OSHKOSH FIRE DEPARTMENT EMS PROTOCOLS 201 6 Paramedic Protocol Table of Contents OSHKOSH FIRE DEPARTMENT Administrative Date Revised A-1 General A-2 Medical Standards of Care A-3 Trauma Standards of Care A-4 Consent A-5 Medical Control A-6 Advanced Skills A-7 Patient Destination Protocol A-8 Trauma Destination Protocol A-9 Medications Approved for Use A-10 Medications Approved for Transport A-11 No Transport A-12 Patient Restraint A-13 Do Not Resuscitate (DNR) A-14 Comfort Management A-15 Physician At Scene A-16 Mass Casualty Triage A-17 LVAD 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 Cardiac B-1 B-2 B-3 B-4 B-5 B-6 B-7 B-8 B-9 Chest Pain/STEMI Bradycardia Tachycardia Cardio-Cerebral Resuscitation CPR Standards Ventricular Fibrillation/ Pulseless Ventricular Tach Pulseless Electrical Activity/ Asystole Post Arrest Care LUCAS 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 Respiratory C-1 C-2 C-3 C-4 C-5 C-6 Asthma/ Bronchospasm Pulmonary Edema Continuous Positive Airway Pressure Rapid Sequence Intubation Post Intubation Care King LTS-D Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 Paramedic Protocol Table of Contents Trauma D-1 D-2 D-3 D-4 D-5 D-6 D-7 Date Revised Multi-Systems Trauma Traumatic Cardiac Arrest C-Spine Protection Immobilization of Athlete in Protective Padding Thermal Burns Chemical Burns. Ocular Irritant Exposure 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 Medical Emergencies E-1 E-2 E-3 E-4 E-5 E-6 E-7 E-8 Anaphylaxis Allergic Reaction CVA/Stoke Diabetic Emergencies Hypertensive Crisis Poisoning and Overdose Seizures Excited Delirium 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 Environmental Emergency F-1 Heat-Related Illness F-2 Hypothermia F-3 Carbon Monoxide Exposure 04/2016 04/2016 04/2016 Pediatric G-1 G-2 G-3 G-4 G-5 G-6 G-7 G-8 G-9 Childbirth and Neonatal Resuscitation Peds Ventricular Fibrillation/ Pulseless VTach Peds PEA/ Asystole Peds Symptomatic Bradycardia Peds Tachycardia Peds Respiratory Emergencies Peds Seizure Peds Diabetic Emergencies Peds Hypothermia Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 04/2016 General These protocols define the standard of care for paramedics of the Oshkosh Fire Department, and delineate the expected practice, actions, and procedures to be followed. No protocol can account for every clinical scenario encountered, and it is recognized that in rare circumstances deviation from these protocols may be necessary and in a patient’s best interest. Variance from protocol should always be done with the patient’s best interest in mind and backed by documented clinical reasoning and judgment. Whenever possible, prior approval by direct verbal order from the department medical director (preferred) or base station physician is desired. Additionally, all variance from protocol shall be thoroughly documented in the Patient Care Report. Patients in the care of the Oshkosh Fire Department shall be offered transport by ambulance, as needed, to an appropriate hospital. In the event a patient for whom EMS has responded refuses transport to the hospital, a properly executed refusal process shall be completed. When transporting patients, contact with the destination hospital should be made as soon as practical. Primary contact shall be made by cell phone and secondary contact shall be by VHF radio. Cell phone is the preferred method of contact in cases of STEMI, Stroke and Trauma Alerts to communicate patient demographics. Conveying patient demographics by radio shall be avoided, unless deemed medically necessary. In the following situations, more than one attendant in the back of an ambulance is strongly recommended, unless there will be an unacceptable delay in transport: • Medical or Traumatic cardiac arrest or post-resuscitation care • Patients requiring active airway assistance (ETT, supraglottic airway, BVM) • Imminent childbirth • If the provider requests a second attendant. During interfacility transport of any patient requiring airway management because the patient is intubated, has a supraglottic airway in place or requires bag-valvemask ventilation, two paramedics must provide care in the back of the ambulance. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-1 4/2016 Assistance in the administration of prescribed medications that belong to a patient or another entity may be administered in a time sensitive, life-threatening situation. Paramedics must be confirm the medication, concentration and proper dose. The Battalion Chief of EMS and the department medical director shall be notified as soon as practical if any of the following occur: • Cardiac and/or respiratory arrest occurring after administration of midazolam (Versed), fentanyl, Ketamine, succinylcholine or rocuronium • Any unsuccessful attempt at needle and/or surgical airways • Unrecognized misplaced advanced airway device or other complication related to advanced airway management • Incorrect medication administration • Any cardiac and/or respiratory arrest or patient injury related to the use of physical restraints • System provider operating outside of scope of practice Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-1 4/2016 Medical Standards of Care The Paramedic Plan will follow the guidelines of the standards of the American Heart Association’s 2015 guidelines for Basic Life Support, Advanced Cardiac Life Support and Pediatric Advanced Life Support, and the Wisconsin Standards and Practices Manual 2014 for the assessment and treatment of all cardiac and medical emergencies. In addition to these practices, paramedics will also deliver oxygen therapy, cardiac monitoring including 12 lead EKG, administration of fluid therapy via peripheral and intraosseous routes, and perform glucometer tests to all appropriate cardiac, respiratory and medical emergency patients. For all cases in which patients require administration of narcotics or sedative agents, continuous cardiac, oxygen saturation, and ETCO2 monitoring shall be performed. The Standard of Care for oxygen administration is that oxygen shall be delivered to patients to maintain oxygen saturation greater than or equal to 92%. In any instance, if the paramedic's clinical assessment causes him/her to believe oxygen is necessary, it shall be administered at his/her discretion. The use of dialysis arteriovenous shunts and advanced catheters (e.g. PICC line, multi-lumen central lines, and Hickman Central Line) by paramedics is to be considered an IV of last resort with the approval of Medical Control. Pediatric Patients are patients less than 12 years old without evidence of physical maturity (underarm hair, breast development, etc). Consultation of the Oshkosh Fire Department Pediatric Drug Sheet, Broselow tape and/or Pedi-Wheel shall be performed for appropriate weight and medication doses. Assessment of the pediatric patient will be performed using the Pediatric Assessment Triangle. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-2 4/2016 If a bag of IV fluid is hung on a pediatric patient, the Buretrol IV tubing set must be used. Patients with an intraosseous line cannot have a Buretrol placed in the IV line. Those patients shall have bolused fluid administration provided with syringes. Vital signs in stable patients will be monitored and documented every 15 minutes. Unstable patients shall have their vital signs monitored and documented every 5 minutes. Baseline vital signs include blood pressure, pulse and respiratory rate. A Glasgow Coma Score must be included at least once, and should be repeated each time there is a change in the patient’s level of consciousness. Henceforth, herein, the medical standards of care will be referred to as, “Routine Medical Assessment.” Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-2 4/2016 Trauma Standards of Care Paramedics will follow the guidelines and standards of the 2014 Wisconsin Standards and Practices Manual criteria for the assessment, treatment, packaging, and transport of all trauma patients. In addition to these practices, paramedics will also deliver oxygen therapy and cardiac monitoring to all appropriate trauma patients. For all cases in which patients require administration of narcotics or sedative agents, continuous cardiac, oxygen saturation, and ETCO2 monitoring shall be performed. The Standard of Care for oxygen administration is that oxygen shall be delivered to patients to maintain oxygen saturation greater than or equal to 92%. In any instance, if the paramedic's clinical assessment causes him/her to believe oxygen is necessary, it shall be administered at his/her discretion. The use of dialysis arteriovenous shunts and advanced catheters (e.g. PICC line, multi-lumen central lines, and Hickman Central Line) by paramedics is to be considered an IV of last resort with the approval of Medical Control. Paramedics will be trained in advanced airway management, needle thoracostomy, cricothryrotomy, and fluid therapy via peripheral and intraosseous access. Pediatric Patients are patients less than 12 years old without evidence of physical maturity (underarm hair, breast development, etc). Consultation of the Oshkosh Fire Department Pediatric Drug Sheet, Broselow tape and/or Pedi-Wheel shall be performed for appropriate weight and medication doses. Assessment of the pediatric patient will be performed using the Pediatric Assessment Triangle. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-3 4/2016 If a bag of IV fluid is hung on a pediatric patient, the Buretrol IV tubing set must be used. Patients with an intraosseous line cannot have a Buretrol placed in the IV line. Those patients shall have bolused fluid administration provided with syringes. Vital signs in stable patients will be monitored and documented every 15 minutes. Unstable patients shall have their vital signs monitored and documented every 5 minutes. Baseline vital signs include blood pressure, pulse and respiratory rate. A Glasgow Coma Score must be included at least once, and should be repeated each time there is a change in the patient’s level of consciousness. Henceforth, herein, the trauma standards of care will be referred to as, “Routine Trauma Assessment”. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-3 4/2016 Consent General Principles: Adults 1. An adult in the State of Wisconsin is 18 years of age or older. 2. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient. 3. A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, that is to say, the patient: a. Understands the nature of the illness/injury or risk of injury/illness b. Understands the possible consequences of delaying treatment and/or refusing transport 4. Given the risks and options, the patient voluntarily refuses or accepts treatment and/or transport. 5. A call to 9-1-1 itself does not prevent a patient from refusing treatment. 6. A patient may refuse medical treatment (IVs, oxygen, medications), but the paramedic should try to inform the patient of the need for therapies, offer again, and treat to the extent possible. 7. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment. 8. Implied Consent: An unconscious or incapacitated adult is presumed to consent to treatment for life threatening injuries/illnesses. a. If an adult appears incapacitated to EMS personnel but refuses transport, law enforcement must determine if the patient is, in fact, incapacitated. In that case, law enforcement officers must place the patient in protective custody. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-4 4/2016 9. Involuntary Consent: a person other than the patient in rare circumstances may authorize Consent. This may include a court order (guardianship), authorization by a law enforcement officer for prisoners in custody or detention, or for persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled. Procedure: Adults 1. Consent may be inferred by the patient's actions or by express statements. This may include consent for treatment decisions or transport and destination decisions. If the paramedic is unsure that consent has been granted, clarify with the patient. 2. Determining whether or not a patient has decision-making capacity to consent or refuse medical treatment in the prehospital setting can be very difficult. Every effort should be made to determine if the patient has decision-making capacity, as defined above. If the patient has a power of attorney, guardian or other responsible party listed, they should be contacted to assist in the decision. 3. If the patient lacks decision-making capacity and the patient's life or health is in danger, and there is no reasonable ability to obtain the patient's consent, proceed with transport and treatment of life-threatening injuries/illnesses. If the paramedic is not sure how to proceed, contact medical control. 4. For patients who refuse medical treatment, if unsure whether or not a situation of involuntary consent applies, contact law enforcement. General Principles: Minors 1. People less than 18 years old in the state of Wisconsin are Minors. 2. A parent, including a parent who is a minor, may consent to medical or emergency treatment of his/her child. a. If the patient is in imminent danger as a result of not receiving medical care, contact law enforcement and the medical director to determine the appropriate course of action. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-4 4/2016 3. Minors may only offer consent in certain circumstances in Wisconsin. Those involve assessment and treatment involving pregnancy and obstetrical issues, sexual assault, sexually transmitted infections, and alcohol and other drugs. As this involves a gray area, consultation with medical control or law enforcement shall be made when questions of consent occur with patients less than 18 years old. Procedures: Minors 1. A parent or legal guardian may provide consent to or refuse treatment in a non- life threatening situation. 2. When the parent is not present to consent or refuse: a. If a minor has an injury or illness, but not a life-threatening medical emergency, you should attempt to contact the parent(s) or legal guardian. If this cannot be done promptly, transport to the hospital of choice, if the minor or other party knows. If the hospital of choice is not known, transport to the closest facility b. If the child does not need transport, they can be left at the scene in the custody of a responsible adult (e.g., teacher, social worker, grandparent). It should only be in very rare circumstances that a child of any age is left at the scene if the parent is not also present. c. If the minor has a life-threatening injury or illness, transport and treat per protocols. If the parent objects to treatment, contact law enforcement and the department medical director immediately and treat to the extent allowable. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-4 4/2016 Medical Control 1. All protocols shall be considered standing orders. Procedures and medications that need medical control will be indicated with “Contact Medical Control” or “Per Medical Control." 2. Medical Control may be obtained from the Oshkosh Fire Department Medical Director, the receiving hospital, or, if the receiving hospital is cannot be contacted and a life threatening condition exists, another local hospital may be contacted for orders. 3. The OFD medical director shall be consulted prior to interfacility transports when questions occur with continued patient care and scope of practice. Contact can also be made with the OFD medical director during the transport. 4. All interfacility transports that involve an obstetrical patient must first be cleared by the OFD medical director or his/her designee. If the OFD medical director is not available, the Battalion Chief of EMS shall be contacted. If neither is available, a consult with the sending obstetrician from the originating facility shall occur. 5. In the case of conflicting medical direction, the final authority lies with the OFD medical director. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-5 4/2016 Advanced Skills 1. Cricothyrotomy, either surgical or by manufactured device 2. Intraossesous Infusion using EZ-IO, humeral or tibial insertion site 3. Needle Thoracostomy 4. External Jugular IV Cannulation 5. Continuous Positive Airway Pressure Ventilation (CPAP) 6. Capnography 7. Nasogastric and Orogastric Tube Insertion on Intubated Patients 8. Supraglottic airway 9. Endotracheal Intubation 10.Rapid Sequence Intubation Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-6 4/2016 Patient Destination 1) Routine Trauma or Medical Assessment: A. Major Trauma Patient? Go to Trauma Destination Protocol. B. Patients condition Life Threatening? - If No: Transport to ED within reasonable distance of Patients choice - If Yes: Can patient be Stabilized at Scene - If No: Transport to Closest ED for Evaluation If Yes: Stabilize, Transport to ED within reasonable distance of Patient’s choice 2) If patient is a Minor or Otherwise to Make Determination: A. Major Trauma Patient? Go to Trauma Destination Protocol. B. Patients condition Life Threatening? - If No: Transport to ED within reasonable distance of Guardian’s choice - If Yes: Can patient be Stabilized at Scene - If No: Transport to Closest ED for Evaluation If Yes: Stabilize, Transport to ED within reasonable distance of Guardian’s choice 3) If patient is in Police Custody or Secure Detention: A. Major Trauma Patient? Go to Trauma Destination Protocol. B. Patients condition Life Threatening? - If No: Transport to ED within reasonable distance of Law Enforcement’s choice If Yes: Can patient be Stabilized at Scene - If No: Transport to Closest ED for Evaluation If Yes: Stabilize, Transport to ED within reasonable distance of Law Enforcement’s choice Life threatening are as follows: Inability to maintain an airway or ventilate a patient, inability to obtain an IV on a patient with a life threatening arrhythmia, non-asystolic cardiac arrest, and labor with concern for complicated delivery (prematurity, meconium staining of amniotic fluid, hemorrhage etc.) Emergency Departments of reasonable distance are as follows: Appleton Medical Center, Aurora Medical Center, Berlin Memorial Hospital, Mercy Medical Center, Ripon Medical Center, St. Agnes, St. Elizabeth’s, and Theda Clark. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-7 4/2016 The Fox Valley RTAC Trauma Field Triage Protocol 1 2 Assess Airway: Patient has a protected airway or able to insert a functioning advanced airway NO Transport to the closest appropriate Hospital or ALS/Air Medical Intercept for RSI/Definitive Airway Treatment YES Measure Vital Signs and Assess Level of Consciousness Glasgow Coma Scale <14 or Heart Rate >130 bpm Systolic Blood Pressure <90 or Respiratory Rate <10 or >29 (<20 in infant <1 year) PEDS: 1 or more abnormality in Pediatric Assessment Triangle YES Expedite transport to the highest level of trauma care within 30 minutes, preferentially a Level I or II Trauma Center. PEDIATRIC TRIANGLE GENERAL IMPRESSION WORK OF BREATHING APPEARANCE CIRCULATION TO SKIN NO Assess anatomy of injury Steps 1--3 attempt to identify the most seriously injured patients. PEDS: Consider transport to a pediatric trauma center within region. All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Flail chest Two are more suspected fractures involving the femur or humerus Crushed, degloved, or mangled extremity Complete or partial amputation proximal to wrist and ankle Pelvic fractures/unstable pelvis Open or depressed skull fracture New onset paralysis (paraplegia/quadriplegia) 3 YES Expedite transport to the highest level of trauma care within 30 minutes, preferentially a Level I or II Trauma Center. Steps 1--3 attempt to identify the most seriously injured patients. PEDS: Consider transport to a pediatric trauma center within region. NO Assess mechanism of injury and evidence of high-energy impact FALLS 4 YES Adults >20 ft. (one story is equal to 10 ft.) Children >10 ft. or 2-3 times the height of the child HIGH-RISK AUTO CRASH Intrusion >12 in. occupant site; >18 in. any site Ejection (partial or complete) from automobile Death in same passenger compartment Vehicle telemetry data consistent with high risk of injury Auto v. Pedestrian/Bicyclist Thrown, Run Over, or with Significant (>20 MPH) Impact Motorcycle Crash >20 MPH Transport to closest appropriate trauma care facility, which depending on the trauma region, need not be the highest level trauma center. NO Assess special patient or system considerations AGE 5 YES Older Adults: Risk of injury death increases after age 55 Children: Consider transport to a pediatric trauma center within region BURNS Without other trauma mechanism: Triage to burn facility With trauma mechanisms: Triage to trauma center Anticoagulation and Bleeding Disorders Time Sensitive Extremity Injury End-Stage Renal Disease Requiring Dialysis Pregnancy >20 Weeks EMS Provider Judgment Contact medical control and consider transport to a trauma care facility or a specific resource hospital. NO Transport according to protocol When in Doubt, Transport to a Level I or II Trauma Center Approved by FVRTAC 2010 Medications Approved for Paramedic Use Adenocard Labetalol Albuterol Lactated Ringers Amiodarone Lidocaine Aspirin Magnesium Sulfate Atropine Morphine Sulfate Atrovent Narcan Brilinta Nitroglycerine Paste Calcium Chloride 10% Nitroglycerine Spray/Tablets CyanoKit 0.9% Normal Saline Dextrose 50% 0.45% Normal Saline D5W Proparacaine Ophthalmic Drops Diphenhydramine Roccuronium Dopamine Sodium Bicarbonate Vecuronium Solu Medrol Epinephrine Succinylcholine Fentanyl Tetracaine Ophthalmic Drops Glucagon Versed Instant Glutose Zofran Ketamine Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-9 4/2016 Medications Approved for Transport Note: Patients may not be transported if they are on more than two medications 1. Antibiotics (any antibiotic running during transport should have initiated at least 20 minutes prior to transport) 2. Benzodiazepines IVP/IN only – Including Versed, Ativan (lorazepam), and Valium 3. Blood and blood products already started before transport 4. Cardizem/Diltiazem Drip 5. Glycoprotein – Including Integrelin (eptifibatide), Aggrastat (tirofiban), and Reopro (abciximab) 6. Narcotics IVP and pump- Morphine Sulfate, Demerol, Dilaudid and Fentanyl 7. Heparin Drip and Bolus 8. Nitroglycerine Drip 9. Amiodarone Drip 10.Lidocaine Drip 11.Bicarbonate IVP and Drip 12.Total Parenteral Nutrition 13.IV fluids of: Lactated Ringers, Normal Saline, Dextrose 5%, and Dextrose 5% and 0.45% Normal Saline *Any requests for transport of medications not listed above must have approval of Medical Director and Battalion Chief of EMS, and require the completion of the State of Wisconsin ‘Patient Side Training Report.’ Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-10 4/2016 No Transport 1. Routine Trauma or Medical Assessment 2. The patient is of sound mind and body and is of decisional capacity. The patient must exhibit the capacity to understand the risks of refusal of care/transport and the benefits of offered care/transport. Patient also appears to be able to care for self. 3. Patient refuses assessment, treatment and/or transport 4. Medical Control must be contacted before release in the following circumstances: a. ALS procedures performed: 12 lead EKG, IV start with or without fluid administration, or any advanced procedure in the “Advanced Skills” protocol b. Administration of any medication by any route c. Any patient with hypoglycemia 5. Contact with Medical Control is recommended when paramedics feel ambulance transport is warranted and the patient refuses. 6. If the patient is 18 years old or older a. Have patient or legal guardian sign ‘No Transport Information Sheet’ b. Inform patient they can contact 911 if they would want service at a later time. c. Enlist aid of law enforcement officer for “incapacitation holds” and “72 hour holds” for patients that do not have the capacity to refuse care. 7. If the patient is less than 18 years old, attempt one of the following, in order: a. Have patient’s parent or legal guardian sign release form b. Attempt to have parent or legal guardian respond to scene c. Obtain release by legal guardian via phone. If this is possible, the patient must be released to an adult (i.e. other family member, chaperone, or childcare if over 18). Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-11 4/2016 d. If patient is not with an adult, try to release patient to law enforcement. e. If the above options are not available, transport to the child’s hospital of choice, if known, or closest facility. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-11 4/2016 Patient Restraint The purpose of restraining patients is to prevent them from harming themselves or others when violent behavior is the result of a medical condition or other unknown cause. Restraints shall never be applied for punitive reasons, nor shall they be applied in ways that restrict breathing or circulation. They also should not be placed in areas that restrict access to monitor the patient. 1. Ensure Scene Safety. Do not enter known violent scene unless law enforcement has cleared it. Involve law enforcement early on if not already on scene. 2. Physical Restraints: Use the least restrictive measures possible. a. Prone is prohibited b. Soft 4 point restraints c. For upper extremities, if practical, secure one arm to the cot above the patient's head and one arm below. d. If law enforcement uses handcuffs, do not place handcuff to the strap pins on the longboard. The handcuffs must go around the entire hand hold of the board. 3. Chemical Restraint: Suspected Excited Delirium or severe agitation. a. See ‘Excited Delirium’ Protocol 4. For spitting patients, apply an oxygen mask with oxygen or apply a spit hood. 5. Attempt vitals and blood sugar reading. 6. If patient is restrained with handcuffs, law enforcement must accompany the patient in the back of the ambulance to the hospital. 7. Mandatory Physical Restraint Documentation a. Why the restraints were applied (including a description of the threat to self or others) b. The time the restraints were applied, and the time(s) of restraint removal (if done before hospital arrival) c. Who (which agency) applied the restraints Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-12 4/2016 d. The type of restraints that were used (for example, soft restraints, handcuffs, Kling, triangular bandages, etc) e. Vital signs and observations of patient status every five minutes f. Evidence that distal neurovascular function was not impaired by the restraints g. The position of the patient after restraints were applied h. Medication(s) used and their effects, including adverse effects i. Any change in the patient’s condition Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-12 4/2016 Do Not Resuscitate ‘Do Not Resuscitate’ orders in the State of Wisconsin are governed under state statute 154. For a DNR order to be valid, the patient must be at least 18 years old. A DNR order instructs EMS providers to not attempt resuscitation but to only provide comfort and care to a person for whom the order is issued, if that person suffers cardiac or respiratory arrest. If there is any question about the presence, validity or meaning (e.g. “chemical code” or “ventilate only”) of a DNR order personnel shall initiate full resuscitation measures and immediately contact medical control for clarification and further orders. “Resuscitation” means cardiopulmonary resuscitation or any component of cardiopulmonary resuscitation, including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications and related procedures. “Resuscitation” does not include the Heimlich maneuver or similar procedure used to expel an obstruction from the throat. The patient’s desire not to be resuscitated is controlling. In the event that a friend or member of the patient’s family requests those resuscitative measures be taken, that person’s request does not supersede a valid DNR order. 1. A valid prehospital DNR order for the City of Oshkosh Fire Department is limited to the following: a. A valid State DNR Bracelet (Plastic or Metal) i. The plastic bracelet (which looks like a hospital identification band) has been used in Wisconsin since 1995. The attending physician or designee attaches a standardized DNR plastic bracelet with an official insert containing the preprinted logo of the State of Wisconsin. The insert must include the physician’s name, business telephone number and signature. ii. The metal bracelet (from ‘Sticky J Medical ID’) displays the internationally recognized symbol Staff of Aesculapius on the front and the words “Wisconsin-DoKerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-13 4/2016 Not-Resuscitate-EMS” and the qualified patient’s first and last name engraved on the back. 1. Previously purchased metal DNR bracelets from Medic Alert are also acceptable iii. A signed standardized state DNR form (Nursing homes, CBRF, Hospice) iv. Direct verbal orders from the patient’s primary care physician (in person or via phone) v. A written, signed notation by the patient’s primary care physician on the patient’s record in a nursing home or extended care facility. 2. The following conditions invalidate a DNR order: a. The patient expresses to any of our personnel or health care provider the desire to be resuscitated. If this is done, the provider shall remove the DNR Bracelet. b. The patient defaces, burns, cuts, or otherwise destroys the DNR Bracelet. c. The patient (or another individual at the patient’s request) removes the DNR Bracelet. d. The DNR bracelet appears to have been tampered with or removed. e. Any Healthcare provider knows the patient to be pregnant. 3. If any of these conditions exist that invalidate the DNR order, the patient care paramedic will record the date, time, place and conditions of revocation. Medical control should be notified as soon as practical. 4. The Wisconsin Declaration to Physicians (DOH 0060) Rev 5/86 or “Living Will” and Durable Power of Attorney are Not Valid for prehospital situations. In this case, initiate resuscitation and contact medical control for clarification and further orders. 5. Copies of all documentation of patient DNR status shall accompany the patient to the hospital if the patient is transported. 6. If a written DNR order is encountered and honored, a copy shall accompany the run report. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-13 4/2016 Comfort Management Note: Patients who receive narcotic or sedative medications shall have continuous cardiac, oxygen saturation and end-tidal CO2 monitoring. 1. Routine Assessment Reveals Pain, Anxiety and/or Nausea 2. Ice, Elevate, Immobilize for injury a. It may be necessary to administer pain management prior to immobilization 3. Pulse oximetry a. Administer oxygen, if needed, to maintain pulse oximetry above 92% 4. Pain management a. Patients older than 12 years old or those with signs of physical maturity: i. Isolated Hip or extremity fractures, Low impact injury mechanism (crush injuries or fall from standing height), Flank Pain suspected of kidney stone origin, and Musculoskeletal Back Pain. ii. Use fentanyl or Ketamine for pain control 1. FENTANYL: 1 mcg/kg IV/IN over 2-3 minutes a. Max dose 75 mcg b. Repeat in 5 minutes, up to three doses total, not to exceed 225 mcg 2. KETAMINE, 0.25mg/kg IV or 1 mg/kg IM 3. Do not give both fentanyl and Ketamine without order from medical control b. Patients 5-12 years old or without signs of physical maturity i. FENTANYL: 1 mcg/kg over 2-3 minutes, max of 25 mcg ii. Repeat in 5 minutes not to exceed 75 mcg iii. Administer KETAMINE only by Medical Control order 5. Patients less than 5 years old, or those with decreased LOC, abdominal pain, hypotension (systolic BP <90), respiratory depression or headache, contact Medical Control for pain medication order Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-14 4/2016 6. Pain Management in multi-systems trauma patients a. Patients with a systolic BP greater than 90 may receive FENTANYL, 1 mcg/kg IV/IN, max dose 75 mcg i. May repeat once in 5 minutes if systolic blood pressure remains greater than 90 mmHg. ii. Additional orders for pain control must be obtained through medical control 7. Antiemetic a. ZOFRAN (Ondansetron Hydrochloride): Adult 4 mg IV b. May be used before the administration of any analgesic to combat nausea c. Exclusion Criteria: Decreased LOC, Hypotension, and Respiratory Depression. 8. Anxiolytics/Muscle Relaxant a. VERSED: 1mg IV/IN repeat in 10 minutes not exceed 2mg. b. Exclusion Criteria: Age less than 5 years old, Decreased LOC, Hypotension, and Respiratory Depression. 9. Conscious Sedation a. Administer KETAMINE 1 mg/kg IV (4mg/kg IM) SLOW IV PUSH for the following: i. Painful Extrication from: 1. Motor Vehicle Collision 2. Industrial Accident 3. Building Collapse 4. Trench Rescue Situation ii. Severe Burns 10. Analgesia following EZIO placement a. For patients who suffer pain following the insertion of an EZIO intraosseous needle: i. Adults: 40 mg LIDOCAINE pushed over two minutes ii. Peds: 0.5 mg/kg LIDOCAINE, pushed over two minutes, not to exceed 40mg iii. After lidocaine, flush line with 5 ml normal saline Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-14 4/2016 Physician On Scene The control of the scene of an emergency should be the responsibility of the individual in attendance who is the most appropriately trained in providing prehospital stabilization and transport. As a representative of the Medical Director of an EMS system, the Prehospital provider fulfills that role. Occasions will arise in which a physician on the scene will desire to direct prehospital care. A standardized scheme for dealing with these contingencies will optimize the care given to the patient. The physician desiring to assume care of the patient must: • Provide documentation of his/her status as a physician (MD or DO) to include a current copy of his/her license to practice medicine in Wisconsin. • Assume care of the patient and allow documentation of his/her assumption of care on the patient care report. • Explicitly express willingness to accept liability for care provided to patient under the physician’s personal medical license number • The physician shall not appear impaired, or under the influence of drugs, alcohol or another medical condition. • Agree to accompany the patient during transport to the hospital. Contact with online medical control must be established as soon as possible. The online medical control physician must agree and relinquish the responsibility of patient care to the physician on scene in order for care to be transferred. Orders provided by the physician assuming responsibility for the patient should be followed as long as they do not, in the judgment of the prehospital provider, endanger patient well being. The prehospital provider will request the physician attend to the patient during transport if the suggested treatment varies significantly from standing orders. If the physician’s care is judged by the prehospital provider to be potentially harmful to the patient, the provider should: • Politely voice his/her objection • Immediately place the on-scene physician in contact with the OLMC Physician Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-15 4/2016 • When conflicts arise between the physician on scene and the OLMC Physician, EMS personnel should: o Follow the directives of the OLMC Physician o Offer no assistance in carrying out the order in question; offer no resistance to the physician performing this care. o If the physician on scene continues to carry out the order in question, offer no resistance and enlist the aid of law enforcement. All interactions with physicians on the scene must be completely documented in the Patient Care Report, including the name and license number of the on scene physician. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-15 4/2016 Mass Casualty: START Triage START Triage uses the ‘RPM’ method to determine victim severity. R: Respirations (30 per minute or inadequate) P: Perfusion (capillary refill 2 seconds) M: Mental Status (able to follow simple commands) Procedure: 1. Instruct all ambulatory patients to gather at a nearby location. These patients are GREEN. 2. Begin the triage process in a methodical approach so as not to miss patients. 3. If not breathing, open the airway using head tilt, chin lift a. If not breathing, tag BLACK b. If breathing, tag RED and move to next patient 4. Respirations a. If >30, tag RED and move to next patient b. If respirations are inadequate, tag RED and move to next patient c. If <30, move to next criterion 5. Assess Perfusion a. If >2 seconds, tag RED and move to next patient b. If <2 seconds, move to next criterion 6. Assess Mental Status a. If unable to follow simple commands, tag RED b. If able to follow simple commands, tag YELLOW Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-16 4/2016 JumpSTART Triage (for patients less than 8) JumpSTART Triage uses the ‘RPM’ method to determine victim severity. R: Respirations (<15 or >45 per minute or inadequate) P: Perfusion (capillary refill 2 seconds) M: Mental Status (able to follow simple commands) Procedure: 1. Instruct all ambulatory patients to gather at a nearby location. These patients are GREEN. 2. Begin the triage process in a methodical approach so as not to miss patients. 3. If not breathing, open the airway using head tilt, chin lift a. If not breathing, administer 5 breaths using pocket mask b. If breathing, tag RED and move to next patient c. If not breathing following breaths, tag BLACK 4. Respirations a. If less than 15 or greater than 45, tag RED and move to next patient b. If respirations are inadequate, tag RED and move to next patient c. If between 15 and 45, move to next criterion 5. Assess Perfusion a. If >2 seconds, tag RED and move to next patient b. If <2 seconds, move to next criterion 6. Assess Mental Status a. If unable to follow simple commands, tag RED b. If able to follow simple commands, tag YELLOW Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-16 4/2016 LVAD- Left Ventricular Assist Device Assessment algorithm for Mechanical Circulatory Assist Device PatientsNon-pulsatile =No Audible Noise 1. Assess Level of Consciousness of Patient 2. Red heart alarm lit up on controller? (ask family) a. May need to contact emergency number for assistance 3. Listen over LEFT CHEST for mechanical hum a. If noise is heard = Pump is on 1. assess for symptoms 2. provide supportive care 3. If no BP transport to closest hospital (it may be difficult to assess BP without a Doppler) b. If noise is not heard = Pump is off - Patient unresponsiveness, follow Cardiac arrest protocol - Contact LVAD manufacturer for instructions on chest compressions 4. Request for and bring the backup battery pack, if possible Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept A-17 4-2016 Chest Pain/STEMI 1. Perform a Routine Medical Assessment. 2. Administer oxygen, if needed, to maintain pulse oximetry above 92%. 3. Apply cardiac monitor. 4. Obtain a 12 lead EKG within 5 minutes of patient contact, if possible. 5. For patients with obvious ST elevation in contiguous leads, have the Comm Center notify the receiving hospital of a ‘STEMI Alert.’ 6. For patients with minimal or uncertain ST elevation, contact the ED physician by phone for consultation on ‘STEMI Alert.’ 7. For normal 12 leads with a suspicion of cardiac cause and/or inferior MI present, perform V4R and label the EKG. 8. Left Bundle Branch Blocks will NOT be interpreted. Do NOT report ST elevation or a STEMI if the patient has a LBBB. 9. Administer ASPIRIN, 324 mg. Have the patient chew it. 10. Establish IV, 18 gauge, if possible. Avoid the right hand or wrist, if possible. 11. Draw blood for Triage Markers 12. Administer NITROGLYCERINE,0.4 mg sublingually = 1 spray or tablet every five minutes for chest pain a. Contraindications: i. Systolic BP < 110 mmHg ii. Erectile dysfunction medication use within the last 48 hours (Viagra, Levitra, & Cialis) iii. Heart rate less than 60 iv. Right sided MI (ST elevation in V4R) v. Inferior ST elevation (II, III, aVF) Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-1 4/2016 13. Assess and document lung sounds. 14. If lung sounds are clear, systolic pressure is less than 100 and signs of hypoperfusion are present (tachycardia, diaphoresis, altered mental status, etc) administer 250cc fluid bolus. 15. If the patient’s systolic blood pressure remains above 110 mmHg, apply one inch of nitroglycerin paste to the patient’s left anterior chest. 16. If the chest pain persists and the patient’s systolic blood pressure remains above 110 mmHg, administer FENTANYL, 1 mcg/kg up to 75 mcg. a. The dose may be repeated once after 10 minutes if pain persists. 17.If the patient has obvious ST elevation in contiguous leads and you have called a STEMI, administer BRILINTA, 180 mg PO. a. If the ST elevation is questionable, consult with Medical Control before administering Brilinta. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-1 4/2016 Bradycardia 1. Routine Medical Assessment 2. Administer oxygen, if needed, to maintain oxygen saturation of greater than or equal to 92% 3. Apply the cardiac monitor and obtain 12 lead EKG a. If the 12 lead shows a STEMI, contact Medical Control before increasing heart rate b. Refer to ‘Chest Pain/STEMI’ protocol 4. Establish IV TKO 5. If the patient is stable, observe 6. If the patient is unstable and requires medical intervention, determine if the rhythm has a wide or narrow QRS WIDE QRS COMPLEX 7. If the patient is in cardiac arrest, go to Cardiac Arrest protocol 8. If the patient has a pulse, perform transcutaneous pacing a. If patient is conscious, administer FENTANYL, 1 mcg/kg up to 75 mcg for pain control b. Anterior/Posterior pad placement is preferred c. Set heart rate for 70 BPM d. Start current at 40 MA e. Increase MA by 10 every 15 seconds until capture is obtained f. Decrease MA by 5 to the lowest level in which capture is 100% g. Consider VERSED, 1mg IV for sedation, if needed Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-2 4/2016 NARROW QRS COMPLEX 9. Administer ATROPINE, 0.5mg IVP a. Repeat to a total of 3 doses 10.If the patient remains symptomatic after ATROPINE, perform transcutaneous pacing a. If patient is conscious, administer FENTANYL, 1 mcg/kg up to 75 mcg for pain control b. Anterior/Posterior pad placement is preferred c. Set heart rate for 70 BPM d. Start current at 40 MA e. Increase MA by 10 every 15 seconds until capture is obtained f. Decrease MA by 5 to the lowest level in which capture is 100% g. Consider VERSED, 1mg IV for sedation 11.DOPAMINE, 5 mcg/kg/min, titrate to maintain heart rate of 60 and systolic BP of 90 Signs and symptoms of symptomatic bradycardia: • • • • • • • Altered Mental Status Chest Pain Marked Dyspnea Nausea/Vomiting Dizziness Diaphoresis PVCs or Ventricular Escape Complexes • Hypotension Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-2 4/2016 Tachycardia 1. Routine Medical Assessment 2. Administer Oxygen, if needed, to maintain an oxygen saturation of equal to or greater than 92%. 3. Apply the monitor and obtain a 12 lead EKG 4. If the patient is stable, establish IV of Normal Saline, TKO. WIDE QRS, UNSTABLE PATIENT 5. Perform immediate SYNCHRONIZED CARDIOVERSION a. 100J b. 200J c. 300J d. 360J 6. FENTANYL, 1 mcg/kg to max of 75 mcg IV may be administered if it does not delay cardioversion WIDE QRS, STABLE PATIENT 7. Administer AMIODARONE, 150mg in 100cc bag of saline, over 10 minutes NARROW QRS, UNSTABLE PATIENT 8. If the patient is in Atrial Fibrillation, contact medical control for treatment guidance a. The concern of dislodging a clot and causing an embolic complication may require that the patient not have the rate or rhythm controlled in the field 9. All other rhythms, perform SYNCHRONIZED CARDIOVERSION a. 100J b. 200J c. 300J d. 360J Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-3 4/2016 10.FENTANYL, 1 mcg/kg to max of 75 mcg IV may be administered if it does not delay cardioversion NARROW QRS, STABLE PATIENT 11.Administer 250-500 ml NORMAL SALINE if the patient has clear breath sounds. 12.Have patient attempt Valsalva maneuver by bearing down 13.Administer ADENOSINE, 6mg by rapid IV push a. Use the ‘two syringe’ technique b. Administer the medication in the proximal port of the IV tubing c. Antecubital IV site is preferred 14.If the patient does not convert, administer ADENOSINE, 12mg by rapid IV push a. Use the ‘two syringe technique b. Administer the medication in the proximal port of the IV tubing c. Antecubital IV site is preferred 15.Contact Medical Control for further orders Signs and Symptoms of symptomatic tachycardia • • • • • • • Altered Mental Status Chest Pain Marked Dyspnea Nausea/Vomiting Dizziness Diaphoresis Hypotension Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-3 4/2016 CCR: Cardio-Cerebral Resuscitation General • CCR is the administration of continuous chest compressions, without ventilations, for up to the first six minutes in patients found in cardiac arrest. • CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac nature. It is not indicated in those situations where other etiologies are probable (overdose, drowning, hanging etc). In these instances CPR is indicated. • CCR is not to be used on individuals less than 18 years of age. • In the event a patient suffers cardiac arrest in the presence of EMS (EMS witnessed cardiac arrest), the absolute highest priority is to apply the AED/Defibrillator and deliver a shock immediately, if indicated. • DO NOT INTERRUPT CHEST COMPRESSIONS! • Designate a “Code Leader” to coordinate transitions, defibrillation and pharmacological interventions. The “Code Leader” should ideally not have any procedural tasks. If the “Code Leader” is needed for a specific task, a new leader must be designated. For cardiac arrest patients with presumed cardiac etiology: 1. Address life threatening hemorrhage 2. Check for responsiveness and check for carotid pulse 3. Begin uninterrupted continuous chest compressions of at least 100/minute 4. Complete three-two minute cycles of continuous chest compressions at 100/minute (6 minutes) a. do not administer positive pressure ventilations 5. Insert an oral airway and nasal airway 6. Place the patient on high flow oxygen at 15L by non-rebreather mask Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-4 4/2016 7. Apply LP1000 or LP15 and immediately charge to 360 joules during compressions 8. Stop chest compressions for no more than ten seconds to interpret rhythm a. if VFib or Pulseless VTach, defibrillate immediately b. if PEA or asystole, dump the charge 9. Immediately resume chest compressions- DO NOT pause to analyze the rhythm after the shock. 10.Apply the LUCAS device with minimal interruption in chest compressions. 11.Establish IV/IO 12.If patient remains in cardiac arrest, or regains a pulse but is unresponsive and cannot protect his airway, insert advanced airway of paramedic's choice a. endotracheal intubation b. King LT c. CombiTube if with First Responders 13.Confirm airway placement with visualization, breath sounds, esophageal detector device and continuous waveform capnography. Reassess often. 14.Continuous capnography is required on any patient with an advanced airway 15.Ventilate the patient asynchronously every 6 seconds 16.Continue with appropriate protocol based on patient's underlying cardiac rhythm Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-4 4/2016 ADULT – CHILD - INFANT CPR Standards CPR Adult & Older Child Child (12 years and older) (1 year old to 12 years old) Carotid pulse Carotid pulse Check pulse (if no pulse or pulse is At least 5 seconds and (if no pulse, start <60 with ventilation not more than 10 compressions) and oxygenation, and seconds signs of poor perfusion, start CPR) CCR for 6 minutes if Start CPR suspected cardiac Standard CPR cause and >18; Standard CPR for respiratory cause or <18 Compression location Lower half of breastbone between nipples Compression method Compression depth Heel of 1 hand, other hand on top (or 1 hand for small victims) 2.0 to 2.4 inches Compression rate Compression ventilation ratio Open the airway Use head tilt-chin lift Breaths 1/3 diameter of chest Infant (less than 1 year old) Brachial pulse (if no pulse or pulse is <60 with ventilation and oxygenation, and signs of poor perfusion, start CPR) Standard CPR Just below nipple line on breastbone 1 rescuer: 2 fingers 2 rescuer: 2 hands encircling technique 1/3 diameter of chest 100-120 per minute 30:2 when not using CCR 30:2 for 1-rescuer CPR 15:2 for 2-rescuer CPR Head tilt-chin lift If potential for C-spine injury, use jaw thrust Give 2 breaths 1 second each, enough to see chest rise Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-5 4/2016 Cardiac Arrest: Ventricular Fibrillation/ Pulseless Ventricular Tachycardia NOTE: In the event a patient suffers cardiac arrest in the presence of EMS, the absolute highest priority is to apply the defibrillator and deliver a shock immediately, if indicated. NOTE: All defibrillations are 360 joules NOTE: During resuscitation attempts, identify potentially correctable causes: - Hypovolemia - Hypoxia - Hydrogen ion - Hypo-Hyperkalemia - Hypothermia - Tension pneumothorax - Tamponade, cardiac - Toxins - Thrombosis, pulmonary - Thrombosis, coronary After implementation of Cardio-Cerebral Resuscitation and initial defibrillation: 1. EPINEPHRINE 1:10,000, 1 mg IV push 2. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 3. AMIODARONE, 300mg IV push. 4. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-6 4/2016 5. EPINEPHRINE 1:10,000, 1 mg IV push 6. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 7. AMIODARONE, 150mg IV push 8. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 9. EPINEPHRINE 1:10,000, 1 mg IV push 10. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 11.MAGNESIUM SULFATE, 2 Grams, over 1-2 minutes. 12.2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 13.Contact Medical Control for further medical orders Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-6 4/2016 Cardiac Arrest: PEA/Asystole NOTE: During resuscitation attempts, identify potentially correctable causes: - Hypovolemia - Hypoxia - Hydrogen ion - Hypo-Hyperkalemia - Hypothermia - Tension pneumothorax - Tamponade, cardiac - Toxins - Thrombosis, pulmonary - Thrombosis, coronary After implementation of Cardio-Cerebral Resuscitation and initial defibrillation, if indicated: 1. EPINEPHRINE 1:10,000, 1 mg IV push 2. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 3. If no shock is indicated and the patient remains in cardiac arrest, perform 2 more minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 4. EPINEPHRINE 1:10,000, 1 mg IV push 5. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-7 4/2016 6. If no shock is indicated and the patient remains in cardiac arrest, perform 2 more minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 7. EPINEPHRINE 1:10,000, 1 mg IV push 8. 2 minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compressions 9. If no shock is indicated and the patient remains in cardiac arrest, perform 2 more minutes of chest compressions a. charge at 1:45 b. pause compressions, analyze rhythm and shock at 2:00, if indicated c. immediately resume compression 10.If 20 minutes into resuscitation with persistent asystole, and ETCO2 less than 10 mmHg, consider contacting medical control for orders to terminate resuscitation. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-7 4/2016 Post Cardiac Arrest Care 1. Return of Spontaneous Circulation (ROSC). 2. Optimize ventilations and oxygenation. a. Maintain oxygen saturation ≥ 92%. b. Consider advanced airway if not already accomplished. i. Any advanced airway requires continuous capnography monitoring ii. If patient has advanced airway in place and sedation is required, refer to ‘Post Intubation Care’ protocol c. Ventilate one breath every six seconds (10 breaths per minute) 3. Treat hypotension (SBP <90 mmHg) a. Administer up to 500 ml normal saline IV/IO TO titrate to a systolic blood pressure of 90 b. if IV fluids do not raise the pressure, administer DOPAMINE, 10 mcg/kg/min i. -titrate to maintain systolic BP of 90 mmHg. 4. Perform 12 Lead ECG. a. If STEMI noted on ECG, contact 911 center for STEMI Alert 5. If not already performed, check blood sugar a. If the blood sugar is less than 70 mg/dl, refer to Diabetic Emergencies protocol 6. Consider correctable causes (H’s & T’s below) -Hypovolemia -Hypoxia -Hydrogen ion -Hypo-Hyperkalemia -Hypothermia - Tension pneumothorax - Tamponade, cardiac - Toxins - Thrombosis, pulmonary - Thrombosis, coronary Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-8 4/2016 LUCAS™ Chest Compression System 1. Intended use: a. The LUCAS Chest Compression System is to be used for external cardiac compressions on adult patients who have acute circulatory arrest, defined as absence of spontaneous breathing and pulse, and loss of consciousness. 2. Contraindications: a. The patient is too small: The suction cup is not being completely compressed when it is extended as far as possible. b. The patient is too large: The support legs of LUCAS cannot be locked to the back plate without compressing the patient. 3. Steps for set up: a. Unpack unit b. Briefly stop chest compressions to lift the patient’s upper body and slide the back plate under the patient just below the armpits. Insure patient's arms are outside the back plate. i. Limit the interruption in compressions to as short a time as possible c. Continue manual chest compressions d. Place the upper part of Lucas over the patient’s chest so that the claw locks of the support legs will engage with the back plate. e. Start by pressing on the support leg nearest to you and then the one on the other side so the support legs lock against the back plate. f. Check by pulling upwards 4. Transfer compressions to the LUCAS device a. Turn the device on by pushing the I/O button. b. Lower the compression piston so it firmly contacts the chest. i. The suction cup must be centered over the lower half of the sternum. ii. Avoid the xiphoid process c. Press the appropriate ‘Play’ button i. The top ‘Play’ button will begin uninterrupted chest compressions at 100 per minute Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-9 4/2016 ii. The bottom ‘Play 30:2’ button will begin chest compression at 100 per minute, pausing after 30 compressions to allow for 2 breaths 5. Adjustment a. It is extremely important that the compression piston remain centered over the lower half of the sternum. b. If the compression piston strays from its position, press the #1 ‘Adjustment’ button to lift the piston from the chest c. Reposition the piston over the lower half of the sternum d. Press the appropriate ‘Play’ button e. Limit interruptions to as short a time as possible 6. Fault or Error code a. If the LUCAS device suddenly stops and sounds a loud tone with a red light illuminated on the display, it has encountered an error b. Turn the machine off using the I/O button c. Turn the machine back on using the I/O button d. Position the device for use as described in (4) above and resume operation e. If the device does not operate properly, quickly remove it and perform manual chest compressions 7. Apply LUCAS Stabilization Strap around neck. 8. Transporting the patient a. Secure the patient’s arms to the device utilizing the straps on the support legs. b. Move patient to long board and secure patient. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept B-9 4/2016 Asthma/Bronchospasm Respiratory patients include the following; Asthma, COPD, bronchospasm, RSV, and croup. 1. Routine Medical Assessment 2. Use side stream capnography cannula to obtain end-tidal CO2 reading. 3. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 4. Administer ALBUTEROL, 2.5 mg (unit dose) and ATROVENT 0.5mg (unit dose) via hand-held nebulizer with a facemask. a. Pediatric patients less than one year old shall not receive ATROVENT. 5. Repeat ALBUTEROL only, 2.5mg (unit dose) for continued Bronchospasm 6. Consider CPAP FOR ASTHMA ONLY: 7. If dyspnea persists, administer EPINEPHRINE, 0.01 mg/kg 1:1000 IM to a max dose of 0.3 mg. a. Contact Medical Control for patients with previous cardiac history or age greater than 55 years old. 8. Administer MAGNESIUM SULFATE, 2 Grams IV over 10 minutes. a. The antidote for Magnesium Sulfate induced hypotension is CALCIUM CHORLIDE, 1 Gram IV 9. Apply the cardiac monitor. 10. If patient is over 50 years old, obtain 12 lead EKG. 11. Regardless if asthma patients receive epinephrine and magnesium sulfate, all shall receive SOLU-MEDROL, 125 mg IV. NOTE: To administer the magnesium sulfate, draw up 2G (4 cc) of magnesium sulfate and inject into a 100ml bag of saline. Administer with 10gtts/ml tubing at a rate of 1.5 drops per second. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-1 4/2016 Pulmonary Edema 1. Routine Medical Assessment 2. Place the patient in an upright position. 3. Administer oxygen by non-rebreather mask. Use side stream cannula under the non-rebreather mask to obtain capnography reading. 4. Immediately consider CPAP 5. If the patient has signs of imminent respiratory arrest, consider Rapid Sequence Intubation. 6. Apply the cardiac monitor and obtain 12 lead EKG. 7. Establish IV of Normal Saline TKO, or saline lock. 8. Administer NITROGLYCERINE, 0.4 mg sublingually if the systolic blood pressure is greater than 110 mmHg. a. Repeat every 5 minutes if systolic blood pressure remains above 110mmHg b. If a patient has used an erectile dysfunction med (e.g., Viagra, Cialis, Levitra) within the previous 48 hours, NTG is contraindicated. 9. If the systolic blood pressure remains greater than 150 mmHg after the initial dose of sublingual nitroglycerine, administer 0.8mg NITROGLYCERINE sublingually (double dose). 10.If the patient’s systolic blood pressure is less than 110 mmHg, contact medical control for orders for sublingual nitroglycerine. 11.Apply NITROGLYNERINE PASTE, 1 G (one packet, one inch) if the patient’s systolic blood pressure remains greater than 110 mmHg a. Apply to the patient’s left anterior chest Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-2 4/2016 Continuous Positive Airway Pressure 1. CPAP may not be administered if any of the following exclusion criteria are present: a. Respiratory or cardiac arrest b. The patient is unable to maintain a patent airway independently c. There is suspicion of pneumothorax or chest trauma d. The patient is vomiting or has active GI bleeding e. Under 12 years old or CPAP mask does not fit 2. If no exclusion criteria are present, CPAP may be administered if at least two of the following inclusion criteria are present: a. Retractions of accessory muscles b. Bronchospasm or rales on exam c. Respiratory rate greater than 25 per minute d. Oxygen saturation less than 92% any time 3. Administer CPAP 5.0 cm/H2O a. May increase to a maximum of 7.5 cm/H2O 4. Continually monitor ETCO2 using side stream cannula 5. Administer VERSED, 1 mg IV/IO as needed for anxiolysis 6. Continue Asthma/Emphysema or Pulmonary Edema protocols concurrently. 7. If the patient is stable or improving, continue with CPAP. 8. If the patient is deteriorating, contact medical control. Continue with Asthma/Emphysema or Pulmonary Edema protocols. Consider endotracheal intubation or RSI. Note: Initial decrease in pulse oximetry is a common occurrence. Pulse oximetry should increase after a few minutes of administration of CPAP`. Approximate oxygen concentration is 40% with CPAP, and the addition of supplemental oxygen can be utilized if saturation does not rise above 92%. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-3 4/2016 Rapid Sequence Intubation To facilitate oral endotracheal intubation of a patient when attempts without muscle relaxation are not successful and the airway cannot be adequately protected. * 2 Paramedics must be at patient side when performing RSI 1. Indications (Possible Candidates for RSI): a. GCS <8 (decreased LOC) b. Potential for airway compromise c. Head-injured patients with airway compromise d. Status epilepticus not responding to anticonvulsants e. Patients unable to protect airway (trauma, CVA, obstruction, overdose, anaphylaxis, etc.) f. Severe Respiratory Distress (COPD, asthma, burns, etc.) g. Insufficient respirations (pulse ox. <85%, shallow respirations, cyanosis, air hunger, etc.) h. Patients with a defined salvage airway plan (BVM, supraglottic airway, or surgical airway) 2. Contraindications: a. Known allergy to necessary medications b. Suspected epiglottitis, edema, or retropharyngeal edema c. Severe oral, mandibular, or anterior neck trauma d. Conscious patient (with stable hemodynamics) who is maintaining an impaired airway e. Age less than 2 years old f. Cricothyrotomy contraindicated (potential contraindication) 3. Preparation a. Verbalized salvage airway plan b. Pre-oxygenate with 100% O 2 for at least 5 minutes(initially NRB mask or NC, then BVM only if needed), avoid hyperventilation c. Listen to lung sounds and document findings 4. Induction- putting the patient to sleep a. KETAMINE, 2 mg/kg IV/IO push i. Same dose for peds and adults b. VERSED, 4 mg IV/IO when Ketamine is relatively contraindicated Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-4 4/2016 i. ii. iii. iv. v. Severe Hypertension with cardiac history Known increased intraocular pressure Pregnancy Pediatric dose 0.1 mg/kg IV/IO not to exceed adult dose Consider the use of Versed in a patient in status epilepticus 5. Paralysis a. SUCCINYLCHOLINE (Anectine), 1.5 mg/kg, max dose 200 mg i. Same dose for peds and adults ii. Succinylcholine is contraindicated in cases of neuromuscular diseases 1. ALS 2. Myasthenia Gravis 3. Guillain-Barre 4. Muscular dystrophy 5. History of Malignant Hyperthermia iii. Alternative paralytic if succinylcholine is contraindicated: ROCURONIUM, 1 mg/kg, max dose 100 mg 6. Intubation a. Start “Passive Oxygenation:”- administer high flow oxygen by nasal cannula, 15 LPM b. Intubate orally at adequate paralysis/relaxation (usually 1.5- 2.0 min.) c. Ventilate manually and confirm tube placement with bilateral breath sounds and absence of gastric sounds. Utilize a secondary means of confirmation, such as the EDD or EtCO 2 . d. Secure the tube. 7. Backup Airway Plan a. If unable to intubate after paralysis i. continue BVM ventilations with 100% O 2 ii. proceed to placement of salvage airway device as needed (King LTDS, CombiTube, surgical airway) iii. Surgical airway is indicated if endotracheal intubation and previous salvage airway attempts fail. 8. Post Intubation a. Care for patient per “Post Intubation Care” protocol Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-4 4/2016 Post Intubation Care This protocol is used to direct care in patients who have had their airways controlled with an advanced airway, either with or without paralytics. This protocol shall be used concurrently with the protocol used to treat the patient’s primary medical condition. 1. Ensure patency of advanced airway using auscultation and end tidal capnography. a. Capnography must be used continuously on any patient with an advanced airway. b. Document vital signs post intubation 2. Ensure that the airway is secured using a Thomas ET tube holder. 3. Place the patient in a cervical collar to prevent head and neck movement. 4. Ventilate the patient at 10 breaths per minute unless instructed otherwise by direct physician order. 5. If patient develops any level of consciousness, or begins to fight or buck the tube, consider sedation a. a)VERSED (midazolam), 4 mg IV/IO -andb. b) FENTANYL, 1 mcg/kg IV, max dose 75 mcg c. May repeat VERSED 4 mg once, if systolic blood pressure greater than 90 mmHg d. For patients with systolic blood pressure less than 90, administer KETAMINE, 1.0 mg/kg IV once. 6. If sedation is not adequately controlling the patient a. Administer ROCURONIUM, 1mg/kg IV –andb. VERSED, 4 mg IV/IO A-18 Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-5 4/2016 King LTS-D Supraglottic Airway 1. Indications a. Cardiac arrest from any cause b. Respiratory arrest with no gag reflex c. Unconscious patient with inadequate respiration and no gag reflex d. Note: The choice of the King LTS-D airway or endotracheal intubation is at the discretion of the paramedic. Each carries equal weight and one is not prioritized over the other. 2. Contraindications a. Patient is under four (4) feet tall for the King LTS-D airway b. Patient has an active gag reflex c. Patient has known or suspected esophageal disease d. Patient has history of ingesting a caustic substance e. Patient has known or suspected foreign body obstruction of the larynx or trachea f. Stoma 3. Preparation a. Maintain ventilation with an oropharyngeal airway, bag-valvemask and oxygen b. Determine and select appropriate airway for size of patient i. Size 3- patients 4 to 5 feet tall ii. Size 4- patients 5 to 6 feet tall iii. Size 5- patients 6 to 7 feet tall 4. Prepare the King LTS-D a. Determine cuff integrity by fully inflating and deflating it b. Lubricate as necessary (avoid ventilation holes with lubricant) c. Insure all necessary components and accessories are at hand 5. Prepare the patient a. Reconfirm original assessment b. Inspect upper airway for visible obstructions and remove Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-6 4/2016 6. Pre-oxygenate the patient 7. Position the patient's head in a neutral position 8. Airway Insertion a. Ventilate the patient at appropriate rate 9. Confirm airway placement by a. Simultaneously gently bag the patient and withdraw the King LTS-D until ventilation is easy and free flowing b. Readjust cuff inflation 10.Secure airway in place with Tube Tamer 11.Continue ongoing respiratory assessment and treatment 12.Tube Removal Indications a. Patient regains consciousness b. Protective gag reflex returns c. Ventilation is inadequate 13.Monitor airway and respirations closely, suction as needed 14. Provide care for patient per ‘Post Intubation Care’ protocol. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept C-6 4/2016 Multi Systems Trauma Transport considerations: Current Trauma Care guidelines call for patients to be transported to a Level I or II Trauma Center within 30 minutes. If the combined response, scene and transport times will delay the patient’s delivery to the Trauma Center, consider calling a helicopter for transport early in the call. DO NOT remain on scene if ready to transport and a helicopter has not landed. 1. Rapid Trauma Assessment 2. Control life threatening injuries a. Bleeding control using the most appropriate method for the type of bleeding encountered, which may include: i. direct pressure ii. combat tourniquet b. Sucking chest wound control, which may include: i. Gloved hand ii. Vaseline gauze iii. Tegaderm iv. Halo dressing v. Defib pad c. Tension pneumothorax, decompressed with needle thoracotomy i. 14 ga needle 1. 2nd intercostal space, midclavicular line 2. 5th intercostal space, midaxillary line 3. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 4. Control the airway a. Consider intubation if GCS less than 8 or rapidly deteriorating LOC b. For patients with an intact gag reflex requiring a protected airway, use RSI c. If unable to maintain an advanced airway because of facial trauma, consider bag-valve-mask ventilation or cricothyrotomy Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-1 4/2016 5. Spinal Immobilization a. Multi-system trauma patients with an identified neurologic deficit, including altered level of consciousness, may be immobilized using a board/collar/CID, and remain on the board to facilitate rapid transport. 6. Begin transport as soon as possible. If prolonged extrication is not required, strive to minimize scene time to less than 10 minutes. 7. Establish up to two large bore IVs of normal saline, TKO. a. Do not delay transport to start IVs. They should be started while en route to the hospital unless extrication is required b. Administer fluid to maintain a systolic blood pressure of 90 i. 250ml boluses to a maximum of 1 liter ii. Contact Medical Control for further fluid orders 8. Apply Cardiac Monitor 9. Pain Control: Follow Comfort Management protocol for pain management in patients with multi system trauma 10.Patients with suspected head injuries should be transported with the head of the bed elevated to 30 degrees. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-1 4/2016 Traumatic Cardiac Arrest 1. Resuscitation from Traumatic Cardiac Arrest is indicated in the following patients, unless obvious signs of death are present: a. All patients less than 18 years old, regardless of cardiac rhythm b. Patients 18 years old and older with i. narrow complex heart rhythm (QRS less than 0.12) ii. wide complex PEA with rate greater than 30 2. Perform CPR to AHA standards, using the Lucas device when practical a. Do not perform CCR 3. Control the airway a. endotracheal intubation b. KingLT supraglottic airway c. Bag-Mask technique with OPA and NPA d. Cricothyrotomy 4. Immobilize/package the patient using longboard/collar/CID 5. Two large bore IV/IOs shall be established en route to the hospital 6. Administer IV fluid wide open with max fluid administration of 1 liter. 7. Perform needle thoracostomy of the chest bilaterally 8. Medications and additional IV fluids shall only be administered per medical control order Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-2 4/2016 Cervical Spine Protection 1. Routine Trauma Assessment. 2. Patients with blunt traumatic injuries with mechanism concerning for spinal injury should be assessed for spinal injury. 3. Patients younger than 5 years old or older than 65 years old with a mechanism concerning for C-Spine injury must have C-spine protection taken. 4. Patients may have all spinal immobilization omitted if ALL of the following conditions apply: a. No major mechanism for severe injury i. Rollover ii. Ejection from vehicle iii. Motorcycle or ATV accident iv. Fall of significant distance b. Conscious, cooperative and able to communicate effectively with provider (GCS of 15) c. No evidence of alcohol or drug intoxication d. No neurological deficits i. Numbness or weakness in an extremity e. No evidence of a distracting injury i. fractures, major burns, crush injuries or severe pain f. No midline back or neck pain or tenderness upon palpation g. Able to move neck 45 degrees either side of midline with no pain 5. If, after assessment, spinal protection is indicated a. Apply a well fitting cervical collar b. If the patient is in a standing position, lie them directly onto the cot c. If the patient is on the ground, either lying or sitting i. Move the patient to the supine position and place on a long board or scoop stretcher ii. Secure the patient using four body straps and cervical immobilization device, if needed iii. Lift the patient to the cot Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-3 4/2016 iv. Remove the long board or scoop stretcher v. Secure the patient snugly to the cot using the cot seatbelts, including the shoulder straps vi. Pad void spaces with towels or blankets vii. Use a cervical immobilization device as needed viii. The head of the cot may be elevated up to 30 degrees for patient comfort d. If the patient is found in the seated position in a chair or a vehicle without neurological deficits i. Assist the patient to the standing position ii. immediately lie them onto the cot iii. Secure the patient snugly to the cot using the cot seatbelts, including the shoulder straps iv. Pad void spaces with towels or blankets v. Use a cervical immobilization device as needed vi. The head of the cot may be elevated up to 30 degrees for patient comfort 6. Patients with complete paralysis or significant neurological deficits shall be immobilized on a full body vacuum mattress supported by a long board. a. A cervical immobilization device shall be applied or fashioned out of the corners of the mattress. b. The patient shall remain on the mattress during transport to the hospital. 7. Multi system trauma patients may remain secured to a long board during transport, without the board being removed, to expedite transport to a Trauma Center. 8. Patients with penetrating traumatic injuries should only be immobilized if a focal neurological deficit is noted on physical exam Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-3 4/2016 Immobilization of Athlete in Protective Padding 1. If Athletic Training staff or other healthcare professional has determined an injured athlete is to be immobilized, the patient will be immobilized even if he/she meets selective c-spine immobilization criteria 2. Examples of athletes in protective padding include football, hockey and lacrosse players 3. Perform Routine Trauma Assessment, including CMS 4. Maintain manual C-Spine stabilization 5. Remove the facemask from the helmet a. Leave the chinstrap in place until ready to remove the helmet 6. Remove the jersey. It will likely need to be cut 7. Untie or cut the strapping on the front of the shoulder pads 8. Release the straps under the arms 9. Remove the chinstrap 10.As a single unit, elevate the patient’s back, shoulders and head to about 30 degrees by pivoting at the hips a. This evolution requires FOUR rescuers, at a minimum. i. Rescuer 1 holds the head/helmet and directs the movement ii. Rescue 2 holds C-spine from the front of the patient’s head, placing hands up under the back of the helmet and cradling the chin to accept the weight of the head once the helmet has been removed iii. Rescuer 3 on the patients left, reaching under the patient to support the back iv. Rescuer 4 on the patient’s right, reaching under the patient to support the back 11.The shoulder pads are peeled away from the patient’s torso Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-4 4/2016 12.Rescuer 1 pulls the helmet sides away from the patient’s temples and removes the helmet while Rescuer 2 assumes the weight of the head 13.All four rescuers assist the patient to a supine position as a unit, again pivoting at the hips 14.Apply a well fitting cervical collar 15.Scoop the patient to a vacuum mattress using scoop stretcher 16.Secure the patient to the vacuum mattress a. Support the mattress with a long board underneath b. Use Multi-Grip head blocks or corners of the mattress to form a CID 17.Re-assess CMS 18.The patient shall remain on the vacuum mattress until delivered to Emergency Department staff Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-4 4/2016 Thermal Burns 1. Routine Trauma Assessment 2. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 3. Airway management a. Administer ALBUTEROL, 2.5mg (unit dose) for bronchospasm b. Consider early intubation with RSI for upper airway burns c. Consider cricothyrotomy if patient presents with laryngeal edema and cyanosis d. Monitor end tidal CO2 4. Monitor carbon monoxide level a. if CO levels are greater than 10%, administer 100% oxygen by non-rebreather mask and refer to Carbon Monoxide Protocol 5. Dress the burn a. Apply plastic cling wrap to area of burn. Do not wrap circumferentially. 6. Estimate Body Surface Area involved (BSA) 7. Fluid resuscitation a. Establish IV of normal saline b. For adults, administer 500ml/hr c. For patients 12 years old and under, administer 250 ml/hr 8. Pain Management- Follow Comfort Management protocol Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-5 4/2016 Chemical Burns 1. Decontaminate the patient with copious amounts of water 2. Remove patient’s clothing 3. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 4. Appropriate airway management a. Administer ALBUTEROL, 2.5 mg (unit dose) for bronchospasm b. Consider early intubation with RSI for upper airway burns c. Consider cricothyrotomy/Per Trach® if patient presents with laryngeal edema and cyanosis 5. Irrigate the burned area with sterile water or normal saline for 20 minutes. 6. After irrigation, apply dry sterile dressing to affected area 7. Establish IV of normal saline for burns >10% BSA. Run IV at 150 cc/hr 8. Pain management: Follow Comfort Management protocol Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-6 4/2016 Ocular Irritant Exposure 1. Routine Medical/Trauma Assessment 2. If the patient has a penetrating eye injury with impaled object, stabilize impalement in place. Patch the unaffected eye. 3. If exposure is result of a foreign object: a. administer 2 drops of PROPARACAINE or TETRACAINE to affected eye b. Patch both eyes c. Do not use the Morgan Lens 4. If the patient does not have a penetrating eye injury: a. Identify the substance involved. b. Bring the container to the ED, if possible c. Bring the MSDS to the ED, if possible d. Instill 2 drops PROPARACAINE or TETRACAINE into the affected eye(s). Repeat once, if necessary. e. Irrigate the affected eye(s) with one liter of normal saline through the Morgan Lens. f. Consider repeating anesthesia and irrigation. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept D-7 4/2016 Anaphylaxis If the patient presents with rapid onset of symptoms, has a systolic blood pressure less than 90, or has airway compromise such as stridor or inability to speak due to edema, the patient is in Anaphylactic Shock. 1. Routine Medical Assessment 2. Remove offending agent 3. Administer oxygen by non-rebreather mask. a. Consider using ETCO2 cannula under mask 4. Apply the cardiac monitor. 5. Establish large bore IV/IO of normal saline. 6. Administer EPINEPHRINE 1:10,000, 0.01 mg/kg slow IV a. max dose is 0.3 mg 7. Administer normal saline IV in 250ml boluses to maintain a systolic blood pressure of 90. Do not exceed 2 liters of fluid without medical control order. 8. Administer ALBUTEROL, 2.5 mg (unit dose) for patients with bronchospasm or wheezing. 9. Administer DIPHENHYDRAMINE, 25 mg IV or 50 mg IM. a. Use cautiously in patients with asthma. 10.For continued hypotension, repeat EPINEPHRINE 1:10,000 0.01 mg/kg slow IV a. max dose is 0.3 mg 11.Alternatively, administer EPINEPHRINE 1:1000, 0.01 mg/kg IM a. The maximum dose is 0.3 mg 12.Administer SOLU-MEDROL, 125 mg IV to all anaphylaxis patients Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-1 4/2016 Allergic Reaction If the patient presents with rapid onset of symptoms, has a systolic blood pressure less than 90, or has airway compromise such as stridor or inability to speak due to edema, the patient is in Anaphylactic Shock. Refer to the Anaphylactic Shock Protocol. 1. Routine Medical Assessment 2. Remove offending agent. 3. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. a. Consider the use of ETCO2 cannula 4. Apply the cardiac monitor. 5. Establish IV of normal saline TKO. 6. If the patient presents with bronchospasm and wheezing, administer ALBUTEROL, 2.5 mg (unit dose). 7. Administer DIPHENHYDRAMINE, 25 mg IV or 50 mg deep IM. a. Use cautiously in patients with asthma. 8. If patient does not respond to albuterol and diphenhydramine, administer EPINEPHRINE, 0.01mg/kg 1:1000 up to a maximum dose of 0.3 mg IM. a. Epinephrine is contraindicated in patients with a cardiac history (MI, angina, CHF, hypertension) 9. If patient receives epinephrine IM, administer SOLU MEDROL, 125 mg IV Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-2 4/2016 CVA/Stroke 1. Routine Medical Assessment 2. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 3. Screen patient for signs of a stroke using the Cincinnati Stroke Scale a. Facial Droop b. Arm Drift c. Slurred Speech 4. If the patient has one or more positive symptoms, have the 911 Center contact the destination hospital and advise them of a ‘STROKE ALERT.’ 5. Determine the exact time of onset of symptoms. 6. Establish IV of Normal Saline, TKO a. 18 gauge in an AC is preferred b. Perform blood draw 7. Check the patient’s blood sugar. If the patient’s blood glucose is less than 70 mg/dl, refer to Diabetic Emergencies protocol 8. Apply cardiac monitor and obtain 12 lead EKG. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-3 4/2016 Diabetic Emergencies The Assure Prism glucometers used by the Oshkosh Fire Department are calibrated for capillary blood only. Venous or arterial blood should not be used for blood sugar monitoring. If the glucometer reads ‘LO’, the blood glucose is less than 20 mg/dl. If it reads ‘HI’, the blood glucose is greater than 600 mg/dl. 1. Routine Medical Assessment 2. Obtain glucometer reading For Hypoglycemia (less than 70 mg/dl or symptomatic) 3. If patient is conscious and can protect their airway, consider administration of one tube Instant Glucose or other food or drink containing sugar 4. If oral intake is not safe or practical, establish IV of normal saline 5. Administer 50% DEXTROSE (D50), 25 Grams 6. If unable to establish IV, administer GLUCAGON, 1 mg IM. For Hyperglycemia with mental status changes (greater than 600 mg/dl (monitor reads “HIGH” or signs and symptoms of DKA) 7. Administer normal saline IV, 250 ml Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-4 4/2016 Hypertensive Crisis SYMPTOMOLOGY: Two blood pressure greater than 200/100, headache, chest pain, shortness of breath 1. Routine Medical Assessment a. Obtain blood pressure readings in both arms 2. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 3. Apply cardiac monitor 4. Perform 12 lead. 5. Establish IV or normal saline TKO or saline lock. 6. Relay findings to Medical Control and request orders for LABETALOL, 10 mg, administered over 2-3 minutes. a. Labetalol is CONTRAINDICATED for patients with a pulse rate less than 70 or who are under the influence of stimulants (cocaine, methamphetamines). i. If the patient has known use of stimulants administer VERSED, 4 mg IV/IO b. Labetolol should not be used if stroke/CVA is suspected c. The goal is to relieve symptoms, not return blood pressure to normal limits 7. Elevate head of bed to at least 30 degrees Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-5 4/2016 Poisoning/Overdose 1. Routine Medical Assessment 2. For non-toxic ingestions contact poison control at 1-800-222-1222. Relay findings and contact person to medical control. 3. Ensure patent airway. 4. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 5. Establish IV or saline lock 6. Administer NARCAN, 0.4-2 mg IV/IN for patients with suspected narcotic overdose causing respiratory depression. 7. Apply cardiac monitor. 8. Obtain baseline 12 lead ECG for suspected cardio-toxic ingestions or any patient with an altered mental status. a. Consider obtaining a baseline 12 lead ECG in all patients 9. Obtain blood sugar reading. 10.Bring pill bottles with contents and any emesis for ED assessment. 11.Contact Medical Control for antidote orders for the following overdoses: Medication Beta blockers Calcium Channel Blocker Amphetamines Cocaine Organophosphate Tricyclic Antidote Glucagon -1mg IV Calcium Chloride – 1 gram Versed - 2mg IV Versed - 2mg IV Atropine -2mg q 2 min Sodium Bicarbonate – 1 amp IV Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-6 4/2016 Seizures 1. Routine Medical/Trauma Assessment. 2. Use appropriate airway management. 3. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 4. Check the patient’s blood sugar. If the patient’s blood glucose is less than 70 mg/dl, refer to Diabetic Emergencies protocol If seizure continues for more than five minutes, or the patient does not regain consciousness between seizures: 5. Establish IV or saline lock 6. If patient is less than 60 years old, administer VERSED, 4 mg IV/IN/IM a. Drug induced seizures may need to have multiple incremental doses of Versed up to 8 mg IV/IO/IN maximum. b. If patient is greater than 60 years old, administer VERSED, 2 mg IV/IN/IM 7. For Pediatric patients 0.1 mg/kg IV/IN/IM and for IM 0.2 mg/kg. i. Maximum Pediatric dose shall not exceed the adult dose 8. If seizures continue, apply cardiac monitor. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-7 4/2016 Pregnancy Related Seizures (Eclampsia) Pregnancy related seizures can occur between 20 weeks gestation and 2 weeks post partum. Seizures occur in patients with a history of Preeclampisa. Signs and Symptoms include: BP greater than 140/90, severe headache, swelling in face and extremities, and a history of protein in the urine. 9. If the pregnant patient is seizing, administer MAGNESIUM SULFATE, 4 grams magnesium sulfate over 2-3 minutes. a. The antidote for Magnesium Sulfate induced hypotension is CALCIUM CHORLIDE, 1 Gram IV 10.If seizures continue, contact medical control for further medication orders NOTE: To administer the magnesium sulfate, draw up 4G (8 cc) of magnesium sulfate and inject into a 100ml bag of saline. Administer with 10gtts/ml tubing and squeeze it in over 2-3 minutes. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-7 4/2016 Excited Delirium Excited Delirium describes a highly agitated state in which patients exhibit the following signs and symptoms: • extreme agitation • making unintelligible sounds or using words that don't make sense • unexpected physical strength not controlled with painful stimuli • fighting with inanimate objects, often punching glass • hyperthermia, and resultant undressing • inappropriate interactions with surrounding and people 1. Ensure the safety of EMS personnel. Involve law enforcement if they have not already been dispatched. 2. Pre-plan the use of KETAMINE, 4 mg/kg IM. a. standard dose: 400 mg drawn up in two 3cc syringes, 200 mg each b. monitor airway closely 3. Coordinate response with law enforcement in controlling the subject. a. Plan for one person per extremity, at minimum, for initial physical restraint b. Police may deploy Taser or physically control the patient on the ground. c. Paramedics administer KETAMINE IM in each lateral thigh i. Do not be concerned about aseptic technique ii. Administer through clothes 4. As patient becomes somnolent, move to the cot and secure using soft restraints. 5. Assess the patient a. Obtain vital signs b. Place the patient on the heart monitor c. Check blood sugar d. Monitor SPO2 e. Monitor ETCO2 6. Establish IV 7. Mandatory Physical Restraint Documentation- Refer to ‘Patient Restraint’ protocol for documentation requirements Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept E-8 4/2016 Heat Related Illness 1. Routine Medical Assessment 2. Remove the patient from heated environment. 3. Administer oxygen, if needed, to maintain oxygen saturation of at least 92%. 4. If the patient is conscious and can protect airway, administer oral fluids as tolerated. 5. Consider an IV of normal saline. 6. If the patient’s vitals are unstable, administer a fluid bolus a. Adults: 250 ml boluses to a total of 1000ml b. Peds: 20 ml/kg 7. If the patient has an altered mental status, obtain glucometer reading. a. If the blood sugar is less than 70 mg/dl, refer to Diabetic Emergencies protocol 8. If the patient has an altered mental status, obtain a rectal temperature. 9. Apply ice packs or cold compresses to the axilla, groin, flanks, and head. 10.Maintain cool airflow over the patient. Spray the patient with water mist. 11.If the patient develops seizures, refer to Seizure protocol. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept F-1 4/2016 Hypothermia • Handle hypothermia patients very carefully. They are prone to ventricular fibrillation. • Mild hypothermia occurs with a core (rectal) temperature between 90-95F. Severe hypothermia occurs with a core (rectal) temperature of less than 90F. • If the patient’s rectal temperature is less than 90 F and the patient is in cardiac arrest, do not go to cardiac protocols, and continue with the Hypothermic Protocol. Patients with rectal temperatures greater than 90 F are to be treated as normothermic according to protocol. • Resuscitation attempts should be made in hypothermic drowning events that have an under water time of 90 minutes or less. 1. Routine Medical Assessment If the patient is UNRESPONSIVE 2. Remove wet clothing and cover with dry blankets. 3. Check the patient’s blood sugar. If the blood sugar is less than 70 mg/dl, refer to the Diabetic Emergencies protocol 4. Begin re-warming procedures with hot packs and warmed IV fluids a. Do not rub skin 5. Administer 100% oxygen by non-rebreather mask 6. Check carefully for spontaneous respirations and pulses 7. Apply the monitor to determine underlying rhythm 8. If the patient is in cardiac arrest, begin CPR Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept F-2 4/2016 9. If the patient is in Ventricular Fibrillation a. Defibrillate once @ 360 J b. Continue CPR c. Insert advanced airway d. Attach LUCAS when available e. Begin transport as soon as practical f. Contact Medical Control for medication orders 10.If the patient is in Asystole a. Continue CPR b. Insert advanced airway c. Attach LUCAS when available d. Begin transport as soon as practical e. Contact Medical Control for medication orders 11.Obtain rectal temperature 12.Establish IV/IO of normal saline, if not already done as part of rewarming procedures If the patient is RESPONSIVE 13.Administer oxygen based on the patient’s clinical presentation a. It is unlikely an accurate pulse oximetry reading will be available because of the patient’s cold extremities 14.Remove wet clothing and cover with dry blankets. 15.Begin passive re-warming procedures with dry blankets and hot packs. 16.Consider establishing an IV of Normal Saline and administering warmed IV fluids. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept F-2 4/2016 Carbon Monoxide SYMPTOMOLOGY: Coma, history of unconsciousness, chest pain, cardiac symptoms, neurological changes, altered mental status 1. Routine Medical Assessment 2. Obtain Carbon Monoxide reading via SPCO monitor on L15. a. Pulse Ox probe automatically senses for carbon monoxide b. Significant CO levels are present if reading is >10% CO c. Reading must be confirmed on multiple fingers while the probe is covered with a towel 3. Administer 100% oxygen by non-rebreather, regardless of pulse oximetry reading. a. Pulse oximetry readings in carbon monoxide poisoning are NOT ACCURATE. 4. Apply cardiac monitor. a. Obtain 12 lead EKG for patients with altered level of consciousness. 5. Establish IV, Normal Saline TKO, or Saline Lock 6. If patient is seizing, refer to Seizure protocol. 7. Obtain blood glucose reading for patients with altered level of consciousness. 8. If the patient exhibits any of the following signs or symptoms, consult with Medical Control and consider diversion to St. Elizabeth Hospital in Appleton if their Hyperbaric Chamber is available: a. Loss of consciousness b. Chest pain c. Neurological changes d. Pregnancy e. Seizures Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept F-3 4/2016 PEDIATRIC PROTOCOL Childbirth and Neonate Resuscitation 1. Following childbirth, always provide the following routine care a. Maintain warmth b. Suction the airway, as needed i. Mouth first, then nose c. Dry the neonate 2. Keep the baby at the level of the vagina until the umbilical cord stops pulsating. 3. Clamp and cut the cord. 4. Assess Respirations, Heart Rate and Color a. If apneic or heart rate less than 100, ventilate with BVM b. If breathing and the newborn’s heart rate is greater than 100 but the patient is cyanotic, administer supplemental oxygen i. If cyanosis persists, ventilate with BVM 5. If the heart rate remains less than 60 with BVM ventilation, perform chest compressions 6. Establish IV/IO 7. If the heart rate remains less than 60 with chest compressions and BVM, administer EPINEPHRINE 1:10,000, 0.01 mg/kg 8. Consider a fluid bolus, 20 ml/kg IV/IO 9. Check blood sugar a. If less than 70 mg/dl, proceed to PEDIATRIC Diabetic Emergencies protocol 10.Intubate the neonate only if unable to manage the airway with Bag-ValveMask Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-1 4/2016 PEDIATRIC PROTOCOL Ventricular Fibrillation/ Pulseless Ventricular Tachycardia 1. Perform CPR a. Two rescuer CPR ratio is always 15:2 b. Two rescuer compressions on an infant uses ‘hands encircling’ technique c. Minimize interruptions in chest compressions 2. If adequately maintaining airway with BVM, do not intubate 3. Apply monitor a. Defib pads may be placed Apex-Sternum or Anterior-Posterior b. Do not let defib pads touch or they will arc 4. Charge defibrillator to 2 J/kg while performing CPR a. If exact energy setting is not available, choose one setting above 5. Defibrillate, if indicated 6. Immediately resume CPR 7. Establish IV or IO 8. At 1:45 of cycle, charge defibrillator to 4 J/kg while performing CPR a. If exact energy setting is not available, choose one setting above 9. At 2:00, stop CPR, interpret rhythm, and shock if indicated 10. Immediately resume CPR 11. Administer EPINEPHRINE 1:10,000, 0.01 mg/kg IV/IO. 12. At 1:45 of cycle, charge defibrillator to 4 J/kg while performing CPR a. If exact energy setting is not available, choose one setting above 13. Defibrillate, if indicated 14. Immediately resume CPR 15. Administer AMIODARONE, 5 mg/kg IV/IO 16. Contact Medical Control for further medication orders Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-2 4/2016 PEDIATRIC PROTOCOL PEA/ Asystole 1. Perform CPR a. Two rescuer CPR ratio is always 15:2 b. Two rescuer compressions on an infant uses ‘hands encircling’ technique c. Minimize interruptions in chest compressions 2. If adequately maintaining airway with BVM, do not intubate 3. Apply monitor a. Defib pads may be placed Apex-Sternum or Anterior-Posterior b. Do not let defib pads touch or they will arc 4. Charge defibrillator to 2 J/kg while performing CPR a. If exact energy setting is not available, choose one setting above 5. If patient is in PEA or Asystole, dump the charge 6. Immediately resume CPR 7. Establish IV or IO 8. At 1:45 of cycle, charge defibrillator to 4 J/kg while performing CPR a. If exact energy setting is not available, choose one setting above 9. At 2:00, stop CPR, interpret rhythm, and shock if indicated 10. If rhythm is PEA or Asystole, dump the charge 11. Immediately resume CPR 12. Administer EPINEPHRINE 1:10,000, 0.01 mg/kg IV/IO 13. Consider possible causes -Hypovolemia -Hypo/hyperkalemia -Hypothermia -Tablets -Tension Pneumo -Hypoxia -Hypoglycemia -Toxins -Tamponade -Thrombosis 14. Contact Medical Control for further medication orders Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-3 4/2016 PEDIATRIC PROTOCOL Symptomatic Bradycardia 1. Routine Medical Assessment using Pediatric Assessment Triangle a. Involvement with 2 or 3 sides of the triangle are symptomatic and require intervention 2. Apply oxygen a. 100% by non-rebreather if conscious b. 100% by BVM if unconscious or pulse rate less than 60 3. Apply the monitor 4. If the patient continues to have poor perfusion with a heart rate less than 60, despite oxygen and ventilation, perform 2 rescuer CPR a. 15:2 compression to ventilation ratio 5. Establish IV or IO 6. If bradycardia persists despite CPR, administer EPINEPHRINE 1:10,000, 0.01 mg/kg IV/IO 7. If bradycardia still persists, administer ATROPINE, 0.02 mg/kg IV/IO a. Minimum dose is 0.1 mg 8. Contact Medical Control for further orders Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-4 4/2016 PEDIATRIC PROTOCOL Tachycardia 1. Routine Medical Assessment using Pediatric Assessment Triangle a. Involvement with 2 or 3 sides of the triangle are symptomatic and require intervention 2. Apply oxygen a. 100% by non-rebreather if conscious b. 100% by BVM if unconscious 3. Apply the monitor 4. Establish IV of Normal Saline, TKO 5. If the QRS is wide a. synchronized cardioversion, 1 J/kg b. If no response, repeat once at 2 J/kg c. If no response, contact Medical Control for further orders 6. If the QRS is narrow and rapid (>220 infants, >180 children) a. Vagal maneuvers- ice water to face b. Administer ADENOSINE, 0.1 mg/kg rapid IV push using 2 syringe technique i. Do not exceed 6 mg Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-5 4/2016 PEDIATRIC PROTOCOL c. If no response, administer ADENOSINE, 0.2 mg/kg rapid IV push using 2 syringe technique i. Do not exceed 12 mg d. If no response, contact Medical Control for further orders Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-5 4/2016 PEDIATRIC PROTOCOL Respiratory Emergencies Respiratory patients include the following; Asthma, bronchospasm, RSV, and croup. 1. Routine Medical Assessment 2. Administer oxygen by Blow-By Bear or Non-Rebreather Mask, if needed, to maintain oxygen saturation of at least 92%. 3. For Bronchospasm or wheezing: a. Administer ALBUTEROL, unit dose (2.5 mg) for all patients experiencing bronchospasm. b. If the patient is older than 1 year old, administer ATROVENT, 0.5 mg (unit dose) with the albuterol c. If Bronchospasm persists, repeat ALBUTEROL, 2.5 mg (unit dose) 4. If respiratory distress continues after the first nebulized treatment: 5. Consider CPAP if patient is 12 years old or older, meets CPAP criteria and the mask fits properly. a. Refer to CPAP protocol 6. FOR ASTHMA ONLY: If patient’s condition does not improve with two nebulizer treatments and CPAP, administer EPINEPHRINE, 1:1000 0.01mg/kg IM a. Max dose 0.3 mg 7. FOR ASHTMA ONLY: Administer SOLU-MEDROL, 2 mg/kg IV. 8. If patient is suffering from croup, administer nebulized NORMAL SALINE, 3.0 ml via hand held nebulizer Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-6 4/2016 PEDIATRIC PROTOCOL Seizure 1. Routine Medical/Trauma Assessment. 2. Administer oxygen, if needed, by mask or Blow By bear. Titrate to maintain oxygen saturation of at least 92%. 3. For patient in Status Epilepticus, establish IV/IO of normal saline 4. If seizure continues for more than five minutes, or the patient does not regain consciousness between seizures, administer VERSED a. 0.1 mg/kg IV/IO/IN not to exceed 4 mg IV -orb. 0.2mg/kg IM not to exceed 4 mg IM c. Contact Medical Control for further medication orders 5. Check blood sugar a. If blood sugar is less than 70 mg/dl, follow Pediatric Diabetic Emergencies protocol 6. Obtain the patient’s temperature 7. Apply cardiac monitor Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-7 4/2016 PEDIATRIC PROTOCOL Diabetic Emergencies 1. Routine Medical Assessment using Pediatric Assessment Triangle 2. Obtain blood sugar reading 3. If the patient’s blood sugar is less than 70 mg/dl, administer DEXTROSE, IV based on the patient’s age a. For patients less than one year old, administer 1 G/kg of D10 or D12.5 b. For patients between 1 and 5 years old, administer 1 G/kg of D25 c. For patients over 5 years old, administer 1 G/kg of D50 d. Do not exceed the adult dose, 25 G 4. For patient’s in which an IV cannot be established, administer GLUCAGON, 0.02 mg/kg IM. a. Max dose 1 mg 5. Intraosseous access for dextrose administration may only be used with medical control approval To dilute D50 to D10: Use the three way stop cock and a 50 cc syringe to draw up the desired grams of D50. For example, 3 G would be 6 ml. Draw up the remaining saline so that the total volume you have is 10 times the number of grams of dextrose you want to administer; for example, 3G would equal 30 ml total Grams 2G 3G 4G 5G D50 4 ml 6 ml 8 ml 10 ml Total Volume 20 ml 30 ml 40 ml 50 ml 6G 12 ml 60 ml 7G 14 ml 70 ml 8G 16 ml 80 ml 9G 18 ml 90 ml 10 G 20 ml 100 ml Notes 2 syringes required 2 syringes required 2 syringes required 2 syringes required 2 syringes required Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-8 4/2016 PEDIATRIC PROTOCOL Hypothermia • Handle hypothermia patients very carefully. They are prone to ventricular fibrillation. • Mild hypothermia occurs with a core (rectal) temperature between 90-95F. Severe hypothermia occurs with a core (rectal) temperature of less than 90F. • If the patient’s rectal temperature is less than 90 F and the patient is in cardiac arrest, do not go to cardiac protocols, and continue with the Hypothermic Protocol. Patients with rectal temperatures greater than 90 F are to be treated as normothermic according to protocol. • Resuscitation attempts should be made in hypothermic drowning events that have an underwater time of 90 minutes or less. 1. Routine Medical Assessment If the patient is UNRESPONSIVE 2. Remove wet clothing and cover with dry blankets. 3. Begin re-warming procedures with hot packs and warmed IV fluids. 4. Check the patient’s blood sugar. If the blood sugar is less than 70 mg/dl, go to Pediatric Diabetic Emergencies protocol 5. Administer 100% oxygen by non-rebreather mask. 6. Check carefully for spontaneous respirations and pulses. 7. Apply the monitor to determine underlying rhythm. 8. If the patient is in cardiac arrest, begin CPR 9. If the patient is in Ventricular Fibrillation a. Defibrillate once @ 2 J/Kg b. Continue CPR Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-9 4/2016 PEDIATRIC PROTOCOL c. Begin transport as soon as practical d. Contact Medical Control for medication orders 10.If the patient is in Asystole for one minute (without CPR) with pulse check a. Continue CPR b. If able to maintain airway with BVM, do not attempt intubation c. Begin transport as soon as practical d. Contact Medical Control for medication orders 11.Obtain rectal temperature 12.Establish IV/IO of normal saline, if not already done as part of re-warming procedures. If the patient is responsive 13.Administer oxygen based on the patient’s clinical presentation a. It is unlikely an accurate pulse oximetry reading will be available because of the patient’s cold extremities 14.Remove wet clothing and cover with dry blankets. 15.Begin re-warming procedures with dry blankets and hot packs. 16.Consider establishing an IV of Normal Saline and administering warmed IV fluids. Kerry Ahrens, MD, MS, FAAEM Medical Director, Oshkosh Fire Dept G-9 4/2016 Adenosine Albuterol Amiodarone Aspirin Atropine Atrovent Brilinta Calcium Chloride CyanoKit Dextrose 50% Diphenhydramine Dopamine Epinephrine 1:10,000 Epinephrine 1:1000 Fentanyl Glucagon Glutose Ketamine Labetalol Lidocaine Magnesium Sulfate Narcan Nitroglycerine tabs/spray Nitro paste Proparacaine/Tetracaine Rocuronium Sodium Bicarbonate Solu Medrol Succinylcholine Versed Zofran Tachycardia Asthma/Bronshospasm Tachycardia Chest Pain/STEMI Bradycardia Asthma/Bronshospasm Chest Pain/STEMI Asthma/Bronshospasm Peds Tachycardia Anaphylaxis Vfib/Vtach Diabetic Emergencies Anaphylaxis Bradycardia Vfib/Vtach Asthma/Bronshospasm Comfort Management Diabetic Emergencies Diabetic Emergencies Comfort Management Hypertensive Crisis Comfort Management Vfib/Vtach Poisoning/Overdose Chest Pain/STEMI Chest Pain/STEMI Ocular Irritant RSI Poisoning/Overdose Asthma/Bronshospasm RSI Comfort Management Comfort Management Allergic Reaction Peds Vfib Peds Respiratory Poisoning/Overdose Peds Respiratory Peds Bradycardia Poisoning/Overdose Seizures Peds Diabetes DILUTE! Allergic Reaction Post Arrest PEA/Asystole Anaphylaxis Chest Pain/STEMI Poisoning/Overdose Anaphylaxis Allergic Reaction Bradycardia Peds Diabetes Childbirth Resusc Peds Respiratory Tachycardia RSI Post Intubation Excited Delirium Asthma/Bronchospasm Seizures Peds Vfib Peds PEA Asystole Peds Bradycardia Poisoning/Overdose Seizures Post Intubation Pulmonary Edema Pulmonary Edema Post Intubation Anaphylaxis Allergic Reaction Peds Respiratory Bradycardia RSI Post Intubation Hypertensive Crisis Peds Seizure