiccup 5. Pain at injectin site (IV/IM), intranasal irritatin if given IN San Luis Obisp Cunty EMS Agency Drug Frmulary Reviewed: Revised:

4 MIDAZOLAM (Versed ) - cntinued Administratin: ADULT DOSE 1. Seizure: 1-2 mg slw IVP 0.1 mg/kg IM 5 mg IN (intranasal) (split dse: 2.5 mg in each nstril). May repeat nce after 10 minutes 2. Pre-cardiversin sedatin: 5 mg IN (intranasal) (2.5 mg each nstril) 1-2 mg slw IVP May repeat nce after 10 minutes 3. Agitated patient sedatin (danger t self r thers): 1-2 mg slw IVP 5 mg IM r IN (intranasal, 2.5 mg in each nstril) May repeat nce after 10 minutes ***EKG, Pulse ximetry, and ETCO2 (when equipment is available) mnitring will be used at all times. PEDIATRIC DOSE 1. Seizure/Agitated Patient Sedatin: 0.1 mg/kg IM/IN (Split dse: ½ dse in each nstril) /slw IVP (may repeat nce after 10 minutes). Max 5 mg all rutes 2. Pre-cardiversin: 0.1 mg / kg slw IVP. Max 2mg ***EKG, Pulse ximetry, and ETCO2 (when equipment is available) mnitring will be used at all times. Onset: minutes IV San Luis Obisp Cunty EMS Agency Drug Frmulary Reviewed: Revised:

5 2-6 minutes IN 15 minutes IM Duratin: 2-6 hurs fr IV/IN/IM San Luis Obisp Cunty EMS Agency Drug Frmulary Reviewed: Revised:

6 San Luis Obisp Cunty Emergency Medical Services Agency End-Tidal CO2 Mnitring/Detectin (Capngraphy) ADULT UNIVERSAL ALGORITHM Scene Safety / PPE ABCs Administer Oxygen Per Plicy 580 INDICATIONS Cnfirmatin, mnitring and dcumentatin f endtracheal intubatin Assessment, mnitring and dcumentatin f respiratry status f the nn-intubated patient experiencing respiratry distress, including but nt limited t the use f CPAP CONTRAINDICATIONS Nne Prcedure Intubated patients Use secndary cnfirmatin device t verify placement ETCO2 detectin r clrimetric device if ETCO2 fails Prcedure Nn-intubated Patients Assess, xygenate and ventilate with apprpriate delivery device fr patient cnditin Apply side stream ETCO2 detectin in cnjunctin with the delivery device being used (e.g. CPAP) Side stream ETCO2 mnitring shuld be cntinued with administratin f nebulized medicatins ALS PROCEDURES PEDIATRIC Plicy N XXX SAME AS ADULT IF PEDIATRIC EQUIPMENT IS AVAILABLE Additinal Infrmatin Dcumentatin Dcument ETCO2 numeric values and crrespnding wave frm capngraphy n the PCR (may attach strip) Take readings after 1 minute, trends, and upn ED arrival. Take additinal reading after mving patient t hspital bed in the intubated patient. Dcumentatin Dcument ETCO2 numeric values and crrespnding wave frm capngraphy n the PCR (may attach strip) Take readings after 1 minute, trends, and upn ED arrival. Take additinal reading after mving patient t hspital bed in the intubated patient. Effective Date: XXXXXXXXXXXXXX Next Review Date: 2013 Thmas Rnay, MD, EMS Medical Directr

7 DIAZEPAM (Valium ) (T be used at the directin f the medical directr when Midazlam is unavailable r as part f a disaster cache) Classificatin: Actins: Indicatins: Anticnvulsant/Tranquilizer 1. Prmtes muscle relaxatin thrugh inhibitin f spinal mtr reflex pathways. 2. Suppresses seizure activity thrugh suppressin f the mtr crtex f the brain. 3. Prduces amnesic effect 4. Skeletal muscle relaxant 1. Active, cntinuus seizure 2. Status epilepticus 3. Sedatin prir t cardiversin 4. Acute behavir disrder 5. Severe muscle spasms (base physician rder nly) Cntraindicatins (relative): 1. Histry f hypersensitivity t the drug 2. Hld fr CNS depressin, respiratry depressin and hyptensin 3. ALOC f unknwn etilgy 4. Eclampsia (base physician rder nly) Adverse Effects: Cardivascular Neurlgical Hyptensin Dizziness Ataxia Respiratry Fatigue Depressin Pain/burning at injectin site Administratin: ADULT DOSE 1. Seizure: 0.3mg/kg slw IVP, titrated t terminate seizure activity, nt t exceed 20 mg. If unable t establish an IV, administer 0.3 mg/kg per rectum (PR) via a lubricated 3 ml syringe, titrated t terminate seizure activity, nt t exceed 20 mg 2. Pre-cardiversin: mg IVP San Luis Obisp Cunty EMS Agency Drug Frmulary Reviewed: 04/01/11 Revised: 09/20/11

8 DIAZEPAM (Valium ) - cntinued PEDIATRIC DOSE 1. Seizure: administer 0.3 mg/kg slw IVP, titrated t terminate seizure activity, nt t exceed 10 mg. If unable t establish an IV, administer 0.3 mg/kg per rectum (PR) via a lubricated 3 ml syringe, titrated t terminate seizure activity, nt t exceed 10 mg 2. Pre-cardiversin: administer 0.3 mg/kg slw IVP, nt t exceed 10 mg Base physician rder fr IM administratin may be cnsidered fr adult r pediatric patients Onset: Duratin: 1-5 minutes, may be lnger fr PR dsing 15 minutes t 1 hur San Luis Obisp Cunty EMS Agency Drug Frmulary Reviewed: 04/01/11 Revised: 09/20/11

9 San Luis Obisp Cunty Emergency Medical Services Agency Plicy N XXX Adult Cardiac Chest Pain/Acute Crnary Syndrme STABLE UNSTABLE (BP >100 Systlic with signs f adequate perfusin) BLS PROCEDURES UNIVERSAL ALGORITHM Scene Safety / PPE ABCs Administer Oxygen Per Plicy 580 Prcedures Reassure/calm patient Psitin f cmfrt Obtain vital signs Obtain medical histry Gather medicatins r list If requested by patient, assist with administratin f patient s Nitrglycerin as lng as patient s systlic bld pressure remains abve 100 Optinal Scpe Pulse Oximetry Administer Aspirin 162 mg (nn-enteric cated) tablets chewed and swallwed Aspirin administratin shuld be cnsidered fr any cmplaint f suspected cardiac rigin regardless f chest pain (BP <100 systlic with signs f pr perfusin) UNIVERSAL ALGORITHM Scene Safety / PPE ABCs Administer Oxygen Per Plicy 580 Prcedures Reassure/calm patient Psitin f cmfrt Obtain vital signs Obtain medical histry Gather medicatins r list Pulse Oximetry Administer Aspirin 162 mg (nn-enteric cated) tablets chewed and swallwed Aspirin administratin shuld be cnsidered fr any cmplaint f suspected cardiac rigin regardless f chest pain Standing Orders Universal Algrithm Identify and treat reversible causes Establish vascular access Obtain 12-lead ECG early Prcedures Nitrglycerin (Nitr) 0.4mg SL tablets r spray fr cardiac chest pain. Administer every 5 minutes until pain is relieved Stp Nitr administratin if BP trending twards r drps < 100 mmhg systlic r in the presence f ther signs/symptms f hemdynamic instability. If pain persists and nt relieved with Nitr: Mrphine 2-10 mg slw IVP titrated t pain imprvement (Maintain systlic BP > 100 mmhg) Universal Algrithm Identify and treat reversible causes Establish vascular access Obtain 12-lead ECG early

10 Base Hspital Orders Only Fluid Blus 500 ml NS Additinal administratin f Mrphine Administratin f tpical Nitrglycerin may be cnsidered after initial dse(s) f SL Nitrglycerin Dpamine 5-20 mcg/kg/min fr persistent hyptensin Additinal Infrmatin Early ntificatin f the SRC with STEMI Alert with a 12-lead ECG reading f ***Acute MI Suspected*** r current equivalent based n mnitr type. Fr STEMI Alerts cnsider establishing secnd IV access with NS lck. The additin f a Luer-Lck is recmmended t assist the Cath Lab in tubing changes. Cnsider Base Physician cnsult fr A-fib with RVR prir t administratin f NTG Effective Date: Nvember 1, 2012 Next Review Date: Nvember 2015 Thmas Rnay, MD, EMS Medical Directr