1	Region 8 2006 SOP Revisions Central DuPage Hospital Edward Hospital Good Samaritan Hospital Loyola University Medical Center
2	SOP Re-release Region 8 Medical Directors chose to have the SOPs reprinted Slated for release and implementation September 1
3	2006 SOP Significant Changes Major Revisions: Cardiac section to accommodate AHA ACLS recommendations Conscious Sedated Intubation à Drug Assisted Intubation Addition of nasal atomizer as drug route for Narcan and Versed Addition of trauma SOP for Taser-type weapons Addition of a table for Pediatric age-related differences Repaired spelling and syntax errors throughout Pediatric/EMSC Bears have age flags
4	AHA Rational There are an estimated 330,000 out-of-hospital and emergency department deaths in the US each year. Many victims of sudden cardiac arrest (SCA) demonstrate ventricular fibrillation. Treatment of VF requires early CPR and shock therapy. High-quality bystander CPR can double or triple survival rates. Fewer than one third of victims of SCA receive bystander CPR and fewer receive high-quality CPR.
5	AHA Major Changes Affecting All Rescuers Emphasis on delivery of effective chest compressions. A single compression-to-ventilation ratio for all single rescuers for all victims except newborns. Rescue breaths to be given over 1 second and should produce visible chest rise. Recommendation for single shocks, followed by immediate CPR. Recommendation for use of AEDs in children 1 to 8 years old.
6	Recommendation for single shocks, followed by immediate CPR for 2 minutes. Why? First shock eliminates VF > 85% of the time. If first shock fails, CPR has greater value than another shock. If shock eliminates VF, it takes several minutes for a normal heart rhythm to return and create heart flow.
7	"CPR à Shock à CPR..." CPR à Shock à CPR for 2 minutes No pause for rhythm verification or pulse check If you detect an organized rhythm, check pulse during CPR. Stop CPR if return of effective circulation
8	Recommendation for use of AEDs in children 1 to 8 years old.
9	General Changes in SOP’s The bears now flag the SOP for some age-related content. IV/IO is the preferred method for drug administration for Adult and Pediatric patients. Each EMS System is researching IO devices for the adult patient. Watt/Seconds changed to Joules
10	Page 14 Suspected Cardiac Patient With Chest Pain Updated to include Revatio used for Pulmonary Hypertension 2. Carefully inquire about the pateint’s use of Viagra (sidenafil), Levitra (vardenafil), Cialis (tadalafil), or Revatio within 36 hours.
11	Page 15 Supraventricular Bradycardia, Second Degree Type-I AV Blocks Atropine 0.5mg rapid IV or 1mg ET; may repeat Atropine x 3 in 3-5 minutes. If patient remains hypotensive and pulse , 60: initiate Transcutaneous Pacing (TCP) at an initial rate of 70 bpm per System procedure. Consider sedation with Versed in 2mg increments IV to a maximum of 10mg. If patient remains symptomatic, Dopamine 2-10 mcg/kg/min IVPB.
12	Page 15 IVR, Second Degree Type II or Third Degree AV Block Initiate Transcutaneous Pacing (TCP) at an initial rate of 70 bpm per system procedure. Consider sedation with Versed in 2mg increments IV to a maximum of 10mg. If patient remains symptomatic, Dopamine 2-10 mcg/kg/min IVPB
13	Page 18 Pediatric Narrow Complex Tachycardia (Rate>220) Added under IMC: Search for possible treatable contributing causes: Possible Causes and Treatments Hypovolemia IV Fluid Hypoxemia 100% Oxygen Hypoglycemia Blood Sugar Hypothermia Rewarming Tamponade (Pericardial) IV Fluid for preload Tension Pneumothorax Pleural decompression
14	Defibrillation Energies Changed to joules (J) from Watt-Seconds Defibrillation Note: Biphasic defibrillation protocols may vary depending on the specific biphasic waveform employed. The specific device may vary from service to service. Providers need to base their defibrillation energy levels on the recommended manufacturer’s guidelines appropriate for the type of device and for the type of waveform used in the delivery of care
15	Recommendations table on page 89 of SOPs Zoll 120-150-200 Medtronic ADAPTIV 200-300-360 Philips SMART 150 non-escalating Welch-Allyn 200-300-260
16	Page 19 Ventricular Tachycardia with Pulse (Wide Complex Tachycardia) Under Unstable: Lidocaine changed from 1.5mg/kg to 1mg/kg for initial dose and Lidocaine rebolus at 0.5mg/kg. See next slide….
17	…Continuation of pg 19 Now reads: Synchronized cardioversion at 100 J (or recommended biphasic energy level) and Lidocaine 1mg/kg IV/IO. Assess pulse and rhythm after each cardioversion Consider cardioversion if rhythm persists If rhythm converts, follow appropriate SOP Anytime VT converts to a supraventricular rhythm, give Lidocaine 1.0mg/kg IV/IO. Rebolus in 10 minutes with Lidocaine 0.5mg/kg IV/IO
18	But Zoll says… Start cardioversion at 50-75 J
19	The Answer The AHA’s recommendations do not say to use manufacturer’s recommendations for cardioversion, only defibrillation
20	Page 20 Ventricular Fibrillation Pulseless Ventricular Tachycardia
21	What happened to 3 shocks?
22	Page 21 Pediatric Ventricular Fibrillation Pediatric PulselessVentricular Tachycardia
23	Pg 21 changes ALS: CPR should only be interrupted for ventilation (until intubated), rhythm check or shock delivery. Initial defibrillation is 2 j/kg X 1 or the manufacturer’s biphasic recommendation. Each successive defibrillation is 4 j/kg X 1 or the manufacturer’s biphasic recommendation after 2 minutes of CPR.
24	Page 22 Asystole/ PEA
25	Page 23 Pediatric Asystolic Arrest Pediatric Pulseless Electrical Activity (PEA)
26	Page 24 Pulmonary Edema (Due to Heart Failure) Maximum total dose of Lasix changed from 120 mg to 100 mg. Now reads:
27	Page 25 Cardiogenic Shock #3 Dopamine drip, dose dependent on clinical condition. If P> 60, begin at 5mcg/kg/min and increase every 3 min to achieve SBP > 100 If P< 60, and refractory to Bradycardia SOP, begin at 2.0 mcg/kg/min and increase every 3 minutes to achieve P>60. If P raised > 60 but SBP < 90, continue increasing up to maximum of 20mcg/kg/min. Revised Calculation Chart.
28	Page 27 Drug Assisted Intubation Name of SOP Changed from Conscious Sedation to “Drug Assisted Intubation – Etomidate” Etomidate education and SOP to follow Post Intubation Sedation Versed Dose.
29	Page 28 Drug Assisted Intubation - Versed Name Changed from Conscious Sedation to Drug Assisted Intubation – Versed. Give Versed prior to giving Benzocaine. Accommodates the longer onset delay of the Versed, as compared to the Benzocaine. Sellick maneuver from the time sedative given until tube passed and cuff inflated Post Intubation Sedation Versed Dose.
30	Sellick and Sedation Once you have administered chemical sedation, protecting the patient’s airway is YOUR responsibility.
31	Page 33 Allergic Reaction/Anaphylaxis All Epinephrine administrations will be given IM instead of SQ for better absorption. Reformatted to simplify use.
32	Page 39 Toxicologic Emergencies Narcotic Overdose
33	Page 49 Psychological Emergencies Added weight based Versed doses.
34	Page 50 Region 8 Trauma Center System Field Triage Guidelines Added under first bullet point:
35	Page 51 Region 8 Trauma Center System Field Triage Guidelines Under II Anatomic Factors, Level 1 Trauma recommended to be bold and starred:
36	Page 52 Region 8 Trauma Center System Field Triage Guidelines Under IV. Motor Vehicle Crashes, added Under VII. Maternal Trauma Patients UNBOLDED and UNSTARRED.
37	Page 53 Specialty Transport The NOTE message was removed
38	Page 54 Specialty Transport Removed a telemetry number from the Ground Specialty Services.
39	Page 55 Initial Trauma Care Changed the wording in the last sentence. Now reads:
40	Page 60 Head Injuries Added # 7
41	Page 63 Traumatic Arrest Added:
42	Page 64 Ophthalmic Emergencies Changed Corneal Abrasions to “Suspected Corneal Abrasion”
43	Page 66 EMD (TASER) Weapons Injuries New SOP – EMD (Taser) Weapons Injury
44	Page 76 Neonatal Resuscitation #10 Added the last sentence:
45	Page 79 Pediatric Resuscitation Guidelines Added the updates according to the current AHA CPR Guidelines.
46	Pages 80 & 81 Pediatric Age Related Emergencies Added Pediatric Age Related Differences.
47	Page 82 Addendum Section Etomidate was removed and included up front. Added: Use of MAD Nasal Atomizer Biphasic Defibrillation Manufacturer Energy Recommendations.