EMS 2018 Treatment Protocol Book Version 1 30 Day Public Comment Period May 24, 2018 to June 24, 2018

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1 3.24 Pg. 65 & 67 Montezuma- Captain Cardoza Febrile seizure cooling measures in adult policy but not pediatric. Section 3.24 & 3.25 pgs 65 & Pg Pg Pg Pg.23 Montezuma Fire District BLS treatment for Adult seizures (pg 65) mentions to initiate cooling measures if febrile, but no mention of this is under pediatric BLS treatment (pg 67) I-Gel sizing is weight based and the color coding is wrong. Please see link for correct info. rway-management/i-gel-supraglotticairway There is no policy 2569 for needle cricothyrotomy. The policy numbers are 2556 and 2549 depending on the device your organization carries. The protocol is out of order with ALS coming before BLS and initial treatment written in before ALS or BLS titling. Also, severe reaction is defined twice and the definitions while close are different. It should be defined only once and if it needs to be twice they should be identical. There is a line of pediatric dosing in the adult protocol. Good catch. This will be corrected in next draft.

2 3.5 Pg.28-3/F/1 Pediatric modalities in an adult protocol. 3.6 Pg.30 -There is no specified concentration for the magnesium sulfate. As many patients with bronchospasm have multiple etiologies fluid overload should be a consideration and concentration specified. No specified concentration or allowable fluid volume for the mag 3.8 Pg Pg Pg.38 E/2/C With pregnant pt in 3 rd trimester with active vaginal bleeding what exactly would we be calling base for Are we not utilizing permissive hypotension with fluid boluses be to a systolic pressure of 90 as we do in traumatic bleeding Policy has us intubating a neonate. As of July 1 st that skill is outside of state scope. Consistency in fluid therapy is being addressed Pg.45 What is the use of a 12-lead on a pt with a diabetic emergency unless they are having symptoms of cardiac compromise Consider 12 lead is important in this patient demographics. It is a recommendation not a mandate Pg.46 Diagnosing DKA in the field is a slippery slope as that is done in hospital setting with lab values. Also if you want to treat hyperglycemia we should do away with DKA, call it hyperglycemia and set parameters for treatment utilizing Noted. DKA has and continues to be taught as part of the national standard curriculum and should be within the abilities of EMTs and paramedics. However, we will consider switching the term to hyperglycemia.

3 RR, ETCO2 and the other signs and symptoms of DKA. No pediatric nausea protocol The addition of a pediatric nausea protocol is still under consideration 3.17 Pg Pg Pg &3.28 Pg Cardiac arrest 4.1vs 4.4 Max single dose is 6mg of morphine but the max initial dose IV is 4mg but then it says if you go IM you can give up to 10mg. No consistency. This policy has us going to straight to administration of racemic epinephrine with any patient suspected of croup. Why would it be beneficial for a child to drink 1-2 glasses of milk or water to dilute a caustic substance but not an adult? All titles and headers wrong. Shock labeled as stroke, adult switched with peds in content The cardiac arrest protocol now has enough variation and is dynamic enough that it needs to be written as flow chart if people are to correctly follow it. Every part of the protocol stops half way through and simply refers to another protocol. They need to be written as flow charts and each should be complete instead of halfway done with a referral to another protocol. 4.1 says transport v-fib/v-tach to SRC after 4 rounds MICR 4.4 says transport to closest hospital after 8 rounds MICR This reference will be changed to max single IV dose and max single IM dose That is correct. If a patient is exhibiting signs and symptoms of croup and is short of breath the correct treatment is racemic epinephrine A flow chart is being created

4 (we only do r rounds MICR) 4.7 Pg.86 Pediatric parameters in adult protocol causes confusion 4.7 Pg.86 Sinus tach and SVT treatment in the wide complex tachycardia protocol 4.8 Pg Pg Pg Pg.98 WHY has synchronized cardioversion been taken away for unstable a-fib/aflutter? Grammar, spelling, punctuation. fluid bolus of 20ml/kg.may repeat with 10 ml/kg x2use caution in history of heart failure or dialysis.. These patients give 10mL/kg per bolts up to four times. Reassess lung sounds and oxygen data between boluses Withholding Ntg for possible inferior AMI with BP at least 180/D is overly cautious. There are multiple studies sighting no difference in ntg precipitated hypotension with inferior vs non-inferior AMI. Of the studies that did find some difference withholding NTG was not an option and was instead to be used with caution. I understand the need for caution but a systolic of 180 needs to be re-evaluated. With ETCO2 being the primary predicter of perfusion in a LVAD patient would it be wise to consider early intubation for the most accurate ETCO2 reading when resources allow. Further revision is being considered. Dr. Buys and Dr. Shafer believe a diastolic blood pressure of 180 is supported by current medical literature. Current LVAD guidelines are focused on expediting transport to a cardiac center. Yes ETCO2 will demonstrate perfusion. However intubating a patient won t fix their broken LVAD.

5 6.2 Pg Pg.121 There is no mention which ventilators we can use. Not all ventilators are the same and will we be allowed to use hospital owned vents or does the transporting provider have to provide one for an ALS vent transfer. Also will ALS vent transfers be limited to pt going to lower level or equal level of care or will we be able to take them to higher level of care. Policy does not specify bolus vs infusion. If infusion is IV pump required/allowed? If IV pump allowed is there a specific make and model we are to use? If both are allowed are the pharmokinetics and/or efficacy of the versed any different in infusion vs bolus? Will a vent be required on these patients are can we utilize a BVM? In Policy 6.2 It states ALS Ambulance providers must apply to and be approved by the San Joaquin County EMS Agency (SJCEMSA) prior to initiating service to perform monitoring of preset mechanical ventilators during interfacility transports. This process will determine the types of ventilators an ambulance service provider may purchase. The use of a transferring hospital ventilator that personnel are unfamiliar with using is not allowed. Policy 6.6 section I. states ALS Ambulance providers must apply to and be approved by the San Joaquin County EMS Agency (SJCEMSA) prior to initiating service to use Versed for sedation of intubated patients during interfacility transports. This process will determine the types of IV pumps an ambulance service provider may purchase. The use of a transferring hospital pumps that personnel are unfamiliar with using is not allowed. Paramedics performing these IFT s must complete SJCEMSA approved training combined protocols AMR Megan Rizzo Much preferred pediatric and adult protocols separate so we aren t having to look through one to get to another. BLS and ALS combined is fine.

6 2018 combined protocols, page AMR Megan Rizzo If the patient has no associated symptoms with a FSBS of , why are we starting an IV of TKO? That accomplishes nothing and a large number of patients will be required to have IV s that are not truly necessary in the field. Also by definition, DKA is the presence of ketones in the urine in addition to a consistently high sugar of over 300, as well as acidemia (ph <7.3) per the Mayo clinic. Noted. DKA has and continues to be taught as part of the national standard curriculum and should be within the abilities of EMTs and paramedics. However, we will consider switching the term to hyperglycemia.