Patient Care Protocols (Blue Book) and EMS Update 2007 Seattle—King County.

Patient Care Protocols (Blue Book)

andEMS Update 2007

Seattle—King County

Seattle—King County EMSSeattle—King County EMS

Introduction

Indicates a change or update from the 2005 blue book (NOT necessarily a change or update to current protocols).


Alerts & After—Care Instructions

EMTs will leave alerts or after—care instructions as indicated for the following patients: High blood pressure

High blood sugar Low blood sugar

You must document that an alert or after—care instruction was provided and verify the patient's home phone

number.

You must document that an alert or after—care instruction was provided and verify the patient's home phone

number.

Page 63



Inclusion

Page 63

Diabetic with sugar ≥ 300Non diabetic with sugar ≥ 175

Paramedic transported patientNursing home patients

Use judgment with trauma patients

Exclusion

Optional



Inclusion

Page 63

Any patient with a systolic ≥ 160 mmHg or diastolic ≥ 100 mmHg

Paramedic transported patientNursing home patients

Use judgment with trauma patients

Exclusion

Optional



Inclusion

Page 63

Diabetic on insulin who responds fully to oral glucose and who is stable enough to remain at home

Paramedic or EMT transported patient

Exclusion


Personal Protective Equipment (PPE)

Pages 104—105

Hand washing is the most effective way to prevent transmission of infectious disease. Hand washing is the most effective way to prevent transmission of infectious disease.

Wash hands:

After patient contactBefore eating, drinking, smoking, or handling foodBefore and after using the bathroomAfter cleaning or checking equipment


PPE, continuedPages 104—105

Gloves and eye protection should be worn for every patient.

Gloves and eye protection should be worn for every patient.

• Gloves • Eye protection (such as glasses,

face shields and goggles)• Fit-tested masks (such as N95

and N100 masks)• Gowns (or suits)

FULL PPE for possible infectious contacts:



Put on PPE before entering the patient area.

The sequence for donning PPE is MEGG:1. Mask2. Eye protection3. Gown4. Gloves

Mask patient if possible.Mask patient if possible.



The sequence for doffing PPE is:

1. Gloves2. Gown—hand washing min 20 sec.3. Eye protection4. Mask—hand washing min 20 sec.

Handle equipment as contaminated waste.

Decontaminate eye protection.

Handle equipment as contaminated waste.

Decontaminate eye protection.



Febrile Respiratory Illness

• Dispatchers will notify units of infectious symptoms or locations.

• Dispatch info or fever w/ cough or illness or possible infectious disease

Full PPE required.

Limit patient contacts.

Full PPE required.

Limit patient contacts.



After patient contact:

• Remove PPE –- (approved sequence).• Dispose of PPE as contaminated waste.

On-scene decontamination:• eye protection & equipment w/

germicidal cleaner.

Hospital decontamination:

• eye protection, equipment and apparatus.



At station:

• Decontaminate affected equipment & contacts (kits, BP/steth, radios, clipboards, etc.).

• Wash hands before leaving apparatus floor.


Taser Dart Removal and Care

See pages 126-128 of the Blue Book (PCP) for a detailed description of Taser darts, Taser removal, EMS care and transport policies for all patients.

Pages 126—127


All EMTs are now encouraged to incorporate the SICK/NOT SICK approach into patient assessment

PCP provides a brief overview of SICK/NOT SICK

Sick/Not SickPages 10—17


ALS Indicators

PCP now has a two-page summary of all ALS Indicators — conditions that require a medic response

Specific ALS indicators for some conditions have been changed and are listed under each condition below

Pages 59-60


Cardiac Arrest

For initial analyis After delivering one shock, immediately begin

2 minutes of CPR If no shock indicated, immediately begin 2

minutes of CPR After 2 minutes of CPR, reanalyze the

rhythm If a shock is indicated, immediately deliver a

single shock If no shock is indicated, immediately check

pulse. If no pulse, then begin 2 minutes of CPR

Pages 22—23


Anaphylaxis

BLS Care

Page 9

• Any patient who receives an EpiPen (pre– or post—EMS arrival) should be transported and evaluated in a hospital.

• Mode of transport depends on clinical symptoms and findings.

• Any patient who receives an EpiPen (pre– or post—EMS arrival) should be transported and evaluated in a hospital.

• Mode of transport depends on clinical symptoms and findings.


Page 75

Epinephrine (EpiPen)

EMTS may deliver epinephrine via an EpiPen injector for ANY case of suspected anaphylaxis (respiratory distress and/or

hypotension must be present.

EMTS may deliver epinephrine via an EpiPen injector for ANY case of suspected anaphylaxis (respiratory distress and/or

hypotension must be present.


Page 75

EpiPen, continued

Seattle EMTs

Patient (any age) has a history of same and a prescription for epinephrine

Patient is less than 18 years of age with no prescription but permission is obtained from parent or legal guardian. This may be written or oral.


King County EMTs

There are no requirements for:

Page 75

EpiPen, continued

Age

Having a prescription

Written/oral permission (beyond standard consent)


Dosages

Page 75

EpiPen, continued

Adults and children over 30 kg or 66 lbs: EpiPen (0.3 mg)

Child under 30 kg or 66 lbs.: EpiPen, Jr. (0.15 mg)


Blood glucometry is within EMT scope of practice

EMTs must complete initial training in glucometry before applying this skill (see EMS Online)

Optional protocol for individual EMS agencies

GlucometryPages 26—27


Pulse oximetry is within the scope of practice for EMTs

EMTs must have initial training in pulse oximetry before applying this skill (see EMS Online)

Optional to EMS agencies

Pages 28—29

Pulse Oximetry


New section to provide more guidance on bloodborne exposures

Definition of reportable exposure General steps to take following an

exposure

Page 30

Reportable Exposures


New ALS indicators Hypoglycemia with decreased LOC Drug or alcohol related seizures

Other Changes Defined time period of 15 minutes or more in

postictal period vs. “not regaining consciousness between seizures”

Signs and symptoms of shock vs. “hypotension”

Page 32

Altered Level of Consciousness


New ALS indicator for asthma Sustained tachycardia (persistent heart rate of

100-120 or greater per minute depending on clinical setting)

Page 35

Asthma


New section to give EMTs more guidance on assessment and treatment of burn injuries

Page 38

Burns


ALS Indicators in this section have changed significantly including Use of nitroglycerin Signs and symptoms of shock such as poor skin signs Sustained tachycardia and hypotension

ALS Indicators now emphasize Discomfort or unusual sensations for those 40 years old

or greater or with a history of heart problems New Special Instructions section has been added

that directs EMTs to be aware of atypical findings seen in the elderly, women and diabetics

Pages 39—40

Chest Discomfort


Hypothermia cardiac arrest protocol has been eliminated

Follow standard cardiac protocols for hypothermic cardiac arrest

Page 44

Cold-Related


Added ALS indicator Unable to lie flat

Page 46

Congestive Heart Failure


ALS Indicator added Sustained tachycardia

Revised BLS indicator Gag reflex intact, as indicated by swallow

Check gag reflex by asking patient if he or she can swallow

DO NOT check a gag reflex by putting a tongue depresser against the back of the throat

Page 48

Diabetic


New variation in BLS care If hypoglycemic and patient is unable to

swallow, position on side, give oxygen, ventilation and await paramedics

Revision of instructions for leaving patient at the scene Patients with hypoglycemia who have

responded to oral glucose may be left at scene (see page 27). These patients must have a repeat glucose level documented and after-care instructions must be left with the patient.

Page 49

Diabetic, continued


Revised BLS care for SCUBA-related injury Position patient flat (supine) to avoid cerebral

edema Former treatment

“Position patient on left side with head and chest lower than feet to prevent air bubbles from moving to lungs, heart and brain (heart down, head down).”

Page 52

Drowning (Scuba Diving)


ALS Indicators added Sustained tachycardia (persistent heart rate

100-120 or greater per minute depending on clinical setting)

Possible ectopic pregnancy

Page 52

Gynecologic


Revised care for suspected c-spine injury when wearing a helmet As long as the airway is not affected and

remains patent AND the c-spine can be secured in an neutral, in-line position, leave football and motorcycle helmets on

All other non-fitted helmets may be removed as soon as possible (e.g., bicycle helmets, skateboard helmets, rollerblade helmets)

Page 57

Head and Neck



Page 58

Heat - Related


New ALS indicators Open fractures except for hands and feet High index of suspicion based on MOI Contact medics for severe pain

Refined realignment of long-bone fractures Long-bone fractures, which occur in the proximal or

distal 1/3, that may or may not involve a joint, may be realigned if compromise of distal circulation or nerve function is detected and definitive care is delayed.

New BLS care for pelvic fractures - “sheet splinting”

Pages 65—67

Orthopedic



Page 70

Respiratory


ALS Indicators added Multiple seizures (status seizures) Drug and alcohol associated seizures Defined a time frame for the postictal period of

greater than 15 minutes

Page 72

Seizures


Revised conditions for assisting with nitrogylcerin The patient should not have taken Viagra or

Levitra within the past 24 hour or Cialis within the past 48 hours

Page 83

Admin of Meds (Nitro)


FATS technique is now referred to as the One EMT Technique

Page 92

Bag—Valve Mask


Revised BLS Care Cover eviscerated abdominal contents with a

large multi-trauma dressing soaked with sterile saline. Then apply an occlusive dressing, if available, to retain heat and moisture.

Former PCP directed EMTs to not moisten the dressing.

Pages 96—97

Dressing and Bandaging


Two approved methods only: Firm earlobe pressure (Figure 1) Firm pressure behind earlobe (Figure 2)

Page 91

Noxious Stimuli

Figure 1 Figure 2


For King County COPD patients (non-Seattle FD) EMTs have the option of using a non-

rebreathing mask if a nasal cannual at 4 L/min is inadequate

Page 106

Oxygen Delivery


Change in technique One arm secured high above the head and the

other low at the patient’s side and both secured to the backboard or stretcher

Pages 113—114

Patient Restraint


Added contraindication Patient with suspected cardiac chest pain

Check vital signs in two positions only: supine or sitting and standing (formerly 3: supine, sitting and standing)

Positive findings have been redefined as follows: Increase in pulse of 20/minute or more and/or a 20 mmHg

or more drop in systolic BP from supine to standing with associated symptoms

OLD: “Decrease in systolic BP of 30 mm/Hg or more from supine to sitting or standing. Systolic BP of less than 90 mm/Hg in sitting or standing position.”

Pages 115—116

Postural Vital Signs


Questions

Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp

EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp

Mike Helbock, M.I.C.P., NREMT-PTraining Division ManagerEmail support: [email protected]

Patient Care Protocols (Blue Book) and EMS Update 2007 Seattle—King County.

Documents

seattleking county ems

seattleking county slide

ems update

doffing ppe

donning ppe

continued pages

patient area

ppe approved sequence