San Luis Obispo Prehospital Policy and Procedure Review BLS

Transcription

1 San Luis Obispo Prehospital Policy and Procedure Review BLS

2 Why was this done? Bring policies into County format Provided consistency Format approved by Clinical and Operations Reduce the number of policies by: Merging BLS and ALS Combining Adult and Pediatric Provide for a comprehensive review Some polices have not been reviewed since 1997

3 Policy and Procedure Organization (renumbering) Administration Communication Destination and Transport Education & Training Operations Personnel/EMT/Paramedic/MICN Specialty Care/STEMI/Trauma(Future Stroke) EMD BLS/ALS Treatment Protocols BLS/ALS Treatment Procedures

4 Treatment Protocol Format

5 Some Treatment Protocols will have Algorithm as an Attachment

6 The EMS App - Update 4/1/2017 ios and Android App Includes Treatment protocols Drug Formulary Routing and distance to receiving facilities Quick dial to ED phones

7 BLS Highlights Airway and Oxygen Administration Medical Care and High Performance CPR Trauma Care and Spinal Motion Restriction Prehospital Determination of Death Base Report and Communication MCI Management, Triage and EMS Aircraft Ops

8 Protocol # 601 Universal Universal applies to all treatment protocols Pulse oximetry is an optional BLS skill for those trained and that have the equipment

9 Definitions for Treatment Protocols Hemodynamic Instability

10 Definitions for Treatment Protocols Stable - Unstable - Extremis and Signs of Life

11 Protocol #602 Airway management Avoid excessive and unnecessary administration of oxygen Oxygen toxicity causes significant complications General: Lung Injury inflammation, Diffuse Alveolar Damage Cardiac: Decreased coronary blood flow microscopic necrosis, vasoconstriction, reduced cardiac output Premature Infants: blindness, seizures Retinopathy (second leading cause of childhood blindness in US) Malhorta, MD, A., Schwartz, MD, D. R., & Schwartzstein, MD, M. R. (2015). Oxygen Toxicity. In T. W. Post (Ed.), UpToDate. Waltham: UpToDate. American Heart Association. (2015). Part 8: Post-Cardiac Arrest Care. In Web-Based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. American Heart Association. (2015). Part 9: Acute Coronary Syndromes. In Web-Based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

12 Airway Management GOAL: Apply O2 to those in need of it Avoid unneeded O2 in Newborns O2 administration is not required if O2 Sat > 94% Titrate O2 Do not withhold O2 if patient is in respiratory distress Pediatric intubation no longer an approved ALS skill

13 Airway Management GOAL: Titrating Oxygen therapy to pulse oximetry if available O2 administration is not required with O2 Sat > 94% Titrate O2 appropriately Use Pulse Oximeter Efficiently Obtain Room Air SpO2 Evaluate quality of pleth waveform

14 Child Birth and Newborn Resuscitation GOAL: Avoid hypoxia without giving unneeded O2 Suction only if needed No need to attempt to suction mouth and nose during delivery in routine cases Suction mouth and nose: Distressed (limp, poor resp.) Meconium staining Obvious obstruction If BVM needed American Heart Association. (2015). Part 13: Neonatal Resuscitation. In Web-Based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

15 Child Birth and Newborn Resuscitation Hypoxia in Newborn usually from inadequate ventilations NOT from lack of Oxygen Ventilate with Room Air Respiratory distress Limp HR <100 Prolonged Cyanosis CPR if HR <60 despite ventilations Connect to O2 Central Cyanosis Normal for several minutes Acrocyanosis (extremities) Normal <10 min AVOID O2 in preterm American Academy of Pediatrics and American Heart Association. (2016). Textbook of Neonatal Resuscitation, 7th Ed. Elk Grove Village, IL: American Academy of Pediatrics. American Heart Association. (2015). Part 13: Neonatal Resuscitation. In Web-Based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

16 Child Birth and Newborn Resuscitation GOAL: Avoid hypoxia without giving unneeded O2 Keys are ventilation, warming and airway management Avoid high-concentration oxygen unless evidence of hypoxia CPR in newborns is 3:1 ratio If doing CPR give O2 Do not use high-concentration oxygen on preterm infants American Heart Association. (2015). Part 13: Neonatal Resuscitation. In Web-Based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

17 Allergic Reaction Protocol # 611 BLS may assist with the administration of a patients prescribed medications

18 Protocol # 612 ALOC Notes included regarding selfadministration of oral glucose

19 Protocol #641 Pulseless Arrest - Pediatric HPCPR for all patients older then 1 month Older then 1 month Compression to ventilations 10:1 1 day 1 month (neonates) Follow BLS recommendations Compression to ventilations 15:2 (with two rescuers) Less then 1 day (newborns) 3:1

20 Pulseless Arrest - Pediatric Pediatric patients 34 kg Emphasize quality CPR rather than immediate transport Stay on scene Vascular access Airway management Administer the first dose of epinephrine followed by 2 min of CPR Nearest Base Hospital (orders and transport) HR less than 60 BPM MAY continue HPCPR

21 Protocol # 660 General Trauma Communicate BP <90 mmhg

22 Protocol #660 A - BLS Attachment

23 Protocol # 662 Burns NEW Policy Stop burning with tepid water Once burning is stopped - dressing Dry dressing for most MAY use moist or gel if BSA < 10%

24 Procedure # 706 Tourniquets/Hemorrhagic Agents Proceed directly to tourniquet if direct pressure fails to control bleeding Don t apply over joint or fracture Least amount of pressure to stop bleeding/distal pulses Hemostatic dressings If tourniquet unsuccessful, or can t be used Use per manufacture directions Tourniquet Removal - ALS Skill

25 Procedure # 702 Spinal Motion Restriction (SMR) Take Home Points of New Protocol Patients should NOT be immobilized based solely on mechanism of injury (MOI) Back boards and short boards are NOT more effective at preventing spinal cord injury then simple in-line movements REMINDER - this is a BLS skill

26 Spinal Motion Restriction (SMR) Spinal Motion Restriction (SMR) is the practice of maintaining the spine in anatomic alignment Back boards and short boards are NOT more effective at preventing spinal movement and cord injury then simple inline movements C-collar KED C-collar Backboard C-collar Climbed out Control Climbed out Engsberg, PhD, J. R., Standeven, PhD, J. W., Shurtleff, OTD, T. L., Eggars, MSOT, J. L., Shafer, MD, EMTP, J. S., & Naunheim, MD, R. S. (2013, January). Cervical Spine Motion During Extrication. Journal of Emergency Medicine, 44,

27 Consider SMR SMR should be considered based on MOI or complaint: High energy blunt trauma (i.e. Step 3 Trauma Criteria) Axial spine loading Traumatic injuries in the high-risk age group < 5 and 65 years old Paralysis or weakness, numbness or tingling associated with trauma SMR NOT required despite MOI if: A&O x 4 No confounders: i.e. distracting injuries, intoxication, etc No symptoms No neuro deficits

28 SMR Evaluation Maintain manual control while examining the patient Is the patient reliable? Yes proceed with exam No apply SMR Spinal pain or tenderness with palpation? No proceed with exam Yes apply SMR Motor/Sensory Exam Normal Exam complete and no SMR required Abnormal - apply SMR IF in doubt Consult Base

29 Indications to do SMR Perform thorough exam Release manual stabilization during final step Note: penetrating trauma does not need SMR unless neuro deficits

30 Applying SMR (when indicated) Manual stabilization to minimize flexion, extension, rotation, or torsion Apply C-Collar Secure in position of comfort Multiple patients, may utilize other means (KED, 3-point seat belts in ambulance, etc) Isolated thoracic/lumbar pain or deformity do NOT require a C- Collar NONAMBULATORY Patients Backboard (or equivalent devices) to transfer to gurney or the transport unit Remove the device, secure for transport Backboards MAY be left in place if removing interferes with critical treatments or interventions AMBULATORY patients may be allowed to self-extricate

31 Applying SMR (when indicated) Back boards MAY be useful for: Blunt trauma patients requiring extrication Patients with ALOC, unable to ambulate When the patient must be moved multiple times A full body splint with multiple extremity fractures Alternative devices may be substituted for ease of use or comfort Helmet removal MAY not be necessary with athletic injuries where shoulder pads are also worn (i.e. football, lacrosse, etc.) and airway management and spinal alignment can be maintained BLS responders when in doubt maintain manual spinal stabilization until ALS personnel evaluate the patient

32 SMR Documentation DOCUMENT all of the following elements in your PCR Patient - reliable/not reliable Pain - present/not present with palpation or movement Neuro exam - normal/ not normal Patient moved as a unit

33 Procedure #713 Pelvic Binder NEW - Pelvic binder (sheet or commercial) Tamponades bleeding blood vessels Decreases volume to bleed into Stabilizes fracture EMRAP: Bad Pelvic Fractures Fiechtl, MD, J. (2017). Pelvic trauma: Initial evaluation and management. In T. W. Post (Ed.), UpToDate. Waltham: UpToDate. National Association of Emergency Medical Technicians. (2016). PHTLS Prehospital Trauma Life Support, 8 th Ed. St. Louis, MO: Elsevier, Mosby Jems.

34 Pelvic Binder Pelvic binder for patients with: Pelvic/low back/groin area pain HIGH RISK mechanism AND Hypotension Base Station Consult prior to removing

35 Pelvic Binder - Assessment Hemodynamically Unstable Blunt Trauma Patient Significant direct blunt force to pelvis (anterior-posterior) Vehicle accident Direct impact to pelvis (intrusion) Head-on or lateral impact on patient side Higher risk if in front seat Unenclosed victim Auto vs pedestrian Motorcycle or like-vehicle collisions Fall from heights Patients > 65 years might suffer significant injury with less substantial mechanism Fiechtl, MD, J. (2017). Pelvic trauma: Initial evaluation and management. In T. W. Post (Ed.), UpToDate. Waltham: UpToDate.

36 Pelvic Binder - Assessment Signs and symptoms of a pelvic fracture: Pain and tenderness in pelvis, especially sacrum assess gently, no rocking or springing Deformity, bruising or swelling over bony prominences Bruising of flanks, perineum, scrotum Abnormal position of legs: length discrepancies, external rotation Bleeding from the rectum, vagina or urethra Note external rotation of greater trochanters and widening of pelvic volume (van Vugt &van Kampen, 2006) Physical Exam is NOT reliable to identify unstable pelvic fracture! Suspect in hypotensive victim of high risk blunt trauma! van Vugt, A. B., & van Kampen, A. (2006). An unstable pelvic ring: the killing fracture. The Bone & Joint Journal. Fiechtl, MD, J. (2017). Pelvic trauma: Initial evaluation and management. In T. W. Post (Ed.), UpToDate. Waltham: UpToDate.

37 Pelvic Binder - Application Application Remove clothing Identify greater trochanters Placement slide under the patient center at the level of the greater trochanter Tighten manufacturer instructions sheet binder: twist knot and secure to maintain tension Do not tighten past greater trochanter/knee/feet in anatomically neutral position Iliac Crest Greater trochanters EMRAP: placement of commercial device Skagit County EMS: Sheet Binder Fiechtl, MD, J. (2017). Pelvic trauma: Initial evaluation and management. In T. W. Post (Ed.), UpToDate. Waltham: UpToDate.

38 Policy # 121 EMS Base Hospital Report What s NEW: Each radio report is preceded with call type Alert, Consultation, Request for Medication, Notification, MCI etc. Simple notifications will contain much less information MICN may provide most orders listed under Marian Hospital may take notifications and alerts No MICNs, can t give orders

39 Base Reports BLS Key Points Consultation (requires a SLO County Base Hospital) Physician Consultation Cardiac Arrest in patient with Ventricular Assist Device (LVAD) (French) Termination Requests Questions about DNR orders, or family requests Guidelines in Determination of Death/Termination Policy #125 Cardiac arrest, adult presumed cardiac (French) Cardiac arrest, pediatric or presumed non-cardiac; i.e. drowning, OD, etc. (Closest Base) Traumatic arrest if you initiated treatment Traumatic Arrest Protocol # 661 SVRMC

40 Policy # 125 Prehospital Determination of Death/Termination NEW: policy merges Determination of Death and Do Not Resuscitate policies into one Clarifications and minor changes: Determinations made by different responders Need for base consult

41 Policy # 125 Prehospital Determination of Death/Termination First Responder may withhold resuscitative measures with: Obvious signs of death Pulseless and apneic with one or more of the following: Decapitation Evisceration of heart or brain Rigor mortis Decomposition or Patient without signs of life and has a confirmed DNR/POLST Legal DNR Order, POLST form (original or photocopy) DNR Medallion In a health care facility, or transferred between facilities: order in chart No hospital contact is required Respect reasonable family wishes, make base consult if questions arise

42 Determination of Death/Termination On-Duty EMT, Paramedic or Fight Nurse may terminate resuscitative measures when: Reliable history of cardiac arrest with no CPR > 20 min Traumatic arrest no signs of life upon EMS arrival Unresponsive, pulseless and apneic Severe, or multiple injuries incompatible with life Information becomes available that would have prevented the initiation of resuscitative measures i.e. POSLT or DNR Even if ALS measures have been initiated CHANGED - No Base Hospital contact is required

43 Determination of Death/Termination Base Hospital contact is required only if: STEMI Receiving Center (FRENCH) Cardiac arrest that does not respond to ALS after 20 min Cardiac arrest and ventricular assist devices present (LVAD) Trauma Center (SVRMC) Traumatic arrest with signs of life on EMS arrival and ALS resuscitative measures were initiated Intended Receiving Base Hospital For other arrests i.e. OD, Pediatric that do not respond to ALS after 20 min

44 Determination of Death/Termination Ventricular assist device (LVAD) Do NOT start CPR Many LVAD patients do not have palpable pulses Comatose, apneic, signs of poor perfusion Attempt: automatic BP (normal mmhg), pulse oximeter Listen for machine whirring over heart Base contact with STEMI Receiving Center (FRENCH) Consider contact with 24/7 LVAD support line Attempt to troubleshoot simple problems with device Alarms Drive line disconnected Battery problems (Stanford Health Care, 2017) Pump Battery Driveline Controller

45 Determination of Death/Termination PCR Documentation for DNRs Physician name on DNR/POLST Date DNR signed Copy or type of DNR Name of the person confirming the patient identity Name and cert # of the person making the determination Name, cert # and agency if the person making determination is not the transporting agency PCR Documentation with determination of death If no resuscitation done - the physical findings If resuscitation started - treatments, results thereof Time, name of person making the determination and the name physician consulted with if treatments were initiated

46 Policy # 155 EMS Aircraft Simplifies First Responder or Medcom requesting criteria Upon arrival or During response Time AND Need

47 Policy #155 EMS Aircraft Need Determined once assessment has been performed

48 Time References

49 Policy # 155 EMS Aircraft

50 Policy # 210 MCI - Highlights Separate training module coming First arriving agency declares a MCI LEVEL I 3-10 patients LEVEL II > 11 patients Use triage tags on ALL MCIs (Level I and II) First arriving ambulance SHALL report to IC and become Transportation Leader MedCom will alert hospitals The IC or Transportation Leader may request MedCom to poll hospitals for capability

51 MCI Continued The estimated required ambulances for a MCI is equal to: = Number of immediate patients (RED Tags) Initial triage with START or JUMPSTART Strict use of START triage criteria Re-triage in treatment area for trauma activation criteria and destination Distribution of patients imperative Ideally trauma patients to TC air resources to go further Hospital Immediate Delayed Minor AGCH or more FHMC or more MMC SVRMC TCCH

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