| 33 |
ALERT
added: “All requests for scene helicopter transports
shall be made through SYSCOM.” The reference to head
injury was removed since no specific head injury protocol was developed.
SYSCOM will be contacted via ECC.
Information
to SYSCOM: “Refer to the trauma decision tree (Protocol page
128) when considering use of aeromedical transport. Provide SYSCOM
with the patient’s Trauma Decision Tree category (A, B, C,
or D)”. This category determination will influence the use
of commercial aeromedical assets in the event a MSP medevac unit
is not readily available.
Click
here for Trauma Decision Tree category explanation.
|
33 |
If time
of arrival at the trauma or specialty referral center via ground unit
is less than 30 minutes, there will generally not be a benefit in
using the helicopter, especially for Trauma Decision Tree classes
C and D. This does not mean take the patient to the local ED. The
patient still meets criteria to be transported to a Trauma or Specialty
Center.
If the helicopters are not flying, it is reasonable to transport the
patient by ground up to an hour to get him/her to a Trauma Center
or Specialty Center. |
37 |
Diazepam
(Valium) IM has been added. Although Valium absorbs very poorly IM,
it may be needed in severe nerve agent exposure.
An auto-injector is available: CANA Valium 10mg IM.
All levels of ALS must consult to use Valium IM unless it is being
administered for a severe exposure to a nerve agent.
See also page 216 (ALS Pharmacology) |
| 38 |
MIEMSS
information on the Protocol roll-out states the Valium rectal dose
by weight and maximum weight have been changed. That change took place
in the 7/1/2004 protocol. The only change in Valium is that the seizure
treatment and the pharmacology pages now agree. |
| 40 |
"Volume
Sensitive Children" are to receive 1/2 the usual dose
of fluids for hypoperfusion, "Volume Sensitive Children"
are defined here on page 40 as well as in the glossary on page 139
as "Children that need smaller fluid bolus volumes due
to special needs including:
a) neonates (0-28 days)
b) congenital heart diseases
c) chronic lung disease
d) chronic renal failure.
Volume Sensitive Children receive 10cc/kg, with a second bolus
of 10cc/kg if determined to be necessary following reassessment.
This change is consistent throughout the document, 9including in
the Pharmacology section, page 229.
Naloxone:
Intranasal (if delivery device is available) was added to the list
of administration routes. See page 234, also. |
41-42 |
Apparent
Life Threatening Event (ALTE)
This is a new protocol specific to the pediatric patient.
Click
here for Apparent Life Threatening Event (ALTE) protocol page
|
46 |
The
order of text was changed. If an AED is available, it should be used
prior to initiating CPR. |
48 |
An
algorithm for ALS Emergency Cardiac Care of pediatric patients was
developed. |
| NOTE:
This conflicts with page 27, which states "Patients
less than 1 year of age: If patient is symptomatic with poor perfusion
(unresponsive or only responds to painful stimuli) and pulse is
less than 60 per minute or absent: Ventilate for
30 seconds. If after 30 seconds, the pulse is less than 60 bpm,
start CPR."
If
the infant is pulseless, contrary to page 27, CPR
needs to be started.
If
the infant is bradycardic, we need to follow page
27 "Patients less than 1 year of age: If patient is symptomatic
with poor perfusion (unresponsive or only responds to painful stimuli)
and pulse is less than 60 per minute... Ventilate for 30 seconds.
If after 30 seconds, the pulse is less than 60 bpm, start CPR."
This is not clearly spelled out in the Pediatric Bradycardia Algorithm
on page 52, either. |
55 |
2nd
& subsequent doses of Epinephrine have been removed
from the Pediatric Asystole/Pulseless Arrest algorithm.
Footnote (b) changes the dilution of Epi in neonates to Epinephrine
ET 0.01 mg/kg (1/10,000) diluted with 1 ml lactated Ringer's.
Footnote (e) reflects the volume infusion in neonates and volume sensitive
children at 10 ml/kg; and 20 ml/kg for infants and children.
See also pages 222-223. |
58 |
Use
of erectile dysfunction drugs as a contraindication for NTG has been
increased from the previous 24 to 48 hours without
medical consultation.
See also page 235. |
59 |
Chest
Pain Protocol: Consultation is required to give morphine. |
62 |
New
protocol for the newly born, or just delivered baby. (Newly Born is
the new terminology for a newborn.) |
| A
Neonate is defined in the glossary on page 136 as: "A term that
describes an infant from birth through the first 28 days of life."
The advent of the Newly Born terminology requires the redefinition
of a neonate to an infant at least 24-36 hours old but less
than 28 days old. |
66-67 |
These
pages have been added in anticipation of a new protocol that will
address possible referral to Chest Pain Centers for balloon angioplasty
and possible cardiac bypass. |
68 |
SIDS
3.a) "if indicated" was added following "and perform
CPR". If the baby is obviously dead, there is no requirement
to perform CPR, it is optional. |
76 |
Dosage
& routes of administration for Morphine Sulfate
in pediatrics have been standardized for pediatric patients.
"Consider Morphine Sulfate 0.1 mg/kg slow IV/IM/IO. Administer
1-2 mg/min. up to a maximum dose of 5 mg."
See also pages 232-233. |
85 |
Hyperbaric
Therapy: The symptoms of possible toxic inhalation are included [
3.a) ]. The intent is for EMS providers to understand that toxic gas
inhalation often involves cyanide, which presents differently from
CO poisoning. |
| |
Hypertensive
Crisis protocol has been deleted. |
88 |
Hypotension
in neonates is defined as a systolic blood pressure
less than 60. |
94-95 |
Syrup
of Ipecac is no longer used for ingested poisoning
and has been removed from the pharmacology section of the protocol
as well.
Activated Charcoal must be without sorbital. (See
also page 205) |
99 |
3.d)
& 3.i) - "Consider PASG, if appropriate."
Adult patients only.
PASG are no longer indicated for pediatric patients under the
age of 15 years old.
See also page 182. |
101
& 102 |
A
new protocol for Pain Management. A patient experiencing
severe pain may receive morphine from an ALS unit without orders from
the receiving hospital. |
103
- 105 |
Allergic
reactions: Consultation is now required to give more than 3 doses
of Epinephrine 1:1000. |
Diphenhydramine
is to be administered slow IVP/IM.
Maximum single dose is 25mg.
Additional doses
require consultation.
Consultation also required to administer to a patient with a mild
allergic reaction.
See also page 219. |
105
|
Infants
(less than 1-year of age) are to be administered albuterol 1.25 mg
via nebulizer. Atrovent is contraindicated
in infants. See page 212 (ALS
Pharmacology) also. |
| The
heading (5) on this page reads: "Administer a combination of
albuterol/atrovent via nebulizer:" For
infants (under 1 year of age), Atrovent is contraindicated.
Infants should be under their own heading to avoid confusion. |
107 |
ALERT
added recommending consultation before giving albuterol/atrovent to
a pediatric asthma/COPD patient with a cardiac history. |
110 |
3.b)
- Consider continuous positive airway pressure (CPAP). If jurisdictionally
approved, CPAP may be administered to the pulmonary edema/CHF patient
without orders. A nebulizer may be used with either a BVM or with
CPAP. |
112
& 113 |
ALERT:
Consult with nearest designated Stroke Center.... Stroke Centers will
hopefully be designated within a year. Note the emphasis on 2
hours of symptom/sign onset. If there is no designated stroke
center within 30 minutes, go to the nearest hospital. |
114 |
Trauma
Protocol: Burns 2.b.2: Defines high voltage as 200 volts or greater
for burn center referral.
Under the ALERT on this page, Toxic exposure was added. |
115 |
Trauma
Protocol: Burns: ALERT: Do not place ice on any patient with burns
more than 5% total body surface area. |
115-119 |
Maximum
dose of morphine for pediatric trauma patients: 5 mg. |
120 |
Hyperventilate
the head-injured patient as follows:
Adult: 20 breaths/minute
Child: 30 breaths/minute
Infant: 35 breaths/minute.
If capnography is used, CO2 cap reading should be around 30. |
121
& 125 |
Hypoperfused
Volume Sensitive Children receive 10cc/kg, with a second bolus of
10cc/kg if determined to be necessary following reassessment.
See page 40 above for definition of "Volume Sensitive Children. |
133
- 139 |
Glossary:
New definitions for: Apnea; Children with Special Healthcare Needs
(CSHN); Emergency Information Form; Erythema; Fluid Bolus; Fluid Challenge;
Neonatal; Newly Born; Optional Supplemental Program; Pallor; Pilot
Program; Volume Sensitive Children. |
141 |
Peak
Expiratory Flow Meter was added to the chart as a standing order for
ALS. |
| CAUTION:
Requiring a person to use a peak flow meter who is
experiencing a severe asthma attack may cause them to hyperinflate,
thus further reducing the patient's tidal volume. |
156 |
"Dependant
lividity" was removed from the PDOA protocol. |
161 |
Symptomatic
Bradycardia is defined: (a) Infant heart rate less then 100; (b) Child
heart rate less then 80. |
171 |
If
using a length-based tape (i.e. Braslow), it must be a 2002 tape. |
172
- 174 |
A
new protocol for changing & suctioning Tracheostomy tubes. This
technique was covered in Montgomery County EMTB refresher classes
from 2000-2002. A hands-on skills program will be implemented for
all county providers in the winter of 2005-2006. The MIEMSS Tracheostomy
Care for All Ages is a 125-slide power point presentation which
may be downloaded or opened for viewing. |
181 |
Cardiac
Pacing: If pacing is causing patient discomfort, administer 1-2 mg/min
Morphine Sulfate IVP if patient is conscious and has adequate blood
pressure. (See page 181). |
182 |
Pneumatic
Anti-Shock Garment (a.k.a. MAST): CONTRAINDICATED in patients under
15 years of age. |
192 |
The
ALS provider may establish a peripheral IV in a patient whose vasoactive
medication has been interrupted due to a malfunctioning long-term
access device that cannot be repaired by the home health caregiver.
The ALS provider can assist in the reestablishment of an existing
vasoactive infusion at the same dose or setting. The patient shall
be transported to the nearest appropriate facility to access the patient's
long-term device.
When in doubt, obtain medical direction. |
205 |
Activated
Charcoal - should only be administered without sorbital. |
208 |
Administer
aspirin 325mg chewed only. Aspirin 162mg has been removed
from protocol. |
209
& 210 |
Atropine
Sulfate: Nerve agents were added to the indications list.
Maximum single dose in pediatrics: Child (10kg - 25kg): 0.5mg
Adolescent (25kg - 40kg): 1mg. |
| Also
refers to Mark 1 kits in WMD protocols for nerve agent exposure. |
| 212 |
Diazepam:
Must consult for permission to administer IM for all ages except
no consultation required for severe nerve agent exposure.
Pediatric dose is reduced to 0.1mg/kg slow IVP/IO/IM to a maximum
dose of 5mg. Maximum dose of rectal Valium has been lowered to 0.2mg/kg
to a maximum dose
of 10mg. |
217 |
Diltiazem
(Cardizem) now has maximum doses of 20mg for the initial bolus,and
25mg for the second dose if needed. |
222
- 224 |
Epinephrine:
Pg. 222 c)(2) now reads "moderate to severe" reaction.
Pg.223 g)(1)(b): The use of 'high dose epinephrine' has been eliminated.
The second and all subsequent doses are the same.
Pg. 223 g)(1)(c): Neonatal dose was added to the Pediatric Bradycardia
Algorithm (page 52) and the Pediatric Asystole & Pulseless Arrest
Algorithm (page 55)
Neonate:
IVP/IO: 1st dose: 0.01 mg/kg (0.1 ml/kg) of 1:10,000; repeat every
3-5 minutes.
ET: 0.01 mg/kg of 1:10,000 diluted with 1 ml lactated ringer's solution. |
225 |
Furosemide
(Lasix): (c)Hypertension is no longer an indication for use. |
233 |
Morphine
Sulfate: Dosage & routes of administration have been standardized
for pediatric patients. Pediatric: 0.1 mg/kg slow IV/IM/IO. Administer
1-2 mg/min. up to a maximum dose of 5 mg.
For cardiac pacing, If patient is conscious and has adequate blood
pressure, administer 1-2 mg/min MS IVP. (See page 181). |
| 267-270 |
EMTB
may administer MARK 1 kits up to a total of 3 kits per patient:
a. as buddy care to public safety personnel or
b. when directed to do so by an ALS provider based on signs & symptoms
in a mass casualty incident or on-site chemical testing that confirms
nerve or organophosphate agent present in a mass casualty incident.
ALS provider may administer 1 Diazepam (CANA) autoinjector after the
patient has received 3 MARK 1 kits. Medical consultation is not required
in these situations. |
Seniors
