2015 REMS protocols revised

1. Protocols 2015
REMO Medical Advisory Committee
for the Collaborative Protocols

2. REMS Notes
• This presentation will have numerous REMS
notes throughout. The presentation from
REMO is intended to be presented in-person.
The REMS notes inserted throughout allow us
to present this in an online format.
• The REMS notes will follow the protocol in the
presentation.

6. REMS Note
• In cardiac arrest protocols, Epinephrine
1:10,000 IV has been moved to the AEMT
level. No significant relevance to us.

8. REMS Note
• No changes to the v-fib/v-tach protocol (other
than the previously mentioned Epi for AEMTs)
• However, Dr. Dailey wanted to stress the use
of Sodium Bicarb if acidosis is the suspected
primary cause of cardiac arrest.
– i.e. If a patient in excited delirium goes into
cardiac arrest, Sodium Bicarb should be the FIRST
medication given, followed by epinephrine (if
necessary)

9. No prehospital
hypothermia

10. REMS Note
• No prehospital hypothermia. Nothing new
there.
• For pressor therapy, consult the appropriate
shock protocol.

12. REMS Note
• Norepinephrine has replaced dopamine in the
medication formulary.
• The full presentation on norepi is later in this CME.
• Norepinephrine may only be administered AFTER 2L
saline bolus, ONLY ADMINISTER UNTIL MAP>65 or SBP
>100, as protocol states.
• Just note, norepinephrine comes in 4mg vials which are
mixed in 1000mL saline. This creates a 4mcg/mL
concentration.
• Administration begins at 2mcg/min or 30 gtts/min
(with 60 drip set) and is titrated up to 20mcg/min
• Pre-mix bags are NOT currently available.

14. REMS Note
• The definition of “wide complex” tachycardia
has not changed, however the way it is
expressed in the protocol has change.
• Dr. Dailey says this is not intended to insult
Paramedics, but rather was a specific request
from several agencies.

16. REMS Note
• Excited delirium’s protocol change warrants a
presentation of its own. This presentation will
come out within a few weeks.
• Haldol and Ketamine have been added to
protocol as Physician Options. Note that
Ketamine may only be used by Paramedics
regardless of OLMC approval. AEMTs and CCs
cannot give Ketamine (No significant
relevance to REMS)

17. REMS Note
• Versed should still be the first medication administered
as quickly as possible if the patient is a danger.
• Haldol works best for acutely psychotic patients –
those who truly do not know what they’re doing or are
hallucinating.
• Ketamine works best for those in true excited delirium
such as those intoxicated, on PCP, or cocaine.
• Ketamine is the best chemical sedation we have.
Regardless of the cause of the excited delirium,
ketamine should be given if the patient poses a serious
risk to providers or themselves.
• Ketamine and Haldol are Medical Control only.

19. REMS Note
• Ketamine has been added to the Procedural
Sedation protocol.
• With Medical Control approval, Ketamine may
be administered for sedation. As Ketamine is
long acting, etomidate should still be used for
short procedures such as cardioversion.
• Ketamine is better suited for long duration
procedures like airway control and
transdermal pacing.

21. REMS Note
• Just a reminder, hypoglycemia is now
considered a glucose level below 60mg/dL.
• Dr. Dailey wants to stress the use of your
clinical judgment. Diabetics with a baseline
glucose of 200mg/dL may show signs of
hypoglycemia at 80 or 90mg/dL. Also,
chronically hypoglycemic people may have no
symptoms with a glucose level of 50mg/dL.

23. REMS Note
• This protocol had a typo:
• 4mg magnesium should be given over 20
minutes, not 2 minutes for pregnant seizure
patients.

25. REMS Note
• Same change as the cardiogenic shock
protocol.
• Norepinephrine may be given only AFTER 2L
saline bolus, ONLY ADMINISTER UNTIL
MAP>65 or SBP >100, as protocol states.

27. REMS Note
• Dr. Dailey wanted to stress the Cincinnati
Stroke Scale. When you report and document
this, do not simply state “positive” or
“negative” but rather report and document
the INDIVIDUAL aspects of the assessment
(i.e. facial droop, arm drift, and speech)

29. REMS Note
• For septic shock, Physician Contact is required
for norepinephrine administration,
• More likely, the physician will order additional
saline boluses.
• ONLY ADMINISTER SALINE UNTIL MAP>65 or
SBP >100, as protocol states.

31. REMS Note
• Dr. Dailey wants to stress the use of
epinephrine for severe asthma. He actually
said that ephinephrine is UNDER utilized for
severe asthma in this region.
• Same thing with anaphylaxis. If there is
respiratory involvement, epinephrine should
be given, then benadryl.

33. REMS Note
• For acute pulmonary edema, CPAP has been
added for AEMTs (no significant relevance to
us)

35. REMS Note
• BLS Narcan on an agency-by-agency basis. (no
significant relevance to us)
• Remember to titrate narcan IV and administer
it slowly.

37. REMS Note
• Dr. Dailey wanted to stress that needle
decompression is for suspected TENSION
pneumothorax, not any pneumothorax.

39. REMS Note
• Dr. Dailey wanted to stress the importance of
bleeding control in major trauma. All other
interventions mean nothing when your
patient dies of blood loss.

41. REMS Note
• For traumatic hypoperfusion, norepinephrine
is a Medical Control option. Remember,
“squeezing the pipes” does very little when
the “pipes need to be filled.”

43. REMS Note
• Once again, the typo has been fixed to read
4mg over 20 minutes.

45. REMS Note
• Same as adult asthma, consider epinephrine
for severe pediatric asthma.

47. REMS Note
• Same as adult anaphylaxis, consider
epinephrine for severe pediatric allergic
reactions.

49. REMS Note
• INTRANASAL fentanyl is now standing order
for pediatric pain management.
• Even if IV access has been established,
fentanyl may NOT be administered IV without
Physician Contact.

51. REMS Note
• Reminder on titration of oxygen.
• Again, Dr. Dailey wanted to stress clinical
judgment. If a patient is having distress at
95%, they may need the extra oxygen. If a
patient (with COPD history) has no distress at
90%, they probably don’t need supplemental.

53. REMS Note
• Dosing for norepinephrine.

54. Thanks.

55. REMS Note
Once again, the start date for protocol has not
been set yet. When it is, we’ll probably be the
first to know from Dean.

56. Questions/Comments
Questions? Comments? Concerns?
Please direct them to me at dhexel@gmail.com