Happy Friday.
Amiodarone Updates:
Please note that Amiodarone vials have been added to the pyxis in volumes of 150 mg. We should be carrying a total of 450 mg. Always check volume and concentrations when replacing any medication from the pyxis at Meritus.
Nitro updates:
Nitroglycerine 25 mg/250 ml bottles have been added to the medication pyxis. This is only to be carried on units that have IV pumps, by clinicians with documented IV pump training.
Under no circumstances should IV nitro be administered without an IV pump. Dial-a-flow sets are NOT an acceptable alternative.
Protocol variation reporting procedures:
Protocol variation reporting should first occur to the patient’s receiving physician, immediately after the recognition of the variation. Your second variation report needs to be to the EMSOP within 24 hours. Reporting will be considered satisfied with an email to mhiggins@washco-net. You may choose to include your immediate supervisor, but it is not required by protocol. In the cases of adverse outcomes, you may also choose to email the Jurisdictional Medical Director at [email protected]<mailto:[email protected]>.
EMEDS documentation of PEEP:
We have added a procedure “Airway- PEEP”. Please start to utilize this procedure when applying any PEEP. Please encourage PEEP valves on BVM use, with or without an ALS adjunct. You should document the PEEP settings on your CPAP and/or ventilators here as well.
Therapy Pad placements:
Please continue to monitor BLS placements of AED therapy pads. We will be scheduling some training in the near future for BLS clinicians. Encourage anterior/posterior as the first placement choice. We do not need to apply both sets of pads until after the third initial shock when we are ready for a vector change or dual sequential shock.
QA trends have indicated the increase in use of the placement of therapy pads for confirmed STEMI patients. Here is some research regarding that practice: S1481803519004081jra 82..85 (cambridge.org)<www.cambridge.org/core/services/aop-cambridge-core/content/view/117D5D859FB3C7179437A3F40B2553BF/S1481803519004081a.pdf/decreasing-time-to-first-shock-routine-application-of-defibrillation-pads-in-…> **** IPEC_A_1076100_O (researchgate.net)<www.researchgate.net/profile/Sheldon-Cheskes/publication/283620608_A_Novel_Approach_to_Improve_Time_to_First_Shock_in_Prehospital_STEMI_Complicated_by_Ventricular_Fibrillation/links/5649f41808ae127…> **** download (washingtoncountyor.gov)<www.washingtoncountyor.gov/hhs/documents/defibrillation-pad-placement-stemi-patients/download?inline> Microsoft PowerPoint – 2021 Cardiac Conference Presentations 12.2.21 (heart.org)<www.heart.org/-/media/Files/Affiliates/MWA/North-Dakota/North-Dakota-Stroke-Cardiac-Conference/Cardiac-Presentations/STEMI-Case-Study.pdf> SETRAC_ACS-Pathway.revision-7-19.pdf<www.setrac.org/wp-content/uploads/2019/12/SETRAC_ACS-Pathway.revision-7-19.pdf> 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (sciencedirectassets.com)<pdf.sciencedirectassets.com/271027/1-s2.0-S0735109712X00093/1-s2.0-S0735109712055623/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjEOD%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQCZhN7NtR…> Paramedic – Evidence Based Medicine (P-EBP) Program (nshealth.ca)<emspep.cdha.nshealth.ca/ProtocolImages/Feb%2020%20CAT%20worksheet%20Aaron%20McClure.pdf> 7401.pdf (remsa.us)<remsa.us/policy/2019/7401.pdf> AR_STEMI_Systems_of_Care_Manual_7.2018.pdf (arkansas.gov)<healthy.arkansas.gov/images/uploads/pdf/AR_STEMI_Systems_of_Care_Manual_7.2018.pdf> SECTION: (id.gov)<adacounty.id.gov/paramedics/wp-content/uploads/sites/62/C-04_-STEMI-protocol-01MAY2022-.pdf> Peel_2013Nov11_STEMI_VF_New_Treatment.pdf (prehospitalmedicine.ca)<www.prehospitalmedicine.ca/wp-content/uploads/2012/message/Peel_2013Nov11_STEMI_VF_New_Treatment.pdf>
Some important points to deciding whether or not to apply therapy pads to STEMI patients:
* 1 in 20 STEMI patients encountered in the field will experience an OHCA prior to arrival in the emergency department * VF/VT occur in 6% of all out-of-hospital STEMI patients * Mortality increases 10% for every minute a patient is in cardiac arrest * There is a 7-10% reduction in the likelihood of successful defibrillation for every minute of delay to first defibrillation * The mean time to defibrillation where pads were already in place was 17.7 seconds, compared to 72.7 seconds where pads had to be placed after the patient arrested
Clinical indicators with likelihood of deterioration Specific injury locations (STEMI locations) more likely to arrest – Anterior Wall STEMI
Amiodarone Updates:
Please note that Amiodarone vials have been added to the pyxis in volumes of 150 mg. We should be carrying a total of 450 mg. Always check volume and concentrations when replacing any medication from the pyxis at Meritus.
Nitro updates:
Nitroglycerine 25 mg/250 ml bottles have been added to the medication pyxis. This is only to be carried on units that have IV pumps, by clinicians with documented IV pump training.
Under no circumstances should IV nitro be administered without an IV pump. Dial-a-flow sets are NOT an acceptable alternative.
Protocol variation reporting procedures:
Protocol variation reporting should first occur to the patient’s receiving physician, immediately after the recognition of the variation. Your second variation report needs to be to the EMSOP within 24 hours. Reporting will be considered satisfied with an email to mhiggins@washco-net. You may choose to include your immediate supervisor, but it is not required by protocol. In the cases of adverse outcomes, you may also choose to email the Jurisdictional Medical Director at [email protected]<mailto:[email protected]>.
EMEDS documentation of PEEP:
We have added a procedure “Airway- PEEP”. Please start to utilize this procedure when applying any PEEP. Please encourage PEEP valves on BVM use, with or without an ALS adjunct. You should document the PEEP settings on your CPAP and/or ventilators here as well.
Therapy Pad placements:
Please continue to monitor BLS placements of AED therapy pads. We will be scheduling some training in the near future for BLS clinicians. Encourage anterior/posterior as the first placement choice. We do not need to apply both sets of pads until after the third initial shock when we are ready for a vector change or dual sequential shock.
QA trends have indicated the increase in use of the placement of therapy pads for confirmed STEMI patients. Here is some research regarding that practice: S1481803519004081jra 82..85 (cambridge.org)<www.cambridge.org/core/services/aop-cambridge-core/content/view/117D5D859FB3C7179437A3F40B2553BF/S1481803519004081a.pdf/decreasing-time-to-first-shock-routine-application-of-defibrillation-pads-in-…> **** IPEC_A_1076100_O (researchgate.net)<www.researchgate.net/profile/Sheldon-Cheskes/publication/283620608_A_Novel_Approach_to_Improve_Time_to_First_Shock_in_Prehospital_STEMI_Complicated_by_Ventricular_Fibrillation/links/5649f41808ae127…> **** download (washingtoncountyor.gov)<www.washingtoncountyor.gov/hhs/documents/defibrillation-pad-placement-stemi-patients/download?inline> Microsoft PowerPoint – 2021 Cardiac Conference Presentations 12.2.21 (heart.org)<www.heart.org/-/media/Files/Affiliates/MWA/North-Dakota/North-Dakota-Stroke-Cardiac-Conference/Cardiac-Presentations/STEMI-Case-Study.pdf> SETRAC_ACS-Pathway.revision-7-19.pdf<www.setrac.org/wp-content/uploads/2019/12/SETRAC_ACS-Pathway.revision-7-19.pdf> 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (sciencedirectassets.com)<pdf.sciencedirectassets.com/271027/1-s2.0-S0735109712X00093/1-s2.0-S0735109712055623/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjEOD%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQCZhN7NtR…> Paramedic – Evidence Based Medicine (P-EBP) Program (nshealth.ca)<emspep.cdha.nshealth.ca/ProtocolImages/Feb%2020%20CAT%20worksheet%20Aaron%20McClure.pdf> 7401.pdf (remsa.us)<remsa.us/policy/2019/7401.pdf> AR_STEMI_Systems_of_Care_Manual_7.2018.pdf (arkansas.gov)<healthy.arkansas.gov/images/uploads/pdf/AR_STEMI_Systems_of_Care_Manual_7.2018.pdf> SECTION: (id.gov)<adacounty.id.gov/paramedics/wp-content/uploads/sites/62/C-04_-STEMI-protocol-01MAY2022-.pdf> Peel_2013Nov11_STEMI_VF_New_Treatment.pdf (prehospitalmedicine.ca)<www.prehospitalmedicine.ca/wp-content/uploads/2012/message/Peel_2013Nov11_STEMI_VF_New_Treatment.pdf>
Some important points to deciding whether or not to apply therapy pads to STEMI patients:
* 1 in 20 STEMI patients encountered in the field will experience an OHCA prior to arrival in the emergency department * VF/VT occur in 6% of all out-of-hospital STEMI patients * Mortality increases 10% for every minute a patient is in cardiac arrest * There is a 7-10% reduction in the likelihood of successful defibrillation for every minute of delay to first defibrillation * The mean time to defibrillation where pads were already in place was 17.7 seconds, compared to 72.7 seconds where pads had to be placed after the patient arrested
Clinical indicators with likelihood of deterioration Specific injury locations (STEMI locations) more likely to arrest – Anterior Wall STEMI
<www.washco-md.net/emergency-services/>
Melanie Higgins, BS, NRP Captain – EMS Quality Assurance Division of Emergency Services 16232 Elliott Parkway Williamsport, MD 21795 (cell) 301-491-2454 (office) 240-313-4376 (fax) 240-313-4375 www.washco-md.net<www.washco-md.net/>