ࡱ> RTMNSFIk+B=gEJFIF``C    #%$""!&+7/&)4)!"0A149;>>>%.DIC;C  ;("(;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;aa" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?Z(帆X2ðzqhJBBk׾'dji1x~ HTu#q`~멼UmmiC2E1!]ⳕXu֫tm7)+H>2"]Au?r3ۅz.(;G^xSMԴ{c|xgF 8RUtHE{i]Tġ*qpu$cC I%Nz]5ue-E8qB{I|D״gU'Wz rOz s^n_%FNXQ죟Zk7ww+a{0 j TǞ:w5z˒M[_wz>aij:l=Aؚs8rJn8rO<~`f4)1̖R,ǹJnk5z3juU /VS6Ys-A%A>} Wc(+/ΏIpI 14bX^}Mzm 4QgwmrI=E&?a<r7&rm= zΛg^+[Mߧ |@M+T-zn#rO JPnSW= _ z~^O :qkCV} 5FF@`7JJi+F }wG㣈*{-۷4?:@Xe&pr7̣9+Zk7%["7 1hgMc`:G+՞)Tp<'G #O0&Fd&qgarW-ۧ[H!I{'m<ݑxhy4b0p621ޙ|DP阴~5{w:y/Bj F_[)ݯ}EL8 :Zi/%rwENҝNf<u6zbͨܩM,W3ԷW^͆ EY'(c{#*/3T85utW̟_AҊLжm3%@Ď\ƺo_%s-AnAZobeC†6҃s֪{=~->gʵaZ.n]6C_X!1->iz5CrH%_i#p: HkѴk0-)\JޭA=;I]K.ĎK0#hFa\^fZ]J2Z[VFt-.`f[b5RNIqs^)'{Kk;[yT R% dMfZue[JK{/*8pIx?QKJ6:!GC#޻pƝzdSƩUPkM('}>_IB)_%D'cdA;'8ohb-Ʊz!,&.pK)|+Asi9#'{+Ŧ:i/nDv %cNy9T渪ƅ,T)7O0ن/u[ጏ)F!ZT x'#񙉯!ԃıDYr+ n|.qY4U0/?lSnKwsq0*zy>@ۯE}qE{|ՑAռƒ*xeYHw g׈ntršEZ;uhX^^mzGojHI"5%yHw9=E/iMvWx\Ldݢ~=D]9.%+zWMj@$_ہh>9@ OU ;9:u#QnM?MclrF93>,:KBss\:T}moӱ\޻En]Yе=+T#GQ$@/_>ƸO?0עoUze,OƊN9|pl㰭xua|c-T0%6c`'A`r g֨5QYݞvg\ttD9>DǂۚyR(`ԓҸjψ< eRL4/+XW WwHAE?FlU:٥XT8[{ 쎎Wcᷟ|lTs1.YOėϊXm.`vķ(q'׎0]z/ 9>cא@Gry Jl/l~$iˣ%l|GdG;$ۺ*.I=t1eXbkB&qRXn&u>wco։l<`!^ѵ%Zڭ> L1`":/"0}}qU*oKՂ( *bhIx|ΊJ8$pdv&} SmdEܩ2_?N~κ|s\m,y ož 5Fɞ@12:g*|c[^خ0@ʸ.ݷ8׊qT~g ŷRTuEgu7=BU[wllDgqW;:֟Oso۬; #awֱzrN 6S cLj*-l1 y*A$-GAqqov FEd얺l$7bE$/#OCVݿß_<hzL&Ƀ`#BkӼ9]7V̖\IRdÎp>5]tp=VħN:G(BMP[IGx9qHp*WYQ@Q@Q@|G*(t#Zg|hWqh((r( S f Phttp://www.snocountyems.org/emshome.htmlPhttp://www.snocountyems.org/emshome.html2rbrownmd@snocountyems.org@mailto:rbrownmd@snocountyems.org/ 00DArialBlackmanttkx: 0DTimes New Romanttkx: 0 DWingdingsRomanttkx: 00DArial Blackmanttkx: 0"@ .  @n?" dd@  @@`` p h  PU    "$&)-02468:<>@BDGIMOQTWY[]_acfhjlnsuwy{}    F G HIJKLMNPQ/X$R$k+B=gEQ 0AA@8  wʚ;|3ʚ;g4WdWdxkx: 03ppp@ <4dddd@ 0tȀk<4!d!d@ 0tȀk 80___PPT10 ?  %X Snohomish County Protocol UpdateJuly 2006 Ron Brown, MD, FACEPEffective DateThese protocols will go into effect September 01, 2006 If your protocols do not say  effective 09/01/06 discard them The most current copy of the protocols can always be found at http://www.snocountyems.org/emshome.html $)X 0ProcessThank you all for being patient The Protocol Committee was started by Dr. Cozzetto Those protocols were finished by committee and adopted in early 2005 Various changes were needed, to provide internal consistency and to stay abreast with prehospital medical care(  JProcessProtocol Committee reconvened 2006 Since then we ve been working through the entire document The new 2006 AHA guidelines came out and those were integrated immediately to be concurrent with recertification training (you all should be working off the new standard already)Implementation<It is required of ALL providers in Snohomish County to review the new protocols during the months of July and August This PowerPoint reviews some of the changes ALL providers must take a protocol test BEFORE September 30, 2006 Failure to pass the exam may result in inability to practice medicine in Snohomish County@=8nImplementationA passing score of 80% must be achieved If less, the provider must retake the exam ALL providers must have a passing score by December 1, 2006  Future Updates|Updates to the protocols will happen yearly unless more immediate changes are needed If the protocols are changed a copy of that Section will be sent out along with the Table of Contents and Index These sections will reflect a  revised date in the footer A short explanation of the changes will accompany the document?? ErrorsPlease notify me of any errors in the protocols (including typographical) via email (rbrownmd@snocountyems.org) or through the Snohomish County EMS Office (425) 259-4172X 0Un  Section 1  Introduction   Introduction & No major changes in this section!!   Section 2  EMS System .Transfer of Care Responsibility and Delegation//&The assessment and decision for transfer of care shall be documented If an ALS provider performs an exam (at any level) and determines BLS transport is appropriate, documentation of their assessment must be completed This is not to say that if a paramedic is on scene acting in a supporting role (taking VS, etc) that they must document their presence Rather this is to ensure if an ALS assessment is performed, that assessment is clearly documented on the MIR.EZZE  Section 3 EMS Protocols EMS ProtocolsNo major changes Section 48Cardiac Emergencies  Adult OrderMost of the protocols are alphabetic by section This did not flow well in either the adult or pediatric cardiac sections The protocols have been re-ordered to make better senseCardiac Chest PainDesignation of Condition As a system we are still having cardiac chest pain patients sent in BLS While not every chest pain requires ALS transport the following line was added: Providers should recognize that there are many types of chest pain and it may be difficult to distinguish between cardiac chest pain and other forms. Caution should be given and err on the side of cardiac in originDCardiac Chest Pain2BLS Providers This is not new but a reminder that EMT-Basic should give Aspirin to a patient suspected of having cardiac chest pain ALS Providers Medical Control must be contacted for use of nitro paste (only in long transport situations) Metoprolol cannot be used in inferior MI sLvv, HCardiac Arrest  Universal Algorithm%%&This was a new protocol created with the new AHA changes If down time is less than 4 minutes then CPR should be performed only until AED is applied and ready to analyze The goal is this situation is rapid defibrillationT3I-+HCardiac Arrest  Universal Algorithm%%&If down time is greater than 4 minutes 2 minutes of CPR (30:2) should be performed without interruption The goal is to perfuse the heart and attempt to rectify the acidic environment During this time ILS/ALS personnel can be establishing IV/IO access^h*sAsystole8Vasopressin was added to reflect current ACLS guidelinesPEAjThe algorithm was changed to highlight the causes Vasopressin was added to reflect current ACLS guidelinesVF/Pulseless VT*Updated to reflect current ACLS guidelines2Bradycardia  Symptomatic,Atropine dose 0.5 mg Decreased from previous&Anti-Emetic Use^This protocol was removed Use anti-emetics in chest pain patients that are vomiting, as neededZCardiac Arrest  Non-Traumatic/Medical Origin..&RemovedCardiac EmergenciesRemoved Section 5@Cardiac Emergencies  Pediatric General/These were updated to reflect new AHA standards  Section 6Medical Emergencies!!Allergic Reaction and Anaphylaxis""&Epinephrine drip (2-10 mcg/min) is now the preferred vasopressor in anaphylactic shock for refractory hypotension instead of Dopamine" Carbon Monoxide PoisoningSomehow or other oxygen therapy was being based off pulse oximetry saturation?! Obviously, pulse oximetry is ineffective during CO poisoning,:$#!Cerebrovascular Accident (CVA)&/The goal is rapid transport to a facility with a CT scanner This may be sent BLS If symptoms are less than 2 hours, emergent (Code Red) transport should be initiated ALS Providers Dextrose administration was reduced to 12.5 GM increments Clarification of EtCO2 numbers were added for intubated patients.Z{Z{$"Chemical/Substance Abuse8Removed Addressed under psychological/behavioral section%#Croup/Epiglottitis@Epiglottitis was removed This protocol now only addresses croup &$Fainting/SyncopekReference to fainting removed ALS providers Cardiac monitoring should be performed on all syncopal patients&,@,@'% HyperthermiaFChanged to  Heat Related Illnesses (&Increased Intracranial PressuremRemoved It was felt this issue was addressed in each individual protocol (CVA, TBI, etc) and was not required)'Toxic Substance ExposureRemoved  *(!Tricyclic Antidepressant Overdose""&dALS Providers Indications for Sodium Bicarbonate have changed Heart rate as an indication is removedD0'0 +) Section 7#Obstetric & Gynecologic Emergencies,*General9This section has been re-organized to achieve better flow-+Neonatal ResuscitationDo not stop delivery to suction the baby in the perineum if meconium stained Instead deliver the entire baby and then suction for meconium .,DVaginal Hemorrhage  Post Delivery##&One dose and indication for Oxytocin (20 units/1000 ml wide open) Don t forget fundal massage,+ /- Spontaneous Rupture of Membranes!!&Removed0. Section 8Psychological/Behavioral1/GeneralDRevised this entire section Please review entire section thoroughly UGeneral|Main issues addressed: Use of restraints-verbal, physical, chemical Evaluating patients to screen for  excited delerium or Sudden Unexpected Death Syndrome while in Law Enforcement custody&oHT Section 9Trauma31Trauma (Blunt and Penetrating)*Removed and replaced with a Shock protocol42Spinal Motion RestrictionSimplified ALL EMS providers are now able to NOT backboard patients under certain conditions Old protocols allowed only ALS providers to do this This is an important protocol Please review thoroughly!WSpinal Motion RestrictionThe concept is that as long as the patient is c/a/o without distracting injuries or significant MOI they do not have to be backboarded When evaluating the next for pain remember it is only POSTERIOR C-SPINE pain that counts$T { ZXSpinal Motion RestrictionLateral neck pain (not directly over the c-spine) does not warrant LSB use SMR is not a benign procedure I will inform the local hospitals so you are not questioned by the ED staff for not having a patient backboarded with lateral neck pain (make sure you document your assessment well)$ F53Trauma Triage CriteriaIReplaced this protocol with Trauma Team Activation Criteria Please review64 Section 10#Communication & Notification Issues75GeneralnKeep reports brief When to speak to a physician Giving report in special situations Requesting medical control&0?0?86 Section 11.Appendix A  Procedures97GeneralThis section was significantly revamped Please review entire section closely Main emphasis on Low Frequency-High Risk procedures Indications Contraindications &:8Airway ManagementNew protocols Includes Recognizing approved management tools, from All Provider maneuvers to advanced ALS interventions Protocol on Drug-Assisted Intubation (DAI) Sedation only Rapid Sequence Intubation:((RAirway ManagementIncludes Difficult Airway Algorithm Failed Airway Algorithm Note ALS Providers should avoid transporting a patient with a failed airway using BVM ventilation, particularly after failed DAI: 3 3;9Assisting with MedicationsJRemoved Felt this was standard information and did not need to be included<:AED"Updated to reflect new AHA changes=< Cardioversion=Removed It was felt this is common knowledge (standard ACLS)>;Central Venous CathetermAdded to clarify options available to ALS providers Accessing preexisting catheter Placing a new central line&4:4:?=CPAPACondensed some information Note indications and contraindications@>CricothyrotomyIThe vertical skin incision is the only approved method for this procedureA?Intraosseous Access eThis is a new skill in Snohomish County There have been some concerns raised by physicians about their use (started on patients that had peripheral access, or did not have a need for life-saving IVF/meds) Clarifies when IO access may be considered First line in cardiac arrest only Otherwise all other patients should have peripheral access attempted first6n dSIntraosseous Access UIf you think of placing a central line, you can think of placing an intraosseous lineD B@ Thoracostomy RNew protocol, old procedure (chest decompression) Outlines procedure Note approach&EECA2Post Intubation Sedation& /This protocol was removed, felt to be redundantDBRSI!Incorporated into Airway ProtocolECTransthoracic Pacing ?Felt to be a basic ACLS skill and not required in the protocolsFD Section 12Special SituationsGE Blood DrawsStill up to each service I do not believe EMS should be drawing blood Legal Blood draws by EMS in the field are NOT currently allowed per protocol I addressed this with Law Enforcement countywide in 2005&99HFInter-Facility TransportPatient should be stabilized by sending facility prior to transport EMS crews may refuse to transport the patient if they believe the patient has not been adequately stabilized61 YIGNon-Transport and RefusalsThese two protocols were revised and combined Please review this protocol carefully! Not all Non-transports are refusals EMS-initiated no-transports have much higher liability Good documentation in necessary Each agency should maintain a release form*yZZyJH3Relationship Between ALS Team and Private Physician44&Addressed elsewhere Removed VTrauma Triage ToolWashington State DOH Document Note the thrust of this document is to get the patient to the highest level trauma Center possible within thirty minutes transport time This will occasionally mean ground transport to Snohomish County hospitals 4ZZ%MKI Section 13FormsLJGeneralThis section completely removedMK Section 14Paramedic Drug Supplement NLRequired DrugsRemoved: Bretylium, Oxytocin, Procainamide from Required Drugs Added Etomidate and Oxygen to Required Drugs Removed all Required (Optional Substitutions) other than benzodiazepinesP   gOM Allowed DrugsChanged  Alcaine to  Topical Ophthalmic Drops (Proparacaine) Removed Mannitol and Etomidate from Allowed Drugs. Mannitol is gone. Added Oxytocin, Procainamide, Ipratroprium Bromide, Metropolol, Terbutaline, and Fentanyl to the Allowed Drugs. Made Dexamethasone and Metaclopramide an optional substitution for Allowed Drugs.FF         -YFentanylKDose increased to 0.3 mg/kg dose Both pediatric and adult dose are the samePN ProtocolsThat outlines some of the main changes in the new versions This does not relieve you from reading the entire protocols The tests will reflect your level of care Paramedics may also have questions from the Drug Supplement Section (doses, indications, contraindications, etc)QOPrehospital CareThank you for your dedication to caring for the sick and injured in Snohomish County Continue to strive to educate yourselves and learnRPSnohomish County EMS Thanks!   /0 TUVWXYZ[\] ^ _ ` a bcdefghijklmnopqrst u!v"w#x$y%z&{'|(})~*+,-.0123456789:;<=>?@ABCDEFGHIJKLMNOQRSTU  0` fffff` ?̙ffE` ff333` C3ff3` &u3` ffff` **@fff̙fl` +3[Xd` 333f` 5D`|f` ?̙ff` ?̙ff>?" dd@*?lPd@ `F `A@`<``( n?" dd@   @@``PP   @ ` `.p>>L0 L D ` (  2T ```  "```"  BkG p"P`` D0 B  C kBCE6FGIQSTUV.WX@` B C "`` B0 hB  s *DԔ"  0Lk "{4 k T Click to edit Master title style! !$  08k " k RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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