2024 Delaware ALS Protocols (Update) Final PDF

2024 Delaware ALS Protocol Update Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness...

2024 Delaware ALS Protocol Update Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Overview Added three new standing orders – Non-Invasive Mechanical Ventilation (NIMV), Adult Whole Blood & Pediatric Whole Blood Addition of Pre-eclampsia guidelines to Hypertensive Crisis Protocol Renamed Traumatic Cardiac Arrest – Pediatric and Adult Traumatic Arrest Added two new Appendices – E: Adult and Pediatric Age- Adjusted Shock Index & Hospital Contacts Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Additions to Skills and Procedures Optional BiPAP Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Radio/Telephone Report Guidelines No significant change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Adult General Patient Care Added Droperidol for NV refractory to Zofran – Administer 1.25 mg slow IVP Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Acute Respiratory Distress - Adult Added verbiage Non-Invasive Ventilation (NIMV) – To include CPAP or BiPAP Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Acute Respiratory Distress – Moderate/Severe Patient not tolerating NIMV – Without IV May give Ketamine 25-50 mg IM Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Acute Respiratory Distress – Moderate/Severe Patients less than 60 years of age in pending respiratory failure – Consider Epinephrine (1mg/mL) 0.5 mg IM – Contact med control for consideration of epi in patients older than 60 years Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pulmonary Edema Due to CHF Nitroglycerin administration guidelines updated – Administer 0.8 mg nitroglycerin (NTG) SL. Repeat NTG 0.8 mg every 3-5 minutes Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Non-Invasive Mechanical Ventilation (NIMV) New Protocol Indications – Patients 15 years of age or older presenting with respiratory distress or failure due to infection, pulmonary edema, congestive heart failure, COPD, or asthma Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Non-Invasive Mechanical Ventilation (NIMV) Contraindications – Active vomiting, facial or cranial trauma, facial burns, severe epistaxis, inability to clear secretions, or any circumstance in which endotracheal intubation or surgical airway is immediately indicated Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Non-Invasive Mechanical Ventilation (NIMV) Procedures – Ensure emergency equipment is immediately available and an alternate airway management plan has been established. – Assure patent airway. – Perform appropriate patient assessment, including obtaining vital signs, pulse oximeter (SpO2) reading, ETCO2, and cardiac rhythm. – Apply BiPAP device per manufacturer's instructions Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Non-Invasive Mechanical Ventilation (NIMV) Procedures continued – Set initial inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) to decrease patient respiratory effort and adjust as needed. Choose the appropriately sized mask for patient. Start with IPAP at 10 cm H20 (max 15 cm H20). Start with EPAP at 5 cm H20 (max 8 cm H20) if using BiPAP. Pressure support to be no less than 5 cm H2O (Difference of IPAP-EPAP). Set back-up ventilatory rate of 8 BPM or higher. (If equipped). Emergency Medical Services and Preparedness Section Update 2024 Non-Invasive Mechanical Ventilation (NIMV) Procedures continued Set FiO2 to appropriate level to maintain an SpO2 of 94 - 99%. Continually reassess the patient after placing the NIMV device. Recheck the mask for leaks and adjust as needed. – Monitor continuous pulse oximetry. – Monitor continuous ETCO2 with nasal prongs. – Monitor HR, BP, and ECG If the patient deteriorates and meets one or more of the contraindications above, then discontinue the use of NIMV. Emergency Medical Services and Preparedness Section Update 2024  Altered Mental Status Opioid Overdose – If respiratory depression continues with assisted ventilation, administer up to 2 mg naloxone (Narcan) IV, IN, or IM. Consider tiered dosing at 0.4 mg per dose – If inadequate respiration continues, administer a second dose up to 2 mg naloxone (Narcan) IV, IN, or IM. Total ALS dosage of up to 6 mg naloxone is authorized Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Buprenorphine Removed need to contact medical control for initial administration Maximum total dose of 24 mg Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Hypertensive Crisis Added section for hypertension secondary to pre- eclampsia – Indications pregnancy greater than 20 weeks gestation (up to 6 weeks post-partum) AND SBP greater than 160 or DBP greater than 110 lasting more than 15 minutes. Must also have associated pre-eclampsia symptoms: – headache – confusion – visual changes – epigastric pain – shortness of breath – focal neurological deficits Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Hypertensive Crisis Procedure – Contact Medical Control for order to administer Labetalol (Trandate) 20 mg over 2 minutes. Target BP140/90. Contact Medical Control for the consideration of administration of a repeat dose of 10-20 mg Labetalol (Trandate) IV 10 minutes after first dose. – Administer 5 g Magnesium Sulfate IV over 20 minutes concurrent with first dose of Labetalol. Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Suspected Stroke No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Seizures Midazolam – IM dose increase to 10 mg – IV dose increase to 5 mg – Total of 3 doses may be given to control seizure Magnesium Sulfate – For seizures secondary to eclampsia administer 5 g IV over 20 minutes concurrent with first dose of Midazolam Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Allergic/Adverse Reactions/Dystonic Reactions Severe allergic reaction – Epinephrine dose increase to 0.5 mg IM Benadryl – Dose change to 50 mg IV, IM, or PO Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Non-Traumatic Hypotension Protocol reformatted and language extended – Appropriately manage Airway, Breathing, and Unstable Bradycardia/Tachycardia prior to treating non-traumatic hypotension – If DFI is indicated, ensure adequate fluid and vasopressor resuscitation prior to DFI – Repeat fluid bolus of NSS 500 mL up to 2000 mL total Norepinephrine dose increased to 10-50 mcg/min; Titrate by 10 mcg/min every 5 minutes to maintain MAP greater than 65 mmHg Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Sepsis POC lactate meters removed Fluid bolus change with ETCO2 less than 25 mm/Hg – Initiate two large bore IV catheters and rapidly infuse 1000 mL bolus of NSS – Continue infusion of fluid up to 30 mL/kg bolus NSS – After a minimum of 1000 mL of fluid consider a 10- 50 mcg/min norepinephrine infusion for continued hypotension not due to hypovolemia. Titrate norepinephrine to maintain MAP greater than 65 mmHg Emergency Medical Services and Preparedness Section Update 2024  Acute Coronary Syndromes (ACS) Blood Pressure guideline update for Nitroglycerin – IV must be established prior to NTG administration for patients with a systolic BP less than 120 mmHg (use cautiously for patients not currently prescribed NTG.) – Removed “If no change in the patient’s chest pain and there are no signs of ischemia or injury, consider discontinuing SL NTG administration after 3 doses” – Discontinue NTG therapy if systolic blood pressure (SBP) is less than 90 mmHg Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 ST Elevation Myocardial Infarction (STEMI) Blood Pressure guideline update for Nitroglycerin – IV must be established prior to NTG administration for patients with a systolic BP less than 120 mmHg (use cautiously for patients not currently prescribed NTG.) – Discontinue NTG therapy if systolic blood pressure (SBP) is less than 90 mmHg Emergency Medical Services and Preparedness Section Update 2024 Hemodynamically Compromising Bradycardia Atropine dose change – Administer 1 mg atropine IV. Repeat 1 mg atropine IV every 3-5 minutes until a maximum of 3 mg of atropine is administered or the pulse rate is 50 BPM or greater Ketamine replaced Fentanyl for discomfort due to pacing – Administer 0.25 mg/kg Ketamine IV/IO, repeat at 20 minutes if needed Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Stable Tachycardia No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Unstable Tachycardia No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  General Adult Cardiac Arrest Bundle of Care Addition to protocol – If at any time the patient receiving high quality resuscitation presents with neurological responsiveness and/or consciousness, consider the administration of 0.5 mg/kg Ketamine IV/IO (maximum 50 mg) for the purpose of sedation Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Pediatric And Adult Traumatic Cardiac Arrest Protocol change to include pediatrics Indication – Added patients of at least 5 years of age Needle Decompression guidelines added for pediatrics – Pediatrics: 14 g x 1.50” - Preferred Site: 4th Intercostal space at anterior axillary line Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Pediatric And Adult Traumatic Cardiac Arrest Addition of Whole Blood – Contact Medical Control to consider administration of Whole Blood in traumatic cardiac arrest patients meeting criteria as outlined in the pediatric and adult Whole Blood protocols on pages 68-70 Changed guideline for discontinuation of CPR – Resuscitative efforts are no less than 20 minutes Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Termination of Resuscitative Efforts & Telemetric Pronouncement of Death Changed guideline for discontinuation of CPR – Resuscitative efforts are no less than 20 minutes Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Guidelines Regarding Do Not Resuscitate Orders No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Ventricular Fibrillation (VF) and/or Pulseless Ventricular Tachycardia (VT) No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Asystole / Pulseless Electrical Activity (PEA) Norepinephrine changes – With return of spontaneous circulation or suspected Pseudo PEA: Maintain a MAP of 90 mmHg using 10-50 mcg/min infusion Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Refusal of Service No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  ALS Release to BLS Vital Sign change – Acceptable vital sign range for this protocol is defined as a heart rate between 60-110 BPM; systolic blood pressure between 100-180 mmHg: respiratory rate between 12-20 BPM; and a Sp02 reading of greater than 92% on room air Emergency Medical Services and Preparedness Section Update 2024  Pediatric General Patient Care No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Acute Respiratory Distress No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Altered Mental Status No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Seizures No significant change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Shock and Hypotension Added guideline – Discontinue fluid bolus if signs of fluid overload develop Added Reference Appendix E: Shock Index Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Allergic Reaction For Severe Allergic Reaction – Epinephrine dose change Administer epinephrine 0.01 mg/kg (1 mg/mL) IM, up to 0.5 mg. Repeat every five minutes up to three (3) times as needed Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Bradycardia Atropine dose change – Administer 0.02 mg/kg atropine for primary AV block. Minimum dose is 0.1 mg IV. Maximum single dose is 1 mg IV. May be repeated once in 3-5 minutes Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Tachycardia No significant change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Pediatric Cardiopulmonary Resuscitation Guidelines Deleted guideline Contact medical control for consideration of transport to ECMO capable facility in cases of arrest secondary to submersion Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024 Pediatric Ventricular Fibrillation (VF) and/or Pulseless Ventricular Tachycardia (VT) No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric Asystole / Pulseless Electrical Activity (PEA) No change Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Pediatric and Adult Trauma Guideline for Pediatric needle decompression update – Pediatrics: 14 g x 1.50” - Preferred Site: 4th Intercostal space at anterior axillary line Head Trauma – Maintain systolic blood pressure greater than 100 mm Hg in adults Treat hemorrhagic shock Fluid resuscitation indicated for adults – In adult patients initiate 1 liter fluid resuscitation if approaching SBP of 90 mm Hg Emergency Emergency Medical Services Medical Services and Preparedness and Section Preparedness UpdateSection 2024  Adult Blood Administration New Protocol Indications – This protocol is for use in the hemodynamically unstable patient, presenting with signs or symptoms of hemorrhagic shock with suspected need for massive blood transfusion due to suspected marked internal and, or external blood loss presenting with sustained tachycardia greater than 110 BPM or sustained hypotension less than 90 mmHg, or a shock index greater than 1.0 (Calculated by HR/SBP), or ETCO2 less than 25 Emergency Medical Services and Preparedness Section Update 2024  Adult Blood Administration Guidelines – *Do not delay transport to initiate blood products.* – Traumatic Hemorrhage Isotonic Crystalloids (0.9 Sodium Chloride) Tranexamic Acid 2 grams IV/IO Consider Blood Transfusion with Online Medical Control (OLMC) Calcium Chloride 1g IV/IO over 3 minutes after each unit of transfused blood product – Upper/Lower GI Hemorrhage Isotonic Crystalloids Consider Blood Transfusion with OLMC Calcium Chloride 1g IV/IO over 3 minutes after each unit of transfused blood product Emergency Medical Services and Preparedness Section Update 2024  Adult Blood Administration Guidelines Continued – Post-Partum Hemorrhage Isotonic Crystalloids Tranexamic Acid 2 grams IV/IO Consider Blood Transfusion with OLMC Calcium Chloride 1g IV/IO over 3 minutes after each unit of transfused blood product *Administration of blood products is optional, as approved by the jurisdictional medical director* Emergency Medical Services and Preparedness Section Update 2024  Adult Blood Administration Transfusion of Blood Products – The paramedic must contact online medical control (OLMC) and obtain orders to administer blood products. The paramedic must speak directly to the medical control physician. – With OLMC approval, Low Titer O Positive Whole Blood (LTOWB) may be administered in accordance with the following indications and the following guidelines Emergency Medical Services and Preparedness Section Update 2024  Adult Blood Administration Guidelines – Indications for transfusion Hemorrhagic Shock: Patients with ongoing, or suspected ongoing, major hemorrhage, based on their presenting injury or diagnosis, and with the clinical signs of shock (tachycardia, delayed capillary refill, hypotension, or mental status changes) should be given blood (LTOWB). – Baseline vital signs should be obtained prior to blood administration, with continuous monitoring throughout the transfusion. Vitals signs, including temperature should be documented every 5 minutes. – Blood Type: Low Titer O Positive Whole Blood Emergency Medical Services and Preparedness Section Update 2024  Adult Blood Administration Guidelines continued – General Guidelines When not being administered, blood shall be stored in a biothermal grade cooler. Blood must be stored between 1-6 Degrees Celsius. The temperature of the stored blood must be monitored constantly. Any deviations in the storage temperature beyond the therapeutic range could result in wasted product. Prior to administration, two paramedics must check and verify blood type, Rh factor, unit numbers, and expiration date. In adults, blood should be administered through a large bore (at least 18 gauge) peripheral IV, or intraosseous needle. Smaller bore or intraosseous needle is acceptable in children. Emergency Medical Services and Preparedness Section Update 2024  Adult Blood Administration Guidelines continued Blood should be administered with 0.9% Normal Saline through blood tubing with a filter. Rapid Infusion and warming devices should be used to facilitate the rapid infusion of the blood product. After the transfusion is complete, amount transfused, and patient’s response should be documented. All unused blood products and empty blood product bags should be left with the receiving facility. Emergency Medical Services and Preparedness Section Update 2024  Adult Blood Administration Guidelines continued – Transfusion Reaction If signs of a transfusion reaction develop [fever, chills, hypotension, dyspnea, tachycardia, pain at the transfusion site, hives, etc.], stop the transfusion immediately. Consider the Allergic/Adverse Reactions/Dystonic Reaction Protocol The unit of blood, the IV bags, and all tubing must be discontinued and sent to the blood bank upon arrival at the receiving hospital. Notify Medical Control immediately for all possible transfusion reactions – Refer to Appendix E – Shock Index Emergency Medical Services and Preparedness Section Update 2024  Pediatric Blood Administration New Protocol – INDICATIONS: This protocol is for use in the hemodynamically unstable trauma patient ages 5 to 15, presenting with signs or symptoms of hemorrhagic shock with suspected need for massive blood transfusion due to suspected marked internal and, or external blood loss – Signs of shock include: Capillary reperfusion >2 sec, change in mental status, absence of brachia/radial pulses, or pale/cool/clammy skin Emergency Medical Services and Preparedness Section Update 2024  Pediatric Blood Administration Guidelines – Must have traumatic mechanism with signs of hemorrhagic shock and one of the following: Elevated pediatric age adjusted shock index (SIPA) OR Systolic BP