ALS Changes 2024 PDF

Standing Order 2024 Change Throughout Document After first use of CPAP/BiPAP refer to as Non-Invasive Mechanical Ventilation (NIMV) Minimum Skills and Procedures (Pg. 10) 17. Added BiPAP after CPAP; 44. Removed (Pilot...

Standing Order 2024 Change Throughout Document After first use of CPAP/BiPAP refer to as Non-Invasive Mechanical Ventilation (NIMV) Minimum Skills and Procedures (Pg. 10) 17. Added BiPAP after CPAP; 44. Removed (Pilot); 45. Changed to (Optional) 46. BiPAP (optional) New Paramedic Radio/Telephone Report TOR added on second bullet. Guidelines (Pg. 11) ALS Priority I moved up before Priority II and III. Adult General Patient Care (Pg. 13) Added 1.25 mg Droperidol for NV refractory to Zofran. Acute Respiratory Distress (Pg. 16) Second paragraph reworded to include NIMV and BiPAP. Ketamine dose changed to 25-50 mg IM. Dosage of Epinephrine changed from 0.3-0.5 to just 0.5mg. Pulmonary Edema due to Congestive Added “For systems using BiPAP”. Heart Failure (Pg. 17) Added follow non-invasive ventilation protocol, page 18. Nitroglycerin dose changed from.4 mg to.8 mg. Non-Invasive Mechanical Ventilation New Protocol (NIMV) (Pg. 18) Altered Mental Status (Pg. 19) Under Opioid Overdose 3rd bullet: Added “consider tiered dosing of 0.4 mg per dose.” 4th bullet added “Total ALS dose of up to 6 mg is authorized.” Deleted “for agencies using Buprenorphine” as all are. Buprenorphine (Pg. 21) Moved protocol from end of document up to page 21. Removed “contact med control for administration”. Maximum dose of 24mg language clarified. Removed “approved agency” as all are approved. Hypertensive Crisis (Pg. 22) Added “For hypertension secondary to suspected pre-eclampsia” section Seizures Active (Pg. 25) Midazolam IM dose increased to 10 mg. Midazolam IV dose increased to 5 mg. Added “May be given a total of 3 doses of Midazolam”. Wording clarification on Magnesium Sulfate administration. Allergic Reaction/Adverse Epinephrine dose increased to 0.5 mg IM. Reaction/Dystonia (Pg. 26) Benadryl: removed range, 50 mg. Non-Traumatic Hypotension (Pg. 28) Protocol reformatted and language extended. Norepinephrine dose changed from 10-40mcg/min to 10-50mcg/min; Titrating by 10 mcg every 5 minutes to maintain MAP greater than 65.  Standing Order 2024 Change Sepsis (Pg. 29) POC lactate meters removed. Fluid Bolus changed from 30 ml/kg to 1000 ml. After 1000 ml bolus, added Norepinephrine infusion. Upper range of Norepinephrine increased to 50 mcg/min. Acute Coronary Syndromes (ACS) (Pg. 30) Decreased Systolic BP from less than 150 to less than 120. Removed bullet “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. ST Elevation Myocardial Infarction Decreased Systolic BP from less than 150 to less than 120. (STEMI) (Pg. 31) Hemodynamically Compromising Atropine dose increased from 0.5 to 1mg Bradycardia (Pg. 32) Added.25mg/kg Ketamine for pain due to pacing Removed Fentanyl General Adult Cardiac Arrest Bundle of Added “If at any time the patient receiving high quality resuscitation presents with neurological Care (Pg. 35) responsiveness and/or consciousness, consider the administration of 0.5mg/kg Ketamine IV/IO with max dose of 50mg for the purpose of sedation” at end of protocol. Traumatic Cardiac Arrest (Pg. 37) Title changed to “Pediatric and Adult Traumatic Cardiac Arrest”. In indication: reworded to “patients of at least 5 years of age”. Added updated needle decompression guidelines for pediatric patients. Addition of whole blood reference. Changed resuscitative efforts to “no less than 20 minutes” from 30 minutes Termination of Resuscitative Efforts & Changed resuscitative efforts to “no less than 20 minutes” from 30 minutes Telemetric Pronounce. of Death (Pg. 38) Asystole/Pulseless Electrical Activity Increased to maintain MAP of 90mmHG for Norepinephrine administration with (PEA) (Pg. 44) return of spontaneous circulation. Upper end of Norepinephrine range increased to 50mcg/min. ALS to BLS Release (Pg. 47) Verbiage changed from normal to acceptable for vital signs Upper limit blood pressure changed to 180 systolic Pediatric Seizures Active (Pg. 54 Combined 2 bullets into 1 under If IV/IO established to read “Administer 0.2 mg/kg midazolam (Versed) IV up to a maximum dose of 5 mg. If blood sugar less than 60mg/dl, (40 mg/dl for neonate) administer up to 25 grams dextrose IV/IO”.  Standing Order 2024 Change Pediatric Shock and Hypotension (Pg. 55) Added discontinue fluid bolus if signs of fluid overload develop. Pediatric Allergic Reaction (Pg. 56) Changed Epinephrine max dose to 0.5 mg. Pediatric Bradycardia (Pg. 57) Reformatted first bullet into 2 bullets. Ensure Adequate oxygenation and ventilation. Initiate BVM ventilation Begin chest compressions if the heart rate remains less than 60 beats per minute. Changed maximum atropine dose to 1 mg. Removed last bullet, it was redundant. Pediatric Tachycardia (Pg. 58) Clarified Adenosine wording Removed “poor perfusion” under narrow complex indications Pediatric CPR (Pg. 59) Deleted the last bullet “Contact Medical Control in patients with cardiac arrest from submersion injury to discuss rapid transport directly to ECMO capable facility”. Pediatric and Adult Trauma (Pg. 63) Language changed to use optional junctional tourniquet and IT clamp if available and indicated In head trauma, added "adult" to BP guidelines. Updated needle decompression guidelines for pediatric patients to 4th intercostal space instead of 2nd intercostal space. Adult Blood Administration (Pg. 68) New Protocol Pediatric Blood Administration (Pg. 70) New Protocol Post Resuscitation Care with Targeted 3rd bullet, added “(only excludes TTM)” Temperature Management (Pg. 72) MAP range 80-90 mmHG removed, change to 90 mmHG Upper range of Norepinephrine changed to 50mcg/min Patient Restraint (Pg. 74) Under Moderate Agitation, added consider administration of 2.5 – 5 mg Droperidol and remover range for Benadryl, changed to 50 mg. Under Extreme Agitation Atropine dose changed to 0.5 mg IV and Midazolam dose changed to 5 mg IM. “These” removed from line referring to patient monitoring Pediatric and Adult Airway Management Language added to begin hemodynamic resuscitation prior to initiating DFI. (Pg. 76) Degenerative or dystrophic neuromuscular disease (Amyotrophic lateral sclerosis, Guillain-Barre disease, myasthenia gravis or muscular dystrophy) moved from absolute to relative contraindication. Under Ventilator Management, bullets 2 through 10 added. Protocol reformatted.  Standing Order 2024 Change Pediatric and Adult Pain Management Tylenol PO dose changed from 1000 mg to 975-1000 mg. (Pg. 80) Pediatric dose of 15 mg/kg to adult max dose added. Toradol dose changed to 15 mg for all adult doses. Changed Fentanyl adult max dose to 400 mcg. Under Toradol, added pediatric dose. Pregnancy added as a contraindication for Toradol. Removed contraindication of “possible surgical candidate with open fracture or fracture deformities/anticipated surgical candidate” for Toradol. Toradol indications reworded to add “in patients greater than 2 years of age.” Mandatory ALS Equipment Inventory ET tubes added cuffed if available. (Pg. 85) Medication list (Pg. 87) Added, Droperidol Interfacility 4.3 Management of Clarified language for medication titration guidelines in 2nd paragraph. Previously Initiated Continuous IV Fusions Reworded 4th paragraph to “If patient’s needs during transport exceed the (Pg. 93) capabilities of the ALS interfacility unit, consider the need for additional specialty transport resources including critical care transport”. Interfacility 4.4 Blood Product Wording changed in 2nd paragraph to “May to initiate blood products after Administration (Pg. 94) confirming with a registered nurse or physician; Any additional units sent with IFT paramedic must be verified by the paramedic and hospital staff prior to departure.” Removed “Blood infusions must be started at the sending facility for at least 15 minutes and at least 50 mL must be infused before transport can begin.” Moved Allergy reference higher in protocol Appendix E (Pg. 99) New – Shock Index; Adult and Pediatric Age Adjusted Appendix F (Pg. 101) New – Hospital Contacts