Southeast Michigan Regional Protocols (edited)

Genesee, HEMS (Wayne), Lapeer, Macomb, Oakland, and Washtenaw/Livingston MCA’s

Guideline for the use of the

Southeast Michigan Regional Treatment Protocols

The Decision to Regionalize

The members of the regional area involved in the development of these protocols recognized that each Medical Control Authority (MCA) had similar, if not identical, treatments for a variety of patient conditions. In an effort to standardize the care patients receive, the attached treatment protocols were developed utilizing treatment protocols from six (6) different MCAs.

Members of the Region

The Southeast Michigan Regional Treatment Protocols have been adopted in the following Medical Control Authorities:

· Genesee

· HEMS

· Lapeer

· Macomb

· Oakland

· Washtenaw/Livingston

Difference Between Regional Protocols and Regional Drug Box

All the Medical Control Authorities listed above EXCEPT Macomb, utilize the Regional Drug Box.

Difference Between “Treatment” and “Operational” Protocols

Only the TREATMENT protocols have been regionalized. These are protocols that relate directly to the treatment of the patient. OPERATIONAL protocols have not been standardized. These protocols, including, but not limited to “Dead on Scene”, “Transportation”, “Rerouting/Status Limitation” and “Helicopter Use”, remain different for each Medical Control Authority. Follow the OPERATIONAL protocols for the specific Medical Control Authority(s) you operate in. Run Forms are considered “operational” and the use of these forms are specified by each MCA.

Using the Southeast Michigan Regional Treatment Protocols

The purpose of the standard operating procedures (SOP’s) is to provide EMS personnel with guidance in the pre-hospital treatment of persons in the care of the EMS system. Specific realms of treatment were purposefully omitted, the MCA’s considered these treatments to be knowledge gained in EMS training and not necessary to repeat in the protocols.

Based on clinical assessment and judgement the EMS personnel may proceed with treatments listed under “Pre-Radio” prior to communicating with medical control. Treatments listed under “Post-Radio” are designed to serve as a guideline for anticipating medical control orders. If a protocol does not have “Post-Radio” treatments listed, it does NOT imply that communication should not be established with medical control . It simply means that all of the treatment listed may be done prior to communication contact. In addition, some protocols specifically state “contact medical control”. This does NOT imply that you should not contact medical control on the other protocols. Follow your Local Medical Control Communications protocol/procedure.

Treatments listed under either pre or post radio are further divided into different levels based on licensure. For example, the treatments listed under MFR/EMT/SPECIALIST/PARAMEDIC may be performed by any of these levels. Another example would be that treatments listed under SPECIALIST/PARAMEDIC may only be performed by those two levels.

Exceptions

There are some MCA’s in this region that are participating in special studies. You will see, for example, PARAMEDIC/(GENESEE-LAPEER SPECIALIST). This indicates that only Genesee or Lapeer Specialists may perform these treatments in accordance with their study guidelines. These treatments are approved only for the specialist level in those specific counties under special studies.

In addition, a couple of protocols will specify that a specific county is excluded from a protocol. For example, Macomb chose not to adopt the surgical cricothyrotomy protocol, therefore, at the bottom of that protocol you will see “Note: Macomb County is excluded from this protocol”.

Communications Failure

If there is a communication failure that prevents contact (radio or other MCA approved communication) with an on-line medical control physician, EMS personnel, within their scope of training, may proceed with appropriate treatment protocols as if they were standing orders unless the protocol specifically prohibits the treatment without contact. Communications failures should be documented on the run form and on any paperwork required from the local Medical Control Authority.

General Airway Protocol

Pre-Radio

MFR/EMT/SPECIALIST/PARAMEDIC

1. Supplemental Oxygen

When indicated, administer oxygen at the highest flow tolerated by the patient.

2. Oropharyngeal and Nasopharyngeal Airways

· When indicated, oral and nasal airways are to be used to assist in maintaining a patent airway.

· Use of one of these devices should be considered when ventilatory support by bag valve mask is provided.

3. Artificial Ventilation (BVM)

· Using a bag valve mask (BVM) is the recommended means of providing ventilatory assistance. The use of positive pressure ventilation (demand valve) is not allowed.

EMT/SPECIALIST/PARAMEDIC/ (EMT Oakland County Special Study)

4. Intubation (Oral and Nasal)

· Intubation may be attempted two (2) times prior to utilizing a Supraglottic Airway Device, unless otherwise indicated in the protocol.

· Nasal intubation may be performed pre-radio.

5. Supraglottic Airway Device (SAD) as approved by local MCA protocol:

· A SAD is the accepted secondary airway device for Specialist and Paramedic.

· BLS agencies may use these devices if they have met the criteria and been approved by the appropriate Medical Control Authority.

· If ALS care becomes available at the scene where a BLS unit has placed a SAD, the ALS unit will take over care of the patient.

· In cardiac arrest patients, a SAD should be considered early in patients whom oral intubation is perceived to be technically difficult.

PARAMEDIC

6. Medications via the Endotracheal Tube:

ALTHOUGH SOME MEDICATIONS MAY BE GIVEN VIA THE ENDOTRACHEAL TUBE, IV OR IO ROUTES OF ADMINISTRATION ARE PREFERRED.

The following medications may be given via the endotracheal tube:

Atropine, Epinephrine

Adults: Dosages given via this route need to be 2 to 2.5 times that of the IV dosage.

Children: Dosages given via this route need to be 2 to 3 times that of the IV dosage. All dosages for pediatric epinephrine administered ET are 1:1000 concentration.

7. Cricothyrotomy

Cricothyrotomy may be performed, as indicated, utilizing protocols for pediatric needle cricothyrotomy or adult surgical cricothyrotomy.

General IV/IO Protocol

Solutions Used

NS (Normal Saline, 0.9% Sodium Chloride)

Sites

· The following sites may be used for establishing a peripheral IV (not necessarily in this order):

Forearm Ankle

Hand Foot

Anticubital Fossa External Jugular

Intraosseous Scalp Vein

· Large veins should be used in priority 1 patients, or patients that are unstable.

· If IV is placed in the vicinity of a joint, the joint should be immobilized.

Attempts

Once the equipment is set up, three (3) attempts to cannulate the vein may be made prior to contacting medical control. After three (3) attempts, contact medical control and additional attempts may be ordered. For a patient in cardiac arrest, if the IV attempts are unsuccessful or are determined, after initial attempts, to be technically difficult proceed to IO infusion

In situations where rapid transport is indicated, IV attempts should be done enroute.

Catheter Size

· Adult trauma patients/patients needing fluid administration - if possible, use at least an 18 gauge catheter.

· Other adult patients – if possible, use at least a 20 gauge catheter for all other IV administrations.

· Pediatric patients – use the most appropriate size catheter for the size of the patient’s veins.

Flow Rate

Unless otherwise indicated in the protocol, the flow rate for IV/IO will be Keep Vein Open (KVO).

Saline Lock (ALS only)

For adult patients in which the need for IV fluid is not anticipated, but for which medications might be needed, start an IV saline lock. A saline lock can be substituted for an IV of Normal Saline, KVO.

Intraosseous (IO)

Use the guidelines approved by your local Medical Control Board for initiating an Intraosseous Infusion.

· In the Regional Medical Treatment Protocols, where it is listed that a drug is administered IV, it may be administered IO instead if an IO is indicated and has been established.

· Drugs administered IO should be followed by a NS flush of 5 ml.

· Fluids must be administered under pressure or with manual injection using a syringe.

Intraosseous Infusion

Indications:

· Venous access via peripheral veins should be attempted prior to attempting intraosseous placement.

· Adult and pediatric life threatening situations where venous access using peripheral veins has been unsuccessful. Situations include:

Cardiac Arrest Severe burn injury with shock

Shock Severe multiple trauma with shock

Status epilepticus

Contraindications

· Osteogenesis imperfecta

· Osteoporosis

· Fracture of the bone

· If possible, placement at or near sites of infection or burns should be avoided.

Site

· Proximal tibia

· Scalp Vein

Insertion

Follow the manufacturer’s recommendations for IO insertion.

General Pre-Hospital Care

In most cases, the stabilization of patients presenting with medical conditions should be carried out at the patient’s side prior to patient movement or transport. Before attempting the following procedures, implement appropriate bloodborne and/or airborne pathogen protective procedures. Contact medical control according to local protocol.

Pre-Radio

MFR/EMT/SPECIALIST/PARAMEDIC

1. Assure ABCs while maintaining c-spine precautions where indicated.

2. Do airway intervention using appropriate airway adjuncts when necessary:

	MFR	EMT	Specialist	Paramedic
Oropharyngeal	X	X	X	X
Nasopharyngeal	X	X	X	X
BVM	X	X	X	X
Double Lumen Airway		X	X	X
Oral/Nasal Intubation		X (Oak. Co. Special Study)	X	X
Needle/Surgical Cricothyrotomy				X

3. Administer oxygen with highest flow tolerated by the patient and assist ventilations when necessary.

4. Obtain a history and physical exam using the following as a guideline:

a. Age and sex

b. Present complaint

c. Pertinent medical history

d. Pertinent medications patient is taking

e. Medication allergies

5. Obtain vital signs approximately every 15 minutes, or as frequently as necessary to monitor the patient’s condition:

a. Blood pressure e. Pupil reactions

b. Pulse rate f. Skin condition and color

c. Respiratory rate g. Level of consciousness

d. Lung sounds

6. Follow specific protocol for patient condition.

SPECIALIST/PARAMEDIC

7. Start an IV in accordance with a specific protocol.

PARAMEDIC

8. Apply cardiac monitor and treat rhythm according to appropriate protocol. If available and applicable apply 12-Lead cardiac monitor. A copy of the rhythm strip should be attached to the Run Form. Copies of significant dysrhythmias should be left at the receiving facility.

Pain Management

Adult/Pediatric

The goal is to reduce the level of pain for patients in the pre-hospital setting. All non-cardiac pain should be assessed and scored according to the “Wong Pain Scale”. Reassessment should be timed according to medication onset of action, changes in patient condition, patient positioning and other treatments.

Pre-Radio

MFR/EMT/SPECIALIST/PARAMEDIC

1. Follow General Pre-Hospital Care Protocol.

2. For trauma patients follow the General Trauma Protocol.

3. Place the patient in the position of most comfort.

SPECIALIST/PARAMEDIC

1. Start an IV NS KVO. If the patient has a systolic blood pressure is less than 100 mm Hg, then administer a bolus of 20 ml/kg.

PARAMEDIC

If indicated, administer pain medication as described below. Systolic BP should be maintained at:

Adult > 100 mm Hg

Pediatric 80 + (2 x age) mm Hg

1. Fentanyl 1 mcg/kg increments IV. If pain persists after two minutes repeat dose up to a maximum dose of 2 mcg/kg. For pediatric patients, administer 1 mcg/kg increments IV up to a maximum of 2 mcg/kg. If IV is unavailable contact medical control for IM consideration (Fentanyl is not used in Macomb County).

2. As an alternative to Fentanyl, administer Morphine Sulfate in 2 mg increments IV, up to a maximum of 10 mg. For pediatric patients administer Morphine Sulfate 0.1 mg/kg IV.

Post-Radio

1. For adults with a systolic BP less than 100 mm Hg, contact medical control.

HEMS and Washtenaw/Livingston MCA’s

Indications for pain management include the following:
Short term pain relief for significantly painful conditions, including:

–Burns, isolated extremity trauma
–Back pain
–Flank pain
–Significant abdominal pain
–Severe headaches with migraine history
–Severe headache without altered mental status
–Significant pain in alert multiple trauma patient

Relative contraindications include (use with care):
-Elderly
-Respiratory depressed
-Pregnancy – not a contraindication to pain treatment unless at term or in labor
-Altered mental status
-Severe respiratory disorders
-Nursing mothers – relative, still treat pain
-Impaired hepatic or renal function – decreased metabolism
-Ingestion of benzodiazapines (ie: Valium) – increased respiratory depression

For conditions in which longer acting pain management is desired and appropriate, i.e. burns, isolated extremity trauma, Morphine may be used preferentially to Fentanyl.

Oakland County MCA

Indications for pain management include the following:
Short term pain relief for significantly painful conditions, including:

–Burns

–Isolated extremity trauma
–Back pain
–Flank pain
–Significant abdominal pain
–Significant pain in alert multiple trauma patient

Use with care:
-Elderly

-Severe headaches with migraine history
-Respiratory depressed
-Pregnancy – not a contraindication to pain treatment unless at term or in labor
-Altered mental status
-Severe respiratory disorders
-Nursing mothers – relative, still treat pain
-Impaired hepatic or renal function – decreased metabolism
-Ingestion of benzodiazapines (ie: Valium) – increased respiratory depression

For conditions in which longer acting pain management is desired and appropriate, i.e. burns, isolated extremity trauma, Morphine may be used preferentially to Fentanyl.

Genesee County MCA

Indications for pain management include the following:

Short term pain relief for significantly painful conditions, including:

–Burns, isolated extremity trauma
–Significant pain in alert multiple trauma patient

–Contact online medical control if you feel a patient should receive pain medication and their symptoms are not identified above.

For conditions in which longer acting pain management is desired and appropriate, i.e. burns, isolated extremity trauma, Morphine may be used preferentially to Fentanyl.

Pleural Decompression

Needle Thoracostomy

INDICATION:

Tension pneumothorax (if unsure that a tension pneumothorax is present, contact medical control).

EQUIPMENT

· Antiseptic solution

14 or 16 gauge IV catheter
Dressing and tape

Pre-Radio

PARAMEDIC

1. Establish a patent airway using appropriate airway adjuncts and high flow oxygen.

2. If intubated, verify endotracheal tube placement.

3. Identify landmarks:

· Mid-clavicular line

· The second intercostal space is between the 2^nd and 3^rd ribs. The 2^nd rib can be felt just inferior to the clavicle. The 2^nd rib is adjacent to the angle of Louis (prominence at the sternal edge approximately 2 cm below the sternal notch)

· ONLY if 2^nd intercostal location is not accessible, then use the superior margin of the 5^th rib at the mid axillary line.

4. Prep the area with antiseptic.

5. On the side of diminished breath sounds, insert the IV catheter over the top of the 3^rd rib until the pleural space is entered. A rush of air from the open needle confirms placement and a diagnosis of tension pneumothorax.

6. Remove needle, leaving catheter in place.

7. Reassess breath sounds and patient’s condition (patient should improve almost immediately).

8. Secure catheter with tape.

Spinal Injury Assessment and Immobilization

The initial field assessment of potential spine injury begins with an assessment of the mechanism of injury. For the purpose of initial field management, a patient with a clearly negative mechanism does not need a spine injury clinical assessment. Patients with a mechanism of injury with the potential for causing spine injury shall have a SPINE INJURY CLINICAL ASSESSMENT performed. Clinical criteria are used as the basis for assessment. If any of the clinical criteria are present or if the assessment cannot be completed, the patient has a positive spine injury assessment.

A negative mechanism means that given the impact and forces involved, there is no reasonable possibility that the spine might be involved. Examples include: a rock dropped onto a foot, twisted ankle without a fall, a gunshot wound limited to an extremity.

A mechanism of injury with the potential for causing spine injury refers to violent impact forces that are clearly capable of damaging the bony spinal column. Examples include: a high velocity vehicle crash, fall from 15 feet, or a gunshot wound to the neck or torso. It also includes mechanisms where there is uncertainty regarding the impact and forces involved. Examples include: trip and falls, falls 2-3 feet in a child, a low-speed "fender bender" MVA, or a moderate speed MVA when the patient initially is ambulatory without obvious injury.

If a mechanism of injury with the potential for causing spine injury exists, the following clinical criteria are assessed:

A) Altered Mental Status

B) Use of Intoxicants

C) Suspected Extremity Fracture

D) Motor and/or Sensory Deficit

E) Spine Pain and/or Tenderness

If any of the clinical criteria are present the patient has a positive spine injury assessment. If none of the clinical criteria are present the patient has a negative spine injury assessment.

Patients over the age of 65 with a mechanism of injury with the potential for causing spine injury will have a rigid extrication collar applied even if the spinal injury clinical assessment is negative.

SPINE INJURY CLINICAL ASSESSMENT PROCEDURE

A. Prevent spinal movement by in-line manual stabilization.

B. Assure adequate management of ABC's

1. Any unstable patient or patient with inadequate ABC's should be treated as a positive spine injury

C. Assess for the presence of Clinical Criteria. A positive assessment for any of the clinical criteria indicates a positive spine injury assessment.

1. Assess for Altered Mental Status

a. Ask patient to identify name, place and date.

b. Assess for any history of confusion

c. Assess for memory deficits

2. Assess for Evidence of Intoxication

a. Ask if intoxicants have been used. Assume intoxication if yes in any amount.

b. Assess for smell of intoxicants

c. Behavior may indicate intoxication

3. Assess for Extremity Fracture above the hand or foot

a. Suspected extremity fracture, including those to the wrist or ankle, may make a clinical assessment for spine pain and/or tenderness unreliable.

4. Assess for Motor and/or Sensory Deficit

a. Ask the patient to move all extremities (the lower extremities alone are not enough, some spinal cord injuries cause more upper extremity than lower extremity weakness).

b. Ask for any history of numbness or shooting pains.

c. Assess for loss of sensation in upper and lower extremities.

5. Assess for Spine Pain and/or Tenderness

a. Ask the patient if there is any pain along the neck or back

b. Feel the neck and ask if there is tenderness

c. If there is no spine pain or neck tenderness the patient may be log rolled (if supine) to feel for thoracic and lumbar spine tenderness.

Procedure for management of a Positive Spine Injury Assessment:

Only approved immobilization devices will be used. Assess for motor and/or sensory deficit before and after spine immobilization

A. Prevent spinal movement by in line manual stabilization.

B. Apply rigid extrication collar.

C. Place patient onto and/or into the extrication device while maintaining C‑spine stability.

D. Secure the patient's body to the extrication device while maintaining C-spine stability.

E. Secure patient's head with appropriate device to prevent anterior or lateral movement. Maintain patient's airway.

Approved Devices:

A. Standard long backboard (non‑metallic recommended).

B. Standard short backboard (non‑metallic recommended).

C. Commercially prepared extrication devices (Zee, KED, Disposable boards).

D. Head secured with rolled blankets and tape or commercial head immobilizer.

E. Rigid extrication collars.

Procedure for management of a Negative Spine Injury Assessment:

A. Treat injuries per appropriate protocol

B. Transport for emergency department evaluation.

Negative injury classification does not exclude the possibility of other nonspine or internal injuries. This policy should never be used to determine if patients can be released at the scene.

Patients over the age of 65 with a mechanism of injury with the potential for causing spine injury will have a rigid extrication collar applied even if the spine injury clinical assessment is negative.

Procedure for Spinal Management in a Tactical Environment:

A. In the event of a possible spinal injury during a tactical scene, it may be necessary in the interest of preserving life to move an injured patient prior to spinal immobilization.

B. When moving a patient with possible spinal injury prior to spinal immobilization, the patient, whenever possible, should be moved in a spinal in-line fashion head first or feet first.

C. The patient may be extricated to a safe zone via:

1. In line drag from vest drag handle

2. Two man in line carry

3. In line drag from clothing

4. In line drag with patient supported under both arms

5. Utilization of a Drag Litter

D. As soon as the patient is extricated to an area where there is no danger from the tactical threat, a full spine injury clinical assessment as described above will be completed.

Surgical Cricothyrotomy for Adults

The cricothyroid membrane is located subcutaneously between the thyroid cartilage and cricoid cartilage. There are two methods of performing a cricothyrotomy – surgical and needle. The needle cricothyrotomy is used on children less than age 8, (see pediatric protocols).

Indications for surgical cricothyrotomy are: total airway obstruction not relieved by other methods, airway compromise from injuries that make oral or nasal intubation impractical and/or inability to ventilate and inability to intubate.

Pre-radio

PARAMEDIC

1. Follow General Pre-Hospital Care Protocol.