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New protocol

New Protocol
Question & Answer
Death in the Field
p. 13 & 14
What if the patient meets all 4 of the presumptive signs of death but does not meet any conclusive signs of death? Section II A, B and C shall stand as written and the paramedic should refer to 1.4 Section III “Discontinuance of CPR”. All of Section III shall apply in the case with the exception of the Disclaimer which states “Section C with an order from medical direction will not apply”. Death in the Field
p. 13 Section II - Determination of Death
What is the definition of a child (children) with regards to contacting medical direction? A child (children) is considered to be 17 years of age or less for the purpose of this protocol. Therefore, all of Section II and III shall apply as written. Refusal of Care
Do you need medical consultation for the patient who refuses care or transport post seizure or post administration on Narcan or D 50? Disclaimer states “Chapter 1, General Protocol 1l1, pg. 2 & 3, Paramedics will not need medical orders or consultation for any protocols in this manual. However, the following guidelines shall apply. 1. No medical direction required for the post seizure patient or the patient with D 50 administration. Disclaimer states General Protocol 1.8, Refusal of Care, Section C, Medical Direction 1(d) contact should be made with the EMS Captain. 2. Narcan administration – patients in which Narcan is administered to the patient, and the patient responds in a positive manner (narcotic overdose), the patient cannot refuse treatment and must be transported. If the administration of Narcan has no effect, then the appropriate protocol should be followed. If the paramedic is unsure if the patient responded to Narcan, then the error should be to the side of worst case scenario and the patient transported. EMS Captain consultation is also an option. 2.2.2 Asthma/Bronchospasm p.
Can epinephrine be given to the patient older than 40 years of age, notes (b)? The protocol stands as written with the exception in the Disclaimer “Mag Sulfate will not be utilized”. The statement notes (b) “caution should be used when the patient is older than 40 years of age or has a history of hypertension or heart disease”, simply means that if the benefit out weighs the risk (respiratory distress vs. severe respiratory compromise) then epinephrine should be given. Can Albuterol be given to the patient with a HR > 140 (a) ?
2.2.4 Pulmonary Edema-CHF
Is the Lasix dose 1mg/kg up to, or a maximum of 80mg? There is flexibility here which means, the paramedic may give Lasix 1 mg/kg or give a standard dose of 80 mg. (80 mg. is not maximum dose of Lasix). However, if Lasix is repeated, it should be repeated at the method previously used. Ex. The Paramedic administers the first dose of Lasix at 1 mg/kg. Then the 2nd dose should be at 1 mg/kg. If the paramedic administered the first dose of Lasix at the standard dose of 80 mg, then the 2nd dose should be 80 mg.
2.3.4 Premature Ventricular Ectopy (P.V.C’s) p.92

ALS Level 2, if the patient is symptomatic, contact physician for further orders? ALS Level 2 and contact physician for further orders does not apply to P.B.C.F.R. see Disclaimer for Chapter 1, General Protocol 1.1, page 2 & 3. Therefore, refer to the appropriate protocols for the symptomatic patient i.e. Bradycardia rate dependent PVC’s., stable V.T., prevention of recurrent VF. Remember, consistent runs of 3 or more PVC’s is considered runs of V.T., and should be treated as such.
2.3.6 Wide Complex Trachycardia with a pulse (Ventricular Tachycardia)
Stable vs. Unstable
The protocol states use only one antiarryhmic medication. If that medication doesn’t work, can we use another? The protocol stands as written. If an antiarrhythmic medication does not convert the patient after maximum dose, treat as unstable, and refer to protocol 2.3.6 Unstable. If Mag. Sulfate does not convert the patient in Torsades de Pointes, can we give the patient Lidocaine or Procainamide? The protocol stands as written. Mag. Sulfate is an antiarrhythmic. If Mag Sulfate administration in protocol 2.3.6 “Stable” did not convert patient, the patient is now treated as “Unstable” and patient is cardioverted. If after cardioversion the patient converts, the paramedic should follow 2.3.6 “Unstable” (e).
2.4.2 Suspected AMI/Acute Coronary Syndrome
Is there a maximum dose of Nitro-spray for chest pain? Disclaimer was vague in this area, so here is the additional clarification. There is no maximum dose of Nitroglycerin (Nitro-spray) and should be repeated every 3-5 minutes as long as the patient remains hemodynamically stable, BP>90 mmHg, HR > 50 bpm.
2.4.3 Hypertensive Emergencies p. 102

Can Nitro-spray be given to this patient instead of Labetolol? Labetolol is the drug of choice and shall be administered via I.V. PBCFR does not carry Nitroglycerin Infusion. Note (b) states if Nitroglycerin Infusion is not available, Nitro-spray may be considered. 1. If I have established an I.V. and PBCFR does not utilize Nitro-Infusions, the drug to administer is Labetolol, not Nitro-spray. 2. If I am unable to establish an I.V. after multiple attempts (2), or if Labetolol is contraindicated (p. 377), Nitro-spray may be used. 3. Since the use of Labetolol and Nitroglycerin are not recommended in the presence of acute stroke (CVA), neither one shall be administered. Refer to protocol 2.5.4 Suspected Stroke. Since no special circumstances are identified in protocols 2.4.3 and 2.5.4, they do not apply. So the medications are not administered unless directed to do so by medical authority during your encode, while en route, which such orders are highly unlikely. What are the lower limits of the blood pressure regarding the administration of Labetolol? The protocol stands as written. If the systolic BP>220 mmHg. and/or a diastolic BP>120 mmHg, and the patient is experiencing symptoms, and underlying causes are eliminated, give 20 mg Labetolol over 2 minutes. If the BP remains systolic BP>220 mmHg, and/or diastolic > 120mmHg. after 20 minutes, repeat Labetolol. If after the first administration of Labetolol, the BP drops below 220 mmHg, systolic and/or diastolic below 120 mmHg, do not administer 2nd dose of Labetolol unless BP becomes systolic > 220 mmHg. and/or diastolic > 120 mm/hg. If at any time the patient becomes hemodynamically unstable, treat accordingly.
2.5.3 Seizure Disorders
Note (b) says if Diastat is not available. Use lubricated tuberculin or 35ml syringe without needle to administer diazepam? 1. This is a typo and should read 3-5 ml syringe. 3. PBCFR will not carry valium in any form other than Diastat. Therefore, Diastat is the only medication for rectal administration.
2.8.2 Diabetic Emergencies
Will we carry oral glucose for the diabetic? No, not at this time. The protocol refers to the self-administration assistance of oral glucose, meaning, it must be the patients. Same as the assisted administration of Epi. Kit is for the severely allergic patient of bee stings. Consider the following, the diabetic frequent-flyer who we give D50 to, and they
respond to the medication and adamantly refuse treatment and transport? You can
now give them Glucagon, which will eliminate having to start I.V.’s and then D/C
them. But this should only be used for those known patients who refuse, and those in
which I.V. attempts are unsuccessful.
2.10.1 Head and Spine Injuries
The protocol says to hyperventilate patient to achieve optimal ETCO2 of 35-40 mmHg. (see Medical Procedure 4.18 – Methods of Intubation). I thought we were not supposed to hyperventilate Head Injury patients? First, Medical Procedure 4.18 refers to “Medication Access point”, and not “Methods of Intubation”, so this is obviously a typo. Secondly, the ventilation rate of the adult patient is 12-20 breaths per minute. So to hyperventilate the patient to obtain 35-40 mmHg, you should ventilate within the adult range of 12-20 breaths to accomplish optimum ETCO2 at 35-40 mmHg. If you are unable to obtain optimal ETCO2 within the adult range, then you should re-consider or re-evaluate cardio-pulmonary perfusion since ETCO2 is proportionate to cardio-pulmonary function. If cardio-pulmonary perfusion issues are being addressed, you should ventilate at a rate to accomplish optimal ETCO2. This may result in ventilating at higher rates. What is the difference between hyperventilation and pre-oxygenate/hyper-oxygenate? With regards to this protocol, the definitions are as follows: Hyperventilation – Ventilating the patient within the appropriate parameters or above (i.e. adult, child, infant, newborn) to achieve optimal ETCO2. Remember that without proper perfusion and oxygenation, organ function decreases. Pre-Oxygenate/hyper-oxygenate - Utilized to ensure complete nitrogen washout for the non-paralytic RSI Algorithm and the Paralytic RSI Algorithm of Medical Procedures 4.28 Smart Airway Management, Difficult Airway Algorithm p. 307 & 308. 3.1.3 Pediatric Medical Supportive Care
Note (a) states “avoid sites below the diaphragm”. Does this mean that no I.V. sites should be below the diaphragm? No, it does not mean this. It means I.V. sites should be above the diaphragm. If the patient is unstable and the benefits out-weigh the risks, I.V. sites can be below the diaphragm after other sites above the diaphragm have been attempted. I.V. sites below the diaphragm should be avoided but are not absolute. Remember, you will need to document the need.
4.35 Vagal Maneuvers

Can we use the alternate method of filling a large glove with ice water? Yes, the protocol stands as written. If the paramedic feels that placing the patient’s entire face in ice water will compromise the patient’s airway or the patient refuses to do so, then use the glove method.
5.46 Procainamide Hydrochloride

It says mix medication in a bag of D5W 100ml. We don’t carry D5W 100ml bags? But we will. The new items have been ordered and will be available prior to the implementation date. Phenergan Protocol
PBCFR will use the current Nausea & Vomiting protocol for Phenergan. Can Phenergan be utilized on patients with nausea and vomiting that is a non-cardiac related event? Phenergan can be utilized on all patients with nausea and vomiting if in the paramedic’s judgement it will benefit the patient.


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