UTSW/BioTel Guidelines for Therapy: Treatment Guidelines Cumulative Review Table

Transcription

1 UTSW/BioTel Guidelines for Therapy: Treatment Guidelines Cumulative Review Table September 2014 Based on Revision D, 15 September 2014 Implementation Date: 1 October 2014 This document summarizes the new and revised UTSW/BioTel EMS System Treatment Guidelines & Procedures from the Guidelines for Therapy. It lists major teaching points for each section. This review does not replace a comprehensive review and understanding of each Treatment Guideline (TG) and Procedure. EMS Providers shall be familiar with all aspects of the Treatment Guidelines and Procedures, and they shall seek clarification from an EMS Supervisor or BioTel when questions arise. A condensed, cumulative review, text version of this document is also available. The UTSW/BioTel EMS System Policies are reviewed in a separate document. Page 1 of 12

2 TG or Procedure or? Content Change General Cross-references General Standardized terminology Teaching Points Added BOLD, CAPITALIZED crossreferences between sections Standardized terminology for procedures, vital signs General Standardized drug dosing, especially benzodiazepines Unless otherwise noted, drug doses have been standardized across all TGs & Procedures General Vital Signs SpO 2 limits standardized to at least 94% Exceptions: o Stroke (at least 92%) o COPD (at least 90%) o ROSC (94-99%) General Vital Signs Adult Hypotension defined as SBP less than 90 mmhg for all TGs (Chest Pain and Pain) and drugs (specifically NTG & Morphine) This exception was removed from Revision D: o Morphine administration (110 mmhg) Definitions and Abbreviations Expanded section Replaces Glossary Notable specific changes: o POC Glucose replaces previous terminology o Emergency Detention replaces APOWW Adult Treatment Overview Sellick maneuver 12-LEAD ECG Intranasal medications Sellick no longer routinely recommended 12-LEAD ECG vital! Clarification of IN meds Pediatric Treatment Overview Added Table of Approximate Normal VS by age Cardiac Arrest details clarified Additional resource if Broselow tape unavailable Infant and Child CPR Chest Compression Depth added Page 2 of 12

3 Cross-reference TB ALTE Allergic Reaction TG Drug dose standardization & clarification (including ml/kg for pedi, when feasible) Removed SQ epinephrine Added optional methylprednisolone standing order for adult & pedi: o Pediatric unit-dosing (identical to Pedi Resp Distress) Dystonic reaction treatment with diphenhydramine clarified Altered LOC TG Pediatric hypoglycemia definition changed Pediatric hypoglycemia age ranges changed (applies to Seizure TG) Clarified Basic Life Support interventions Naloxone use more restrictive Glucagon dosing standardized Pedi Hypoglycemia (mg/dl): o Non-diabetic: less than 70 o Diabetic: less than 70 or symptomatic Dextrose dosing: o Neonate under 1 mo: 2 ml/kg of D10% o Infant 1 mo 1 yr: 5 ml/kg of D10% o Child 1 13 yr: 2 ml/kg of D25% o Adult at least 14 yr: 1 ml/kg of D50 Naloxone indications & dosing clarified & strengthened Glucagon dosing standardized Amputation TG Clarified removal of improvised tourniquets & application of EMS tourniquets Improvised devices applied prior to EMS arrival should be replaced with EMS device (if needed) and then removed Cross-reference TOURNIQUET POLICY Page 3 of 12

4 Asystole/PEA TG Changed PEDI needle thoracostomy to standing order Clarified drug dosing PEDIATRIC needle thoracostomy for presumed tension pneumothorax now standing order Use of sodium bicarbonate & calcium chloride for prolonged cardiac arrest changed to and/or Bradycardia TG Removed adult atropine as standing order Pedi atropine changed to consider after excluding hypoxia New emphasis on TCP for unstable bradycardia with 3 block Routine use of atropine, especially in elderly patients & those with coronary disease, is associated with tachycardia-induced myocardial ischemia 3 block, unstable: TCP preferred Sinus bradycardia/1 /2, unstable: Treat associated conditions (e.g. chest pain) & consult BioTel, for possible atropine or other treatment Cross-reference TB PACING Burns TG ABA Criteria for transport to burn unit Reminder to remove contact lenses, especially for chemical burns New treatment algorithm, emphasizing signs/symptoms SpCO greater than 20% or greater than 10% with symptoms must go to HBO List of criteria mandating transport to PMH Burn Center revised & clarified Added reminder to remove contact lenses, if possible Carbon Monoxide Exposure TG New algorithm with new SpCO level limits, new patient criteria, and new requirement for transport to HBO destination, if possible, for patients with certain criteria (high SpCO ± symptoms) Page 4 of 12

5 destination, if possible Added BUMC as HBO destination New hospital (BUMC) added to existing HBO site (THR Dallas) Reminder that severe CO intoxication requires BioTel contact in order to notify HBO destination hospital Cardiac Arrest TG Clarification of CPR Process details Chest Compression depth & other CPR process details clarified Pedi Needle Thoracostomy changed to standing order Chest Pain TG Cyanide Toxicity TG Adult Hypotension defined as SBP less than 90 mmhg Destination criteria strengthened 12-LEAD ECG emphasized Complicated STEMI flow-chart removed Entirely new content added, including use of hydroxocobalamin Standardized definition of adult hypotension Importance of proper destination for patient outcome 12-Lead ECG vital! Cross-reference TB CHEST PAIN Cross-reference with CYANIDE ANTIDOTE ADMINISTRATION POLICY Excited Delirium TG Entirely new content added Cross-reference with RESTRAINT OF PATIENT POLICY Higher starting doses of benzodiazepine sedation than other TGs NO Ketamine for pediatric patients! Eye Injury TG Minor revision Added hospital transport recommendations for persistent crowd-control agent symptoms Neonatal Care TG Extensive revision for consistency with MRSOPA Resuscitation guidelines Page 5 of 12

6 current practices & AHA/AAP Guidelines Infant Pre-ductal (right hand/wrist) SpO 2 monitoring New supplemental oxygen administration guidelines New hypoglycemia definition (45 mg/dl) & treatment (0.2 g/kg of D10% or oral dextrose) Removal of naloxone Cross-reference with EMERGENCY CHILDBIRTH S Obstetrical/ Gynecological Emergencies TG Prolapsed cord instructions clarified Midazolam & magnesium sulfate administration clarified Nitrous Oxide removed Standard opioid analgesia per PAIN TG added Midazolam & magnesium sulfate dosing standardized & clarified Cross-reference with EMERGENCY CHILDBIRTH S Fentanyl/Morphine replaces nitrous oxide (caution in high-risk patients) Pain Management TG Clarified & strengthened wording re: indications for pain management Prohibit pediatric traction splinting Nitrous oxide removed Indications, dosing, dosage intervals & other medication details clarified & standardized Pediatric fractures should be splinted, as needed, but traction splints should not be used Nitrous oxide removed Poisoned Patient TG BioTel MUST be contacted to coordinate care with NTPCC Add cross-reference to CYANIDE TOXICITY TG & ANTIDOTE POLICY Do not contact NTPCC directly for poisoned/overdose patient Contact BioTel directly, so that care can be coordinated Page 6 of 12

7 Post-Cardiac Arrest Care TG Drug dose standardization & clarification Standardization & clarification of drug doses, especially benzodiazepines Psychiatric Emergency TG Prone positioning for transport is absolutely prohibited! Relies heavily on DESTINATION POLICY and/or BioTel consultation, especially for pediatric & adolescent patients Respiratory Distress ADULT TG Extensive revision & split from Pediatric Respiratory Distress TG Different etiologies & treatments require different TGs Optional methylprednisolone added (same as allergic reaction) SBP limit for NTG: 90 mmhg Supplemental oxygen guidelines: o At least 94%, except o COPD: At least 90% Respiratory Distress PEDIATRIC TG Extensive revision & split from Adult Respiratory Distress TG Different etiologies & treatments require different TGs: o Under 2 years o At least 2 years and/or asthma history o Probable Croup Removed SQ epinephrine Optional methylprednisolone added (same as allergic reaction): o Pediatric unit-dosing (identical to Pedi Allergic Reaction) Seizures TG BLS treatments clarified Pediatric Oral glucose gel dosing clarified Pedi hypoglycemia: Page 7 of 12

8 hypoglycemia definitions & treatments standardized & clarified (see ALTERED LOC TG) Drug dose standardization & clarification o Non-diabetic: 70 o Diabetic: 70 or symptomatic Pediatric age ranges: o Infant: 1 mo 1 yr o Child: 1 13 yr o Adult: 14 yr & older Monitor for need & prepare for assisted ventilation/advanced airway management before benzodiazepine administration, especially for pedi Order of preference for pediatric seizure meds: o IN midazolam (divide dose between both nares for children over 6 months of age, if possible) o IV/IO midazolam o PR diazepam Shock TG Adult IV/IO fluid bolus changed to 20 ml/kg, unless otherwise noted Needle thoracostomy for tension PTX changed to standing order for adult & pedi Fluid bolus volume changed to be consistent with NREMTP For pedi profound shock/cardiac arrest due to suspected tension PTX, needle decompression is now a standing order; however paramedics should contact BioTel ASAP after the procedure Stroke TG Focus on symptom onset time Destination guidelines clarified Stroke scales/scores added Last known normal o Adult: Must contact BioTel or destination hospital o Pedi/Adolescent: Must contact BioTel Stroke scales/scores added for reference Cross-reference Page 8 of 12

9 DESTINATION POLICY Cross-reference TB STROKE Tachycardia Stable TG Reorganized from Narrow/Wide Extensive Revision Reminder for 12-Lead ECG Pedi Narrow (SVT): Call BioTel BEFORE administering adenosine (no longer a standing order) Tachycardia Unstable TG Reorganized from Narrow/Wide Extensive Revision Reminder for 12-Lead ECG before treatment, if possible Adult: Consult device manufacturer and/or BioTel for synch cardioversion dose Pedi Narrow (SVT): Prepare for adenosine or synchronized cardioversion, but contact BioTel before shock, if possible: o 1 st dose: J/kg o 2 nd dose: 2 J/kg Pedi Wide (VT): Prepare for synch cardioversion, but contact BioTel before shock, if possible: o 1 st dose: J/kg o 2 nd dose: 2 J/kg Trauma TG Extensively and simplified Prehospital Trauma Triage Criteria Cross-reference DESTINATION POLICY Cross-reference TB Trauma Triage Criteria Ventricular Fibrillation/ pulseless Ventricular Tachycardia TG No significant changes Clarification of existing wording Added reminder NOT to administer more than 2 doses of anti-arrhythmic during the resuscitation, without BioTel authorization (rarely indicated). No antiarrhythmic should be Page 9 of 12

10 routinely given to patients in ROSC. Vomiting TG Removed Adult IV promethazine (IM only, optional medication) Added oral Ondansetron for Adults (optional) Promethazine IV associated with severe adverse reactions o Pedi no change: still contraindicated by all routes Ondansetron dosing for adults & pedi clarified CPAP Lower age limit 13 years Can be used in children under 13, IF prior Medical Director Authorization, with proper training and equipment Cricothyrotomy Needle cricothyrotomy procedure added Percutaneous cricothyrotomy procedure NOT included, as there is no standardized device among agencies Each agency must provide training for the device it carries Emergency Childbirth Normal Emergency childbirth (normal) procedures added Cross-reference Emergency Childbirth Abnormal and OB/GYN TG and Neonatal TG Low-frequency, highliability procedure Emergency Childbirth Abnormal Emergency childbirth (Abnormal) procedures added Emphasis on special circumstances (prolapsed cord & breech) and on conditions requiring immediate C-section Cross-reference Emergency Childbirth Normal and OB/GYN TG and Neonatal TG Low-frequency, highliability procedure Page 10 of 12

11 EZ-IO Intraosseous Infusion Nasotracheal Intubation Needle Thoracostomy Indications, contraindications, equipment, procedure, considerations and complications Indications, contraindications, equipment, procedure, considerations and complications Indications, contraindications, equipment, procedure, considerations and complications High-frequency procedure Low-frequency, highliability procedure Low-frequency, highliability procedure Pedi: changed to standing order for cardiac arrest, profound shock or dysrhythmia consistent with tension pneumothorax Pharmacologically- Assisted Intubation (PAI) Taser Barb Removal POLICIES PHARMACOLOGY Indications clarified Premedication drugs clarified & standardized Post-PAI maintenance drug doses clarified and standardized Minor revisions and Refer to POLICIES REVIEW Table Extensive revision, correction, clarification & standardization to all sections Ketamine added as a premed option (adult and pedi) 0.6 mg/kg pediatric premedication dose added o This is not a typo! Minor clarification & formatting changes Refer to POLICIES REVIEW Table Rationale: consistency between TGs, Procedures & Policies & adherence to best practices PHARMACOLOGY Diphenhydramine Dilution instructions for pediatric IV/IO administration added Page 11 of 12

12 PHARMACOLOGY Dopamine PHARMACOLOGY Etomidate PHARMACOLOGY 40% Oral Glucose Gel PHARMACOLOGY Hydroxocobalamin added PHARMACOLOGY Ketamine added PHARMACOLOGY Magnesium sulfate PHARMACOLOGY Methylprednisolone Changed to optional medication Dosing clarification, including 0.6 mg/kg for pediatric PAI premedication Age-based pediatric unit dosing added Neonatal dosing added Cyanide Antidote Kit Optional medication For authorized agencies Optional medication Dosing parameters and dilution/administration instructions added Standing order for pediatrics, but paramedics shall contact BioTel prior to administration to reconfirm dosage calculations Dosing parameters and dilution/administration instructions added Age-based pediatric unit dosing added PHARMACOLOGY Nitrous Oxide retained as drug sheet only Orphan drug sheet retained for use in the event of narcotic shortage or other contingency PHARMACOLOGY 2-Pralidoxime Chloride to optional medication Page 12 of 12