NYS Collaborative Protocol Rollout

[Eddie2170]

Who else has done their 2014 Protocol rollout?

Any comments?
Likes/dislikes/hates?

In the Hudson Valley Region now with Adirondack, Mountain Lakes, Hudson Mohawk, Susquehanna, & Westchester

As a Basic im pretty excited about EpiPen administration for Exacerbated Asthma with no improvment (Physician option) & IN Narcan for equiped units/agencies, which my volly corp has already expressed interest in & with longer ALS intercept & a high population of Opiate users im very happy

And the use of Epi for Anaphylaxis for Basics was finally clarified because the former left it far too open to interpretation

At my paid job I ride almost always ALS EMT-B/EMT-P so i try to be a little more informed
I know some of the larger changes are

Pain management has been redefined for both CCT and Paramedic providers.
Fentanyl is moved to a standing order for adult patients
Morphine is still in the formulary, as a long-lasting option
Ketorolac (Toradol) has been added as a physician option

Midazolam has been defined as the only benzodiazepine in the formulary,
decreasing the amount of controlled substances carried

Vasoactive medications, such as dopamine, epinephrine, and lidocaine, given as drips must be on either pumps or dial-a-flow sets

And certain ACLS meds/interventions have changed significantly depending on the region

So for everyone in NYS what do you think?

 

[Eddie2170]

Link
http://www.hvremsco.org/wp-content/uploads/2013/10/Collaborative-Protocols-Hudson-Valley-Rollout-2014.pdf

 

[platon20]

Giving epinephrine before solumedrol for pediatric asthma is stupid.

The standard of care for pediatric asthma is rapid acting beta agonist first followed by IV/IM steroids. PERIOD.

Epinephrine is a distant 3rd/4th option along with mag sulfate.

 

[Eddie2170]

I was simply speaking for the BLS/Intermediate level of care for Non-improving Exacerbated asthma with extended ALS intercept or transport time.

Having another option other than 3 albuterol treatments, contacting med control for more, & praying they don't go into respiratory failure, ill gladly take the EpiPen option, its not like they can give us solumedrol as basics, plus its only a MedControl/Physician option anyway.

And the Basics EpiPen option is just letting us use a tool, that we're already required to carry on all BLS units, for more conditions, plus its in the early phases all used by BLS crews must be reported to the Region for QI

I cannot explain the reason for the ALS standing orders, but yes the Pediatric standing orders are Epi IM, then solumedrol for medics or med control option for CCTs, and then nebulized Epi or IM/IV Epi & Mag all as a Pysician/Med Control option

 

[firecoins]

1 set of protocols is good for those who work in multiple regions.

 

[medicsb]

Giving epinephrine before solumedrol for pediatric asthma is stupid.

The standard of care for pediatric asthma is rapid acting beta agonist first followed by IV/IM steroids. PERIOD.

Epinephrine is a distant 3rd/4th option along with mag sulfate.

Is epi not a beta agonist? In certain cases, it may very well be prudent to give epi and mag before any steroid. To not do so in many situations would be... Stupid?

 

[Tigger]

Is epi not a beta agonist? In certain cases, it may very well be prudent to give epi and mag before any steroid. To not do so in many situations would be... Stupid?

This was the focus of a recent conference I attended. While we know IV steroids lessen mortality rates, there onset time is measured in hours. EMS should still be giving them but they will likely not make a difference during transport. If "traditional" beta agonists are not effective, an epi drip is generally well tolerated by most patients and effective.

 

[unleashedfury]

This was the focus of a recent conference I attended. While we know IV steroids lessen mortality rates, there onset time is measured in hours. EMS should still be giving them but they will likely not make a difference during transport. If "traditional" beta agonists are not effective, an epi drip is generally well tolerated by most patients and effective.

agreed, IV Solu-medrol or decadron depending on where your working, lessen mortality rates but the onset is 4 to 6 hours.

But with the eip drip increasing contractility and rate of the heart can we cause or increase an infarct??

I know there is discussion of adding the mag drip as a 3rd or 4th option in our protocol book but the idea is still being kicked around yet.

 

[medicsb]

But with the epi drip increasing contractility and rate of the heart can we cause or increase an infarct??

Use enough epi and yeah, you could induce an MI or arrhythmia. Folks with known CAD require very much caution if you're going to use epi at all. However, we're pretty much talking about peds, so you'd really have to overdose them to induce an MI.

 

[platon20]

Epinephrine is a nonselective alpha/beta agonist. Selective inhaled beta2 agonists such as albuterol are superior for pediatric asthma compared to epinephrine.

Epinephrine should only be used as an adjunct after multiple trials of inhaled beta2 agonists have failed and after steroids have already been given. THEN it is appropriate to try epi.

I'm not saying that epi shouldnt be used with ashtma, I'm saying it needs to be moved further down the priority tree and should only be given after steroids are given. Yes, steroids can take a few hours to kick in, and you dont have to wait for the full effect of the steroids before you can give epi.

 

[Carlos Danger]

Giving epinephrine before solumedrol for pediatric asthma is stupid.

Why?

I think withholding epi from someone having a severe asthma attack is stupid.

The standard of care for pediatric asthma is rapid acting beta agonist first followed by IV/IM steroids. PERIOD.

Epinephrine is a distant 3rd/4th option along with mag sulfate.

Do basics in NY even carry mag or solumedrol?

Do they carry nebulizers?

 

[medicsb]

Epinephrine is a nonselective alpha/beta agonist. Selective inhaled beta2 agonists such as albuterol are superior for pediatric asthma compared to epinephrine.

Epinephrine should only be used as an adjunct after multiple trials of inhaled beta2 agonists have failed and after steroids have already been given. THEN it is appropriate to try epi.

I'm not saying that epi shouldnt be used with ashtma, I'm saying it needs to be moved further down the priority tree and should only be given after steroids are given. Yes, steroids can take a few hours to kick in, and you dont have to wait for the full effect of the steroids before you can give epi.

No one said to not give beta2 agonists.

One does NOT need to give steroids prior to epi. In severe cases, when epi would be needed, it would be a folly to wait until steroids have been given.

Have you ever encountered anyone who is so constricted that they are barely able to produce an effective tidal volume? Epi can be crucial for such patients.

 

[Smash]

Epinephrine should only be used as an adjunct after multiple trials of inhaled beta2 agonists have failed and after steroids have already been given. THEN it is appropriate to try epi.

So in the severely broncho-constricted patient who cannot speak, is gas-trapping with minimal tidal volume and has poor perfusion from increased intra-thoracic pressure, you would give several doses of inhaled albuterol prior to giving epi?

 

[Eddie2170]

Do basics in NY even carry mag or solumedrol?

Do they carry nebulizers?

No we don't carry mag or solumedrol

Yes the protocol for basics & intermediates for adult & peds asthma is 3 nebulized albuterol only treatments

After 3 treatments with no improvement contact med control for authorization for more albuterol or use of an Epipen

 

[Eddie2170]

Adult protocol is as follows IN order
Basics 3 nebulized albuterol treatments
Intermediate after basic intervention CPAP ( with inline nebs)
Contact med control for use of epipen or more albuterol

CCT/Medics after basic & intermediate interventions (except use duonebs instead above)
Epi .3-.5 IM
125 solumedrol IV
2 mag IV (infused over 10mins)

Contact medical control for
More albuterol
Nebulized epi
Infused epi (imminent respiratory arrest)
More mag

 

[usalsfyre]

Epinephrine is a nonselective alpha/beta agonist. Selective inhaled beta2 agonists such as albuterol are superior for pediatric asthma compared to epinephrine.

Epinephrine should only be used as an adjunct after multiple trials of inhaled beta2 agonists have failed and after steroids have already been given. THEN it is appropriate to try epi.

I'm not saying that epi shouldnt be used with ashtma, I'm saying it needs to be moved further down the priority tree and should only be given after steroids are given. Yes, steroids can take a few hours to kick in, and you dont have to wait for the full effect of the steroids before you can give epi.

That's just like, your opinion man....

Steroids and epi have completely different roles in pediatric asthma. Steroids EVENTUALLY reduce mortality. Epi reduces mortality RIGHT NOW.

 

[Eddie2170]

Pediatric protocol IN Order

For Basics & Intermediates
3 Nebulized Albuterol treatments
- If no improvement contact MED Control for Epipen use

CCT - after Basic/Intermediate Interventions
(Substitute Duonebs for regular Albuterol treatments above)
Epi .01mg/kg IM max .5 IM

Paramedic After Basic/Intermediate/CCT interventions
Solumedrol 2mg/kg IV



Med Control Options after Above

CCT
Solumedrol 2mg/kg IV

for both CCT & Medics
Epi .01 mg/kg max .5 IM (repeat doses)
Nebulized Epi
Epi .1-1.5 mcg/kg/min IV drip
Mag sulfate 50 mg/kg over 10 mins IV
Continuous Nebulized albuterol treatments

 

[Aprz]

Sounds like wasting a lot of time.

 

[usalsfyre]

Pediatric protocol IN Order

For Basics & Intermediates
3 Nebulized Albuterol treatments
- If no improvement contact MED Control for Epipen use

CCT - after Basic/Intermediate Interventions
(Substitute Duonebs for regular Albuterol treatments above)
Epi .01mg/kg IM max .5 IM

Paramedic After Basic/Intermediate/CCT interventions
Solumedrol 2mg/kg IV



Med Control Options after Above

CCT
Solumedrol 2mg/kg IV

for both CCT & Medics
Epi .01 mg/kg max .5 IM (repeat doses)
Nebulized Epi
Epi .1-1.5 mcg/kg/min IV drip
Mag sulfate 50 mg/kg over 10 mins IV
Continuous Nebulized albuterol treatments

I don't see an issue here, unless you actually have to follow the protocol IN ORDER without skipping inappropriate steps. If that's the case....there's WAY bigger issues in NY State than the pedi asthma protocol.

 

[Eddie2170]

I don't see an issue here, unless you actually have to follow the protocol IN ORDER without skipping inappropriate steps. If that's the case....there's WAY bigger issues in NY State than the pedi asthma protocol.

No obviously if your an AEMT you dont need to call for the bls stuff before your AEMT interventions can be done etc.

& i really just posted the actual protocols because i was getting annoyed reading peoples responses to what was stupid and arguing over stuff they obviously didnt read or know anything about, completely basing their opinion on prior posters interpretation of what i said which was strictly changes

And im so glad my thread turned from a protocol thread to an asthma treatment argument when I expected answers like this

1 set of protocols is good for those who work in multiple regions.