SLO County Emergency Medical Services Agency Bulletin 2012-09 PLEASE POST Updated Policies and Procedures # s 606, 607, 610, 611, 612, 613, 625, 628, 630, 631, and 633 (ACLS Protocols and Policies) July 6, 2012 To All SLO County EMS Providers and Training Institutions: The following policy was adopted by the San Luis Obispo County EMS Agency and will become effective August 2, 2012 at 0800 hours. Policy # Policy Revision 606 Adult Bradycardia 12 Lead ECG moved to Universal Algorithm 607 Adult Cardiac Chest Pain Morphine is no longer a progressive step in the algorithm; it is now a consideration after 3 doses of Nitroglycerin with no patient improvement. 610 Adult Pulseless Arrest Removed Atropine from Asystole/PEA branch. CPR references within the algorithm have been reduced. Monophasic references have been removed from the algorithm 611 Adult Respiratory Distress Added suggested starting points for CPAP. 612 Adult Supraventricular Tachycardia Monophasic references have been removed from algorithm. 613 Adult Ventricular Tachycardia with a Monophasic references have been removed from algorithm. Pulse 625 Pediatric Bradycardia Addition of 12 Lead to Universal Algorithm at top of algorithm 628 Pediatric Pulseless Arrest Removed Atropine from Asystole/PEA branch. Box 1 now reads Consider Reversible Causes and Monitor ETCO2 in addition to and Shockable Rhythm. Reduced CPR references and Monophasic settings within the algorithm. 630 Pediatric Supraventricular Tachycardia Added 12 Lead ECG to Universal Algorithm 631 Pediatric Ventricular Tachycardia Removed Monophasic references from algorithm. with a Pulse 633 Continuous Positive Airway Pressure Addition of suggested starting points for CPAP. These policies will be uploaded to the EMSA website www.sloemsa.org by July 13 Do not hesitate to contact the EMSA office at (805) 788-2511 with any questions or concerns. Page 1 of 1
ADULT BRADYCARDIA Identify and treat reversible causes Establish vascular access Obtain 12 lead ECG, when available STABLE UNSTABLE Observe/Monitor Consider Atropine 0.5 mg IVP, repeat every 3-5 min, not to exceed 3 mg Obtain 12 lead ECG BASE PHYSICIAN ORDER ONLY Fluid Bolus 500 ml NS Dopamine 5-20 mcg/kg/minute Sodium Bicarbonate for tricyclic antidepressant OD Calcium Chloride for suspected hyperkalemia, suspected renal failure or calcium channel blocker OD Glucagon for beta blocker OD Higher doses of Atropine for organophosphate OD Policy Reference No. 606
ADULT CARDIAC CHEST PAIN Identify and treat reversible causes Establish vascular access Obtain 12-lead ECG early Early notification of the SRC with a STEMI Alert with a 12-lead ECG reading of ***Acute MI Suspected*** Consider establishing second IV with NS Lock BP < 100 SYSTOLIC with signs of poor perfusion Aspirin 162 mg (non-enteric coated) tablets chewed and swallowed BASE PHYSICIAN ORDER ONLY Additional administration of Morphine Administration of topical Nitroglycerin may be considered after initial dose(s) of SL Nitroglycerin Dopamine 5-20 mcg/kg/minute for persistent hypotension Fluid Bolus 500 ml NS BP > 100 SYSTOLIC with signs of adequate perfusion Nitroglycerin 0.4 mg SL tablets or spray, may repeat every 5 min, Titrate to pain, BP and other signs of perfusion Do not administer nitroglycerin if BP drops < 100 systolic or in the presence of other signs/symptoms of hemodynamic instability Aspirin 162 mg (non-enteric coated) tablets chewed and swallowed After three administrations of NTG with no patient improvement, consider Morphine 2-10mg slow IVP titrated to patient improvement. Do not administer Morphine if BP drops < 100 systolic Note: Consider Base Physician consult for A-fib with RVR prior to administration of NTG Next Review Date: May 1, 2014 Policy Reference No. 607
ADULT PULSELESS ARREST 2 SHOCKABLE VF/VT 1 Consider Reversible Causes Monitor ETCO2 8 NOT SHOCKABLE ASYSTOLE/PEA 3 Give 1 Shock Biphasic 120 J or equivalent Establish Vascular Access and Airway 9 Establish Vascular Access and Airway Epinephrine 1:10,000, 1 mg IVP/IO, repeat every 3-5 mi 5 4 Give 1 Shock Biphasic 150 J When vascular access available, administer: Epinephrine 1:10,000 1mg IVP/IO during CPR, repeat every 3-5 min 6 NO NO 10 NOT SHOCKABLE If asystole, go to Box 9 If electrical activity, check pulse. If no pulse go to Box 9 If pulse present, begin post resuscitation care SHOCKABLE 11 12 Go to Box 3 7 Give 1 Shock Biphasic 200 J Lidocaine 1.5 mg/kg IVP/IO repeat every 3-5 min, not to exceed 3 mg/kg Give during CPR (before or after shock) Preform 2 minutes of uninterrupted CPR between treatment modalities. Provider agencies using monophasic defibrillation should refer to American Heart Association Guidelines for settings. Policy Reference No. 610
ADULT RESPIRATORY DISTRESS Identify and treat reversible causes Establish vascular access Consider CPAP ASTHMA Dyspnea/Wheezing/Shock: Albuterol 2.5-5 mg via CPAP/ HHN/mask/BVM with adjunct over 5-10 min, repeat as needed Epinephrine 1:1,000 0.01 mg/kg IM, not to exceed 0.5 mg, may repeat every 5 min, not to exceed 3 doses Severe Shock/Extremis and no IV access: Epinephrine 1:1,000 0.01 mg/kg SL injection, not to exceed 0.5 mg, may repeat every 5 min, not to exceed 3 doses PULMONARY EDEMA Nitroglycerin 0.4 mg SL tablets or spray, may repeat every 5 min - titrated to symptoms and VS With CPAP - Administer first dose(s) of Nitroglycerine SL and apply 2% topical Nitroglycerin patch - 1 Gm pre-packaged single dose: apply to chest area once mask is applied Monitor BP trends-withold and consult base physician with significant decreases Do not administer if BP < 100 systolic COPD Albuterol 2.5-5 mg via CPAP/ HHN/mask/BVM with adjunct over 5-10 minutes, repeat as needed BASE PHYSICIAN ORDER ONLY Epinephrine: 1:10,000 0.01 mg/kg slow IVP titrated, not to exceed 0.5 mg for patients in extremis and unresponsive to previous therapy Furosemide 0.5-1 mg/kg slow IVP for patients with significant pulmonary edema Morphine 1-3 mg slow IVP for patients with significant pulmonary edema and BP > 100 unresponsive to previous therapy Suggested CPAP Settings Illness ASTHMA PULMONARY EDEMA COPD Suggested Starting Point 3.0-5.0 cm /H2o 7.5-10.0 cm/h2o 5.0-7.5 cm/h2o Maximum 15.00 cm/h2o 15.00 cm/h2o 15.00 cm/h2o Policy Reference No. 611
ADULT SUPRAVENTRICULAR TACHYCARDIA Identify and treat reversible causes Establish vascular access with IV NS in large proximal vein QRS < 0.12 seconds typical for SVT STABLE UNSTABLE Attempt vagal maneuvers Consider administration of Adenosine If rhythm and symptoms remain unchanged: Adenosine 6 mg rapid IVP, followed immediately by a 20 cc NS bolus If no conversion: Adenosine 12 mg rapid IVP, followed immediately by a 20 cc NS bolus, may repeat once SYNCHRONIZED / UNSYNCHRONIZED CARDIOVERSION SEQUENCES: Consider pre-medication if possible: Diazepam 2.5-10 mg IVP BIPHASIC 50 J 70/75 J 120 J 150 J 200 J or equivalent CONSIDERATIONS Vascular access may be omitted prior to cardioversion if in extremis If synchronized mode is unable to capture, then use unsynchronized cardioversion Obtain 12-lead EKG, if available, before and after cardioversion Provider agencies still using monophasic defibrilation should refer to American Heart Guidelines for settings. Policy Reference No. 612
ADULT VENTRICULAR TACHYCARDIA WITH A PULSE Identify and treat reversible causes Establish vascular access with IV NS in large proximal vein QRS > 0.12 seconds typical for VT STABLE UNSTABLE Lidocaine: 1.5 mg/kg IVP If arrhythmia persists: May repeat Lidocaine 0.75 mg/kg IVP every 5-10 minutes, not to exceed 3 mg/kg SYNCHRONIZED / UNSYNCHRONIZED CARDIOVERSION SEQUENCES: Consider pre-medication if possible: Diazepam 2.5-10 mg IVP CONSIDERATIONS Vascular access may be delayed prior to cardioversion if in extremis If synchronized mode is unable to capture, then use unsynchronized cardioversion Obtain 12-lead EKG, if available, before and after cardioversion Provider agencies using monophasic defibrilation should refer to American Heart Association guidelines for settings. BIPHASIC 50 J 70/75 J 120 J 150 J 200 J or equivalent Lidocaine: 1.5 mg/kg IVP If arrhythmia persists: May repeat Lidocaine 0.75 mg/kg IVP every 5-10 minutes, not to exceed 3 mg/kg BASE PHYSICIAN ORDER ONLY For post-cardioversion Lidocaine use Policy Reference No. 613
PEDIATRIC BRADYCARDIA Identify and treat reversible causes Establish vascular access Utilize current Broselow tape Use adult protocols for patients > 34 kg Obtain 12-Lead EKG, when available STABLE UNSTABLE OBSERVE/MONITOR Epinephrine 1:10,000 0.01 mg/kg (0.1 ml/kg) slow IVP/IO, not to exceed 0.3 mg per dose, repeat every 3-5 min Atropine 0.02 mg/kg IVP/IO, minimum dose of 0.1 mg and a maximum dose of 0.5 mg, may repeat once in 3-5 min, not to exceed 1 mg BASE PHYSICIAN ORDER ONLY Dopamine 5-20 mcg/kg/minute Sodium Bicarbonate for tricyclic antidepressant OD Calcium Chloride for suspected hyperkalemia, suspected renal failure or calcium channel blocker OD Glucagon for beta blocker OD Higher doses of Atropine for organophosphate OD Fluid Bolus 20 ml/kg NS Policy Reference No. 625
PEDIATRIC PULSELESS ARREST 3 5 SHOCKABLE VF/VT Give 1 Shock Biphasic 2 J/ Establish Vascular Access and Airway 4 2 1 NO Consider Reversible Causes NOT SHOCKABLE 8 Monitor ETCO2 Asystole/PEA (<60) BPM) 9 Resume CPR immediately and establish vascular access and airway Epinephrine 1:10,000 0.01 mg/kg (0.1 ml/kg) slow IVP/IO, repeat every 3-5 min For patients > 34 kg, follow Adult Pulseless Arrest algorithm Give 1 Shock Biphasic 4 J/kg Epinephrine 1:10,000 0.01 mg/kg (0.1 ml/kg) slow IVP/IO, repeat every 3-5 minutes 10 7 6 NO Give 1 Shock Biphasic 4 J/kg Lidocaine 1 mg/kg IVP/IO, repeat in 10-15 min, not to exceed 100 mg 11 Not Shockable If asystole, go to Box 9. If electrical activity, check pulse. If no pulse go to Box 9. If pulse present, begin post resuscitation care. Shockable Go to Box 3 Preform 2 minutes of uninterrupted CPR between treatment modalities Provider Agencies using monophasic defibrillation should refer to American Heart Association guidelines for settings. 12 Policy Reference No. 628
PEDIATRIC SUPRAVENTRICULAR TACHYCARDIA Identify and treat reversible causes Establish vascular access with IV NS in large proximal vein QRS < 0.08 seconds Utilize current Broselow tape Use adult protocols for patients > 34 kg 12 Lead ECG if available, don t delay therapy STABLE UNSTABLE Attempt vagal maneuvers Consider administration of Adenosine If rhythm and symptoms remain unchanged: Adenosine 0.1 mg/kg rapid IVP, followed immediately by a 20 cc NS bolus, not to exceed 6 mg Adenosine 0.2 mg/kg rapid IVP, followed immediately by a 20 cc NS bolus, not to exceed 12 mg Do not repeat SYNCHRONIZED / UNSYNCHRONIZED CARDIOVERSION SEQUENCES: Consider pre-medication if possible: Diazepam 0.3 mg/kg slow IVP, not to exceed 10 mg BIPHASIC 1 J/kg 2 J/kg 2 J/kg CONSIDERATIONS Vascular access may be omitted prior to cardioversion if in extremis. If synchronized mode is unable to capture, then use unsynchronized cardioversion. Obtain 12-lead EKG, if available, before and after cardioversion. Notify base station for wide complex tachycardia (> 0.08 seconds). Provider agencies using monophasic defibrillation should refer to American Heart Association guidelines for settings. Policy Reference No. 630
PEDIATRIC VENTRICULAR TACHYCARDIA WITH A PULSE Identify and treat reversible causes Establish vascular access with IV NS in large proximal vein/io QRS > 0.08 seconds Utilize current Broselow tape Use adult protocols for patients > 34 kg STABLE UNSTABLE Lidocaine 1 mg/kg IVP/IO If arrhythmia persists: Repeat Lidocaine 0.5 mg/kg IVP/IO every 5-10 minutes, not to exceed 100 mg SYNCHRONIZED / UNSYNCHRONIZED CARDIOVERSION SEQUENCES: Consider pre-medication if possible: Diazepam 0.3 mg/kg slow IVP, not to exceed 10 mg BIPHASIC 1 J/kg 2 J/kg 2 J/kg Lidocaine 1 mg/kg IVP/IO If arrhythmia persists: Repeat Lidocaine 0.5 mg/kg IVP/IO every 5-10 minutes, not to exceed 100 mg CONSIDERATIONS Vascular access may be omitted prior to cardioversion if in extremis. If synchronized mode is unable to capture, then use unsynchronized cardioversion. Obtain 12-lead EKG, if available, before and after cardioversion. Notify base station for wide complex tachycardia (> 0.08 seconds). Provider agencies using monophasic defibrillation should refer to American Heart Association guidelines for settings. Policy Reference No. 631
SAN LUIS OBISPO COUNTY EMERGENCY MEDICAL SERVICES AGENCY PREHOSPITAL POLICY Policy Reference No: 633 Effective Date: 08/02/12 Supersedes: N/A Review Date: 11/01/12 SUBJECT: CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) I. PURPOSE: A. To define the indications, contraindications, and procedure of Continuous Positive Airway Pressure (CPAP). II. AUTHORITY: A. California Health and Safety Code, Division 2.5, Ch. 4 Art. 1, Ch. 5 Sections 1798(a & b), and 1798.2 B. California Code of Regulations, Title 22, Division 9 Ch. 2 Art. 2, Sections 100063, Ch. 4, Art. 2, Sections 100144, 100145, and 100147 III. DEFINITIONS: A. EMS Agency San Luis Obispo County Emergency Medical Services Agency, Inc. B. Advanced Life Support Provider (ALS Provider) An agency or entity approved by the San Luis Obispo County EMS Agency to provide Advanced Life Support emergency care, including transporting and non-transporting providers. C. Continuous Positive Airway Pressure (CPAP) a device that transmits an increased airway pressure to patients IV. INDICATIONS: CPAP may be utilized in conscious, breathing patients greater than 34Kg. with severe respiratory distress secondary to the following: A. Acute pulmonary edema B. COPD C. Asthma D. Near drowning E. Pneumonia V. CONTRAINDICATIONS: A. Unconscious or decreased level of consciousness with inability to adequately ventilate B. Respiratory or cardiac arrest Policy Reference # 633 Page 1 of 3
C. Tracheostomy D. Sign and symptoms of a pneumothorax E. Major facial, head or chest trauma F. Vomiting or upper GI bleed G. Epistaxis moderate to severe H. Unable to control secretions I. Uncooperative patient after coaching VI. PROCEDURE: A. Place patient in seated position and explain procedure B. Continuously monitor and document ECG, and VS (BP, HR, RR, SaO2 and ETCO2) C. Set up CPAP per manufacturers recommendation- allowing O2 to flow for one to two seconds before placing over patients nose and mouth D. Instruct patient to inhale through nose and exhale through mouth E Suggested starting points for CPAP use are as follows: Asthma 3.0-5.0 cm/h2o Pulmonary Edema 7.50-10.0cm/H2o COPD 5.0-7.5 cm/h2o Slowly titrate in 3cm/H2O increments to a maximum of 15 cm/h2o according to patient improvement and tolerance as documented by improved vital signs and symptoms: 1. Improved respiratory effort 2. Heart rate 3. Blood pressure 4. SaO2 levels 5. CO2 levels Note: Some patients may not tolerate application initially until medications take effect. In such cases have the patient hold mask on their face until medications take effect and application is tolerated. E. Medication administration 1. CPAP delivered utilizing 100% oxygen 2. Albuterol 2.5 5 mg may be delivered via in-line nebulizer utilizing a minimum of 8-10 LPM oxygen flow Policy Reference # 633 Page 2 of 3
3. Nitroglycerin when indicated, should be delivered per San Luis Obispo County EMS Agency drug formulary Note: BVM ventilation or endotracheal intubation should be utilized if patient fails to show improvement F. Notify the Base Hospital in radio report when CPAP is utilized VII. IMMEDIATELY DISCONTINUE CPAP (and continue to support respirations with BVM/Intubation) A. Hypotension Systolic BP < 100 remove and/or discontinue any nitroglycerine products B. Increasing respiratory distress C. Evidence of barotrauma e.g. subcutaneous air or pneumothorax D. Other signs or symptoms of decompensation ALOC, sustained decrease in SaO2 Sat, etc. VIII. DOCUMENTATION A. Pressure setting in cmh2o and any adjustments made B. Continuous pulse oximeter readings C. Capnography/CO2 readings - when available D. Continuous VS and ECG recording E. Document patient response on PCR Policy Reference # 633 Page 3 of 3