Proton Porc?es rocedures 201 6-201 8 Basic EMT I A-EMT I Paramedic moved Emma 2018 Table of Contents Preliminary Information Introduction……………………………………………………………………………………………………………………….………..……….……..……………….. 1 Guidelines……………………………………………………………………………………………………………………………………..…..……….…....………….. 2 Dedication…………………………………………………………………………………………………………………………………..…………….………....………. 3 Policies Medical Transport Destination…………………………………………………………………………………………………………………..…..….…………..4 Request for Helicopter EMS (HEMS)………………………………………………………………………………………………………………..………....... 5 Helicopter EMS (HEMS) Landing Zones………………………………………………………………………………………………………………...……….. 6 Do Not Resuscitate (DNR)…………………………………………………………………………………………………………………………………...………….7 Child / Elder Abuse Recognition and Reporting…………………………………………………………………………………………………...………... 8 Criteria for Death / Withholding Resuscitation………………………………………………………………………………………………….…….……..9 Documentation of Patient Care……………………………………………………………………………………………………………………………………...10 Documentation of Vital Signs………………………………………………………………………………………………………………………………..………..11 Domestic Violence (Spousal and/or Partner Abuse Recognition and Reporting)……………………………………………………..........12 Emergent Interhospital Transfers…………………………………………………………………………………………………………………………………...13 Lights and Siren During Patient Transport……………………………………………………………………………………………………………………... 14 Non-Paramedic Transport of Patients……………………………………………………………………………………………………………………………. 15 Paramedic Intercept Guidelines…………………………………………………………………………………………………………………………………….. 16 Patient Care During Transport……………………………………………………………………………………………………………………………………….. 17 Patient Without a Protocol……………………………………………………………………………………………………………………………………………..18 Physician on Scene………………………………………………………………………………………………………………………………………………………….19 Poison Control……………………………………………………………………………………………………………………………………………………………….. 20 Patients in Police Custody……………………………………………………………………………………………………………………………………………….21 Radio Report Format……………………………………………………………………………………………………………………………………………………… 22 Termination of Resuscitation…………………………………………………………………………………………………………………………………………. 23 Transfer of Care at Hospital…………………………………………………………………………………………………………………………………………….24 Persons with EMS Care Plans……………………………………………………………………………………………………………………………..…………..25 Adult Medical Protocols General Approach…………………………………………………………………………………………………………………………………………………………..26 Airway / Breathing Airway Management………………………………………………………………………………………………………………………….……….………….. 27 Rapid Sequence Airway………………………………………………………………………………………………………………………….…….…………. 28 Post-RSA Sedation…………………………………………………………………………………………………………………………………………………...29 Failed Airway……………………………………………………………………………………………………………………………...……………….…………. 30 COPD / Asthma…………………………………………………………………………………………………………………………………………….…………. 31 CHF / Pulmonary Edema……………………………………………………………………………………………………………………………...…………. 32 Circulation Cardiac Arrest……………………………………………………………………………………………………………………………………………..………….. 33 Pulseless Electrical Activity (PEA) Arrest…………………………………………………………………………………………………...……………..34 Asystole Arrest……………………………………………………………………………………………………………………………..………...……………… 35 V-Fib / Pulseless V-Tach Arrest……………………………………………………………………………………………………………….....…………... 36 Post-Resuscitation………………………………………………………………………………………………………...…………………..…………………… 37 Chest Pain / Suspected Acute Coronary Syndrome………………………………………………..………………………………..……………… 38 ST-Elevation Myocardial Infarction (STEMI)………………………………………………………………………………………………..…………...39 Narrow Complex Tachycardia With a Pulse…………………………………………………………………………………..…………….………….. 40 Wide Complex Tachycardia With a Pulse……………………………………………………………………………….…………………..…………... 41 Bradycardia With a Pulse…………………………………………………………………………………………………………………………....………….. 42 Abdominal Pain………………………………………………………………………………………………………………………………………………...…………...43 Allergic Reaction………………………………………………………………………………………………………………………………………….………………... 44 Altered Mental Status………………………………………………………………………………………….………………………………………...……………...45 Behavioral / Excited Delirium…………………………………………………………………………………………………………………………...…………… 46 Diabetic Emergencies………………………………………………………………………………………………………………….…………………….………….. 47 Hypertension………………………………………………………………………………………………………………………………………………...……………….48 IV Access……………………………………………………………………………………………………………..………………………………………………........... 49 Table of Contents Adult Medical Protocols (continued) Obstetrics and Gynecology OB General………………………………………………………………………………………………………………………………………………….….…. 50 OB / Vaginal Bleeding………………………………………………………………………………………………………………………………...……...51 Labor / Imminent Delivery……………………………………………………………………………………………………………………………...…. 52 Newly Born………………………………………………………………………………………………………………………………………………...……...53 Toxicology Overdose and Poisoning, General………………………………………………………………………………………………………………………. 54 Anticholinergic / Organophosphate Overdose……………………………………………………………………………………………………. 55 Beta Blocker Overdose………………………………………………………………………………………………………………………………………..56 Calcium Channel Blocker Overdose……………………………………………………………………………………………………………………..57 Carbon Monoxide Poisoning………………………………………………………………………………………………………………………..……..58 Cyanide Poisoning……………………………………………………………………………………………………………………………………………….59 Antipsychotic Overdose / Acute Dystonic Reaction……………………………………………………………………………………………..60 Opiate Overdose……………………………………………………………………………………………………………………………………….………..61 Cocaine and Sympathomimetic Overdose…………………………………………………………………………………………………….……. 62 Tricyclic……………………………………………………………………………………………………………………………………………………………... 63 Pain Management……………………………………………………………………………………………………………………………………………………..64 Refusals Refusal Protocol………………………………………………………………………………………………………………………………………...……... 65 Refusal After EMS Treatment Protocol………………………………………………………………………………………………………………..66 Hypotension / Shock (Non-Trauma)……………………………………………………………………………………………………………………...…. 67 Neurology Seizure…………………………………………………………………………………………………………………………………………………………...…. 68 Suspected Stroke……………………………………………………………………………………………………………………………………………….. 69 Thrombolytic Screening……………………………………………………………………………………………………………………………………………. 70 Adult Trauma Protocols General Approach……………………………………………………………………………………………………………………………………….…….. 71 Destination Determination………………………………………………………………………………………………………………………….…….. 72 Bites and Envenomations…………………………………………………………………………………………………………………………….…….. 73 Blast Injury…………………………………………………………………………………………………………………………………………………...…... 74 Burns…………………………………………………………………………………………………………………………………………………………………. 75 Traumatic Cardiac Arrest……………………………………………………………………………………………………………………………………. 76 Chemical / Electrical Burn………………………………………………………………………………………………………………………………….. 77 Chest Injury……………………………………………………………………………………………………………………………………………………….. 78 Prolonged Crush Injury…………………………………………………………………………………………………………………………………..….. 79 Near-Drowning / Submersion Injury…………………………………………………………………………………………………………………...80 Environmental – Hyperthermia………………………………………………………………………………………………………………………….. 81 Environmental – Hypothermia…………………………………………………………………………………………………………………….…….. 82 Extremity Injury…………………………………………………………………………………………………………………………………………………. 83 Eye Pain……..………………………………………………………………………………………………………………………………………………….….. 84 Hazmat, General………………………………………………………………………………………………………………………………………………... 85 Head Injury………………………………………………………………………………………………………………………………………………….…….. 86 Hemorrhage Control……………………………………………………………………………………………………………………………………….…. 87 Lightning Strike………………………………………………………………………………………………………………………………………………….. 88 Pain Management……………………………………………………………………………………………………………………………………………... 89 Radiation Injury…………………………………………………………………………………………………………………………………………………. 90 Electronic Control Device (a.k.a. TASER)…………………………………………………………………………………………………………….. 91 Long Board Selective Spinal Immobilization……………………………………………………………………………………………………….. 92 Sexual Assault / Intimate Partner Violence………………………………………………………………………………………………………... 93 WMD / Nerve Agent Exposure…………………………………………………………………………………………………………………………... 94 Special Operations Public Safety Personnel Rehab……………………………………………………………………………………………………………………….….. 95 Table of Contents Peds Medical Protocols Quick Reference…………………………………………………………..………………………………………………….……………………….……………... 96 Destination Determination………………………………………………………………………………………………………………………………………..97 General Approach…………………………………………………………………………………………………………………………………………………….. 98 Airway / Breathing Airway Management…………………………………………………………………………………………………………………………………………..99 Failed Airway……………………………………………………………………………………………………………………………………………………...100 Wheezing / Asthma……………………………………………………………………………………………………………………………………………. 101 Circulation Cardiac Arrest, General………………………………………………………………………………………………………………………………………. 102 Pulseless Electrical Activity (PEA) Arrest…………………………………………………………………………………………………………….. 103 Asystole Arrest…………………………………………………………………………………………………………………………………………………...104 V-fib / Pulseless V-Tach Arrest…………………………………………………………………………………………………………………………….105 Neonatal Resuscitation………………………………………………………………………………………………………………………………………. 106 Post Resuscitation Care……………………………………………………………………………………………………………………………………... 107 Bradycardia……………………………………………………………………………………………………………………………………………………….. 108 Tachycardia……………………………………………………………………………………………………………………………………………………….. 109 Allergic Reaction………………………………………………………………………………………………………………………………………………………. 110 Altered Mental Status………………………………………………………………………………………………………………………………………………. 111 Apparent Life-Threatening Episode (ALTE)………………………………………………………………………………………………………………...112 Diabetic Emergencies……………………………………………………………………………………………………………………………………………….. 113 IV Access………………………………………………………………………………………………………………………………………………………………….. 114 Toxicology Overdose and Poisoning, General………………………………………………………………………………………………………………………. 115 Pain Management……………………………………………………………………………………………………………………………………………………. 116 Refusal Protocol……………………………………………………………………………………………………………………………………………………….. 117 Seizure……………………………………………………………………………………………………………………………………………………………………...118 Hypotension / Shock (Non-Trauma)…………………………………………………………………………………………………………………………..119 Sickle Cell Crisis………………………………………………………………………………………………………………………………………………………... 120 Peds Trauma Protocols Quick Reference……………………………………………………………………………………………………………………………………………………….. 121 Destination Determination………………………………………………………………………………………………………………………………………..122 General Approach…………………………………………………………………………………………………………………………………………………….. 123 Traumatic Cardiac Arrest………………………………………………………………………………………………………………………………………….. 124 Bites and Envenomations…………………………………………………………………………………………………………………………………………. 125 Burns……………………………………………………………………………………………………………………………………………………………………….. 126 Chest Injury……………………………………………………………………………………………………………………………………………………………….127 Prolonged Crush Injury…………………………………………………………………………………………………………………………………………….. 128 Near-Drowning / Submersion Injury…………………………………………………………………………………………………………………………. 129 Environmental – Hyperthermia………………………………………………………………………………………………………………………………….130 Environmental – Hypothermia…………………………………………………………………………………………………………………………………..131 Extremity Injury……………………………………………………………………………………………………………………………………………………….. 132 Eye Pain……………………………………………………………………………………………………………………………………………………………………. 133 Head Injury………………………………………………………………………………………………………………………………………………………………. 134 Hemorrhage Control………………………………………………………………………………………………………………………………………………….135 Pain Management……………………………………………………………………………………………………………………………………………………..136 Sexual Assault / Intimate Partner Violence………………………………………………………………………………………………………………..137 Spinal Immobilization………………………………………………………………………………………………………………………………………………..138 Table of Contents Procedures Cardiac Monitoring 12-Lead ECG………………………………………………………………………………………………………………………………………………….…….139 Right Sided ECG……………………………………………………………………………………………………………………………………………….... 140 Posterior ECG………………………………………………………………………………………………………………………………………………….…. 141 Airway Airway Obstruction………………………………………………………………………………………………………………………………………….... 142 Rapid Sequence Airway……………………………………………………………………………………………………………………………………… 143 Pulse Oximetry……………………………………………………………………………………………………………………………………………...….. 144 Intubation……………………………………………………………………………………………………………………………………………………….....145 King LTS-D Laryngeal Tube Airway…………………………………………………………………………………………………………….……….. 147 LMA…………………………………………………………………………………………………………………………………………………………………….149 Suctioning (Basic)…………………………………………………………………………………………………………………………………………….... 151 Suctioning (ET Tube and Stoma)…………………………………………………………………………………………………………………………. 152 Continuous Positive Airway Pressure (CPAP)…………………………………………………………………………………………………...... 153 Bougie……………………………………………………………………………………………………………………………………………………..………... 154 Capnography………………………………………………………………………………………………………………………………………………..……. 155 Cricothyrotomy……………………………………………………………………………………………………………………………………………….....156 Cricothyrotomy (Open) Surgical…………………………………………………………………………………………………………………..…….. 157 Needle Jet Insufflation………………………………………………………………………………………………………………………………….……. 158 Blood Glucose……………………………………………………………………………………………………………………………………………………..…... 159 Carbon Monoxide Measurement………………………………………………………………………………………………………………………..……. 160 Cardiac Cardioversion………………………………………………………………………………………………………………………………………………..…...161 Cardio-Cerebral Resuscitation………………………………………………………………………………………………………………………….... 162 Cardiopulmonary Resuscitation……………………………………………………………………………………………………………………...…. 163 Defibrillation…………………………………………………………………………………………………………………………………………………...… 164 External Cardiac Pacing………………………………………………………………………………………………………………………………...…… 165 Mechanical CPR Device………………………………………………………………………………………………………………………………………. 166 Remote Ischemic Conditioning…………………………………………………………………………………………………………………...……...168 Chest Decompression………………………………………………………………………………………………………………………………………...……..169 Cincinnati Stroke Screen……………………………………………………………………………………………………………………………………...…...170 Intranasal………............................................................................................................................................................171 Orogastric Tube Insertion………………………………………………………………………………………………………………………..………………..172 Restraints……………………………………………………………………………………………………………………………………………………..…………..173 Spinal Immobilization…………………………………………………………………………………………………………………………………………..….. 174 Spinal Immobilization of Athletes with Helmets…………………………………………………………………………………………..…………...175 Splinting……………………………………………………………………………………………………………………………………………………………..……. 176 Tourniquet (CAT – Combat Application Tourniquet)…………………………………………………………………………………………………. 177 Venous Access Accessing Peripherally Inserted Central Catheter (PICC)……………………………………………………………..……………………….178 Extremity Venous Access…………………………………………………………………………………………………………………………..………..179 Intraosseous Venous Access…………………………………………………………………………………………………………………..………….. 180 External Jugular Venous Access…………………………………………………………………………………………………………………..……...181 Ventricular Assist Device (VAD)………………………………………………………………………………………………………………………………….182 Wound Care………………………………………………………………………………………………………………………………………………………….…..183 Table of Contents Pharmaceuticals Overview…………………………………………………………………………………………………………………………………………..…………..………….184 Adenosine………………………………………………………………………………………………………………………………………………………..…..…..185 Albuterol…………………………………………………………………………………………………………………………………………………………..……...186 Amiodarone………………………………………………………………………………………………………………………………………………………..…….187 Aspirin………………………………………………………………………………………………………………………………………………………………….….. 188 Atropine……………………………………………………………………………………………………………………………………………………………..……. 189 Calcium……………………………………………………………………………………………………………………………………………………….…….…….. 190 Dextrose……………………………………………………………………………………………………………………………………………………………..…... 191 Diazepam………………………………………………………………………………………………………………………………………………………….……... 192 Diltiazem……………………………………………………………………………………………………………………………………………………………...…..193 Diphenhydramine…………………………………………………………………………………………………………………………………………….…..…..194 Dopamine………………………………………………………………………………………………………………………………………………………………….195 DuoDote………………………………………………………………………………………………………………………………………………………………..... 196 Epinephrine…………………………………………………………………………………………………………………………………………………………...... 197 Etomidate…………………………………………………………………………………………………………………………………………………………..……. 198 Famotidine……………………………………………………………………………………………………………………………………………………….……….199 Fentanyl……………………………………………………………………………………………………………………………………………………………….….. 200 Glucagon………………………………………………………………………………………………………………………………………………………………….. 201 Glucose (Oral)…………………………………………………………………………………………………………………………………………………….……..202 Haloperidol………………………………………………………………………………………………………………………………………………………….…...203 Hydroxocobalamin…………………………………………………………………………………………………………………………………………………….204 Ipratropium……………………………………………………………………………………………………………………………………………………………….205 Ketamine…………………………………………………………………………………………………………………………………………………………………..206 Lidocaine………………………………………………………………………………………………………………………………………………………………….. 207 Lorazepam……………………………………………………………………………………………………………………………………………………………….. 208 Magnesium………………………………………………………………………………………………………………………………………………………………. 209 Mark 1 Kit………………………………………………………………………………………………………………………………………………………………….210 Methylprednisolone…………………………………………………………………………………………………………………………………………………. 211 Midazolam……………………………………………………………………………………………………………………………………………………………….. 212 Morphine…………………………………………………………………………………………………………………………………………………………………. 213 Naloxone…………………………………………………………………………………………………………………………………………………………………..214 Nitroglycerine…………………………………………………………………………………………………………………………………………………….……..215 Ondansetron……………………………………………………………………………………………………………………………………………………….…….216 Rocuronium………………………………………………………………………………………………………………………………………………………….….. 217 Sodium Bicarbonate…………………………………………………………………………………………………………………………………………….…... 218 Succinylcholine……………………………………………………………………………………………………………………………………………………...... 219 Vasopressin……………………………………………………………………………………………………………………………………………………………….220 Authorization: In accordance with Wisconsin Statute 256 and Chapter 110 of the Wisconsin Administrative Code, effective February 1st, 2016 the following medical protocols are authorized by the Dane County EMS Medical Director for use in the County. Changes to these protocols can be made only with the authorization of the Medical Director. Michael T. Lohmeier, MD, FACEP Dane County Medical Director Michael Mancera, MD Dane County Associate Medical Director Introduction: The Dane County EMS Protocols contained within this document are intended to provide and ensure uniform treatment for all patients who receive care from EMS Agencies and Providers participating in the Dane County EMS System. These protocols apply exclusively to agencies responding via the 9-1-1 System within the County. Any other use must receive prior approval from the Medical Director of Dane County EMS. These protocols are the direct result of countless hours reviewing evidence-based guidelines, historically proven treatments and the best practices of EMS Systems recognized as leaders in the nation. We sincerely hope that this document will be viewed as an invaluable tool for learning, teaching and reference so that the Dane County EMS System may continue to provide the highest quality of out-of-hospital care. Although we have attempted to address all patient care scenarios, it is possible that unforeseen circumstances and patient care needs will arise. In these situations, the EMS Provider should rely on their education, experience and clinical judgment combined with the principle of patient centered care to achieve optimal results. As always, On-Line Medical Control is available for consultation and assistance with patients, scenarios or presentations that do not fall within the scope of this document. Acknowledgements: The protocols contained within this document have been extensively reviewed not only by the Dane County EMS Office, but by representatives from all aspects of the local medical community. They are intended to create a seamless and consistent treatment plan across provider levels, and have been evaluated for applicability as well as internal consistency. While they may not be perfect, it is our sincere hope that this document is viewed as the most complete and robust protocol set possible, and that they meet or exceed the standard set by the top EMS Services in the nation. The Office would like to specifically acknowledge the following individuals and groups for their contributions to this document. Dane County EMS Commission Dr. Michael Mancera Dr. Megan Gussick Dane County Medical Advisory Subcommittee Dr. Vanessa Tamas Dr. Suresh Agarwal Dane County ALS Consortium Dr. Ryan Wubben Dr. Michael Kim Meriter Hospital Dr. Ankush Gosain Dr. Charles Leys St. Mary’s Hospital Dr. Lee Faucher Dr. Hee Soo Jung William S. Middleton Memorial Veterans Hospital Carrie Meier Tim Hillebrand Stoughton Hospital Charles Tubbs, Sr. Dr. J. Brent Myers University of Wisconsin Hospitals and Clinics Stephanie Lehmann Dr. Azita Hamedani University of Wisconsin Emergency Education Center Dane County Protocol Workgroup (in alphabetical order) – Greg Bailey, Chris Carbon, Ryan Dockry, Jeff Dostalek, Kim Feiner, Kim Jack, Carrie Meier, Jen Minter, Jen Román, Scott Russell, Brandon Ryan, Ché Stedman “If you are going to achieve excellence in big things, you develop the habit in little matters. Excellence is not an exception, it is a prevailing attitude.” -Colin Powell 1 Guidelines for Use of Protocols: In general, the protocols are divided into Adult and Pediatric sections, with subheadings for Medical and Trauma. For pediatric patients, the appropriate pediatric-specific protocol should be used if one exists. If there is no pediatric-specific protocol for a condition, use the adult protocol but use weight-based dosing for medications. The adult dose of a medication should never be exceeded for a pediatric patient. There have been a great many changes from previous versions of the Dane County EMS Protocols. While the core of the protocols remains the same – to provide the highest level of patient centered care possible – this protocol book may almost be viewed as a completely new document. A summary of the major formatting changes appears below this paragraph, but it is not a replacement for careful study of the protocol book itself. Please take the time to orient yourself and become familiar with the look and flow of the content. In order to make the flowcharts easier to read, a standardized presentation has been adopted. For circumstances where an EMS Provider needs to make a decision, the question appears in a diamond-shaped box with the answers coming off in separate, usually opposite directions. For simplicity, every attempt was made to make these “yes/no” or dichotomous decisions whenever possible. When an EMS Provider is referenced to another Protocol within the book, the name of the Protocol appears in a rectangular box, with a lime-green shadow. If there is a bi-directional arrow referencing another Protocol, the intention is that the EMS Provider returns to the current Protocol after a critical assessment or treatment is completed in the referenced Protocol. For example, a bi-directional arrow referencing the Airway Management, Adult Protocol would imply that after the airway has been addressed that the Provider return to the current Protocol for further evaluation and patient management. When an EMS Provider is referenced to a Procedure within the book, the name of the Procedure appears in a rectangular box, with a purple shadow. If referencing a Policy, it appears with a brown shadow. A P M When medications are referenced in the Protocol, they are coded to the level of the EMS Provider with a key attached to the left side of the medication box. Procedures and medications that are in the scope of all providers have a clear box attached to the left side, Advanced EMTs have a yellow box with the letter A and Paramedics have a blue box with the letter P. Any time Medical Control must be contacted for approval or authorization, the key is red with the letter M. The Legend appears in the top left corner of all Protocols for reference. Rather than have multiple boxes attached to each medication, the supposition is that all providers credentialed at a level higher than the key are authorized to administer the medication. For example, albuterol has a clear box in the key and is authorized for the Basic, Advanced EMT and Paramedic. Under the heading for each Protocol, there are two sections immediately below entitled, “Pertinent Positives and Negatives” and “Differential”. These boxes are meant to be a guide to assist with the pertinent historical information as well as a reminder of the multiple potential causes for a patient presentation that should be considered by the EMS Provider. It is expected that these elements be considered in the patient evaluation and appear in the documentation for the call. Finally, the “Pearls” section at the bottom of the page provides further guidance as well as some tips to keep in mind when assessing patients and scenes. It is impossible to condense all of Emergency Medicine into a single page flow chart, but the pearls section allows for expanded medical advice, dosages and descriptions of special situations. Please study these sections along with the rest of the flowcharts – there is likely to be something new to learn on every page! These protocols are the basis of the care we provide. Combined with your experience and education, this document should help you provide patient care that rivals the best in the world. 2 In Memoriam: The Dane County Medical Director would like to acknowledge the significant work of two individuals, Dr. Darren Bean and Robert L. Brunning. Dr. Darren Bean served as the Medical Director for the City of Madison Fire Department until 2008. His vision, dedication and drive were instrumental in the development of the current ALS System as well as the expansion of Dane County EMS. His passion was to create a unified out-of-hospital system so that the highest level of compassionate, quality medical care could be rendered to all people in Dane County. Tragically, Dr. Bean died on May 10, 2008 while transporting a patient in his capacity as a Med Flight Physician. We will never forget Dr. Bean, Pilot Steve Lipperer or Nurse Mark Coyne, RN. Robert L. Brunning served as the first Dane County EMS System Coordinator. “Bob” was hired with the mission to transition medical care from the Dane County Traffic Police to fully trained EMS Personnel with specialized equipment and vehicles. In the 1970's he won several Federal Grants for Dane County to purchase ambulances and equipment for use by all services. He was able to successfully coordinate over 21 different EMS Agencies in the County, and it was not uncommon for him to be out at 3am helping a District in any way he could. Sadly, Bob passed away in 1995. In his memory the Dane County EMS office established the Robert L. Brunning Award of Excellence. In memoriam, we thank Dr. Darren Bean and Robert Brunning for their vision, passion and dedication. We hope these Protocols make you proud. Dedication: These protocols are dedicated to you, the EMS Providers of Dane County. It is your tireless dedication, commitment to continuous improvement and solemn promise to care for the sick and injured that makes Dane County, Wisconsin the special community that it is. While missed time with family and friends comes too often and the ‘thank yous’ come far too infrequently, please know that your time and efforts are sincerely appreciated. Some people spend a lifetime wondering if they made a difference in the world; you don’t have that problem. EMS, Fire and Law Enforcement Honor Guards: Lastly, we would like to acknowledge all of the EMS, Fire and Law Enforcement Honor Guards within Dane County, who ensure that fallen members of the EMS profession are given the honor, respect and dignity they deserve for the vital service in public safety they so willingly provided to their communities. Thank you for honoring those who have dedicated their lives to others. “Perfection is not attainable, but if we chase perfection we can catch excellence.” -Vince Lombardi 3 A Legend EMT A-EMT P Paramedic M Medical Control Medical Transport Destination Purpose: To provide guidelines for the transport of patients with Time Critical Diagnoses (TCDs) to the most appropriate facility that can provide definitive level care. Policy: Comprehensive Stroke Center: UW Hospital – Main Campus Primary Stroke Center: Mercy Hospital – Janesville Meriter Hospital St. Mary’s – Madison VA Hospital Acute Stroke Ready (CT and TPA Only): Fort Memorial Hospital – Ft. Atkinson The Richland Hospital – Richland Center Stoughton Hospital St. Clare Hospital – Baraboo St. Mary’s – Sun Prairie St. Mary’s – Janesville Upland Hills Health – Dodgeville UW at The American Center Burn Unit: UW Hospital – Main Campus ST-Segment Elevation MI: Meriter Hospital Monroe Clinic St. Mary’s – Madison UW Hospital – Main Campus VA Hospital Pediatric Trauma Unit: UW Hospital – Main Campus Level I Trauma: UW Hospital – Main Campus Level II Trauma: Mercy Hospital – Janesville Level III Trauma: Meriter Hospital Sauk Prairie Hospital St. Clare Hospital - Baraboo St. Mary’s – Madison St. Mary’s – Janesville Level IV Trauma: Monroe Clinic Stoughton Hospital St. Mary’s – Sun Prairie Upland Hills Health – Dodgeville Pediatric Intensive Care Unit: UW Hospital – Main Campus Neonatal Intensive Care Unit: Meriter Hospital St. Mary’s - Madison UW Hospital – Main Campus OB, Labor and Delivery Receiving: Fort Memorial Hospital – Ft. Atkinson Mercy Hospital – Janesville Meriter Hospital Monroe Clinic The Richland Hospital – Richland Center OB, Labor and Delivery Receiving (cont): Sauk Prairie Hospital St. Clare Hospital - Baraboo St. Mary’s – Madison St. Mary’s – Janesville Upland Hills Health – Dodgeville SANE (Sexual Assault Nurse Examiner) Nurse: Meriter Hospital Any patient who is judged to be too unstable for transfer to definitive care may be transported to the closest Emergency Department for immediate stabilization Medical Transport Destination 4 Policies Policies When feasible, patients AND/OR their healthcare power of attorney should be permitted to make autonomous decisions regarding their destination hospital, and given the opportunity to choose. Occasionally, patients may need to be directed away from their preferred institution in favor of a specialty resource center, which can provide advanced levels of care not available at every hospital. In those instances, the EMS Provider’s decision should be calmly and respectfully communicated to the patient and their family. By keeping a patient-centered focus and always working to do what is right for the patient, transport to the most appropriate level of care will hopefully be an obvious decision. At the time of publication, the following centers have achieved the appropriate level of credentialing for each of the Time Critical Diagnoses (TCDs) and Specialty Resource Center listed: A Legend EMT A-EMT P Paramedic M Medical Control Request for Helicopter EMS (HEMS) Purpose: To provide general guidelines for the appropriate utilization of Helicopter EMS (HEMS) during routine daily operations. Policy: Helicopter EMS activation should be considered in Time Critical Diagnoses (TCDs) when the transport time to definitive care is prolonged, as well as situations when advanced resources and skills may help improve the patient’s chances of survival. Depending on the situation and resources present, it may be prudent to begin transport by ground ambulance and arrange for a rendezvous at an existing airfield or helipad rather than establish a scene Landing Zone (LZ) and wait for HEMS. Please see the next page for a listing of local airfields and hospital-based helipads that would not require establishment of an LZ by Fire or Law Enforcement. Procedure: When considering air transport, the following terminology should be referenced when speaking with HEMS Dispatch: “Status Inquiry” or “Inquiry” - contact asking whether HEMS is available to fly or not based on current weather conditions, aircraft availability and crew status. An aircraft will NOT be reserved based on an “Inquiry”, and if another flight “Request” is received before final decision is made the second “Request” WILL be accepted by HEMS. “Stand-by” - for all calls within the borders of Dane County, an aircraft will be pulled out and prepared for flight, but WILL NOT lift off until final decision is made regarding HEMS use. Anyone in Public Safety may put a helicopter on “Stand-by”. If another flight request is received before final decision is made, the second “Request” will NOT be accepted by HEMS. “Request” - final decision has been made by the EMS Provider(s) on scene to transport the patient by air, and the helicopter will launch to the scene or rendezvous point as soon as possible. The highest credentialed EMS Provider on scene will determine if a HEMS unit is appropriate for the patient. That EMS Provider will request the Dane County 9-1-1 Center to contact Helicopter EMS and “Request” dispatch of the closest, most appropriate HEMS unit. A safe landing zone (LZ) must be established per protocol prior to HEMS arrival. If using a landing zone (LZ) in Dane County such as a grass airstrip at night, it should be marked by flares, strobes, vehicle lights or other suitable ground based lighting. The highest quality patient care should be continued per Dane County Protocols until HEMS arrival, at which time care may be transitioned to the HEMS medical crew. Patients coming from a Hazardous Materials (HazMat) scene need to be fully decontaminated prior to HEMS transport. This includes contamination with various fuels as well as ingestions of volatile substances which may cause off-gassing. Under NO circumstances should patient transport be delayed to use a helicopter. There are multiple Helicopter Landing Zones (LZs) in and around Dane County that do NOT require Fire or Law Enforcement establishment. If appropriate for the situation, weather and patient condition, these locations may be considered for rendezvous with the HEMS unit and transfer of patient care. This will take clear communication from the EMS Providers on scene and coordination through the Dane County 9-1-1 Center and the HEMS Dispatcher. Please see the following page for a map and list of airfields and helipads in the greater Dane County area that may be considered. Request for Helicopter EMS (HEMS) 5 Policies Policies A helicopter may be considered for request under the following circumstances but not limited to: Patient meets Level I Trauma Center criteria under the Destination Determination Protocol AND ground transport time is estimated to be greater than 30 minutes Patient is critically ill or injured AND entrapped with extrication expected to last greater than 20 minutes Patient has unstable Vital Signs (VS) and ALS intercept would further delay arrival at definitive care Patient has field diagnosed ST-Segment Elevation MI and is not expected to make the goal first medical contact-to-balloon time of <90 minutes without HEMS assistance Patient requires specialized medical attention in the field that is beyond the scope of the EMS Providers present on scene or available at the time of the emergency (i.e. field amputation, pediatric intubation) Mass Casualty Incident with multiple critically ill or injured patients, when activation would not put the responding HEMS unit at increased risk (i.e. active shooter without neutralized threat) A Legend EMT A-EMT P Paramedic M Medical Control Helicopter EMS (HEMS) Landing Zones Policies Policies Sauk Prairie Hospital Helipad UW at The American Center Helipad Waunakee Airport Jana Airport Stoughton Hospital Helipad Stoughton Airport (Matson) Lodi Lakeland Airport Edgerton Hospital Helipad Syvrud Airport Sauk Prairie Airport St. Mary’s Sun Prairie Helipad Sugar Ridge Airport Elert Airport Middleton Airport – Morey Field Verona Airport Mathaire Field Blackhawk Airfield Helicopter EMS (HEMS) Landing Zones 6 A Legend EMT A-EMT P Paramedic M Medical Control Do Not Resuscitate (DNR) Purpose: To clarify the State of Wisconsin Do Not Resuscitate (DNR) laws, and to provide guidance for several exceptions to the rule. Policy: As defined in Wisconsin Statute 154.17(2), a valid Do Not Resuscitate (DNR) order directs EMS Providers not to attempt cardiopulmonary resuscitation on the person for whom the order is issued if that person suffers cardiac or respiratory arrest. As further defined in 154.17(5), “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 or upper airway. DNR patients should still receive appropriate treatment from EMS Personnel under the Dane County Protocols, to include but not limited to: clearing the airway, administering supplemental O2, positioning for comfort, splinting extremities, hemorrhage control, providing pain medications, providing emotional support and transporting to an Emergency Department for evaluation. DNR orders shall be followed by EMS Providers, except in the following situations: The Do-Not-Resuscitate bracelet appears to have been tampered with or removed The emergency medical technician, first responder or member of the emergency health care facility knows that the patient is pregnant The Do-Not-Resuscitate order is revoked. Methods for revocation may occur at any time by the following (154.21): The patient expresses to an emergency medical technician, first responder or to a person who serves as a member of an emergency health care facility’s personnel the desire to be resuscitated. The emergency medical technician, first responder or the member of the emergency health care facility shall promptly remove the do-not-resuscitate bracelet. The patient defaces, burns, cuts or otherwise destroys the do-not-resuscitate bracelet. The patient removed the do-not-resuscitate bracelet or another person, at the patient’s request, removed the do-notresuscitate bracelet The Guardian or Health Care Agent of an incapacitated qualified patient may direct an emergency medical technician, first responder or a person who serves as a member of an emergency health care facility's personnel to resuscitate the patient. The emergency medical technician, first responder or the member of the emergency health care facility shall promptly remove the do-not-resuscitate bracelet. (154.225) Under Wisconsin Statute 154.23, no physician, emergency medical technician, first responder, health care professional or emergency health care facility may be held criminally or civilly liable, or charged with unprofessional conduct, for any of the following: Under the directive of a do-not-resuscitate order, withholding or withdrawing, or causing to be withheld or withdrawn, resuscitation from a patient Failing to act upon the revocation of a do-not-resuscitate order unless the person or facility had actual knowledge of the revocation Failing to comply with a do-not-resuscitate order if the person or facility did not have actual knowledge of the do-notresuscitate order or if the person or facility in good faith believed that the order had been revoked. Do Not Resuscitate (DNR) 7 Policies Policies There are two types of DNR bracelets available to identify a person with a valid DNR order. One is a plastic ID bracelet, which looks like a hospital ID band. The other is a metal bracelet, which is currently available from StickyJ® Medical ID. Per Wisconsin Statute 154, StickyJ® is the current State of Wisconsin authorized vendor of the metal bracelets; however, the previous MedicAlert® bracelets will continue to be recognized. Legend EMT A-EMT A P Paramedic M Medical Control Child/Elder Abuse Recognition and Reporting Purpose: To provide guidelines for the EMS Provider who encounters suspected and/or confirmed cases of child or elder abuse while on duty. Policy: Child Abuse is the physical and mental injury, sexual abuse, negligent treatment and/or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare. The recognition of abuse and the proper reporting is a critical step to improving the safety of children and preventing child abuse. An elderly person is defined in the State of Wisconsin as a person >60 years of age. Elder abuse is the physical and/or mental injury, sexual abuse, negligent treatment or maltreatment of a senior citizen by another person. Abuse may be at the hand of a caregiver, spouse, neighbor or adult child of the patient. The recognition of abuse and the proper reporting is a critical step to improve the health and well-being of senior citizens. Effective management of a case of suspected abuse or neglect is based upon the following: Protect the patient from harm Suspect that the patient may be a victim of abuse, especially if the illness/injury is not consistent with the reported history Respect the privacy of the patient and the family Collect as much information as possible, and preserve any physical evidence There are may subtle signs of abuse that may be missed without a high index of suspicion. ALL patients evaluated by EMS should be screened for these cues. Some include: Psychological cues – excessively passive behavior, fearful behavior, excessive aggression, violent tendencies, excessive or inappropriate crying, substance abuse, medical noncompliance or repeat EMS requests for seemingly minor problems. Physical cues – injuries inconsistent with the reported mechanism, defensive injuries (i.e. forearms), injuries during pregnancy are suggestive of abuse. Multiple bruises and injuries in various stages of healing may also suggest repeated violence against the victim. Signs of neglect – inappropriate level of clothing for weather, poor hygiene, absence of and/or inattentive caregivers, poor living conditions and physical signs of malnutrition. EMS Providers in the State of Wisconsin are required by law to report suspected cases of child abuse and neglect as well as those situations in which they have reason to believe that a child / elder has been treated with abuse or neglect or that abuse or neglect will occur. For Suspected Elder Abuse or Neglect Cases in Dane County NOT in a State-licensed facility, contact the Dane County Department of Human Services Elder Abuse/Neglect Helpline at (608) 261-9933. Cases in Dane County that ARE in a State-licensed nursing home, contact the State Division of Quality Assurance at (608) 266-7474. Cases in Dane County that ARE in a State-licensed program such as assisted living, community based residential facility (CBRF), adult family home (AFH), contact the Wisconsin State Bureau of Assisted Living at (608) 264-9888. Cases outside of Dane County, call the Elder Care Locator at (800) 677-1116. See the Wisconsin Department of Health Services internet listing of County elder abuse agencies as necessary. http://www.dhs.wisconsin.gov/aps/Contacts/eaaragencies.htm For Suspected Child Abuse or Neglect Contact the Dane County Department of Human Services Protective services: Mon-Fri, 7:45AM-4:30PM – (608) 261-KIDS (5437) After hours and on weekends – (608) 255-6067 If caregivers are refusing the evaluation or treatment of a child that you suspect may be the victim of abuse or neglect, do not hesitate to contact Medical Control for advice. If necessary, Law Enforcement may be consulted to help settle disagreements on scene, while maintaining the effective management principles above. In the RARE instance that a child has a life or limb threatening illness or injury AND the caregivers are refusing evaluation, the child should be transported to the closest appropriate facility, with simultaneous contact of Law Enforcement and On-Line Medical Control. If your Service Medical Director is unavailable, the Dane County Medical Director should be contacted to assist as needed. When abuse or suspected abuse is reported to Law Enforcement, it is required that name and badge number of the officer receiving the report be captured in your documentation. See the Dane County Department of Human Services Protective Services website for additional information as necessary: http://www.danecountyhumanservices.org/ProtectiveServices/Child/ Child/Elder Abuse Recognition and Reporting 8 Policies Policies Any findings of abuse or neglect OR suspicion of abuse or neglect must be reported immediately to Law Enforcement or Protective Services upon arrival to the receiving hospital. In cases of suspected abuse or neglect where a patient contact does not result in transport, Law Enforcement or Protective Services must be notified prior to clearing the scene. A Legend EMT A-EMT P Paramedic M Medical Control Criteria for Death / Withholding Resuscitation Purpose: To provide guidelines for situations when initiation of resuscitative efforts by EMS Personnel is not appropriate. For patients with a valid Do-Not-Resuscitate (DNR) order, please refer to the Do Not Resuscitate Policy. Policy: Resuscitative efforts should not be undertaken for an adult patient >18 years of age who is pulseless and apneic IF one or more of the following criteria are met: Decapitation Incineration Decompensation of Body Tissue Rigor Mortis and/or Dependent Lividity Massively Deforming Head or Chest Injury Do not initiate resuscitative measures for patients meeting the above criteria. Confirmation of asystole with a 4-lead cardiac monitor is acceptable if appropriate for the situation. If the circumstances are unknown or unclear, or if there is question about the validity of a DNR order, initiate resuscitation while simultaneously contacting On-Line Medical Control for further advice. Notify Law Enforcement of the patient’s death and involve the Dane County Medical Examiner. If the patient is in a medical facility (nursing home, physician’s office, rehab facility) and under the supervision of medically trained personnel (physician or RN), you may contact the patient’s primary physician directly and involve the Dane County Medical Examiner All EMS Providers will handle the deceased subjects in a uniform, professional and timely manner. Once the determination has been made that resuscitative efforts will not be initiated, respect for the patient and family with protection of the dignity of the deceased is critically important. As with every EMS call, situational awareness should be a high priority. Maintain vigilance and be aware that these patient calls may be investigated as a crime scene; do your best to avoid disturbing the scene or any potential evidence. ~ This Space Intentionally Left Blank ~ Criteria for Death / Withholding Resuscitation 9 Policies Policies If resuscitative efforts are in progress, consider discontinuation of efforts (EMT-P only), or contact Medical Control for consultation. If the arrest is traumatic in nature, go to the Traumatic Arrest Protocol. If the patient is believed to have severe hypothermia (core temperature <82oF or <28oC), go to the Environmental, Hypothermia – Adult, Trauma Protocol A P M Legend EMT A-EMT Paramedic Documentation of Patient Care Medical Control Purpose: To provide guidelines and to set best practice for documentation of patient encounters in the electronic Patient Care Report (ePCR). Policy: A clear history of the present illness with chief complaint, onset time, associated complaints, pertinent positives and negatives, mechanism of injury, etc. This should be included in the subjective portion of the PCR. The section should be sufficient to refresh the clinical situation after it has faded from memory. Consider the P-SOAP-delta format for the narrative o P – prearrival information, including delays to scene or factors inhibiting patient access or treatment o S – subjective information (what the patient tells the EMS Provider) o O – objective information (VS, physical exam findings, etc.) o A – assessment (EMS Provider Impression of patient illness as well as differential diagnosis) o P – plan of treatment (EMS Provider interventions planned to administer) o Delta – change in patient condition due to EMS Provider interventions An appropriate physical assessment that includes all relevant portions of a head-to-toe physical exam. When appropriate, this information should be included in the procedures section of the PCR. At least two complete sets of vital signs for transported patients and one complete set for non- transported patients (pulse, respirations, auscultated blood pressure, pulse oximetry at minimum). These vital signs should be repeated and documented after drug administration, prior to patient transfer, and as needed during transport. For Children age < 3, blood pressure measurement is not required for all patients, but should be measured if possible, especially in critically ill patients in whom blood pressure measurement may guide treatment decisions. Only approved medical abbreviations may be used – see Appendix. The CAD to PCR interface embedded within the PCR system should be used to populate all PCR data fields it supplies. When 91-1 center times are improperly recorded, these may be edited as necessary. Medications administered, dosages, route, administration time, treatments delivered and patient response shall be documented. Extremity neurovascular status after splinting affected limb, or all limbs after spinal immobilization shall be documented. For IV administration, the catheter size, site, number of attempts, type of fluid, and flow rate. Requested Medical Control orders, whether approved or denied, should be documented clearly. Any waste of controlled medications should include the quantity wasted, where wasted, and name of the person who witnessed the waste. Hospital personnel should be utilized (if available) to witness. ALL crew members are responsible for, and should review, the content of the PCR for accuracy. After the ePCR is closed, patient care information may not be modified for any reason. Corrections or additions should be in the form of an addendum to the ePCR, with note for the reason of the addendum. When possible, all ePCRs should be completed and the report closed prior to leaving the hospital. If the ePCR cannot be completed and a copy left with a receiving caregiver before departing the hospital, a draft version of the narrative, medications administered and vital signs shall all be given to the receiving team prior to departing. Paper copies of the ECG, DNR paperwork, Skilled Nursing Facility documentation and - when applicable - documentation of refusal to accept an appropriate assessment, treatment, or hospital destination shall be provided to the receiving hospital. If patient transported from the scene with red lights and siren, be sure to document the reason for doing so. Remember – if you didn’t document it, it never happened! Documentation of Patient Care 10 Policies Policies As EMS Providers and out-of-hospital care becomes increasingly more important to the healthcare community, it has brought a focus on the documentation of patient encounters and a need to have a more robust set of standards for the Patient Care Reports generated. The hospitals are sending a clear message to the EMS Providers nationally – what you document is almost as important as what you see and the interventions you make to help your sick and injured patients. To that end, these criteria should help set the standards for documentation and maximize your productivity as members of the healthcare delivery team. At a minimum, every electronic Patient Care Report (ePCR) should include: A Legend EMT A-EMT P Paramedic M Medical Control Documentation of Vital Signs Purpose: To provide guidelines and to set best practice for documentation of vital signs (VS) in the electronic Patient Care Report (ePCR). Policy: Vital Signs (VS) play a critical role in patient assessment and evaluations, and must be documented in the ePCR for any patient. An initial complete set of VS includes Pulse Rate, Systolic AND Diastolic Blood Pressure (may substitute cap refill for children <3 years), Respiratory Rate, SpO2, Pain and GCS for trauma patients. If no interventions are made during EMS Provider evaluation and management (including IV Fluids, dextrose and naloxone), palpated Blood Pressures are acceptable for REPEAT VS. Based on the patient condition, complaint and/or treatment protocol used, VS may also include Temperature, EtCO2, Level of Awareness If the patient refuses EMS evaluation, an assessment of capacity must be completed AND documented in the ePCR. Detailed documentation should be captured regarding the patient’s clinical presentation, reason for refusing (if known) and the refusal process in the ePRC narrative. Be sure to capture the names of family members, Law Enforcement personnel or other EMS personnel who are present for this conversation and evaluation. Any abnormal VS should be followed closely, and repeated as indicated by change in patient subjective status or clinical condition. Remember – if you didn’t document it, it never happened! ~ This Space Intentionally Left Blank ~ Documentation of Vital Signs 11 Policies Policies For children, the need for Blood Pressure measurement should be determined on a case-by-case basis, considering the clinical condition of the child and the EMS Provider’s rapport with the patient. Every effort should be made to document Blood Pressure, particularly in critically ill patients, or cases where treatment decisions are guided by VS and/or changes in VS. A Legend EMT A-EMT P Paramedic M Medical Control Domestic Violence (Spousal and/or Partner Abuse) Recognition and Reporting Purpose: To provide guidelines and resources for the EMS Provider who encounters suspected and/or confirmed cases of domestic violence while on duty. Policy: Domestic Violence is physical, sexual or psychological abuse and/or intimidation which attempts to control another person in a current or former family, dating or household relationship. The recognition, appropriate reporting and referral of abuse is an essential step to improving patient safety, providing quality care and preventing further abuse. Effective management of a case of suspected abuse or neglect is based upon the following: Protect the patient from harm Suspect that the patient may be a victim of abuse, especially if the illness/injury is not consistent with the reported history Respect the privacy of the patient and the family Collect as much information as possible, and preserve physical evidence There are many subtle signs of abuse that may be missed without a high index of suspicion. Some include: Psychological cues – excessively passive in nature, fearful behavior, excessive aggression, violent tendencies, excessive or inappropriate crying, substance abuse, medical noncompliance or repeat EMS requests for seemingly minor problems. Physical cues – injuries inconsistent with the reported mechanism, defensive injuries (i.e. forearms), injuries during pregnancy are suggestive of abuse. Multiple bruises and injuries in various stages of healing may also suggest repeated violence against the victim. Signs of neglect – inappropriate level of clothing for weather, poor hygiene, absence of and/or inattentive caregivers, poor living conditions and physical signs of malnutrition. For Suspected Domestic Violence – EMS Providers should attempt in private to provide the victim with the Dane County Domestic Abuse Intervention Services (DAIS) helpline, (608) 251-4445 or (800) 747-4045. Both numbers are available 24 hours per day. EMS Providers may also provide the National Hotline (800) 799-SAFE (7233) Depending on the situation, transport should be considered regardless of the illness or injury, so that the victim may receive the expert consultation and additional services that are available in the Emergency Department See the Dane County Domestic Abuse Intervention Services (DAIS) website for additional information as necessary: http://www.abuseintervention.org ~ This Space Intentionally Left Blank ~ Domestic Violence (Spousal and/or Partner Abuse) Recognition and Reporting 12 Policies Policies Any findings of abuse or neglect OR suspicion of abuse or neglect must be handled with sensitivity and delicacy by the EMS Provider. Provision of emotional support is key, without passing judgment on the victim or alleged perpetrator of domestic violence. Discretion should be a high priority, and when possible questions regarding abuse and safety should be done in private. Offering the resources below to the patient may feel awkward at the time, but are excellent resources and may be used at any time in the future. Have a low threshold to transport patients of suspected or confirmed domestic violence, as they may not have other means of escaping their assailant and accessing resources that may be available at the hospital. A Legend EMT A-EMT P Paramedic M Medical Control Emergent Interhospital Transfers Purpose: To provide guidelines for EMS Provider expectations and medical care of patients during emergent transfer between Hospitals. This Policy does not supersede or replace existing EMTALA regulations. This Policy is not intended to authorize services or care that are not part of an EMS Services’ operational plan with the State of Wisconsin. Rather, it is intended to provide guidance for the rare but forseeable circumstances when a critically ill or injured patient may need to be rapidly moved to a higher level of care, and time is of the essence. Policy: In general, Dane County EMS Providers should only perform Emergent Interhospital Transfers for Time Critical Diagnoses (TCDs), usually involving patients requiring management at a specialty care facility (Trauma, STEMI, Stroke, Pediatrics, OB) when an authorized service is not available within a reasonable amount of time. Dane County EMS Providers may also be called upon to assist with Emergent Interhospital Movement of patients during large-scale or Mass Casualty Incidents (MCIs), or during a situation necessitating the implementation of Crisis Standards of Care – in these cases, there is likely to be heavy involvement of the Dane County Medical Director as well as each of the EMS Service Medical Directors (or their designees) to help provide realtime guidance on how to proceed. Emergent Interhospital Transport decisions should be made based on the needs of the patient(s), any expected changes in their clinical condition and the familiarity / comfort level of the responding EMS Providers with the clinical situation as well as any medications or devices being used. If a patient has unstable vital signs prior to departure from the sending facility, the EMS Provider responding is not knowledgeable of the medications being administered and/or the medications infusing are not in the Wisconsin Scope OR on an IV pump with inadequate reserve to last the anticipated duration of the transfer, it is the responsibility of the referring hospital to supply an additional provider. The additional provider shall be credentialed at the RN level or higher, familiar with the medications and devices to accompany the patient AND present for the entire transfer to the receiving facility. If there is any difficulty with this provision, the Service EMS Supervisor should be contacted immediately for guidance on how to proceed. Communication and coordination between hospitals and EMS Providers is essential before an Emergent Interhospital Transfer is initiated to ensure patient safety and the appropriate medical management en route between the hospitals. A clear plan for responsibility of patient care while moving between facilities should be in place prior to departing the transferring hospital. In general, if the patient unexpectedly deteriorates while en route, the transferring facility should be notified, but the receiving facility should be contacted for additional Medical Control orders. The standing Dane County Protocols in this book may be followed as situation appropriate until Medical Control can provide further direction. Unless there are extenuating circumstances (i.e. Mass Casualty Incident, Crisis Standards of Care), any Dane County EMS Service performing an Emergent Interhospital Transfer should only deliver patients to the Emergency Department of the receiving facility, where additional interventions and coordination of care may take place. As with any Protocol, contact On-Line Medical Control with any questions or concerns. ~ This Space Intentionally Left Blank ~ Emergent Interhospital Transfers 13 Policies Policies If a Dane County EMS Provider is contacted for the Emergent Interhospital Transfer of a non-TCD patient, contact your Service EMS Supervisor for consultation prior to responding and transporting the patient. A Legend EMT A-EMT P Paramedic M Medical Control Lights and Siren During Patient Transport Purpose: To provide guidelines for the appropriate use of red lights and siren when transporting a patient from the scene of an emergency to the hospital. This Policy intends to help identify patients for whom safe use of red lights and siren can potentially reduce morbidity and mortality, and eliminate the unnecessary use of emergency lights and siren during transport to improve patient comfort, reduce anxiety and enhance safety for the patient, the EMS team and the Dane County community. At the discretion of the ambulance crew, driving with lights and siren may be considered if the following clinical conditions or circumstances exist: Difficulty in sustaining the ABCs (airway, breathing, circulation) including (but not limited to): Inability to establish an adequate airway or ventilation. Severe respiratory distress or respiratory injury not responsive to available field treatment. Acute coronary syndrome with one or more of the following: ST elevation in two or more contiguous leads, acute congestive heart failure (CHF), hypotension, bradycardia, wide complex tachycardia, or other signs of impending deterioration. Cardiac dysrhythmia accompanied by signs of potential or actual instability (hypotension, acute CHF, altered level of consciousness, syncope, angina, resuscitated cardiac arrest), which is unresponsive to available field treatment. Severe uncontrolled hemorrhage. Shock, unresponsive to available treatment. Severe trauma including (but not limited to): Penetrating wounds to head, neck, and torso. Two or more proximal long bone fractures. Major amputations (proximal to wrist or ankle). Neurovascular compromise of an extremity. Multi-system trauma. Severe neurological conditions including (but not limited to): Status epilepticus. Substantial or rapidly deteriorating level of consciousness. For a suspected stroke where a significant reduction of time to receive thrombolytic therapy can be achieved and the patient meets treatment inclusion criteria. Obstetrical emergencies including (but not limited to): labor complications that threaten survival of the mother or fetus, such as: prolapsed cord, breech presentation, arrested delivery, or suspected ruptured ectopic pregnancy. For any transport where reducing time to definitive care is clinically indicated, consider options other than emergent driving. In these cases, an alternative mode of transportation or higher level of care (such as ALS intercept or air-medical) should be considered if it is available and appropriate. Critical-care level emergent interhospital transport patient transports should not automatically be handled as lights and siren events. Clinical judgement and the patient criteria listed above should be applied on transfers to determine the level of urgency and transport mode. When a physician or nurse attempts to order lights and siren transport for a patient when it is believed by the crew to be contraindicated, attempt to resolve the issue with the ordering physician/nurse. If necessary, contact Medical Control to assist in resolving the issue. For any lights and siren transport, specifically document in the narrative the patient’s condition, case circumstances and the rationale for choosing emergent transport. Lights and Siren During Patient Transport 14 Policies Policies Policy: A Legend EMT A-EMT P Paramedic M Medical Control Non-Paramedic Transport of Patients Purpose: To provide guidelines for interactions of EMS Providers while on scene, and to help guide determination of the most appropriate level of service to transport patients to the Emergency Department. This policy is intended to clarify expectations of providers on scene during situations when multiple levels of provider with transport capability arrive concurrently. It is NOT intended to be used as justification for refusal of transfer to a Paramedic level of service when a lower level is requesting it. Policy: For the purposes of this Policy, “Paramedic” refers to a Dane County EMS System credentialed Paramedic with no current restrictions on their clinical practice. The provider with the highest level of Dane County EMS System credentialing on scene will conduct a detailed interview and physical assessment of the patient to determine the chief complaint and level of distress. If the provider determines that the patient is stable and ALL patient care needs can be managed by an EMS Provider at a lower level than Paramedic, then patient care may be transferred and transport initiated AND/OR completed by the lower level provider. All personnel are encouraged to participate in patient care while on-scene, regardless of who “attends” with the patient while en route to the hospital. The highest credentialed EMS Provider who performs the assessment and determines the appropriate level of care for transport must document the findings of their assessment. Additional documentation shall be completed by the transporting provider. As with all documentation, both providers are responsible for the content of the report. Patients who meet the criteria below shall be attended by Paramedics (per their operational plan) in the patient care compartment, unless mass casualty incident, natural disaster or previously approved by policy or the On-Line Medical Control. The care of the following patients cannot be transferred to a lower level of credentialing: Any patient who requires or might reasonably require additional or ongoing medications, procedures AND/OR monitoring beyond the scope of practice of the lower credentialed provider. This includes any critically ill or unstable patient as advanced airway management may be required in any decompensating patient. EMT-Basic and EMT-Advanced providers may be credentialed to perform some but not all airway management, and medications associated with airway management are limited to the Paramedic scope of practice by the Wisconsin State Medical Board. Any patient for whom ALL EMS providers on scene do not agree can be safely transported without a Paramedic in attendance in the patient care compartment. As a general rule, if providers are questioning who should attend the patient, the highest credentialed level of care should attend. Any patient suffering from chest pain of suspected cardiac origin, cardiac dysrhythmia, moderate to severe respiratory distress, multiple trauma or imminent childbirth. Post-ictal patients with high probability of recurrent seizure. Patients who have been medicated on the scene cannot be transferred to a provider of a lower credentialing level UNLESS the provided medication is included in the receiving EMS Provider’s scope ~ This Space Intentionally Left Blank ~ Non-Paramedic Transport of Patients 15 Policies Policies The determination of who attends should be based on the patient’s immediate treatment needs and any reasonably anticipated treatment needs while en route to the hospital. The highest credentialed provider on scene retains the right to make the decision to personally attend to any patient transported based on his or her impression of the patient’s clinical conditions, current needs or anticipated needs based on the EMS Provider’s evaluation and experience. A Legend EMT A-EMT P Paramedic M Medical Control Paramedic Intercept Guidelines Purpose: To outline circumstances in which an Advanced Life Support (ALS) Service should be requested for intercept with a non-ALS level Service. Policy: The situations listed below are not all-inclusive, but are intended to serve as examples of when a higher level of care would be appropriate for advanced interventions and patient safety. In addition to advanced skills and additional medication options, Paramedics also bring an experience with critically ill and injured patients, and can assist with the safe evaluation and destination determination process. While the care of the patient should be the top priority of all providers in the Dane County System, many factors go into the decision to request an ALS intercept. Time of day, traffic conditions, weather and proximity to appropriate medical care all may be considered when making the decision. When possible, arrangements may be made to rendezvous with an ALS service while en route to the hospital, so that the delay to advanced skills and medications may be minimized. Cardiopulmonary Arrest Altered Mental Status not explained by simple hypoglycemia or opiate overdose Severe Respiratory Distress AND/OR Impending Airway Compromise Multi-System Trauma Unstable or Deteriorating Vital Signs Chest Pain with Hemodynamically Compromising Dysrhythmia ST-Segment Elevation MI with Hypotension, Altered Mental Status or Impending Cardiac Arrest Complex Seizures (First Seizure without History, Seizure After Head Injury, Recurrent Seizure without Return to Baseline) Allergic Reaction assessed to be ‘Severe’ or ‘Impending Cardiac Arrest’ Asthma Exacerbation not improving after Albuterol OR Requiring Multiple Nebs Complications of Childbirth Mass Casualty Incident Any Situation that the Dane County EMS Provider OR Medical Control feels warrants ALS Evaluation and Management We are all working together to get the right patient to the right level of care at the right time! ~ This Space Intentionally Left Blank ~ Paramedic Intercept Guidelines 16 Policies Policies Some examples of patients that may benefit from ALS level evaluation and management include but are not limited to; A Legend EMT A-EMT P Paramedic M Medical Control Patient Care During Transport Purpose: To provide general guidelines and to set best practice when caring for patients both on the scene of an emergency as well as in the ambulance during transport to the receiving facility. Policy: All sick or injured persons requesting transport shall be transported without delay to the most appropriate Emergency Department, with high consideration given to patient preference. Exceptions to this policy are as follows: The following situations shall require more than one EMS Provider in the passenger compartment of the transporting vehicle, to provide adequate medical care. The additional provider(s) is/are present not only to serve as additional “hands”, but to expand the critical thinking of the team and to help optimize patient outcomes. For these circumstances, students with the current training permit may assist with patient care, but may NOT count as one of the additional EMS Providers. Cardiac Arrest of Medical OR Traumatic etiology Post Resuscitation Return of Spontaneous Circulation (ROSC) patients, even if Vital Signs are stable Active Airway Management, regardless of modality chosen (Endotracheal Tube, Blindly Inserted Airway Device (BIAD) or BagValve Mask (BVM) Impending Arrest or “Peri-Code” Situation Imminent Delivery Newly Born Patients (Mother and Newborn count as two patients, and require an attendant for each) At the Attending EMS Provider’s Judgement, for cases not covered above If a second EMS Provider is not available and transport would be delayed, initiation may be started under these two circumstances: An Advanced Care Intercept (Ground ALS or HEMS) has been contacted and arrangements made for rendezvous en route OR The case has been reviewed with On-Line Medical Control (OLMC) AND approval granted ~ This Space Intentionally Left Blank ~ Patient Care During Transport 17 Policies Policies An “appropriate local Emergency Department” includes all Dane County Emergency Departments as well as hospitals in contiguous counties as designated in this Procedures and Protocols Handbook. The ability of a patient to pay or the insurance status (if known) should not play a part in this decision. If EMS Unit availability will be a concern due to requested destination, contact your Service EMS Supervisor prior to initiating transport. All sick or injured persons requesting transport who do not express a preference or who rely on the knowledge of the EMS Provider should be transported to the closest, most appropriate local Emergency Department. Patients who are suffering from a Time Critical Diagnosis (TCD) or a condition covered under the Destination Determination Protocols should be transported in accordance with the specialty resource required by the treatment flowchart. All other patients should be transported per the policy statement above. Transport destination decisions should take into consideration the preexisting healthcare relationships that a patient may have. In general, a patient should be taken to the hospital at which they typically receive care and/or where their primary care physician has affiliation, unless the patient expressly requests otherwise. Providers should discuss risks and benefits of transport to a facility that has not previously cared for the patient, and document the discussion clearing in the electronic Patient Care Report (ePCR). A Legend EMT A-EMT P Paramedic M Medical Control Patient Without A Protocol Purpose: To ensure the provision of appropriate medical care for every patient, regardless of presenting problem or medical condition. Policy: Any person requesting EMS service shall receive a professional evaluation, treatment and transportation as necessary in a systematic, orderly fashion regardless of the chief complaint, medical condition or ability to pay. Medical evaluation and management for all patient encounters that can be triaged into a Dane County EMS Protocol shall be initiated and conducted as per the standing protocols. When confronted with an emergency situation or patient condition that does not fit into an existing Dane County EMS Protocol, evaluation and management of the patient should be started under the General Approach – Adult, Medical OR General Approach – Peds, Medical Protocols, as appropriate. On-Line Medical Control should be contacted for consultation as soon as possible for further direction and instructions on patient management within your scope of practice. Policies Policies ~ This Space Intentionally Left Blank ~ Patient Without A Protocol 18 A Legend EMT A-EMT P Paramedic M Medical Control Physician On Scene Purpose: To define the responsibilities of EMS Providers responding to an emergency scene, to identify the chain of command and to prevent potential conflicts regarding patient care that may arise during EMS evaluation and management when a licensed physician is on scene. No other healthcare professionals are permitted to provide medical direction under this policy. This policy is not intended to apply to Service Medical Directors. Policy: Provide photo identification verifying his/her current credentialing as a physician (MD/DO) AND a current copy of his/her license to practice medicine in the State of Wisconsin AND Assume care of the patient AND allow documentation of of his/her assumption of care on the electronic Patient Care Report (ePCR), as verified by his/her signature, AND Agree to accompany the patient during transport to the receiving hospital AND Not appear to be impaired or under the influence of drugs, alcohol or medical conditions AND Explicitly express willingness to accept liability for the care provided to the patient under their personal medical license Contact with Medical Control must be established as soon as possible, and the Medical Control Physician must agree to relinquish responsibility for patient care to the Physician On Scene. Once care has been transferred from the On-Line Medical Control to the Physician On Scene, the EMS Provider may provide care under the license and authority of the Physician On Scene. Direction provided by the Physician On Scene assuming care of the patient should be followed by the EMS Provider, granted that the interventions are not believed by the EMS Provider to endanger the well-being of the patient. Orders received from an authorized (as determined by this Policy) Physician On Scene may be followed, even if they conflict with existing local protocols, provided the orders encompass skills AND/OR medications approved by both the Dane County Medical Advisory Subcommittee and the Wisconsin State Medical Board for a provider’s level of credentialing. Under no circumstances shall EMS Providers perform procedures or give medications that are outside of their scope of practice AND/OR credentialing. Conflict with Physician On Scene: If the Physician On Scene is judged by the EMS Provider on scene to be potentially harmful or dangerous to the patient, the EMS Provider should politely voice their objection, and immediately contact On-Line Medical Control for further assistance. On-Line Medical Control should be briefed by the EMS Provider, and the Physician On Scene allowed to communicate directly with the OnLine Medical Control. When at all possible, these conversations should be held on a recorded line. If the Physician On Scene and On-Line Medical Control are in conflict, it is the responsibility of the EMS Provider to: Follow the directions of On-Line Medical Control Enlist the aid of Law Enforcement as necessary to regain control of the emergency scene and resume authority of the scene Documentation: All interactions with Physicians On Scene must be thoroughly documented in the electronic Patient Care Report (ePCR), including the full name and medical license number of the Physician On Scene, as well as the interventions performed at their direction. Physician On Scene 19 Policies Policies The medical evaluation and management of patients at the scene of an emergency is the responsibility of the person most appropriately trained in emergency medical care. As an agent of the EMS Service Medical Director and operating under the Dane County EMS Protocols, the EMS Provider routinely fills this role. Occasions may arise when a physician on scene may wish to deliver care to a sick or injured patient, or to direct EMS personnel in medical management. In order for a physician to assume care of a patient, they MUST: A Legend EMT A-EMT P Paramedic M Medical Control Poison Control Purpose: To provide guidelines for involving Poison Control with out-of-hospital management of patients with potential or actual poisonings. Policy: Patients who have sustained significant poisonings, envenomations, and environmental/biochemical terrorism exposures in the out-of-hospital setting require timely and appropriate level of care, including the decisions regarding scene treatment and transport destination. By integrating the State Poison Center into the out-of-hospital response plan for HazMat and biochemical terrorism incidents, this policy aims to empower the out-of-hospital care provider and enhance the ability to deliver the most appropriate care to the patient possible. If the patient is assessed by the EMS Provider and no immediate life threat or indication for immediate transport is identified, the EMS Provider may conference call with the Poison Center at the Wisconsin State Poison Center at 1 (800) 222-1222. If EMS transport is determined to not be necessary, the contact phone number for the patient will be provided to the Poison Center. The Poison Center will make a minimum of one follow-up phone call to determine the status of the patient. Additionally, the EMS Provider must contact On-Line Medical Control to review the case and discuss the recommendations of the Poison Center and what is believed to be in the best interest of the patient. As detailed elsewhere in this document, exposures and/or poisonings that are the result of suicide attempts or gestures, or children who sustain an exposure and/or poisoning due to child abuse or neglect SHOULD NOT be allowed to refuse transport. These are both vulnerable populations who are at an increased risk of death or permanent disability if not cared for appropriately. As always, good Provider judgment and patient advocacy will be the cornerstones of making sound, defensible patient treatment decisions. In any cases of poisoning, whether accidental, intentional or the consequence of a bioterrorism event, the safety of the First Responders should be of the highest priority. At a minimum, the following information should be gathered so that the Poison Center can make the best recommendations for the current situation Age of the patient Substance(s) involved with the exposure (if known) Time and Duration of exposure (if known) Signs and Symptoms Any Treatments provided and the response to the intervention As with many of the EMS Protocols, a significant amount of information is collected by the EMS Providers on scene and can be extremely valuable for downstream providers. Be sure to notice and document HazMat placards in cases of transportation incidents, any MSDS sheets available in the industrial / manufacturing setting, or the contents and volumes of products / substances present in the cases of household ingestion. ~ This Space Intentionally Left Blank ~ Poison Control 20 Policies Policies The Poison Center will help evaluate the exposure and make recommendations regarding the need for on-site treatment and hospital transport in a timely manner. If EMS transport to the hospital is determined to be necessary, the Poison Center will contact the receiving hospital and provide information regarding the poisoning, including treatment recommendations. EMS may also contact On-Line Medical Control for further instructions or for treatment options. A Legend EMT A-EMT P Paramedic M Medical Control Patients in Police Custody Purpose: To provide guidelines for the evaluation and management of patients requiring EMS assessment while in the custody of Law Enforcement. As with every patient interaction, it is important that the EMS Provider serve as a patient advocate and use their best medical judgment to assist Law Enforcement in making safe, appropriate decisions regarding medical aid and disposition decisions. Policy: As a general rule, when evaluating a patient who is in the custody of Law Enforcement, the EMS Provider should approach the patient with the same respect and consideration as patients who are not being detained. While EMS is not equipped or authorized to provide “Medical Clearance” before transport to jail, it is the responsibility of the EMS Provider to provide an unbiased assessment and to make recommendations based on Dane County Protocols as well as EMS Provider experience and judgment. If a patient in custody of Law Enforcement is evaluated by EMS and felt to need transport to the Emergency Department and the patient is refusing transport: Evaluate the capacity of the patient to make informed decisions as outlined in the Dane County Protocols Advise the Law Enforcement Agent of the decision of the patient, and consider potential risks or hazards to Law Enforcement if the patient were to refuse (i.e. lacerations that may pose a biohazard to officers or other detainees) If Law Enforcement requests transport, document their request and coordinate safe transport to the closest, most appropriate Emergency Department. In these instances, the Law Enforcement Agent must take the patient into Protective Custody and effectively making decisions as the healthcare power of attorney for the patient. Document that Law Enforcement has taken Protective Custody of the patient. In this instance, the Law Enforcement Agent must accompany the patient to the Emergency Department. If the patient is evaluated to have capacity and does not pose an undue risk to Law Enforcement, execute a Patient Refusal as outlined in the Dane County Protocols If a patient in custody of Law Enforcement is evaluated by EMS and felt to need transport to the Emergency Department and the Law Enforcement Agent is refusing transport: Advise the Law Enforcement Agent that transport is indicated by Dane County Protocols, and that medical clearance is not authorized by EMS Personnel in the field. Contact On-Line Medical Control for consultation and assistance as needed. If Law Enforcement continues to decline transport for medical evaluation and management, allow the patient to remain in the custody of the Law Enforcement Agent, and advise them that EMS may be re-contacted at any time to provide medical assistance as needed The Law Enforcement Agent in these situations is taking the patient into Protective Custody and effectively making decisions as the healthcare power of attorney for the patient. Document that Law Enforcement has taken Protective Custody of the patient. Document the Law Enforcement Agency as well as the name and badge number of the responsible officer along with specifics of the discussion in your electronic Patient Care Report (ePCR). If a patient in custody of Law Enforcement requires transport to the Emergency Department and is requiring physical restraint by the Law Enforcement Agent for behavior modification: Advise the Law Enforcement Agent that Dane County EMS Policy requires their accompaniment in the patient compartment of the ambulance during transport to the Emergency Department. With active restraints in place, it is an issue of patient safety as well as provider safety Consider the Behavioral Emergencies Protocol in the Dane County Protocol book, OR contact On-Line Medical Control for advice regarding medication management as appropriate to assist with safe and expeditious transport Patients in Police Custody 21 Policies Policies These patient encounters have a higher than average incidence of scrutiny on review; as such, take steps to ensure that your documentation is clear, descriptive and complete. Law Enforcement Agent names and badge numbers are essential in the EMS Provider documentation. A Legend EMT A-EMT P Paramedic M Medical Control Radio Report Format Purpose: To provide guidelines for clear communication between EMS Providers and receiving facilities prior to delivery of the patient. Policy: For all patients being transported to the hospital by EMS, every effort should be made to contact the receiving facility as early as possible once the destination facility has been chosen and transport initiated. By making proactive contact with the receiving facility, it provides the opportunity to collect personnel, resources and equipment that may be needed to care for critically ill or injured patients, and thereby improve patient survival and realization of the EMS mission. Procedure: Begin each transmission with the agency name and unit number, and wait for acknowledgement from the receiving facility. After the receiving facility acknowledges contact with your unit, give a clear, concise report which includes the following: Triage category and triage color Triage Category Triage Color Definition Common Examples (NOT All-Inclusive List) Red High acuity of illness, unstable VS or critically ill Hypotension, Extreme Tachycardia, Multiple Medications (other than Albuterol), Airway Management, Altered Mental Status, Failure to Respond to EMS Therapy Yellow Serious medical illness with potential to decompensate, but VS currently stable COPD improving with nebs, Chest Pain with Cardiac History, Abdominal Pain in Pregnancy, Fever without hypotension or tachycardia (not believed to be sepsis) Green Low acuity medical illness, VS stable Hypoglycemia resolved with Dextrose, Intoxication without airway compromise or indication of trauma Peds <12 years of age OR absence of sigs of puberty / secondary sex characteristics Red Severe mechanism of injury, life or limb threatening injury Traumatic injury with hypotension, tachycardia, uncontrolled/poorly controlled hemorrhage, Altered Mental Status, pain not improving with EMS Intervention Yellow Serious mechanism of injury, potential for decompensation but VS currently stable Head Injury with anticoagulant use, deformed extremities after trauma, significant pain improved after EMS intervention Green Minor mechanism of injury, no outward signs of trauma, VS stable Head Injury without LOC or Altered Mental Status, Traumatic Extremity pain with intact CMS and without deformity Trauma Peds <18 years of age STEMI ALERT Red STEMI Interpretation of Field ECG (EMS or Monitor) **Call with early notification** Goal time for first EMS Contact to balloon time <90 minutes STROKE ALERT Red Focal Neurologic Deficit with Last Known Normal <9 Hours Include collateral information, bring witnesses to corroborate history when/if appropriate Estimated time of arrival (ETA) Age and Chief Complaint of the patient Very brief background of events including: Mechanism of injury and description of injuries found (if traumatic) Provider Primary Impression and nature of patient complaint (if medical) Treatments provided and/or underway as well as patient response Current Vital Signs including GCS Any anticipated delay in transport (i.e. extrication) Contacting Medical Control Medical Control may be contacted for any additional orders, to consult as needed for patients refusing transport and for any questions regarding patient management on scene or en route to the receiving facility. Any orders given should be repeated back for clarification and patient safety. Make sure your request of Medical Control is clearly communicated, and be prepared to answer follow up questions regarding the protocol you are following as well as your assessment of the situation. Several protocols have suggested medications and dosages outlined in the protocol, to help facilitate the conversation with Medical Control Remember: you are the one who has the patient in front of you – your assessment and impression matter! Radio Report Format 22 Policies Policies Medical A Legend EMT A-EMT P Paramedic M Medical Control Termination of Resuscitation Purpose: To provide guidelines for discontinuation of resuscitative efforts in the out-of-hospital environment, when attempts have not resulted in Return Of Spontaneous Circulation (ROSC). Policy: The successful resuscitation of an out-of-hospital cardiac arrest requires a very well coordinated team effort, aggressive management of malignant dysrhythmias and thoughtful consideration of the reversible causes of cardiac arrest (the proverbial H’s and T’s). Unfortunately, there are a significant number of patients that – despite appropriate and aggressive medical management – are not able to achieve ROSC in the field. This policy is evidence driven and based on best practice, and it is intended to provide guidance for arrests when it is more prudent to stop resuscitation efforts than to risk provider and public safety with a patient transport. If ALL 7 criteria above are NOT met, the ACLS algorithm must be followed for a minimum of 20 minutes and then Medical Control contacted for approval of field termination of resuscitation if the patient does not achieve ROSC. The EMS Provider always has the discretion to continue resuscitative efforts if provider safety, scene safety, location of arrest or bystander input compels the decision. Resuscitative efforts should not be discontinued once the patient has been moved to the ambulance or if transport has been initiated. In these instances, resuscitation should continue to be attempted as per the AHA ACLS algorithms and the Dane County Protocols, with the ultimate disposition decision determined by the receiving facility upon arrival. As there currently are no reliable, evidence based criteria for field termination of resuscitation in the pediatric population, this Policy is for use in the ADULT population ONLY (defined as >18 years of age for this policy). All pediatric cardiac arrest cases should follow the PALS and Dane County Pediatric Cardiac Arrest algorithms, and transported in compliance with the Dane County Pediatric Destination Determination Protocol. ~ This Space Intentionally Left Blank ~ Termination of Resuscitation 23 Policies Policies This policy may ONLY be considered by EMT-Paramedics without Medical Control contact if ALL of the criteria below are met: 1. The patient is an ADULT (>18 years of age) and the arrest is presumed to be of a primary cardiac origin 2. The initial rhythm on patient contact is asystole, and is confirmed in at least two leads on a printed strip 3. The American Heart Association ACLS algorithm for cardiac arrest has been followed for a minimum of 20 minutes 4. A minimum of 4 doses of epinephrine have been administered, as per the ACLS and Dane County Cardiac Arrest algorithms 5. The airway has been secured with either an Endotracheal Tube (ETT) OR Blindly Inserted Airway Device (BIAD), and confirmed by digital capnography 6. The quantitative End-tidal CO2 (EtCO2) is <10mmHg despite effective compressions and after 20 minutes of ACLS 7. The final rhythm is asystole, and is again confirmed in at least two leads on a printed strip A Legend EMT A-EMT P Paramedic M Medical Control Transfer of Care at Hospital Purpose: To provide guidelines for in-person communication with receiving facilities, and to clarify expectations of EMS Provider documentation. Policy: When delivering a patient to the receiving facility, it is imperative that a clear, concise communication happen between the EMS Provider and the emergency medical staff assuming care. In order to prevent miscommunication, a full verbal report should be communicated in a face-to-face fashion, preferably with the entire medical team assembled at the patient bedside. On the occasion that the complete team is not available, verbal report should be given to a receiving caregiver credentialed at the RN level or higher. Verbal Report Verbal report at the time of handoff shall include all pertinent known information about the patient, the history of present illness or mechanism of injury, treatments administered by EMS Providers as well as the patient’s responses to treatment. In addition, all prehospital ECGs and provided paper medical records should be turned over to the treatment team assuming care. Written Report Wisconsin DHS Administrative Rule 110.34(7) specifically addresses EMS responsibility for written patient report at the time of handoff at the receiving facility. The rule states: An emergency medical service provider shall, “...submit a written report to the receiving hospital upon delivering a patient, and a complete patient care report within 24 hours of patient delivery. A written report may be a complete patient care report or other documentation approved by the department and accepted by the receiving hospital.” The expectation is that there will be written documentation left at the receiving facility, and conveyed either in printed or electronic format prior to your departure and returning available to service. It is not required that the documentation left at the facility be the completed, finalized electronic Patient Care Report (ePCR). HOWEVER, all EMS Providers in Dane County are integral members of the healthcare team, and may hold key pieces of information not available to any of the downstream providers and which are at significant risk of being lost, overlooked or miscommunicated if not documented in a prompt manner. Given the nature of EMS and out-of-hospital care, it should be the goal of every Dane County EMS Service at minimum to have a draft narrative, list of the EMS interventions, medications given and vital signs documented prior to leaving the facility and returning to duty. ~ This Space Intentionally Left Blank ~ Transfer of Care at Hospital 24 Policies Policies All treatments and interventions initiated under the Dane County Protocols may be continued after arrival in the receiving facility up until the appropriate personnel and equipment are assembled to assume care of the patient. At that time, responsibility for all medical care and continued treatment is transferred to the facility, and the Dane County EMS Protocols are no longer authorized for patient management. On-Line Medical Control should not be contacted for additional orders once this handoff has occurred. In the rare circumstance that the EMS Provider is requested/invited to participate, direction will be at the authorization and the discretion of the supervising on-scene physician. It is important that the involvement, orders received and name of the responsible physician be captured in the electronic Patient Care Report (ePCR) as part of the medical care provided by EMS. A Legend EMT A-EMT P Paramedic M Medical Control Persons with EMS Care Plans Purpose: To establish a uniform approach for the evaluation and management of persons having an established Care Plan, developed by the EMS Service and approved by the Medical Director. Policy: All sick or injured persons requesting transport shall be transported without delay to an appropriate local Emergency Department of the patient’s preference. The only exceptions to this rule are found below: There may be exceptions to this guideline, and if there are questions while evaluating a patient with a Care Plan, do not hesitate to contact the Officer In Charge (OIC) or the Medical Director or Medical Director’s designee for clarification. ~ This Space Intentionally Left Blank ~ Persons with EMS Care Plans 25 Policies Policies Patients who are suffering from a Time Critical Diagnosis (TCD) or whose condition is covered under the Destination Determination Protocols shall be transported in accordance with those specialty algorithms to the appropriate receiving facility. The presence of a Care Plan DOES NOT supersede the Destination Determination Protocol. Patients known to have been discharged from an Emergency Department within the last 48 hours should generally be transported back to the same ED, unless they meet specialty center destination criteria, as outlined in the Destination Determination Protocol. Patients who have been identified as frequent users of the EMS System may have a designated Care Plan, which has been developed with the patient and/or their healthcare providers, the EMS Service and one or more of the Dane County hospitals. If a patient has a formal Care Plan approved by the EMS Service Medical Director, the patient should be evaluated, treated and transported in accordance with the Plan, unless the patient meets criteria for transport to a specialty receiving center, as outlined above. Regardless of the existence of a Care Plan, all patients should be treated with respect and dignity, and fully evaluated as per the standards set forth in this Protocol Book. A Legend EMT A-EMT General Approach – Adult, Medical P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Source of blood loss, if any (GI, vaginal, AAA, ectopic) Source of fluid loss, if any (vomiting, diarrhea, fever) Pregnancy history Mental Status Pale, Cool Skin Delayed Cap Refill Coffee Ground Emesis Tarry Stools Allergen Exposure Differential Cardiac Dysrhythmia Hypoglycemia Ectopic Pregnancy AAA Sepsis Occult Trauma Adrenal Insufficiency Assessment Scene All Patients should remain Nothing By Mouth (NPO) Unless Specified by Treatment Protocol Patient Safety Unsafe Insufficient Stage, Call for Law Enforcement and/or Additional Resources Presentation OR Traumatic Mechanism PPE No Sufficient Check for Pulse Yes Go To Appropriate Adult Trauma Protocol Pulseless, Apneic Go To Cardiac Arrest Protocol p33 Present Hazmat Yes Go To Airway Management Protocol p27 Notify Comm Center, Activate Hazmat Resources Minimize Scene Time, Notify Receiving Facility of Critical Patient Early Obstructed Airway, Ventilations Inadequate Exsanguinating Hemorrhage A,B,C’s Go To Hemorrhage Control Protocol p87 Ventilations Adequate, BP and RR Adequate Support Airway, Support Oxygenation, Support Circulation M Contact Medical Control Doesn’t Fit Protocol, Exhausted Protocol Evaluate and Treat Per Appropriate Medical Protocol Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Nature of Complaint 12-Lead ECG should be done early for any non-traumatic pain complaint between the ear lobes and the umbilicus (belly button). Include Blood Glucose reading for any patient with complaints of weakness, altered mental status, seizure, loss of consciousness or known history of diabetes Measure and document SpO2, EtCO2 for ANY patient with complaint of weakness, altered mental status, respiratory distress, respiratory failure or EMS managed airway If hypotensive ( Systolic BP<100mmHg) and/or clinical evidence of dehydration, consider IV Access Protocol and Shock (Non-Trauma) Adult Medical Protocol Any patient contact which does not result in an EMS transport must have a completed refusal form. Never hesitate to consult medical control for assistance with patient refusals that can’t meet all required fields, clarification of protocols or for patients that make you uncomfortable. General Approach – Adult, Medical 26 Medical Protocols - Adult Medical Protocols - Adult Safe A Legend EMT A-EMT P Paramedic M Medical Control Airway Management - Adult Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of CHF, COPD, Asthma Differential Head Injury Electrolyte Abnormality COPD Exacerbation CHF Exacerbation Lung Sounds before AND after intervention Allergen Exposure Toxic / Environmental Exposure DM, CVA, Seizure, Tox Sepsis Asthma Exacerbation Drug Ingestion / Overdose General Approach – Adult, Medical Anticipate and Prepare for the Difficult Airway Supplemental Oxygen As Appropriate (Nasal Cannula, Facemask) LEMON Rule Look Externally Evaluate with 3:3:2 Rule Mallampati Classification Obstruction Neck Mobility (or lack thereof) Assess A,B,C’s (RR, Effort, Adequacy) Adequate Inadequate Basic Airway Maneuvers (Open Airway, Suction, NPA vs. OPA) Consider Need for ALS Level Service EARLY If obstruction suspected, Go to Airway Obstruction Procedure p142 Assess Mental Status Altered AND/OR Apneic Bag-Valve Mask P x2 Awake OR Protecting Airway Consider Rapid Sequence Airway Protocol p28 Decompensating Consider Blindly Inserted Airway Device (BIAD); Max 2 Attempts Go To Failed Airway Protocol p30 Consider CPAP Procedure IF Awake, Following Commands and SBP >100 p153 M Poor Chest Rise OR Poor Air Exchange Assess Air Movement and Chest Rise Good Chest Rise AND Good Air Exchange Consider Midazolam 1mg IV/IN If needed for CPAP compliance Document Response to Procedure Continuous EtCO2, SpO2 Monitoring Call for ALS Level Service IMMEDIATELY Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Head, Neck, Blood Glucose Digital capnography is the standard of care and is to be used with all methods of advanced airway management and endotracheal intubation. If a service does not have digital capnography capabilities and an Invasive Airway Device is placed, an intercept with a capable service MUST be completed Goal EtCO₂=35-45mmHg If Airway Management is adequately maintained with a Bag-Valve Mask and waveform SpO2 >93%, it is acceptable to defer advanced airway placement in favor of basic maneuvers and rapid transport to the hospital Always assume that patient reports of dyspnea and shortness of breath are physiologic, NOT psychogenic! Treatment for dyspnea is O2, not a paper bag! Gastric decompression with Oral Gastric Tube should be considered on all patients with advanced airways, if time and situation allow Once secured, every effort should be made to keep the endotracheal tube in the airway; commercially available tube holders and C-collars are good adjuncts For all protocols, an Intubation Attempt is defined as passing the tip of the laryngoscope blade or Invasive Airway Device tube past the teeth Airway Management - Adult 27 Medical Protocols - Adult Medical Protocols - Adult Evaluate and Treat Per Appropriate Adult, Medical Protocol A Legend EMT A-EMT Rapid Sequence Airway - Adult P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of CHF, COPD, Asthma Lung Sounds before AND after intervention Allergen Exposure Toxic / Environmental Exposure Airway Management – Adult, Medical P x2 DM, CVA, Seizure, Tox Sepsis Asthma Exacerbation Drug Ingestion / Overdose Indications for Invasive Airway Management Age >18 years old for Paralytic Use Apnea Decreased Level of Consciousness with Respiratory Failure Poor Ventilatory Effort with Hypoxia Unable to Maintain Airway with Noninvasive Methods Burns with Suspected Airway Involvement o Singed Facial Hair o Hoarseness o Wheezing o Subjective Shortness of Breath Consider Rapid Sequence Airway Procedure p143 Preparation (8 Minutes Before Attempt) IV, O2, Continuous Cardiac Monitor, SpO2, EtCO2, BP Check Laryngoscope Bulb, ETT Balloon, Stylet, Syringes Prepare Rescue Airway Device Medications Drawn Up and Labeled Preoxygenate (5 Minutes Before Attempt) 100% O2 x 5 Minutes 8 Vital Capacity Breaths via BVM or NRB Continue Until Airway Secured Contraindications for Invasive Airway Management Medication Hypersensitivities Inability to Ventilate with BVM Suspected Hyperkalemia o History of ESRD, Burns, Crush Injury History Malignant Hyperthermia Myopathy or Neuromuscular Disease Recent Burn (>48 Hours after Burn and <1 week) Recent Spinal Cord Injury (>72 Hours but <6 Months) Pretreatment (3 Minutes Before Attempt) Cricoid Pressure (Sellick’s Maneuver) Lidocaine 1.5mg/kg IV/IO If Head Injury (max 150mg) Paralysis and Induction (0 Minutes Before Attempt) Etomidate 0.3mg/kg IV/IO (max 20mg) OR M Ketamine 2mg/kg IV/IO Unsuccessful Succinylcholine 2mg/kg IV/IO (max 200mg) OR Rocuronium 1.0mg/kg (max 100mg) Placement with Proof (30 Seconds After Attempt) Continuous EtCO2, Auscultation, Chest Rise, Fogging in Tube Secure Device Print capnography strip and document depth Unsuccessful OR Poor Proof Go To Failed Airway, Adult Protocol p30 Post Placement Management (60 Seconds After Success) Notify Receiving Facility, Contact Medical Control As Necessary Go To Post-RSA Sedation Adult p29 Consider Rocuronium 1.0mg/kg IF transport time >10min Pearls REQUIRED EXAM: VS, GCS, Head, Neck, Blood Glucose, Lung Exam, Posterior Pharynx Digital capnography is the standard of care and is to be used with all methods of advanced airway management and endotracheal intubation. If a service does not have digital capnography capabilities and an Invasive Airway Device is placed, an intercept with a capable service MUST be completed If Airway Management is adequately maintained with a Bag-Valve Mask and waveform SpO2 >93%, it is acceptable to defer advanced airway placement in favor of basic maneuvers and rapid transport to the hospital Gastric decompression with Oral Gastric Tube should be considered on all patients with advanced airways, if time and situation allows Once secured, every effort should be made to keep the endotracheal tube in the airway; commercially available tube holders and C-collars are good adjuncts For all protocols, an Intubation Attempt is defined as passing the tip of the laryngoscope blade or Invasive Airway Device tube past the teeth Recent history of Upper Respiratory Infection, Missing / Loose Teeth or Dentures all will increase complexity of airway management Rapid Sequence Airway - Adult 28 Medical Protocols - Adult Medical Protocols - Adult Differential Head Injury Electrolyte Abnormality COPD Exacerbation CHF Exacerbation A Post RSA Sedation – Adult, Medical Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Differential Cardiac Dysrhythmia Hypoglycemia Overdose Toxidrome Mental Status Pale, Cool Skin Delayed Cap Refill Sepsis Occult Trauma Adrenal Insufficiency Rapid Sequence Airway – Adult, Medical Successful Airway Placement Go To Failed Airway Protocol p30 No Monitor VS Closely Notify Receiving Facility, Contact Medical Control As Necessary No Monitor VS Closely Notify Receiving Facility, Contact Medical Control As Necessary Assess and Document BP, HR, SpO2, Continuous Cardiac Monitoring, EtCO2 Signs of Discomfort Yes Patient Still Paralyzed Signs of Discomfort No Yes No Yes Rising BP, Increasing HR, Tearing Systolic BP >120 Yes P Morphine 0.1mg/kg (max 4mg) IV/IO AND Midazolam 4mg IV/IO May Repeat x 2 P Consider Ondansetron 4mg IV/IO Pulling at Lines and Tubes, Coughing or Gagging on Invasive Airway Device, Clinical Signs of Agitation No Improved Comfort Yes P Fentanyl 1mcg/kg (max 75mcg) IV/IO AND Midazolam 4mg IV/IO May Repeat x 2 P Consider Ondansetron 4mg IV/IO No Notify Receiving Facility, Contact Medical Control As Necessary P Consider Ketamine 0.2mg/kg IV/IO (max 20mg) if patient still agitated M Additional Narcotics, Long-Acting Paralytic As Appropriate Pearls REQUIRED EXAM: VS, GCS, Nature of Complaint Paralytics block movement of skeletal muscle but do NOT change awareness. Remember that without sedation, patients may be awake but paralyzed Monitor Vital Signs closely when managing airways and sedation. Changes that indicate pain, anxiety as well as tube dislodgment may be subtle (at first)!! Document Vital Signs before and after administration of every medication to prove effectiveness ANY change in patient condition, reassess from the beginning. Use the mnemonic DOPE (Dislodgment, Obstruction, Pneumothorax, Equipment) to troubleshoot problems with the ET Tube Ketamine may be considered for sedation AFTER standard regimen exhausted AND if Ketamine NOT used as induction agent for intubation Continuous End Tidal CO2 is mandatory for all intubated patients – color change is not sufficient proof of ET Tube in the trachea Post RSA Sedation – Adult, Medical 29 Medical Protocols - Adult Medical Protocols - Adult Yes Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of CHF, COPD, Asthma Failed Airway - Adult Lung Sounds before AND after intervention Allergen Exposure Toxic / Environmental Exposure Differential Head Injury Electrolyte Abnormality COPD Exacerbation CHF Exacerbation DM, CVA, Seizure, Tox Sepsis Asthma Exacerbation Drug Ingestion / Overdose Airway Management Protocol – Adult, Medical Two (2) unsuccessful attempts at RSA by EMT-Paramedic OR Anatomy Inconsistent with Continued Attempts AND Unable to Ventilate or Oxygenate adequately during or after one (1) unsuccessful Intubation Attempt Call for additional resources as available Expedite Transport to closest Emergency Dept. Do NOT spend time on scene Bag-Valve Mask Airway Adjuncts Adjust Positioning Go To Appropriate Medical Protocol SpO2 >93% Unsuccessful M Notify Medical Control (As Practical) P Cricothyrotomy Procedure p156 Yes Significant Facial Trauma / Swelling / Airway Distortion No Blindly Inserted Airway Device (BIAD) Procedure p147 BIAD Successful No M Notify Medical Control (As Practical) P Cricothyrotomy Procedure p156 P Continue Ventilations and Support Airway Maintain SpO2 >93% Goal EtCO2 is 35-45mmHg M Notify Medical Control (If Not Already Done) Yes P Continue Ventilations and Support Airway Maintain SpO2 >93% Goal EtCO2 is 35-45mmHg M Notify Medical Control (If Not Already Done) Continue Ventilations and Support Airway Maintain SpO2 >93%, Goal EtCO2 35-45mmHg Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Lung Sounds, RR, Skin, Neuro A patient with a “failed airway” is near death or dying, not stable or improving. Inability to pass an ET Tube or low SpO2 alone are not indications for surgical airway. Continuous digital capnography is the standard of care and is to be used with ALL methods of advanced airway management and endotracheal intubation. If a service does not have digital capnography capabilities and an Invasive Airway Device is placed, an intercept with a capable service MUST be completed If Airway Management is adequately maintained with a Bag-Valve Mask and waveform SpO2 >93%, it is acceptable to defer advanced airway placement in favor of basic maneuvers and rapid transport to the hospital Gastric decompression with Oral Gastric Tube should be considered on all patients with advanced airways, if time and situation allow Once secured, every effort should be made to keep the endotracheal tube in the airway; commercially available tube holders and C-collars are good adjuncts For this protocol, an Intubation Attempt is defined as passing the tip of the laryngoscope blade or Invasive Airway Device past the teeth Failed Airway - Adult 30 Medical Protocols - Adult Medical Protocols - Adult Each Attempt should include change in approach and/or equipment NO MORE THAN TWO (2) ATTEMPTS TOTAL Legend EMT A-EMT A COPD / Asthma - Adult P Paramedic M Medical Control Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2 SAMPLE history OPQRST history Asthma, COPD, CHF history Home meds used prior to call (Nebs, Steroids, Theophylline) Wheezing, Rhonchi Accessory Muscle Use Decreased Ability to Speak History of CPAP/Intubation/ICU Admission from previous flares Smoke Exposure, Inhaled Toxins Differential Simple Pneumothorax Tension Pneumothorax Pericardial Tamponade STEMI, CHF Inhaled Toxins (CO, CN, etc.) Anaphylaxis Asthma/COPD General Approach – Adult, Medical Airway Patent, Respirations Adequate, Apply O₂ No Go To Airway Management Protocol p27 Yes Go To Allergic Reaction Protocol p44 Yes Allergic Reaction/ Anaphylaxis No A IV Access Protocol p49 Wheezing / Lower Airway Lung Exam Albuterol 2.5mg/3mL Neb Ipratropium 0.5mg Neb * P Stridor / Upper Airway Albuterol 2.5mg/3mL Neb * 12 Lead ECG Procedure p139 Consider Methylprednisolone 125 mg IV/IO Improving Consider Airway Management Protocol p27 No Albuterol 2.5mg/3mL Neb Ipratropium 0.5mg Neb * Consider Epi 0.3mg IM (1:1000) IF HR<150, Age <50 and no CAD No No Improving Yes P Consider Mag Sulfate 2g IV/IO Infuse over 10 minutes M Consider Epi 0.15 mg IM (1:1000) IF HR >150, Age >50 or CAD Notify Receiving Facility, Contact Medical Control As Necessary P Nebulized Epinephrine 1mg Neb (1:1000) in 2 mL NS P Methylprednisolone 125 mg IV/IO Improving Yes Pearls REQUIRED EXAM: VS, 12 Lead, GCS, RR, Lung Sounds, Accessory muscle use, nasal flaring Do not delay inhaled meds to get extended history Supplemental O2 for all cases of hypoxia, tachypnea, subjective air hunger Keep patient in position of comfort if partial obstruction If COPD, monitor mental status Severe Asthma may restrict airway to have no wheezing Contact Medical Control PRIOR to IM Epi if age >50, HR >150, or history of coronary artery disease **Contact Medical Control and request authorization for ½ of IM Epi dose (0.15mg of 1:1000) OR Epi Pen Junior. * Albuterol max 3 doses total, Ipratropium max 2 doses total COPD / Asthma - Adult 31 Yes Medical Protocols - Adult Medical Protocols - Adult Cardiac Monitor Legend EMT A-EMT A CHF / Pulmonary Edema - Adult P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history CHF, CAD, Chest Pain History Peripheral Edema Home meds used prior to call (Digoxin, Lasix, Viagra, Cialis) Respiratory Distress, Rales Orthopnea, JVD Pink, Frothy Sputum Differential Myocardial Infarction Pericardial Tamponade Pulmonary Embolism Congestive Heart Failure Toxic Exposure COPD Exacerbation Acute Renal Failure General Approach – Adult, Medical Airway Patent, Respirations Adequate Go To Airway Management Protocol p27 No Yes Go To Appropriate Arrhythmia Protocol Dysrhythmia 12-Lead ECG Procedure p139 STEMI OR **Acute MI** A No Access IV Access Protocol p49 M Continuous Cardiac Monitor P Nitroglycerin Paste (If Available) SBP >100, 1 inch of paste SBP >150, 1.5 inches of paste SBP >200, 2 inches of paste SBP <100 Nitroglycerin 0.4mg SL Repeat every 5 min., max 3 doses Repeat and Document BP Successful Access SBP >100 Symptoms Improved Severity of Symptoms Continuous Cardiac Monitor Mild Moderate / Severe Cardiogenic Shock Normal HR Normal or Elevated SBP (>100 but <180) Increased HR Markedly Elevated SBP (>180) Initial Tachycardia, then later Bradycardia Initial HTN, then progressing to Hypotension A Nitroglycerin Tab/Spray 0.4mg SL Repeat every 5 min., max 3 doses A Nitroglycerin Tab/Spray 0.4mg SL Repeat every 5 min., max 3 doses P Nitroglycerin Paste (if available) P Nitroglycerin Paste (if available) Improving Consider CPAP Procedure IF SBP >100* p153 No M Yes SBP <100 P Dopamine 5-20mcg/kg/min IV/IO Titrate to SBP >100 Consider Airway Management Protocol p27 Consider Midazolam 1mg IV If needed for CPAP compliance Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Head, Neck, Blood Glucose If CHF / Cardiogenic Shock is from inferior MI (II, III, aVF), consider RIGHT sided ECG If ST Elevation in V3, V4 OR Inferior Leads (II, III, aVF), Nitroglycerin may cause severe hypotension requiring IV Fluid boluses If patient reports no relief with home Nitroglycerin, consider potency of medication (is the medicine expired? Would EMS supply be useful?) *Consider Midazolam 1mg IV to assist with CPAP compliance. BE CAUTIOUS – Benzodiazepines may worsen respiratory depression, altered mental status, agitation especially if recent EtOH or illicit drug use. This med should be considered with EXTREME caution. All efforts should be made to verbally coach compliance PRIOR to BZD use in respiratory distress CHF / Pulmonary Edema - Adult 32 Medical Protocols - Adult Medical Protocols - Adult Aspirin 324mg PO Chewed or Powdered IF Awake and Protecting Airway Go To STEMI Protocol p39 Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Events leading to arrest Estimated downtime Past Medical History Medications Existence of terminal illness Signs of lividity, rigor mortis Code Status (Full Code, DNR, Partial) Differential Medical or Trauma Vfib vs Pulseless Vtach Asystole Pulseless electrical activity (PEA) General Approach – Adult, Medical Pulseless, Apneic No Go To Appropriate Adult Medical Protocol Yes Consider ALS Early Criteria for Death / No Resuscitation Yes IF AT ANY TIME Patient has Return of Spontaneous Circulation (ROSC) Go to Post Resuscitation Protocol No Contact Law Enforcement and/or Medical Examiner Bystander / First Responder Compressions Adequate Yes Medical Protocols - Adult Medical Protocols - Adult Do Not Attempt Resuscitation, Go to Criteria for Death/Withholding Resuscitation Policy p9 No Continuous Chest Compressions x 2 Minutes Continue Chest Compressions Apply Monitor and Analyze Rhythm Apply Monitor and Analyze Rhythm Yes Defibrillate Immediately AND Go To CCR Procedure p162 3 Cycles Over Approximately 6 Minutes ROSC No No Shockable A IV Access Protocol p49 Initiate BVM Ventilations AND Go To CPR Procedure p163 Go To Airway Management Protocol p27 Continue CPR Procedure Per AHA Guidelines x 20 Minutes Go To Appropriate Arrest Protocol Yes Go To Post Resuscitation Protocol p37 ROSC No ROSC Consider Termination of Resuscitation Policy p23 Pearls RECOMMENDED EXAM: Mental Status, Pulse, Initial and Final Rhythm Immediately after defibrillation, resume chest compressions with a different operator compressing. Do not pause for post-shock rhythm analysis. Stop compressions only for signs of life (patient movement) or rhythm visible through compressions on monitor or pre-defibrillation rhythm analysis every 2 minutes and proceed to appropriate protocol CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac nature. CCR is NOT to be used in cardiac arrest due to overdose, hanging, drowning, trauma or individuals less than 18 years of age. In the event a patient suffers cardiac arrest in the presence of EMS, the absolute highest priority is to apply the AED/Defibrillator and deliver a shock immediately if indicated. Reassess airway frequently and with every patient move. Cycle compressors frequently – compression quality deteriorates before fatigue is perceived. Designate a “code leader” to coordinate transitions, defibrillation and pharmacological interventions. “Code Leader” ideally should have no procedural tasks. External Compression Devices may be considered if available and will not impede patient care. Cardiac Arrest - Adult 33 Pulseless Electrical Activity (PEA) Arrest - Adult Legend EMT A-EMT A P Paramedic M Medical Control Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis Medications Pertinent Positives and Negatives Age (if known) Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Cardiac Arrest – Adult, Medical Shockable Go To V-Fib / Pulseless V-Tach Arrest, Adult Protocol p36 Yes No Asystole, PEA CPR x 2 Minutes (No Rhythm / No Pulse Check) P IF AT ANY TIME Return Of Spontaneous Circulation (ROSC) Go To Post Resuscitation Protocol Expedite Transport A Epinephrine 1mg IV/IO (1:10,000) Pulse Go To Post Cardiac Arrest Care Protocol p37 Yes Notify Receiving Facility, Contact Medical Control As Necessary No P Epinephrine 1mg IV/IO (1:10,000) every 3-5 min No IV Access Protocol p49 Shockable CPR x 2 Minutes (No Rhythm / Pulse Check) No Treat Reversible Causes (Run the H’s and T’s) Pulse Yes Go To V-Fib / Pulseless V-Tach Arrest, Adult Protocol p36 Yes Go To Post Cardiac Arrest Care Protocol p37 No AND ACLS x 20min with >4 Epi Given Notify Receiving Facility, Contact Medical Control As Necessary Consider Termination of Resuscitation Policy p23 Consider Special Circumstances P M Contact Medical Control Consider Chest Decompression Procedure p169 Pearls RECOMMENDED EXAM: Mental Status In order to successfully resuscitate ANY cardiac arrest patient, a cause of arrest must be identified and corrected Airway is the most important intervention. This should be addressed immediately. Survival is often dependent on successful airway management Airway management with BVM is often sufficient in the Pediatric patient. A single attempt at intubation may be made, if time allows. Do not prolong transport or scene time to attempt intubation If evidence of tension pneumothorax - unilateral decreased or absent breath sounds, tracheal deviation, JVD, tachycardia, hypotension – consider needle thoracostomy. Chest decompression may be attempted at the 2nd intercostal space, mid clavicular line Pulseless Electrical Activity (PEA) Arrest - Adult 34 Medical Protocols - Adult Medical Protocols - Adult Consider Airway Management, Adult Protocol p27 Blood Glucose, Treat for <70 Legend EMT A-EMT A P Paramedic M Medical Control Medications Pertinent Positives and Negatives Age (if known) Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis Cardiac Arrest – Adult, Medical Shockable Continue Positive Pressure Ventilations AND Continue CPR Procedure p163 Hypoxia – secure airway and ventilate Hypoglycemia – Dextrose 12.5-25g or D10W 100ml IV/ IO Hyperkalemia – Sodium bicarbonate 1mEq/kg IV/IO - Calcium Chloride 1g IV/IO Hypothermia – Active Rewarming Calcium Channel and B-Blocker OD – Glucagon 3mg IV/ IO Calcium Channel Blocker OD – Calcium Chloride 1g IV/ IO (avoid if patient on Digoxin/Lanoxin) Tricyclic antidepressant OD – Sodium Bicarbonate 1mEq/kg IV/IO Possible Narcotic OD – Naloxone 2mg IV/IO P Epinephrine 1mg IV/IO (1:10,000) every 3-5 min Epinephrine 1mg IV/IO (1:10,000) P Pulse Shockable CPR x 2 Minutes (No Rhythm / Pulse Check) No Treat Reversible Causes (Run the H’s and T’s) Pulse Consider ALS Early IF AT ANY TIME Patient has Return of Spontaneous Circulation (ROSC) Go to Post Resuscitation Protocol Go To Post Resuscitation Care Protocol p37 Yes Notify Receiving Facility, Contact Medical Control As Necessary No No Go To V-Fib / Pulseless V-Tach Arrest, Adult Protocol p36 Yes Go To V-Fib / Pulseless V-Tach Arrest, Adult Protocol p36 Yes Go To Post Resuscitation Care Protocol p37 No AND ACLS x 20min with >4 Epi Given Notify Receiving Facility, Contact Medical Control As Necessary Consider Termination of Resuscitation Policy p23 Consider Special Circumstances P M Contact Medical Control Consider Chest Decompression Procedure p169 Pearls RECOMMENDED EXAM: Mental Status In order to successfully resuscitate ANY cardiac arrest patient, a cause of arrest must be identified and corrected Airway is the most important intervention. This should be addressed immediately. Survival is often dependent on successful airway management Airway management with BVM is often sufficient in the Pediatric patient. A single attempt at intubation may be made, if time allows. Do not prolong transport or scene time to attempt intubation If evidence of tension pneumothorax - unilateral decreased or absent breath sounds, tracheal deviation, JVD, tachycardia, hypotension – consider needle thoracostomy. Chest decompression may be attempted at the 2nd intercostal space, mid clavicular line Asystole Arrest - Adult 35 Medical Protocols - Adult Medical Protocols - Adult Consider Correctable Causes P Yes A V-Fib / Pulseless V-Tach Arrest Adult Legend EMT A-EMT P Paramedic M Medical Control Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis Medications Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Pertinent Positives and Negatives Age (if known) Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Cardiac Arrest – Adult, Medical Shockable SPECIAL CIRCUMSTANCES Yes If you suspect hyperkalemia as cause of arrest (dialysis dependent, peaked T-waves): Ventricular Fibrillation, Pulseless Ventricular Tachycardia Give Calcium Chloride 1g IV/IO AND Sodium Bicarb 50mEq IV/IO IF AT ANY TIME Return Of Spontaneous Circulation (ROSC) Go To Appropriate Dysrhythmia Protocol Expedite Transport Defibrillate Separate IV sites or flush between CPR x 2 Minutes (No Rhythm / No Pulse Check) If you suspect hypomagnesemia as cause of arrest (Torsades de Pointes, alcoholic, chemo): Give Magnesium Sulfate 2g IV/IO over 2min Begin CCR Procedure p162 Meets Criteria for CCR Yes Begin CPR Procedure p163 No Go To Airway Management, Adult Protocol After Defibrillation, resume CCR without pulse check Continuous Chest Compression Change Compressors every 2min Limit pauses to <5sec After Defibrillation, resume CPR without pulse check Continuous Chest Compression Change Compressors every 2min Limit pauses to <5sec Go To Airway Management, Adult Protocol after 6min Compressions p27 Ventilate with 100%O2 as per AHA Standard 8-10 Breaths per Minute Oxygenate with 100% O2 NRB Mask at 15LPM A IV Access Protocol p49 Pulse Epinephrine (1:10,000) 1mg IV/IO Repeat every 3-5min P No Shockable Yes Defibrillate Yes No P Go To PEA / Asystole, Adult Protocol p34 P Yes Epinephrine (1:10,000) 1mg IV/IO Repeat every 3-5min Amiodarone 300mg IV/IO May repeat once at 150mg IV/IO Pulse No Pulse Yes Shockable Go To PEA / Asystole, Adult Protocol p34 No No AND ACLS x 20min with >4 Epi Given V-Fib / Pulseless V-Tach Arrest - Adult 36 No Go To Post Resuscitation, Adult Protocol p37 Yes Yes Shockable No Resume Chest Compressions and Oxygenation as Appropriate Go To Post Resuscitation, Adult Protocol p37 IV Access Protocol p49 A Consider Chest Decompression Procedure p169 M Contact Medical Control Medical Protocols - Adult Medical Protocols - Adult Go To Pulseless Electrical Activity (PEA) Arrest, Adult Protocol p34 No A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Events leading to arrest Estimated downtime Past Medical History Medications Existence of terminal illness Signs of lividity, rigor mortis Code Status ( DNR) Differential Medical or Trauma Vfib vs Pulseless Vtach Asystole Pulseless electrical activity (PEA) V-Fib / Pulseless V-Tach – Adult, Medical OR PEA / Asystole – Adult, Medical Criteria for Therapeutic Hypothermia No Go To Appropriate Dysrhythmia Protocol Yes IV Access Protocol (if not already done) p49 A Perform and Document Complete Neurologic Exam Cold Normal Saline Bolus 30mL/kg IV/IO (Max 1L) P Consider Post RSA Sedation, Adult Protocol p29 Yes Shivering No Go To Appropriate Adult Medical Protocol Consider Pain Management, Adult Protocol p64 12-Lead ECG Procedure p139 Regardless if completed prior to arrest Optimize Ventilation and Oxygenation SpO2 >93% EtCO2 goal 35-45mmHg Monitor for Hypotension, Dysrhythmias, or Airway Compromise Notify Receiving Facility, Contact Medical Control As Necessary Pearls RECOMMENDED EXAM: Mental Status, Pulse, Initial and Final Rhythm Immediately after defibrillation, resume chest compressions with a different operator compressing. Do not pause for post-shock rhythm analysis. Stop compressions only for signs of life (patient movement) or rhythm visible through compressions on monitor or pre-defibrillation rhythm analysis every 2 minutes and proceed to appropriate protocol CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac nature. CCR is NOT to be used in cardiac arrest due to overdose, hanging, drowning, trauma or individuals less than 18 years of age. In the event a patient suffers cardiac arrest in the presence of EMS, the absolute highest priority is to apply the AED/Defibrillator and deliver a shock immediately if indicated. Reassess airway frequently and with every patient move. Cycle compressors frequently – compression quality deteriorates before fatigue is perceived. Designate a “code leader” to coordinate transitions, defibrillation and pharmacological interventions. “Code Leader” ideally should have no procedural tasks. Post Resuscitation - Adult 37 Medical Protocols - Adult Medical Protocols - Adult Go To Airway Management, Adult Protocol (if not already done) p27 Legend EMT A-EMT A P Paramedic M Medical Control Chest Pain / Suspected Acute Coronary Syndrome - Adult Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE History OPQRST History CHF, CAD, Chest Pain History Differential Pericardial Tamponade Pericarditis Asthma / COPD Aortic Dissection Home meds prior to EMS Arrival (Digoxin, Lasix, ASA, Viagra, Cialis) Respiratory Distress Orthopnea, JVD Sympathomimetic Overdose Pulmonary Embolism Esophageal Spasm Gastroesophageal Reflux (GERD) General Approach – Adult, Medical P Nitroglycerin Paste (If Available) SBP >100, 1 inch of paste SBP >150, 1.5 inches of paste SBP >200, 2 inches of paste Chest Pain OR Signs/Symptoms of Ischemia No Dyspnea OR Atypical Cardiac Symptoms Yes No STEMI read OR **Acute MI** 12-Lead ECG Procedure p139 Obtain and Transmit within 5 minutes Yes ASA 324mg (chewed or powdered) Go To STEMI Protocol p39 No STEMI Consider IV Access PROTOCOL p49 A Consider Remote Ischemic Conditioning Procedure p168 Consider Ondansetron 4mg IV/IO/ODT Go To CHF / Pulmonary Edema Protocol p32 Successful Access Yes Evidence of CHF / Pulmonary Edema No No Access AND SBP >100 AND Continued Symptoms M Nitroglycerin 0.4mg SL Repeat every 5 min., max 3 doses Repeat Vitals and Document BP after each dose Systolic BP >100 Yes No NS Bolus 250mL IV/IO No Access Continuous Cardiac Monitor P A Go To Appropriate Medical Protocol Continued Ischemic Symptoms A Nitroglycerin 0.4mg SL Repeat every 5 min., max 3 doses P Nitroglycerin Paste (if available) Consider Shock (Non-Trauma) Protocol p67 Symptom Free Consider Pain Management Protocol, Adult p64 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, RR, Lung Sounds, Cardiac Exam, JVD Avoid Nitroglycerin in any patient who has used Viagra (Sildenafil) or Levitra (Vardenafil) in the last 24 hours or Cialis (Tadalifil) in the last 36 hours If no IV Access, ECG MUST be obtained and reviewed by Medical Control prior to administration of Nitroglycerin (even patient supplied) Morphine is contraindicated if Systolic BP <90 Use Nitroglycerin and Morphine / opiates with caution if Inferior, Right Ventricle or Posterior MI is suspected Elderly patients, diabetics and women are more likely to have atypical chest pain – SOB, fatigue, weakness, back pain, jaw pain Have a low threshold to get a 12-Lead ECG. They are minimally invasive, painless and can evolve with time If ST Elevation in V3, V4 or Inferior Leads (II, III, aVF), Nitroglycerin may cause hypotension requiring IV Fluid Boluses Chest Pain / Suspected Acute Coronary Syndrome - Adult 38 Medical Protocols - Adult Medical Protocols - Adult Notify Receiving Hospital Early, “STEMI Alert” ST Elevation Myocardial Infarction - Adult Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE History OPQRST History CHF, CAD, Chest Pain History Home meds prior to EMS Arrival (Digoxin, Lasix, ASA, Viagra, Cialis) Respiratory Distress Orthopnea, JVD Differential Pericardial Tamponade Pericarditis Asthma / COPD Aortic Dissection General Approach – Adult, Medical P Long Transport Time Consider Air Transport Yes STEMI Interpretation of 12-Lead OR **Acute MI** No Sympathomimetic Overdose Pulmonary Embolism Nitroglycerin Paste (If Available) SBP >100, 1 inch of paste SBP >150, 1.5 inches of paste SBP >200, 2 inches of paste Go To Appropriate Medical Protocol Yes Apply Defib Pads ASA 324mg (chewed or powdered) if not already done P A Consider IV Access Protocol p49 No Go To CHF / Pulmonary Edema Protocol p32 Yes Go To Shock (Non-Trauma) Protocol p67 No Systolic BP >100 Go To Thrombolytic Screening Protocol p70 Consider Ondansetron 4mg IV/IO/ODT Inferior Wall MI (Elevation in II, III, aVF) CHF / Pulmonary Edema Perform Right Sided ECG Procedure (if Time Allows) p141 Yes A IV Access Protocol p49 A NS Bolus 250mL IV/IO Yes Systolic BP >100 No No Yes M If No IV, Nitroglycerin 0.4mg SL Repeat every 5 min., max 3 doses A Nitroglycerin 0.4mg SL Repeat every 5 min., max 3 doses P Nitroglycerin Paste (if available) Continued Ischemic Symptoms Symptom Free Consider Pain Management Protocol, Adult p64 Go To Shock (Non-Trauma) Protocol p67 Notify Receiving Facility, Contact Medical Control As Necessary Consider Remote Ischemic Conditioning Procedure, As Time Allows p168 Pearls REQUIRED EXAM: VS, GCS, RR, Lung Sounds, Cardiac Exam, JVD Goal is First Medical Contact (YOU!!) to balloon time <90 minutes Goal is to limit on-scene time with a STEMI patient to <10 minutes If long transport time expected due to geography, traffic, etc. consider activation of Air EMS for delivery directly to cath lab The Remote Ischemic Conditioning Procedure should not delay transport to the hospital or precede any evaluations or treatments Transmit STEMI or **Acute MI** 12-Leads early and call STEMI receiving hospital with “STEMI Alert” early; inform them of full report to follow. ST Elevation Myocardial Infarction - Adult 39 Medical Protocols - Adult Medical Protocols - Adult Notify Receiving Hospital Early, “STEMI Alert” A Narrow Complex Tachycardia With A Pulse - Adult Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE History OPQRST History CHF, CAD, Chest Pain History QRS <0.12 sec (<3 small squares) Differential Pericardial Tamponade Pericarditis Asthma / COPD Aortic Dissection Home meds prior to EMS Arrival (Digoxin, Lasix, ASA, Viagra, Cialis) Respiratory Distress Orthopnea, JVD Sympathomimetic Overdose Pulmonary Embolism General Approach – Adult, Medical Uncontrolled A-Fib Unstable / Imminent Arrest Patients with a history of Atrial Fibrillation may have Rapid Ventricular Response (“A-fib with RVR” or “Uncontrolled A-fib”) as their response to hemorrhage, hypovolemia, sepsis or medication noncompliance. 12-Lead ECG Procedure p139 Go To Synchronized Cardioversion Procedure p161 P Consider Sedation Before Cardioversion P Midazolam 2-4mg IM/IN/IV/IO (max 4mg) OR Fentanyl 1.0mcg/kg IV/IO(max 75mcg) OR Lorazepam 0.04mg/kg IV/IO (max 2mg) IV Access PROTOCOL p49 A QRS >0.12sec Continuous Cardiac Monitor QRS <0.12sec Yes Sinus Yes Regular Rhythm No No Look for and Treat Underlying Causes Yes SVT, Rate generally >150 A Symptomatic NS Bolus 250mL IV/IO No Look for and Treat Underlying Causes No Change Consider Shock (Non-Trauma) Protocol p67 P Vagal Maneuvers Improved M P Adenosine 6mg IV/IO Rapid Push Consider Shock (Non-Trauma) Protocol p67 No Change No Change Consider Pain Protocol p64 Diltiazem 0.25mg/kg IV/IO (Max 20mg) Improved P Consider Synchronized Cardioversion Procedure p161 Consider Pain Protocol p64 No Change P Adenosine 12mg IV/IO Rapid Push; May repeat x1 Improved No Change M Diltiazem 0.25mg/kg IV/IO (Max 20mg) OR Amiodarone 150mg IV/IO Over 10 Minutes Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, RR, Lung Sounds, Cardiac Exam, JVD Not all cases of tachycardia need to be rate controlled; sepsis, hypovolemia, and acute hemorrhage will do worse if their ability to compensate is taken away Continually monitor for signs of decompensation and be prepared to move to synchronized cardioversion if the patient condition changes. Place the pads while reaching for the meds Adenosine has a very short half life (5sec or less) so it must be infused rapidly in a patent IV site that is preferably in the AC fossa or more proximal Elderly patients, diabetics and women are more likely to have atypical chest pain – SOB, fatigue, weakness, back pain, jaw pain Have a low threshold to get a 12-Lead ECG. They are minimally invasive, painless and can evolve with time Narrow Complex Tachycardia With A Pulse - Adult 40 Medical Protocols - Adult Medical Protocols - Adult P No Keep in Mind; this may be their version of Sinus Tachycardia! Go To Wide Complex Tachycardia With A Pulse Protocol p41 Yes Wide Complex Tachycardia With A Pulse - Adult Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE History OPQRST History CHF, CAD, Chest Pain History QRS >0.12 sec (>3 small squares) Home meds prior to EMS Arrival (Digoxin, Lasix, ASA, Viagra, Cialis) Respiratory Distress Orthopnea, JVD Differential Pericardial Tamponade Pericarditis Asthma / COPD Aortic Dissection Sympathomimetic Overdose Pulmonary Embolism General Approach – Adult, Medical Uncontrolled A-Fib Unstable / Imminent Arrest Patients with a history of Atrial Fibrillation may have Rapid Ventricular Response (“A-fib with RVR” or “Uncontrolled A-fib”) as their response to hemorrhage, hypovolemia, sepsis or medication noncompliance. Yes P Go To Synchronized Cardioversion Procedure p161 P Consider Sedation Before Cardioversion No 12-Lead ECG Procedure p139 Keep in Mind; this may be their version of Sinus Tachycardia! Go To Narrow Complex Tachycardia With A Pulse Protocol p40 Continuous Cardiac Monitor QRS <0.12sec QRS >0.12sec Yes Yes Sinus, Bundle Branch Block on ECG Look for and Treat Underlying Causes Torsades de Pointes IV Access PROTOCOL p49 Regular Rhythm, Monomorphic QRS Prolonged QT may result in R-on-T phenomenon and Torsades. Congenital and Acquired etiologies include: Amiodarone, Methadone, Lithium, Amphetamines, Procainamide, Sotalol Hypokalemia, Hypomagnesemia, Heart Failure, Hypothermia, Subarachnoid Hemorrhage No No Yes SVT, Rate generally >150 P Torsades de Pointes Mag Sulfate 2g IV/IO Infuse over 1-2min No Look for and Treat Underlying Causes No Change Consider STEMI Protocol IF New or Presumably New LBBB p39 P Vagal Maneuvers Improved A NS Bolus 250mL IV/IO Consider Shock (Non-Trauma) Protocol p67 No Change Consider Shock (Non-Trauma) Protocol p67 P Adenosine 6mg IV/IO Rapid Push No Change Improved Consider Pain Management Protocol p64 No Change Consider Pain Management Protocol p64 P Adenosine 12mg IV/IO Rapid Push; May repeat x1 Improved M Contact Medical Control M Contact Medical Control No Change M Contact Medical Control M Diltiazem 0.25mg/kg IV/IO (Max 20mg) OR Amiodarone 150mg IV/IO Over 10 Minutes Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, RR, Lung Sounds, Cardiac Exam, JVD Not all cases of tachycardia need to be rate controlled; sepsis, hypovolemia, and acute hemorrhage will do worse if their ability to compensate is taken away Continually monitor for signs of decompensation and be prepared to defibrillate if the patient condition changes. Place the pads while reaching for the meds Adenosine has a very short half life (5sec or less) so it must be infused rapidly in a patent IV site that is preferably in the AC fossa or more proximal Elderly patients, diabetics and women are more likely to have atypical chest pain – SOB, fatigue, weakness, back pain, jaw pain Have a low threshold to get a 12-Lead ECG. They are minimally invasive, painless and can evolve with time. Transmit them and seek MD Consult at any time Narrow Complex Tachycardia With A Pulse - Adult 41 Medical Protocols - Adult Medical Protocols - Adult A Legend EMT A-EMT A Bradycardia With A Pulse - Adult P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE History OPQRST History CHF, CAD, Chest Pain History QRS <0.12 sec (<3 small squares) Home meds prior to EMS Arrival (Digoxin, Lasix, ASA, Viagra, Cialis) Respiratory Distress Orthopnea, JVD Differential Pericardial Tamponade Pericarditis Pacemaker Failure Hypothermia Sinus Bradycardia Head Injury Spinal Cord Injury Sick Sinus Syndrome Acute MI AV Block (1o, 2o, 3o) General Approach – Adult, Medical P Go To External Cardiac Pacing Procedure p165 Yes HR <60bpm AND Unstable / Imminent Arrest P Consider Sedation Before Initiation of Pacing P Midazolam 2-4mg IM/IN/IV/IO (max 4mg) OR Fentanyl 1.0mcg/kg IV/IO(max 75mcg) OR Lorazepam 0.04mg/kg IV/IO (max 2mg) 12-Lead ECG Procedure p139 A NS Bolus 250mL IV/IO P Atropine 0.5mg IV/IO May Repeat every 3-5min; Max 3mg Go To Appropriate Cardiac Treatment Protocol IV Access PROTOCOL p49 Continuous Cardiac Monitor Supplemental O2 to maintain SpO2 >93% Yes A Arrthythmia/ STEMI Symptomatic Improving No Yes Look for and Treat Underlying Causes No P Dopamine 5-20 mcg/kg/min IV/IO OR P Epinephrine 2-10 mcg/min IV/IO (1:10,000) P Consider External Cardiac Pacing Procedure p165 Consider Shock (Non-Trauma) Protocol p67 Consider Overdose and Poisoning, General Protocol p54 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, RR, Lung Sounds, Cardiac Exam, JVD Not all cases of bradycardia need to be treated with medicine or pacing; use good clinical judgement and follow symptoms Continually monitor for signs of decompensation and be prepared to move to external cardiac pacing if the patient condition changes. Place the pads while reaching for the meds Titrate Epinephrine OR Dopamine infusions to HR >60 AND SBP <180 Atropine is unlikely to work in cases of complete heart block. Atropine is contraindicated in patients with narrow angle glaucoma Elderly patients, diabetics and women are more likely to have atypical chest pain – SOB, fatigue, weakness, back pain, jaw pain Have a low threshold to get a 12-Lead ECG. They are minimally invasive, painless and can evolve with time Bradycardia With A Pulse - Adult 42 Medical Protocols - Adult Medical Protocols - Adult No A Legend EMT A-EMT P Paramedic M Medical Control Abdominal Pain / GI Bleeding Adult Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Last Meal / Oral Fluids Menstrual / Pregnancy History Anticoagulant Use Nausea, Vomiting, Diarrhea Constipation Hematochezia (Bloody Stool) Recent Travel Recent Antibiotics Differential AAA +/- Rupture Perforated Ulcer Appendicitis Ectopic Pregnancy +/- Rupture Diverticulitis Small Bowel Obstruction Splenic Enlargement / Rupture General Approach – Adult, Medical IV Access Protocol p49 A Medical Protocols - Adult A Normal Saline Bolus 500mL Repeat every 5 min., max 2L No SBP <100 Repeat and Document BP Nausea and/or Vomiting SBP >100 Yes P Persistent Hypotension No Go To Shock (Non-Trauma) Protocol p67 Consider Chest Pain/Suspected Acute Coronary Syndrome Protocol p38 Ondansetron 4mg IV/IO/ODT Consider Pain Management Protocol – Adult, Medical p64 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Focal Tenderness, Rebound Tenderness, Distal Pulses, Abdominal Masses Nothing by mouth (NPO) Status for all patients with abdominal pain If pain is above the umbilicus, perform a 12-Lead ECG. Go to Chest Pain Protocol as indicated Abdominal pain in women of child bearing age should be treated as an ectopic pregnancy until proven otherwise The diagnosis of AAA should be considered in patients >50 years old. Assess the abdomen for a midline pulsatile mass and feel for pulses in feet / legs Rebound tenderness is pain that is increased when releasing pressure from palpation Appendicitis may present with vague, peri-umbilical pain that slowly migrates to the Right Lower Quadrant (RLQ) over time Blood loss from the GI Tract has a very distinct smell; use all of your senses when evaluating your patients. GI Bleed patients have a high risk of serious hemorrhage Abdominal Pain and known pregnancy, go to OB Protocol Abdominal Pain / GI Bleeding - Adult 43 Medical Protocols - Adult Hypotension (SBP <100) Yes Legend EMT A-EMT A P Paramedic M Medical Control Allergic Reaction - Adult Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Onset and Location of Symptoms Differential Urticaria (Rash Only) Anaphylaxis (Systemic Effect) Shock (Vascular Effect) Angioedema Lung Sounds before AND after intervention Allergen Exposure Toxic / Environmental Exposure Subjective throat “tightness” OR “closing” Aspiration / Airway Obstruction Vasovagal Event Asthma / COPD CHF General Approach – Adult, Medical Mild Moderate Severe Imminent Cardiac Arrest Flushing, Hives, Itching, Erythema Normal BP, No Respiratory Involvement Flushing, Hives, Erythema PLUS Dyspnea, Wheezing Chest Tightness Derm symptoms may not be present, depending on perfusion Wheezing, Dyspnea, Hypoxia, Nausea/Vomiting PLUS Hypotension Altered Mental Status, Hypotension, Pallor, Diaphoresis, Weak Pulses A IV Access Protocol p49 P Diphenhydramine 50mg IV/IM/IO/PO P Famotidine 20mg IV/IO Consider Epi 0.3mg IM (1:1000) IF HR<150, Age <50 and no CAD M Epi 0.3mg IM (1:1000) IF HR<150, Age <50 and no CAD Consider Epi 0.15 mg IM (1:1000) IF HR >150, Age >50 or CAD M Albuterol 2.5mg/3mL Neb May repeat Q10min, Max 3 Consider Epi 0.15 mg IM (1:1000) IF HR >150, Age >50 or CAD Albuterol 2.5mg/3mL Neb May repeat Q10min, Max 3 A IV Access Protocol p49 A IV Access Protocol p49 P Diphenhydramine 50mg IV/IM/IO P Diphenhydramine 50mg IV/IM/IO P Famotidine 20mg IV/IO P Famotidine 20mg IV/IO P Methylprednisolone, 125mg IV/IO Stable / Improving Monitor and Reassess Document Response to Medications Epi 0.3mg IM (1:1000) A IV Access Protocol p49 M Contact Medical Control (As Practical) P Epi 0.1mg IV/IO over 5min 0.1mL of 1:1000 into 10mL NS Yes Worsening / Refractory Consider Airway Management Protocol p27 Worsening / Refractory Notify Receiving Facility, Contact Medical Control As Necessary Improving M Epi Infusion 2-10mcg/min IV/IO OR Repeat Dosing of IV Dose Epi Pearls REQUIRED EXAM: VS, GCS, Skin, Cardivascular, Pulmonary Contact Medical Control prior to administering epinephrine in patients who are >50 years old, have a history of CAD or if HR is >150, as epi may cause acute MI. These patients should receive a 12-Lead ECG prior to med administration, if practical given the clinical situation Medical Control may authorize Epinephrine at ½ dose (0.15mg OR EpiPen Jr.) for patients >50, known CAD or if HR >150 Epinephrine Infusion: Mix 1mg (1:1,000) in 250mL NS. If worsening or refractory anaphylaxis, contact Med Control first. Start at 2mcg/min, titrate up. Famotidine: Mix 20mg in 100mL D5W. Infuse over 15 minutes In general, the shorter the time from allergen contact to start of symptoms, the more severe the reaction Consider the Airway Management Protocol early in patients with Severe Allergic Reaction or subjective throat closing Allergic Reaction - Adult 44 Medical Protocols - Adult Medical Protocols - Adult Severity of Symptoms A Legend EMT A-EMT P Paramedic M Medical Control Altered Mental Status - Adult Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of DM, medic alert bracelet Drug paraphernalia or report of illicit drug use Evidence of environmental toxin / ingested toxin Differential Head Injury Electrolyte Abnormality Psychiatric Disorder Cardiac Dysrhythmia DM, CVA, Seizure, Tox Sepsis Hypothermia Hypothyroidism Pulmonary General Approach – Adult, Medical Go To Appropriate Cardiac Dyshrhythmia or STEMI Protocol Blood Glucose Abnormal <70 or >250 Go To Diabetic Emergencies Protocol p47 12 Lead ECG Procedure p139 12-Lead Normal, Blood Glucose >70 and <250 Overdose Yes No Go To Suspected Stroke Protocol p69 Stroke or Seizure Yes, Stroke Yes, Seizure Go To Seizure Protocol p68 >104oF (>40oC) Go To Environmental Hyperthermia Trauma Protocol p81 No Go To Environmental Hypothermia, Trauma Protocol p82 <95o F (<35o C) Temperature >95o and <104oF (>35o and <40oC) Go To Appropriate Dysrhythmia Protocol Abnormal Cardiac Rhythm STEMI Go To STEMI Protocol p39 Normal Rhythm Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Head, Neck, Blood Glucose Pay special attention to head and neck exam for bruising or signs of injury Altered Mental Status may be the presenting sign of environmental hazards / toxins. Protect yourself and other providers / community if concern. Involve Hazmat early Safer to assume hypoglycemia if doubt exists. Recheck blood sugar after dextrose/glutose administration and reassess Do not let EtOH fool you!! Alcoholics frequently develop hypoglycemia, Alcoholic Ketoacidosis (AKA) and often hide traumatic injuries! Altered Mental Status - Adult 45 Medical Protocols - Adult Medical Protocols - Adult Go To Overdose and Poisoning, General Protocol p54 Legend EMT A-EMT A P Paramedic M Medical Control Behavioral / Excited Delirium Adult Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Situational Crisis Psychiatric Illness / Medication History Medic Alert Bracelet, DM History Anxiety, Agitation or Confusion Suicidal / Homicidal Thoughts or History Evidence of Substance Use / Overdose Differential EtOH Intoxication / Withdrawal Toxic Ingestion Substance Use / Abuse Schizophrenia Hypoglycemia Hypoxia Head Injury Occult Trauma Cerebral Hypoperfusion General Approach – Adult, Medical Stage, Call for Law Enforcement and/or Additional Resources No Consider Altered Mental Status Protocol, As Appropriate p45 Provider Safety Yes Consider Need for ALS Level Service EARLY Evidence of Exposure / Toxidrome Yes Go To Overdose / Poisoning General Protocol p54 Yes Go To Head Injury, Adult Trauma Protocol p86 No Remove Patient from stressful environment, use verbal calming techniques No Consider Restraints Procedure, As Appropriate p173 No Go To Diabetic Emergencies Protocol p47 <70 Severe Agitation P Ketamine 2-4mg/kg IM (max 200mg) Reassess. Follow Mental Status, SpO2, Respiratory Effort and Rate CLOSELY Monitor for Laryngospasm A M IV Access Protocol (When Appropriate) p49 Contact Medical Control Evidence of Head Injury Patient Refusing Blood Sugar >70 OR Unobtainable Due to Condition Moderate Agitation Uncooperative AND Danger To Self or Others P No P Reassess. Follow Mental Status, SpO2, Respiratory Effort and Rate CLOSELY A If <60kg: *Haloperidol 5mg IM AND/OR Lorazepam 1mg IM If >60kg: *Haloperidol 10mg IM AND/OR Lorazepam 1-2mg IM IV Access Protocol (When Appropriate) p49 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Skin, Cardivascular, Pulmonary Safety First – For Providers, Police and Patients! Never restrain any patients in the prone (face down) position All patients who require chemical restraint MUST be continuously monitored by ALS Personnel on scene or immediately upon their arrival Patients who are actively fighting physical restraints are at high risk for Excited Delirium and In-Custody Death; Have a low threshold to activate ALS for chemical restraint Transport of patients requiring handcuffs or Law Enforcement (LE) restraint require LE to ride in the ambulance to the hospital – they have the keys! Avoid Haloperidol in patients with known history of MAOI Antidepressant use (Phenelzine, Tranylcypromine) OR history of Parkinson’s Disease If a patient with Excited Delirium suddenly becomes cooperative/quiet, reassess them quickly! Sudden Cardiac Death is common in this population Behavioral / Excited Delirium - Adult 46 Medical Protocols - Adult Medical Protocols - Adult Consider Safety of ALL Responders including Law Enforcement A Legend EMT A-EMT P Paramedic M Medical Control Diabetic Emergencies - Adult Pertinent Positives/Negatives: Age, VS, Blood Glucose Reading SAMPLE History OPQRST History Last Meal, History of Skipped Meal Differential Toxic Ingestion Head Injury Sepsis Stroke/TIA Diaphoresis Siezures Abnormal Respiratory Rate History of DKA Seizure EtOH Abuse/Withdrawal Drug Abuse/Withdrawal General Approach – Adult, Medical <70 Blood Glucose >250 >70 and <250 Mental Status Hypotension SBP >100 SBP <100 Altered and/OR Compromised Gag Glutose 15g PO May repeat x1 Go To Appropriate Adult Medical Protocol Glucagon 1mg IM One time Clinically Dehydrated A IV Access Protocol p49 No A IV Access Protocol p49 Yes Go To Appropriate Adult Medical Protocol Blood Sugar <70 Reassess Mental Status Blood Glucose within 10 minutes A Go To Hypotension / Shock (Non-Trauma) Protocol p67 Dextrose Dosing: D10W 125mL IV/IO OR D5W 250mL IV/IO OR D50 25mL IV/IO Titrate to effect Blood Sugar >70 Mental Status Altered from Baseline OR Unknown Go To Altered Mental Status Protocol p45 Baseline Yes Taking Oral Diabetes Meds Full Assessment Evaluate for Secondary Complaint No Issue Discovered Go To Appropriate Adult Medical Protocol Declines Execute and Document Refusal of Transport Protocol p65 None Notify Receiving Facility, Contact Medical Control As Necessary Accepts Recommend Transport Pearls REQUIRED EXAM: VS, SpO2, Blood Glucose, Skin, Respiratory Rate and Effort, Neuro Exam Do NOT administer oral glucose to patients that can’t swallow or adequately protect their airway Prolonged hypoglycemia may not respond to Glucagon; IF IM Glucagon fails, be prepared to start an IV and administer IV Dextrose Alcoholics and patients with advanced liver disease may not respond to Glucagon due to poor liver glycogen stores Patients on oral diabetes medications are at a very high risk of recurrent hypoglycemia and should be transported. Contact Medical Control for advice/ patient counseling if patient is refusing. See Refusal after Hypoglycemia Treatment Protocol for additional information as necessary. Always consider intentional insulin overdose, and ask patients / family / friends / witnesses about suicidal ideation or gestures Diabetic Emergencies - Adult 47 Medical Protocols - Adult Medical Protocols - Adult Awake Protecting Airway A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Acute Pain Hypertension - Adult Headache Nosebleed Blurred Vision Dizziness Chest Pain Differential Aortic Dissection Pre-Eclampsia / Eclampsia Hypertensive Encephalopathy Stimulant Use / Abuse Acute Stroke Head Injury / Cushing’s Reflex (Bradycardia + HTN) Primary HTN General Approach – Adult, Medical Consider Aortic Dissection Asymmetric Measure BP in Bilateral Arms Symmetric Yes Go To Stimulant / Sympathomimetic Overdose Protocol p62 Yes Go To Appropriate Adult Medical Protocol based on Symptoms Altered Mental Status Go To Altered Mental Status, Adult Protocol p45 CHF Go To CHF/Pulmonary Edema Protocol p32 Stimulant Use Systolic BP >220 OR Diastolic BP >120 No *Go To Chest Pain / STEMI Protocol p38/p39 Yes Chest Pain No Go To Suspected Stroke Protocol p69 Signs of Stroke or Altered Mental Status Stroke No Go To OB General Protocol p50 Pregnancy Yes No Go To COPD/Asthma Protocol p31 Asthma Asthma / CHF No Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Hypertension based on two elevated readings taken >5 minutes apart. Never treat BP based on one set of vital signs Hypertensive Emergency is based on evidence of end-organ failure: STEMI/ACS, Hypertensive Encephalopathy, Renal Failure, Vision Change, Acute Stroke Patients with symptomatic hypertension should be transported with the head of the stretcher elevated 30 degrees Ensure Blood Pressure is checked with appropriate sized blood pressure cuff for patient size *Patients with long standing high blood pressure may have changed their “normal” set point; do not decrease their Systolic Blood Pressure >40 points Hypertension - Adult 48 Medical Protocols - Adult Medical Protocols - Adult No A Legend EMT A-EMT P Paramedic M Medical Control IV Access - Adult General Approach – Adult, Medical First Access For Cardiac Arrest Yes A Intraosseous Venous Access Procedure p180 No Consider PO Medications As Appropriate for Condition Emergent OR Potentially Emergent Medical OR Traumatic Condition No A Go To Extremity Venous Access Procedure p179 Successful Go To Appropriate Medical Protocol Unsuccessful/ Peripherally Exhausted P Go To External Jugular Venous Access Procedure (Adults Only) p181 A Go To Intraosseous Venous Access Procedure (Life Threatening Event) p180 Success in <3 Total Attempts Monitor Access Site for Swelling, Pain, Redness, Evidence of Extravasation Yes A No Yes M Life Threatening Condition Monitor Infusion of IV Fluids No Notify Receiving Facility, Contact Medical Control As Necessary Contact Medical Control Pearls In the setting of CARDIAC ARREST ONLY, any preexisting dialysis shunt or central line may be used by Paramedics For patients who are hemodynamically unstable or in extremis, Medical Control MUST be contacted prior to accessing any preexisting catheters Upper Extremity sites are preferred over Lower Extremity sites. Lower Extremity IVs are discouraged in patients with peripheral vascular disease or diabetes In post-mastectomy patients and patients with forearm dialysis fistulas, avoid IV attempts, blood draws, injections or blood pressures in the upper extremity on the affected side Saline Locks are acceptable in cases where access may be necessary but the patient is not volume depleted; having an IV does not mandate IV Fluid infusion The preferred order of IV Access is: Peripheral IV, External Jugular IV, Intraosseous Line UNLESS medical acuity or situation dictate otherwise. IV Access - Adult 49 Medical Protocols - Adult Medical Protocols - Adult Yes Legend EMT A-EMT A P Paramedic M Medical Control OB General - Adult Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Pregnancy History (G’s and P’s) Headache Abdominal Pain +/- Contractions Blurred Vision Vaginal Bleeding Chest Pain, Dyspnea, Hypoxia Differential Pre-Eclampsia / Eclampsia Ectopic Pregnancy Hypertensive Encephalopathy Uterine Rupture Pulmonary Embolism Threatened / Impending / Missed Spontaneous Abortion Head Injury / Cushing’s Reflex (Bradycardia + HTN) Domestic Abuse General Approach – Adult, Medical Remember you have TWO patients during pregnancy; evaluate, treat and protect BOTH Yes Left Lateral Recumbent Position takes pressure off of the Inferior Vena Cava and prevents supine hypotension Left Lateral Recumbent Position A Preeclampsia and Eclampsia are typically encountered in 3rd trimester, but may be in late 2nd trimester and up to 6 weeks after delivery No Go To Appropriate Medical Protocol IV Access Protocol p49 Blood Sugar <70 Consider Diabetic Emergencies Protocol p47 >70 P If no IV, Midazolam 5mg IM/IN P Magnesium Sulfate 4g IV/IO Over 10 minutes AND P Lorazepam 1-2mg IV/IO May Repeat x 1, Max 4mg OR P Midazolam 5mg IV/IO May Repeat x 1, Max 10mg Yes Go To Labor / Imminent Delivery Protocol p52 Seizure Activity No Yes Vaginal Bleeding / Abdominal Pain Pain Labor Bleeding Continued Seizure Activity M No No Hypotension / Shock Yes A Normal Saline Bolus 500mL Repeat every 5 min., max 2L Consider Hypotension Protocol p67 Yes No Contact Medical Control Notify Receiving Facility, Contact Medical Control As Necessary M Contact Medical Control Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Magnesium is the priority for pregnant seizures (eclampsia), but if seizing on EMS arrival give IM/IN Midazolam until IV Access achieved If after Magnesium 4gm IV/IO administered, continued seizure x 5 minutes OR recurrent seizure, contact Medical Control for authorization of additional Magnesium 2gm. Continuous monitoring is required, as magnesium may cause hypotension and decreased respiratory drive Hypertension, Severe headache, vision changes, RUQ pain, diffuse edema may indicate preeclampsia. This may progress to seizures (eclampsia). Any pregnant patient involved in an MVC or other trauma should be evaluated by MD for evaluation and fetal monitoring OB General - Adult 50 Medical Protocols - Adult Medical Protocols - Adult Known / Suspected Pregnancy OR Missed Period A Legend EMT A-EMT OB / Vaginal Bleeding - Adult P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Pregnancy History (G’s and P’s) Abdominal Pain +/- Contractions Blurred Vision Estimated Blood Loss (Pads / Tampons Per Hour) Chest Pain, Dyspnea, Hypoxia Differential Ectopic Pregnancy Domestic Violence Sexual Assault Dysfunctional Uterine Bleeding Threatened / Impending / Missed Spontaneous Abortion Normal Menstrual Period General Approach – Adult, Medical Known / Suspected Pregnancy OR Missed Period Yes Go To OB General Protocol p50 A IV Access Protocol p49 A Normal Saline Bolus 250mL Yes Hypotension / Shock No Improving Yes Blood Sugar <70 Go To Diabetic Emergencies Protocol p47 Cramping, Urge to Push Consider Labor/Imminent Delivery Protocol p52 If situation appropriate No >70 Go To Shock (Non-Trauma) Protocol p67 Consider Abdominal Pain Protocol p43 Yes Abdominal Pain No Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Always suspect pregnancy as a cause of vaginal bleeding in reproductive age women; patient report regarding menstrual history and sexual activity may not be accurate Ectopic pregnancy is a surgical emergency! Patients with vaginal bleeding, unstable vital signs and suspected ectopic pregnancy should be transferred to an OB receiving facility for emergent evaluation and management when possible Always have a high suspicion for domestic violence and /or sexual assault when evaluating a female with a reproductive or GU related complaint OB / Vaginal Bleeding - Adult 51 Medical Protocols - Adult Medical Protocols - Adult No Legend EMT A-EMT A Labor / Imminent Delivery - Adult P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Pregnancy History (G’s and P’s) Estimated Due Date Prenatal Care / High Risk Pregnancy Time of Contraction Onset, Frequency Rupture of Membranes and Time Sensation of Fetal Movement Differential Endometritis Normal Active Labor Abnormal Presentation Prolapsed Cord Preterm Labor Threatened / Impending / Missed Spontaneous Abortion Premature Rupture of Membranes Placenta Previa / Placenta Abruption General Approach – Adult, Medical Unable To Deliver Abnormal Vaginal Bleeding / Hypertension Create air passage by supporting presenting part of infant Place 2 fingers alongside the nose and push away from the infant’s face No Transport in Knee-Chest or Left Lateral Recumbent Position Left Lateral Recumbent Position Cord Double clamp cord 10-12cm from infant abdomen, once cord stops pulsating cut between the clamps Contact Medical Control Inspect Perineum NO Digital Vaginal Exam No Crowning Crowning, <36 Weeks Gestation Abnormal Presentation Severe Vaginal Bleeding Multiple Gestation Crowning, >36 Weeks Gestation Monitor and Document VS Reassess Frequently Activate ALS Crowning, >36 Weeks Gestation Yes A Expedite Transport to Nearest OB Receiving Facility IV Access Protocol p49 No Prolapsed Cord / Shoulder Dystocia Breech / Footling / Abnormal Presentation Crowning, Delivery Imminent Hips Elevated, Knees to Chest Transport knees to chest Unless Delivery Imminent Control delivery with gentle support of head to prevent injury to Mother/Baby Insert Gloved Fingers Into Vagina Relieve Pressure on Umbilical Cord Encourage Mother to Refrain from Pushing Check for nuchal cord; if present slip over head gently Moist Saline Dressing Over Cord Eval Fetal Heart Rate / Cord Pulsation Support Presenting Parts, Do NOT Pull Gently apply downward pressure to deliver anterior shoulder, then upward to deliver posterior shoulder Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular If Delivery is Completed, go to Newly Born Protocol for evaluation and management of the infant Remember that you have TWO patients during Pregnancy, Labor and Delivery; be sure to monitor and protect both throughout your management After Delivery, massage the uterus through the anterior abdomen and wait for the placenta; NEVER pull on the umbilical cord to expedite the afterbirth Record the APGAR Scores for the infant at 1minute and 5minutes after delivery; if either in the Moderately Depressed range, continue to record and document every 5 minutes while supporting the infant per the Newly Born Protocol Labor / Imminent Delivery - Adult 52 Medical Protocols - Adult Medical Protocols - Adult M Go To OB General Protocol p50 Yes Legend EMT A-EMT A P Paramedic M Medical Control Newly Born - Peds Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Pregnancy History (G’s and P’s) Estimated Due Date Prenatal Care / High Risk Pregnancy Time of Contraction Onset, Frequency Rupture of Membranes and Time Sensation of Fetal Movement Airway Suctioning Routine Suctioning of the Newborn is NO LONGER Recommended Term Gestation Breathing or Crying Good Muscle Tone Meconium Present Non-Vigorous Newborns may undergo suctioning under direct laryngoscopy Contact Medical Control If Any Questions Medical Protocols - Adult 1 Point 2 Points Activity (Muscle Tone) Absent Arms and Legs Flexed Active Movement Pulse Absent <100 bpm Grimace (Reflexes, Irritability) Flaccid Appearance (Skin Color) Blue, Pale >100 bpm Active Motion (Sneeze, Cough, Pull Away) Completely Respirations Absent Some Flexion of Extremities Body Pink, Extremities Blue Slow, Irregular No Pulse Oximetry Continuous Cardiac Monitor Warm, Dry and Stimulate Infant Clear Mouth, then Nose As Needed Skin-To-Skin Contact With Mother If Situation Appropriate Points Totaled No Heart Rate <100 Agonal Breathing OR Apnea No Labored Breathing / Persistent Cyanosis Yes Yes Pink BVM Assisted Ventilations with 10-15L X 30 seconds, 60bpm Vigorous Cry Severely Depressed 0-3 Moderately Depressed 4-6 Excellent Condition 7-10 Consider Neonatal Resuscitation Protocol p106 Provide Warmth, Dry Infant Wipe Mouth, then Nose As Needed Yes Pulse Oximetry Continuous Cardiac Monitor Supplemental O2 via Blow-By Maintain SpO2 >93% Yes Heart Rate <100 No Pulse Oximetry Continuous Cardiac Monitor Skin-To-Skin Contact With Mother If Situation Appropriate Yes BVM Assisted Ventilations with 10-15L X 30 seconds, 60bpm Pulse Oximetry Continuous Cardiac Monitor Go To Neonatal Resuscitation Protocol p106 Yes Heart Rate <60 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Most Newborns requiring resuscitation will respond to supplemental O2, BVMs, airway clearing maneuvers. If not, go to Neonatal Resuscitation Protocol Consider birth trauma during evaluation of non-vigorous Newborn; pneumothorax, hypovolemia, hypoglycemia Term gestation, strong cry / adequate respirations with good tone will generally need no resuscitation Expected Pulse Ox Readings: Birth – 1min = 60-65%, 1-2min = 65-70%, 3-4min = 70-75%, 4-5min = 75-80%, 5-10min = 80-85%, >10min = >90% APGAR scores at 1min and 5 min. Appearance, Pulse, Grimace, Activity, Respirations. Each score gets 0, 1 or 2 points (Total 10). If either in the moderately depressed range, continue to record and document every 5 minutes. Newly Born - Peds 53 Medical Protocols - Adult 0 Points Congenital Heart Defect Maternal / Newborn Infection / Sepsis Airway Obstruction – Secretions Choanal Atresia (imperforate nares) Labor / Imminent Delivery – Adult, Medical Clear Amniotic Fluid Suction ONLY when obstruction is present and/or BVM is required M Differential Maternal Medication Effect Hypovolemia Pneumothorax Hypoglycemia A Legend EMT A-EMT P Paramedic M Medical Control Overdose and Poisoning, General Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGEM DUMBELLS Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Differential Head Injury Hazmat Exposure Electrolyte Imbalance DM, CVA, Seizure Sepsis General Approach – Adult, Medical Call For Additional Resources, Stage Until Safe Yes Hazmat Scene No Pulse Absent Go To Cardiac Arrest Protocol p33 Inadequate Airway Management Protocol p27 Present <70 Adequate Blood Sugar Assess Respirations, Ventilations and Oxygenation >70 12 Lead ECG Procedure p139 A Arrhythmia / STEMI Go To Appropriate Arrhythmia Protocol Altered / Somnolent, Not Protecting Airway Consider Opiate Overdose Protocol p61 IV Access Protocol p49 Assess Mental Status Unchanged Awake, Protecting Airway Potential Causes Pesticide or Nerve Gas Exposure SLUDGEM Symptoms Go To Organophosphate OD Protocol p55 Bradycardia, AV Block History of Beta Blocker Ingestion Ventricular Dysrhythmia, Seizure History of TCA Ingestion Altered Mental Status, Seizure Smoke Exposure Bradycardia, AV Block History of Ca Channel Block Ingestion Go To Beta Blocker OD Protocol p56 Go To Calcium Channel Blocker OD Protocol p57 Go To Tricyclic Antidepressant OD Protocol p63 Go To Cyanide OR Carbon Monoxide Poisoning Protocol p58-59 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Skin, Blood Glucose Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Bring pill bottles, contents, emesis to the ED for evaluation and assessment Be careful of off-gassing in cases of inhalation of volatile agents Many intentional overdoses involve multiple substances, some of which can have cardiac toxicity; a 12-Lead ECG should be obtained on all overdose patients unless the situation dictates otherwise. Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 SLUDGEM – Salivation, Lacrimation, Urination, Defecation, GI Upset, Emesis, Miosis DUMBELLS -Diarrhea, Urination, Miosis/Muscle Weakness, Bronchorrhea, Emesis, Lacrimation, Lethargy, Salivation/Sweating Overdose and Poisoning, General - Adult 54 Medical Protocols - Adult Medical Protocols - Adult Go To Diabetic Emergencies Protocol p47 Legend EMT A-EMT A P Paramedic M Medical Control Anticholinergic / Organophosphate Overdose Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGEM DUMBELLS Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Differential Head Injury Hazmat Exposure Electrolyte Imbalance DM, CVA, Seizure Sepsis Overdose and Poisoning, General - Adult Stage, Call for Law Enforcement and/or Additional Resources No Scene Safe Yes Organophosphate / Pesticide Exposure Patient Management Consider provider safety, number of patients and early notification of receiving facility Consider Hazmat, General – Adult p85 Evidence of Exposure / Toxidrome Yes Toxicity to the crew may occur from inhalation or topical exposure to the offending agent DuoDote AND/OR Mark-I Kit may be used for civilians IF cache released from the State of Wisconsin No Estimate Symptom Severity A Consider IV Access Protocol p49 Go To Seizure, Adult Medical Protocol p68 Major Symptoms Altered Mental Status, Seizure, Respiratory Distress/Failure Minor Symptoms Respiratory Distress + SLUDGE Asymptomatic Yes A IV Access Protocol p49 A IV Access Protocol p49 P Atropine 2mg IV/IO/IM Repeat Q5 min until symptoms resolve P Atropine 6mg IV/IO/IM Repeat Q5 min until symptoms resolve * DuoDote x 1 dose IM EMS Provider Use only May repeat x1 if symptoms return at 10 minutes * DuoDote x3 doses IM EMS Provider only Seizure No Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro *Each DuoDote Kit contains 600mg 2-PAM and 2.1mg of Atropine. The kits in the ambulance are intended for responder use only. If/When the emergency cache has been released by the State of Wisconsin, those kits may be used for the general public. SLUDGEM – Salivation, Lacrimation, Urination (Incontinence), Defecation (Incontinence), GI Upset, Emesis, Miosis For patients with major symptoms, there is no max dosing for Atropine; continue administering until salivation/secretions improved Follow all Hazmat procedures, strictly adhere to personal protective equipment for exposure prevention and begin decontamination early Patients who have been exposed to organophosphates are highly likely to off-gas; be sure to use all responder PPE and to avoid exposure to clothing or exhalations of victims. Helicopter EMS is generally NOT appropriate for these patients. Anticholinergic / Organophosphate Overdose - Adult 55 Medical Protocols - Adult Medical Protocols - Adult Begin Triage and Decontamination, As Appropriate Legend EMT A-EMT A P Paramedic M Medical Control Beta Blocker Overdose - Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGEM DUMBELLS Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting QT <450 Differential Status Epilepticus Anticholinergic Syndrome Meningitis, Tetanus Hyperventilation Hypocalcemia, hypomagnesemia Oropharyngeal Infections Serotonin Syndrome Sepsis Overdose and Poisoning, General - Adult Airway Evaluation Compromised Go To Airway Management Protocol p27 Adequate IV Access Protocol p49 A Normal Saline Bolus 250mL IV/IO If at any time patient loses pulses GO IMMEDIATELY to CARDIAC ARREST PROTOCOL Medical Protocols - Adult Clinical Features of Beta Blocker Overdose Cardiovascular – hypotension, bradycardia, AV block Pulmonary – bronchospasm, wheezing Metabolic – Hypoglycemia, Hyperkalemia Neuro - Stupor Monitor for Prolonged QT / Torsades de Pointes P If Yes, Magnesium Sulfate 2g IV/IO over 1-2 minutes A Dextrose Dosing: D10W 125mL IV/IO OR D5W 250mL IV/IO OR D50 25mL IV/IO Titrate to Effect Administer Supplemental O2 **In the setting of overdose, these patients need CPR, not CCR 12-Lead ECG Procedure (If Not Already Done) p139 Beta Blocker Ingested Identified Sotalol Propranolol If Yes Sodium Bicarbonate, 1mEq/kg IV/IO over 5 minutes As Needed P No OR “Other” <70 Monitor for QRS Widening Blood Sugar >70 P Atropine, 0.5mg IV/IO May repeat x 2 P No change Glucagon, 50mcg/kg (max 5mg) IV/IO P No change External Cardiac Pacing Procedure p165 Yes HR <60 AND Symptomatic No Peaked T-waves OR Suspected HyperK Yes No P Sodium Bicarbonate, 1mEq/kg IV/IO over 5 minutes P Calcium Chloride, 1g IV/IO bolus Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Many beta blocker ingestions do not cause symptoms; exceptions are the elderly, poor cardiac/respiratory reserve, and coingestions with other cardiac medications Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Many intentional overdoses involve multiple substances, some of which can have cardiac toxicity; a 12-Lead should be obtained on all overdose patients Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 Beta Blocker Overdose - Adult 56 Medical Protocols - Adult A A Legend EMT A-EMT P Paramedic M Medical Control Calcium Channel Blocker Overdose - Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGE DUMBELLS Differential Status Epilepticus Anticholinergic Syndrome Meningitis, Tetanus Hyperventilation Hypocalcemia, hypomagnesemia Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Oropharyngeal Infections Serotonin Syndrome Sepsis Overdose and Poisoning, General - Adult Airway Evaluation Compromised Go To Airway Management Protocol p27 Clinical Features of Calcium Channel Blocker Overdose Cardiovasccular – hypotension, bradycardia, shock Pulmonary – pulmonary edema, rales, crackles Metabolic – Hyperglycemia (can be a marker of severity) Neuro – Seizures, myoclonus, dizziness, syncope GI – Nausea and vomiting A Dextrose Dosing: D10W 125mL IV/IO OR D5W 250mL IV/IO OR D50 25mL IV/IO A IV Access Protocol p49 A Normal Saline Bolus 250mL IV/IO If at any time patient loses pulses GO IMMEDIATELY to CARDIAC ARREST PROTOCOL Administer Supplemental O2 **In the setting of overdose, these patients need CPR, not CCR 12-Lead ECG Procedure (If Not Already Done) p139 No OR Blood Sugar “Other” <70 >70 P Atropine, 0.5mg IV/IO May repeat x 2 P Calcium Chloride, 1g IV/IO bolus HR <60 AND Symptomatic Yes No Calcium Chloride, 1g IV/IO bolus P Notify Receiving Facility, Contact Medical Control As Necessary Stable OR Improving Yes Notify Receiving Facility, Contact Medical Control As Necessary P No Unstable P Glucagon, 50mcg/kg (max 5mg) IV/IO No change Consider External Cardiac Pacing Procedure p165 P No change Epinephrine, 0.1-1mcg/kg/min 1:10,000 (max 10mcg/min) IV/IO Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Sustained release preparations may have delayed onset of toxic symptoms (up to 12 hours) Overdoses with Calcium Channel Blockers have a high mortality!! Electrical conduction abnormalities, vasodilation, myocardial depression are severe Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Many intentional overdoses involve multiple substances, some of which can have cardiac toxicity; a 12-Lead should be obtained on all overdose patients Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 Calcium Channel Blocker Overdose - Adult 57 Medical Protocols - Adult Medical Protocols - Adult Adequate Legend EMT A-EMT A P Paramedic M Medical Control Carbon Monoxide Poisoning - Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Known or suspected CO Exposure Source and Duration of Exposure Dysrhythmias Differential Acute Myocardial Infarction Hypoglycemia Diabetic Ketoacidosis Subarachnoid Hemorrhage Acute Stroke Headache, Nausea/Vomiting Chest Pain, Arrhythmias Respiratory Distress Seizures Mental Status Change Vomiting Influenza Other toxic inhalation Tension Headache Overdose and Poisoning, General - Adult Stage, Call for Law Enforcement and/or Additional Resources No Provider Safety Consider SCBA if Toxic Inhalation Suspected Yes Go To Diabetic Emergencies Protocol p47 <70 Assess Blood Sugar Level >70 Go To Appropriate Medical Treatment Protocol No Clincal Suspicion of CO Toxicity No No SpCO <15% AND/OR SpO2 >93% Yes Measure SpO2 on Room Air CarboxHgb (SpCO) Available Consider Safety of ALL Responders including Law Enforcement Yes Yes Symptoms of Hypoxia OR CO Toxicity Consider Need for ALS Level Service EARLY >5% Asses and Docment SpCO <5% SpCO >15% AND/OR SpO2<93% Treatment for CO Not Indicated Go To Appropriate Medical Treatment Protocol Administer 100% O2 via NRB 12-Lead ECG Procedure p139 Arrhythmia / STEMI Go To Appropriate Cardiac Arrhythmia or STEMI Protocol p39 Positive Go To Suspected Stroke Protocol p69 Negative Notify Receiving Facility, Contact Medical Control As Necessary Sinus Rhythm Treatment for CO Not Indicated Consider Screening Home/Work Environment for elevated CO Cincinnati Stroke Screen Procedure p170 Go To Appropriate Medical Treatment Protocol Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Fetal hemoglobin has a stronger affinity for CO than adult, and will preferentially take the CO from the Mother, giving her a FALSE LOW SpCO level Hospital evaluation should be strongly encouraged for any pregnant or suspected to be pregnant females The absence or low levels of SpCO is not a reliable predictor of firefighter/victim exposures to other toxic byproducts of combustion. Consider the Cyanide Poisoning Protocol Multiple patients presenting with vague, influenza-like symptoms simultaneously should raise your suspicion of CO exposure. Ask about home heating methods, generator use, exposure to combustible fuels Carbon Monoxide Poisoning - Adult 58 Medical Protocols - Adult Medical Protocols - Adult Remove patient from Suspicious Environment, Administer 100% SpO2 Legend EMT A-EMT A P Paramedic M Medical Control Cyanide Poisoning - Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Known or suspected CO Exposure Source and Duration of Exposure Dysrhythmias Headache, Nausea/Vomiting Chest Pain, Arrhythmias Respiratory Distress Seizures Mental Status Change Vomiting Differential Acute Myocardial Infarction Hypoglycemia Diabetic Ketoacidosis Subarachnoid Hemorrhage Acute Stroke Influenza Other toxic inhalation Tension Headache Overdose and Poisoning, General - Adult Stage, Call for Law Enforcement and/or Additional Resources No Provider Safety Consider SCBA if Toxic Inhalation Suspected Yes Go To Diabetic Emergencies Protocol p47 <70 Assess Blood Sugar Level Consider Need for ALS Level Service EARLY Consider Safety of ALL Responders including Law Enforcement >70 Go To Airway Management Protocol p27 Protecting Airway No If Cyanokit is appropriate, contact and make arrangements with receiving ED or equipped ALS unit ASAP Yes Continuous Cardiac Monitor Go To Appropriate Cardiac Treatment Protocol Go To Appropriate Medical Treatment Protocol A IV Access Protocol p49 A Normal Saline Bolus 250mL IV/IO Arrhythmia/ STEMI 12-Lead ECG Procedure (If Not Already Done) p139 High Suspicion of Cyanide No Yes P Cyanokit, 70mg/kg IV/IO (max 5g) Infuse over 15 minutes if available Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Consider Cyanide when exposed to any products of combustion, mining incidents or industrial organic chemistry exposure. Fetal hemoglobin has a stronger affinity for CO than adult, and will preferentially take the CO from the Mother, giving her a FALSE LOW SpCO level Hospital evaluation should be strongly encouraged for any pregnant or suspected to be pregnant females The absence or low levels of SpCO is not a reliable predictor of firefighter/victim exposures to other toxic byproducts of combustion Multiple patients presenting with vague, influenza-like symptoms simultaneously should raise your suspicion of CO exposure. Ask about home heating methods Cyanide Poisoning - Adult 59 Medical Protocols - Adult Medical Protocols - Adult Remove patient from Suspicious Environment, Administer 100% SpO2 Legend EMT A-EMT A P Paramedic M Medical Control Antipsychotic Overdose / Acute Dystonic Reaction - Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGEM DUMBELLS Differential Status Epilepticus Anticholinergic Syndrome Meningitis, Tetanus Hyperventilation Hypocalcemia, hypomagnesemia Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Oropharyngeal Infections Serotonin Syndrome Sepsis Overdose and Poisoning, General - Adult Common Causes of Dystonic Reactions Airway Evaluation Compromised Go To Airway Management Protocol p27 Adequate IV Access Protocol p49 A Administer Supplemental O2 Go To Appropriate Cardiac Treatment Protocol Arrythmia/ STEMI 12-Lead ECG Procedure (If Not Already Done) p139 P P Lorazepam 1-2mg IV/IO OR Midazolam 5mg IV/IO if <60 y/o Midazolam 2.5mg IV/IO if >60y/o Diphenhydramine 25mg IV/IO May repeat x 1 after 10 minutes No Improving Yes Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Acute dystonic reactions are extrapyramidal side effects of antipsychotic and certain other medications. 90% occur within 5 days of starting a new med Dystonia refers to sustained muscle contractions, frequently causing twisting, repetitive movements or postures, and may affect any part of the body Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Many intentional overdoses involve multiple substances, some of which can have cardiac toxicity; a 12-Lead should be obtained on all overdose patients Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 Antipsychotic Overdose / Acute Dystonic Reaction - Adult 60 Medical Protocols - Adult Medical Protocols - Adult Antipsychotics – i.e. Haldol, Prolixin, Thorazine Antiemetics – i.e. prochlorperazine, metaclopramide Antidepressants – i.e. buspirone, sumitriptan Antibiotics – i.e. erythromycin Anticonvulsants – i.e. carbamazepine, vigabatrin H2 receptor blockers – i.e. ranitadine, cimetidine Recreational Drugs – i.e. cocaine Legend EMT A-EMT A P Paramedic M Medical Control Opiate Overdose - Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGE DUMBELLS Differential Post-ictal After Seizure Hypothyroidism EtOH / BZD overdose Intracranial Hemorrhage Hypoglycemia Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Head Injury Encephalitis Liver Failure CO2 Retention (Hypercarbia) Polysubstance Overdose In opiate overdoses, poor respiratory effort is what kills patients; emphasis should be on ventilation support first, and Naloxone administration second Airway Evaluation Intranasal Naloxone is ONLY effective if there is a pulse; circulatory support is key Adequate Compromised Naloxone 0.5-1mg IN per nare, may repeat OR IN Naloxone has a slower onset, but seems to have a lower incidence of agitation and aggression after administration A IV Access Protocol p49 A Naloxone 0.5-2.0mg IV/IO/IM, May repeat x1 Go To Airway Management Protocol p27 Single Agent Opiate Medications Oxycodone Hydrocodone Morphine Heroin Dilaudid Fentanyl Codeine Administer Supplemental O2 to maintain SpO2 >93% Combination Opiate Medications Go To Appropriate Cardiac Care Protocol A Dextrose Dosing: D10W 125mL IV/IO OR D5W 250mL IV/IO OR D50 25mL IV/IO Arrhythmia/ STEMI <70 12-Lead ECG Procedure (If Not Already Done) p139 Vicodin – Hydrocodone + Tylenol Norco – Hydrocodone + Tylenol Percocet – Oxycodone + Tylenol Darvocet – Darvon + Tylenol Vicoprofen – Hydrocodone + Ibuprofen T3 – Tylenol + Codeine No OR Blood Sugar “Other” Long-Acting Opiate Medications >70 Oxycontin MS Contin Methadone Monitor RR, SpO2 and Mental Status If at any time patient loses pulses GO IMMEDIATELY to CARDIAC ARREST PROTOCOL Improved **In the setting of overdose, these patients need CPR, not CCR Consider Altered Mental Status Protocol p45 No Yes Notify Receiving Facility, Contact Medical Control As Necessary M Contact Medical Control Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Opiates may be taken orally, intravenously and inhalational (smoked/snorted). All routes are capable of causing respiratory arrest in overdose All opiates have effects that last longer than Naloxone. Extended Release and Long-Acting formulations will likely need repeat Naloxone dosing in overdose Naloxone has been connected to flash pulmonary edema after administration for opiate overdose; for this reason, all opiate OD patients must be transported Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Many intentional overdoses involve multiple substances, some of which can have cardiac toxicity; a 12-Lead should be obtained on all overdose patients Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 Opiate Overdose - Adult 61 Medical Protocols - Adult Medical Protocols - Adult General Approach – Adult, Medical Legend EMT A-EMT A P Paramedic M Medical Control Cocaine and Sympathomimetic Overdose Adult Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGE DUMBELLS Differential Status Epilepticus Anticholinergic Syndrome Meningitis, Tetanus Hyperventilation Hypocalcemia, hypomagnesemia Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Oropharyngeal Infections Serotonin Syndrome Sepsis Subarachnoid Hemorrhage Pheochromocytoma Overdose and Poisoning, General - Adult Airway Evaluation Adequate Clinical Features of Cocaine or Sympathomimetic Overdose A IV Access Protocol p49 Hypertension, Tachycardia, Agitation, Seizure, Dilated Pupils A Normal Saline Bolus 250mL IV/IO Go To Airway Management Protocol p27 If at any time patient loses pulses GO IMMEDIATELY to CARDIAC ARREST PROTOCOL **In the setting of overdose, these patients need CPR, not CCR Administer Supplemental O2 12-Lead ECG Procedure (If Not Already Done) p139 A Dextrose Dosing: D10W 125mL IV/IO OR D5W 250mL IV/IO OR D50 25mL IV/IO <70 Arrhythmia/ STEMI Go To Appropriate Cardiac Care Protocol No OR Blood Sugar “Other” >70 Consider Behavioral / Excited Delirium Protocol p46 Agitation Yes P Lorazepam 1-2mg IV/IO/IM OR Midazolam 2-4mg IV/IO/IM/IN (max 4mg) No Chest Pain in the setting of Cocaine use should be treated with IV Fluids and Benzodiazepines. Seizure Beta Blockers are CONTRAINDICATED in cocaine use, as it can result in unopposed alpha activity Yes Go To Seizure Protocol p68 No Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular Patients on MAOIs for depression may have symptoms of a Sympathomimetic Overdose after eating certain foods such as aged cheese, beer, mushrooms Patients with Cocaine or Sympathomimetic Overdose are at high risk of Arrhythmias, Myocardial Infarction and Stroke Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Many intentional overdoses involve multiple substances, some of which can have cardiac toxicity; a 12-Lead should be obtained on all overdose patients Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 Cocaine and Sympathomimetic Overdose - Adult 62 Medical Protocols - Adult Medical Protocols - Adult Sympathomimetics are drugs that mimic the effects of the sympathetic nervous system Compromised A Legend EMT A-EMT Tricyclic Overdose - Adult P Paramedic M Medical Control Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGEM DUMBELLS Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Differential Head Injury Hazmat Exposure Electrolyte Imbalance DM, CVA, Seizure Sepsis Overdose and Poisoning, General - Adult Any Coingestants Yes Collect Pill Bottles, Pill Fragments and Prescriptions as possible and bring to the ED Amitriptyline Clomipramine Doxepin Imipramine Nortryptyline Protriptyline 12-Lead ECG Procedure (If Not Already Done) p139 Wide QRS >0.12sec A IV Access Protocol (If Not Already Done) p49 P Sodium Bicarbonate, 1mEq/kg IV/IO over 5 minutes <0.12sec A IV Access Protocol (If Not Already Done) p49 A Normal Saline Bolus 250mL IV/IO SBP <100 Hypotension BP Improved AND QRS Narrowing Yes No SBP >100 P Improved Improving Yes Sodium Bicarbonate, 1mEq/kg IV/IO over 5 minutes If Airway Managed, Hyperventilate to goal EtCO2 30-35mmHg No Seizure Go To Shock (Non-Trauma) Protocol p67 Yes No Go To Appropriate Arrhythmia Protocol Yes Arrhythmia No A IV Access Protocol (If Not Already Done) p49 P Lorazepam 1-2mg IV/IO/IM OR Midazolam 2-4mg IV/IO/IM/IN (One Time) Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Neuro, Abdominal Exam, Cardiovascular If arrhythmias occur in TCA Overdose, the first step is to give more Sodium Bicarbonate. Then move on to the Appropriate Arrhythmia Protocol Administer IV Sodium Bicarbonate 1mEq/kg over 5 minutes, and repeat every 5 minutes until BP improves and QRS complex begins to narrow. Avoid beta-blockers and amiodarone as they may worsen hypotension and conduction abnormalities Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Many intentional overdoses involve multiple substances, some of which can have cardiac toxicity; a 12-Lead should be obtained on all overdose patients Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 Tricyclic Overdose - Adult 63 Medical Protocols - Adult Medical Protocols - Adult Common Tricyclic Antidepressants: Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS SAMPLE History OPQRST History History of chronic pain Differential Head injury Spine Injury Compartment Syndrome Fracture, Sprain, Strain Pneumo/hemo-thorax Pericardial effusion Aortic Dissection Internal organ injury General Approach – Adult, Medical Patient Care per Appropriate Adult Medical Protocol None – Mild Pain (0-4) Consider IV Access Protocol p49 A Moderate Pain (5-8) Severe Pain (9-10) Place patient on cardiac monitor, continuous SpO2 and EtCO2 Place patient on cardiac monitor, continuous SpO2 and EtCO2 P Consider IN Fentanyl 1.5mcg/kg (max 50mcg per nare) P Consider IN Fentanyl 1.5mcg/kg (max 50mcg per nare) A Consider IV Access Protocol p49 A Consider IV Access Protocol p49 Document response to meds, VS (HR, BP, SpO2, EtCO2) Document response to meds, VS (HR, BP, SpO2, EtCO2) SpO2 >93%, EtCO2 <45, SBP >90 Reassess Pain SpO2 >93%, EtCO2 <45, SBP >90 Unchanged OR Worsening P Fentanyl 1mcg/kg IV/IO/IM (max 75mcg) May repeat x 1 P Consider Ondansetron 0.1mg/kg IV/IO/ODT (max 4mg) M Consider Morphine 0.1mg/kg IV/IO (max 4mg) Improved Reassess and Document VS, including Pain Scale Continue with Adult Medical Specific Protocol Pearls REQUIRED EXAM: Vital Signs, GCS, Neuro Exam, Lung Sounds, Abdominal Exam, Musculoskeletal Exam, Area of Pain Provider Discretion to be used for patients suffering from chronic pain related issues. However, please note that history of chronic pain does not preclude the patient from treatment of acute pain related etiologies. Pain severity (0-10) is a vital sign to be recorded pre- and post-medication delivery and at disposition As with all medical interventions, assess and document change in patient condition pre- and post-treatment Opiate naive patients can have a much more dramatic response to medications than expected; start low and titrate up as appropriate Allow for position of maximum comfort as situation allows Pain Management – Adult 64 Medical Protocols - Adult Medical Protocols – Adult Assess Pain 0-10 Pain Scale OR FACES Scale A Legend EMT A-EMT P Paramedic M Medical Control Refusal Protocol - Adult Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Mental Status Pale, Cool Skin Delayed Cap Refill Differential Cardiac Dysrhythmia Hypoglycemia Overdose Toxidrome Sepsis Occult Trauma Adrenal Insufficiency General Approach – Adult, Medical >18 Years of Age OR Court Emancipated Minor OR Legally Married Person of Any Age OR Unwed Pregnant Female <18 IF and ONLY IF EMS Call Related to Pregnancy Parent/Legal Guardian of Patient Can Be Contacted No No Altered Mental Status OR Impaired Decision Making Ability OR Hallucinations or Thought Disorder OR Incapacitated* OR Suicidal or Homicidal Ideation Pediatric Refusal Protocol p117 Transport Required Under Implied Consent OR Police Protective Custody Yes No Clinically Intoxicated** OR EtOH Use AND Prudent EMS Provider Believes Treatment IS Needed Consult PD To Determine Appropriate Disposition Transport by Ambulance or Alternative (Wisconsin State Statute 51.45) Police Officer Name and Badge Number REQUIRED in Documentation Yes No Bronchospasm Resolved after ONE Nebulizer Treatment OR Insulin Only Induced Hypoglycemia Resolved After ONE Treatment Refusal After EMS Treatment Protocol p66 Yes No Document assessment including mental status, physical exam, vitals, blood glucose and SpO2 Assure that the patient/parent/guardian understands the possible consequences of refusal Complete documentation of refusal and obtain signatures Contact On-Line Medical Control for refusals that arise after EMS treatment has been initiated Pearls REQUIRED EXAM: VS, GCS, Nature of Complaint *Incapacitated definition: A person who, because of alcohol consumption or withdrawal, is unconscious or whose judgment is impaired such that they are incapable of making rational decisions as evidenced by extreme physical debilitation, physical harm or threats of harm to themselves, others or property. Evidence of incapacitation: inability to stand on ones own, staggering, falling, wobbling, vomit/urination/defecation on clothing, inability to understand and respond to questions, DTs, unconsciousness, walking or sleeping where subject to danger, hostile toward others. **Intoxicated definition: A person whose mental or physical functioning is substantially impaired as a result of the use of alcohol. If there is ANY question, do not hesitate to involve Law Enforcement to ensure the best decisions are being made on behalf of the patient. Refusal Protocol - Adult 65 Medical Protocols - Adult Medical Protocols - Adult Yes Yes A Refusal After EMS Treatment Adult Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Differential Cardiac Dysrhythmia Hypoglycemia Overdose Toxidrome Mental Status Pale, Cool Skin Delayed Cap Refill Sepsis Occult Trauma Adrenal Insufficiency Refusal Protocol – Adult, Medical Reason for EMS Activation Asymptomatic After One Treatment Presentation is Consistent with Mild Asthma/COPD Exacerbation No pain, no sputum, afebrile, no hemoptysis Not hypoxic after Treatment (SpO2 >93%) Complete Resolution of Symptoms Vital Signs WNL after Treatment ANY ‘No’ Insulin-only Induced Hypoglycemia ANY ‘No’ Transport Required OR Police Protective Custody Contact On-Line Medical Control as necessary Asymptomatic After Dextrose Infusion Patient is on insulin ONLY (does not take ANY oral diabetes medications) Presentation consistent with simple hypoglycemia Rapid and complete improvement after Dextrose infusion Vital Signs WNL after Treatment No indication of intentional overdose ALL ‘Yes’ ALL ‘Yes’ Consider Additional Patient Safety Measures A Family Member or Caregiver is available to stay with the patient to assist/activate EMS if symptoms return Assure that the patient/parent/guardian understands the possible consequences of refusal Request the patient to follow up with their physician as soon as possible and/or to contact 9-1-1 if symptoms return ALL ‘Yes’ ANY ‘No’ Document assessment including mental status, physical exam, vitals, blood glucose and SpO2 Assure that the patient/parent/guardian understands the possible consequences of refusal Complete documentation of refusal and obtain signatures Transport Required OR Police Protective Custody Contact On-Line Medical Control as necessary Pearls REQUIRED EXAM: VS, GCS, Nature of Complaint *Incapacitated definition: A person who, because of alcohol consumption or withdrawal, is unconscious or whose judgment is impaired such that they are incapable of making rational decisions as evidenced by extreme physical debilitation, physical harm or threats of harm to themselves, others or property. Evidence of incapacitation: inability to stand on ones own, staggering, falling, wobbling, vomit/urination/defecation on clothing, inability to understand and respond to questions, DTs, unconsciousness, walking or sleeping where subject to danger, hostile toward others. **Intoxicated definition: A person whose mental or physical functioning is substantially impaired as a result of the use of alcohol. If there is ANY question, do not hesitate to involve Law Enforcement to ensure the best decisions are being made on behalf of the patient. Refusal After EMS Treatment - Adult 66 Medical Protocols - Adult Medical Protocols - Adult Bronchospasm, Resolved after Nebulizer A Hypotension / Shock (NonTrauma) - Adult Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Source of blood loss, if any (GI, vaginal, AAA, ectopic) Source of fluid loss, if any (vomiting, diarrhea, fever) Pregnancy history Mental Status Pale, Cool Skin Delayed Cap Refill Coffee Ground Emesis Tarry Stools Allergen Exposure Differential Cardiac Dysrhythmia Hypoglycemia Ectopic Pregnancy AAA Sepsis Occult Trauma Adrenal Insufficiency General Approach – Adult, Medical Blood Glucose Go To Appropriate Cardiac Dyshrhythmia or STEMI Protocol p39 Go To Diabetic Emergencies Protocol p47 <70 or >250 12 Lead ECG Procedure p139 Abnormal BOTH Normal IV Access Protocol p49 A History, Exam, Circumstances Suggest Etiology of SBP <100? Trauma Medical Hypovolemic (Dehydration, GI Bleed) A Distributive (Sepsis, Anaphalaxis) Cardiogenic (STEMI, CHF) Normal Saline Bolus 500mL Repeat every 5 min., max 2L A Obstructive (PE, Tamponade) Normal Saline Bolus 250mL Repeat every 5 min., max 1L SBP <100 SBP <100 Repeat and Document BP Repeat and Document BP Yes Improved? Yes Improved? No No P Dopamine 5-20mcg/kg/min IV/IO OR Epinephrine 0.1-0.5mcg/kg/min IV/IO (1:10,000) Titrate to SBP >100 OR P Dopamine 5-20mcg/kg/min IV/IO Titrate to SBP >100 OR M Norepinephrine 8-12mcg/min IV/IO IF available Titrate to SBP >100 M Norepinephrine 8-12mcg/min IV/IO IF Available Titrate to SBP >100 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, RR, Lung sounds, JVD Shock may present with normal VS and progress insidiously. Tachycardia may be the first and only sign of shock. If evidence or suspicion of trauma, move to Hemorrhage Protocol early Acute Adrenal Insufficiency – State where the body cannot produce enough steroids. Primary adrenal disease vs. recent discontinuation of steroids (Prednisone) after long term use. ** If Adrenal Insufficiency suspected, contact Medical Control and review case. Medical Control may authorize Methylprednisone 125 mg IV/IO. Document respiratory rate, SpO2 and breath sounds with IV Fluids, and consider Pulmonary Edema Protocol as appropriate. Hypotension / Shock (Non-Trauma) - Adult 67 Medical Protocols - Adult Medical Protocols - Adult Go To Hemorrhage (Trauma) Protocol p87 Consider Airway Management Protocol p27 Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS, SpO2, Blood Sugar SAMPLE History OPQRST History Seizure History, Med Compliance Differential Hypoxia Hypoglycemia Electrolyte Imbalance Eclampsia Stroke Hyperthermia Bowel or Bladder Incontinence Tongue Biting Pregnancy History Evidence of Trauma Number of Seizures and Duration Drugs, EtOH Abuse Drugs, EtOH Withdrawal Occult Head Injury Tumor Liver / Kidney Failure Infection / Sepsis General Approach – Adult, Medical Consider ALS Early Prolonged Seizures Are BAD for Neurologic Outcomes! Environmental Cause or Toxic Exposure Notify Comm Center and Hazmat Team Ensure Responder and Public Safety Yes Go To Hazmat, Trauma Protocol p85 No Actively Seizing on EMS Arrival Blood Glucose <70 Yes Go To Diabetic Emergencies Protocol p47 Blood Glucose <70 >70 >70 Loosen Constrictive Clothing Protect Patient from Injury A Consider Airway Management Protocol p27 P Midazolam 5mg IM/IN if <60 y/o Midazolam 2.5mg IM/IN if >60 y/o IV Access Protocol p49 Consider Long Board Selective Spinal Immobilization Protocol p92 Monitor and Reassess Loosen Constrictive Clothing Protect Patient from Injury A Normal Mental Status Yes No Consider Altered Mental Status Protocol p45 Seizure Returns No IV Access Protocol p49 Still Seizing Yes Yes No No Notify Receiving Facility, Contact Medical Control As Necessary Status Epilepticus Contact Medical Control P Lorazepam 1-2mg IV/IO OR Midazolam 5mg IV/IO if <60 y/o Midazolam 2.5mg IV/IO if >60y/o Yes Pearls REQUIRED EXAM: Blood Sugar, SpO2, GCS, Neuro Exam Midazolam is effective in terminating seizures. Do not delay IM/IN administration to obtain IV access in an actively seizing patient Do not hesitate to treat recurrent, prolonged (>1 minute) seizure activity Status epilepticus is >2 successive seizures without recovery or consciousness in between. This is a TRUE EMERGENCY requiring Airway Management and rapid transport Assess for possibility of occult trauma, substance abuse Active seizure in known or suspected pregnancy >20 weeks, give Magnesium 4gm IV/IO over 2-3 minutes Seizure - Adult 68 Medical Protocols - Adult Medical Protocols - Adult No A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positive/Negative: SAMPLE History OPQRST History History of CVA, TIA Previous Cardiac, Vascular Surgery Anticoagulant Use Weakness / Paralysis Aphasia / Dysarthria Headache Vertigo Seizure Differential TIA Seizure Hypoglycemia Tumor Occult Trauma Stroke -Thrombolic (~85%) -Hemorrhagic (~15%) General Approach – Adult, Medical Consider Altered Mental Status Protocol p45 0/3 positives Cincinnati Stroke Screen Procedure p170 >1/3 items positive Keep Scene Time < 10 min. Blood Glucose Go To Appropriate Cardiac Dysrhythmia or STEMI Protocol p39 Abnormal Go To Diabetic Emergencies Protocol p47 <93% Go To Airway Mangement Protocol p27 <12 hours Call Early “Stroke Alert” to Stroke Facility 12 Lead ECG Procedure p139 SpO2 >93% Elevate Head of Stretcher 15-30 degrees A IV Access Protocol p49 Establish Definite Time of Symptom Onset >12 hours Initiate Transport to Hospital Consider Hypotension / Shock (Non-Trauma) Protocol p67 SBP <100 Monitor and Reassess BP SBP >220 AND/OR DBP >120 M Consider BP Management SBP >100 AND <220 Thrombolytic Screening Protocol p70 Monitor and Reassess Symptoms Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, SpO2, Blood Glucose, Neuro Exam, Cincinnati Stroke Scale Thrombolytic Screening Protocol should be completed for any suspected stroke patient Think FAST – Facial Asymmetry, Arm Strength, Speech and Time since last seen normal Be very diligent observing for airway compromise in suspected acute stroke (swallowing, vomiting, aspirating) Hypoglycemia, Infection and Hypoxia can present with Neurologic deficit, especially in the elderly. IV Access is important, but establishment of a line should not significantly delay initiation of transport. Time lost is brain lost! Suspected Stroke - Adult 69 Medical Protocols - Adult Medical Protocols - Adult <70 or >250 A Legend EMT A-EMT P Paramedic M Medical Control Step One Thrombolytic Screening - Adult Chest Discomfort OR Ischemic Symptoms >15 minutes AND <12 hours? Stroke Symptoms <12 hours? Yes Yes ECG with STEMI, **ACUTE MI**, or new/presumably new Left Bundle Branch Block (LBBB)? Positive Cincinnati Stroke Scale? Yes Yes Step Two Are there contraindications to fibrinolytics? Systolic BP >180mmHg OR Diastolic BP >100mmHg? Right vs. Left arm SBP difference >15mmHg? History of structural central nervous system disease? Significant closed head / facial trauma within 3 months? Recent Stroke >3 hours or <3 months? Major trauma, surgery (including laser eye surgery) within 4 weeks? Any history of intracranial hemorrhage? Bleeding or Clotting disorder OR taking anticoagulant medications? Is the patient pregnant? Serious systemic disease (i.e. adrenal cancer, severe liver or kidney disease)? ANY “Yes”, fibrinolytics may be contraindicated No Step Three Is the patient at high risk for bleeding complications? Heart rate >100 And Systolic Blood Pressure <100 Pulmonary Edema on Lung Exam (rales, basilar crackles) Signs of Shock (cool, clammy skin) Contraindications to fibrinolytics (above) Required CPR and/or CCR at any point ANY “Yes”, must transport to PCI capable center No Step Four Assess Special Patient or System Considerations Age ≥55 years Anticoagulation and bleeding disorders Known Coronary Artery Disease End Stage Renal Disease requiring Hemodialysis Pregnancy ≥20 weeks EMS provider judgment Contact Medical Control Consider Specialty Stroke Center OR Cardiothoracic Surgical Center No Transport according to Appropriate Medical Protocol Thrombolytic Screening - Adult 70 Medical Protocols - Adult Medical Protocols - Adult OR Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS Time of Injury, Mechanism of Injury DCAP-BTLS SAMPLE History Differential Stroke STEMI Overdose OPQRST History Pain / Swelling Mental Status Hypotension / Shock Elder Abuse Domestic Violence Non-Accidental Trauma Assessment Patient >18 years old Scene ≥5 Notify Comm Center, Activate MCI Incident <5 Consider Additional Resources, MCI if Necessary Multiple Patients Safety Unsafe Safe Insufficient Presentation OR Traumatic Mechanism No Go To Appropriate Adult Medical Protocol Pulseless, Apneic Go To Traumatic Cardiac Arrest Protocol p76 Yes Sufficient Hazmat Primary Survey Yes Go To Airway Management Protocol p27 Airway Patent, Poor Chest Compliance OR Unstable VS Consider Chest Decompression Procedure p169 P Notify Comm Center, Activate Hazmat Resources Obstructed Airway, Ventilations Inadequate Minimize Scene Time, Notify Receiving Facility of Trauma Patient Early A,B,C’s Exsanguinating Hemorrhage Go To Hemorrhage Control Protocol p87 Ventilations Adequate, BP and HR Adequate Support Airway, Support Oxygenation, Support Circulation Go To Long Board Selective Spinal Immobilization Protocol p92 Transport Per Appropriate Trauma Protocol Pearls REQUIRED EXAM: Vital Signs, GCS, Loss of Consciousness, Location of Pain (then targeted per Appropriate Trauma Protocol) Assess for major trauma criteria immediately upon patient contact -RR <10 or >29; SBP <90; Pulse <50 or >140; GCS <13; SpO2<93% -Transport to Trauma Center, minimize scene time to goal of <10 minutes Disability – assess for neuro deficits including paralysis, weakness, abnormal sensation Suspect Tension Pneumothorax when: -Mechanism consistent with Chest Trauma; Resp Distress; Decreased Breath Sounds; JVD; Low BP; Tachycardia; Tracheal Deviation -Signs and Symptoms of Tension Pneumothorax may be present with or without positive pressure ventilations -Needle Decompression should be performed with a 3" 14ga needle at the 2nd intercostal space, midclavicular line -If repeat decompression necessary, continue to move laterally along the superior aspect of the 3rd rib General Approach – Adult, Trauma 71 Trauma Protocols - Adult Trauma Protocols - Adult PPE Stage, Call for Law Enforcement and/or Additional Resources A Legend EMT A-EMT P Paramedic M Medical Control Step One Any Airway Compromise not able to be managed by EMS should be taken to the CLOSEST FACILITY for stabilization immediately Measure Vital Signs and Level of Consciousness Glasgow Coma Scale Systolic blood pressure (mmHg) Respiratory rate ≤13 <90 mmHG <10 or >29 bpm OR need for ventilation support Yes No Transport to Level 1 Trauma Center; Notify via Radio as early as possible Assess Anatomy of Injury Penetrating Injury to head, neck, torso, extremities proximal to knee Chest wall instability or deformity ≥2 proximal long bone fractures Crushed, degloved, or mangled extremity Amputation proximal to wrist or ankle Pelvic fracture Open or depressed skull fracture Paralysis Yes No Step Three Assess Mechanism of injury and evidence of High Energy Impact Falls > 20 ft High Risk Auto Crash Auto vs. Pedestrian/Bicyclist thrown, run over or significant (>20 mph) impact Motorcycle crash >20 mph Yes Transport to closest appropriate Leveled Trauma Center Yes Contact Medical Control; Consider Trauma Center or Specialty Resource Center No Step Four Assess Special Patient or System Considerations Age ≥55 years Anticoagulation and bleeding disorders Burns - without other trauma, transport to burn facility - with traumatic mechanism, transport to trauma center End Stage Renal Disease requiring Hemodialysis Pregnancy ≥20 weeks EMS provider judgment No Transport according to Appropriate Trauma Protocol Destination Determination – Adult, Trauma 72 Trauma Protocols - Adult Trauma Protocols - Adult Step Two Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Pulses distal to wound SAMPLE History OPQRST History Description or photo of offending creature Tetanus status Immunization History of Creature (if known) Domestic vs. Wild Animal Allergic Reaction Hypotension, Shock, Fever Differential Penetrating Trauma Dry Bite (Snake) Abscess/Cellulitis Non-Accidental Trauma Projectile Injury General Approach – Adult, Trauma Offending Organism(s) Neutralized No Contact Dane Co. Animal Control 1-608-255-2345 Yes Yes Active Hemorrhage No Allergic Reaction Yes Go To Allergy and Anaphylaxis Protocol p44 No Evaluate Pain Moderate OR Severe Consider Pain Management – Adult, Trauma Protocol p89 None or Mild Identification of Offending Organism Mammalian Bite (including Human) Immobilize Injury, Remove jewelry distal to bite Snakebite Immobilize Injury, Remove jewelry distal to bite Muscle Spasms Immobilize Injury, Remove jewelry distal to bite Wound Care Procedure p183 Mark Edges of Erythema with Marking Pen Notify Receiving Facility, Contact Medical Control As Necessary Spider, Bee, Wasp, Hornet No Yes P Consider Midazolam 5mg IM/IN OR Midazolam 2mg IV/IO Pearls REQUIRED EXAM: VS, GCS, Evidence of Intoxication, Affected Extremity Neurovascular Exam Cat bites may not initially appear serious, but can progress rapidly to severe infection Human bites have higher rates of infection than animal bites and necessitate evaluation in the Emergency Department for antibiotics Bites on the hands and lacerations over knuckles should be assumed to be “Fight Bites” until proven otherwise, and need evaluation Brown recluse spider bites are usually painless at the time of bite. Pain and tissue necrosis develops over hours to days Immunocompromised patients have higher risk of infection – Think: Diabetes, Chemotherapy, Organ Transplant Bites and Envenomations – Adult, Trauma 73 Trauma Protocols - Adult Trauma Protocols - Adult Go To Hemorrhage Control Protocol p87 Call For Resources, Stage Until Scene Safe A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Events Leading Up To Injury SAMPLE History OPQRST History Other Injury Loss of Consciousness Airway Compromise Blood from Ears, Nose Hoarseness or Wheezing Nature of Device Differential Thermal Injury Electrical Injury Chemical Burn Aspiration Radiation Injury Blast Lung Blunt Trauma General Approach – Adult, Trauma Go To Appropriate Burn Injury Protocol p75 Thermal / Chemical / Electrical Burn Yes No Blast Injury Patient Management Radiation Burn or Exposure Yes Blood from the ears or poor hearing indicates ruptured tympanic membranes, and likely a significant blast wave No Go To Prolonged Crush Injury Protocol p79 Yes Crush Injury No Consider Airway Management Protocol Continuous Cardiac Monitor A Consider IV Access Protocol p49 Maintain SpO2 >93% Consider Airway Management Protocol p27 Yes Blast Lung Injury No Consider Pain Management, Trauma Protocol p89 >5/10 OR Severe Pain <5/10 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro, Ear Exam, Nose Exam Primary Blast Injury – Injuries from Overpressure Wave; Secondary Blast Injury – Flying Debris that Hits People; Tertiary Blast Injury – Flying People that Hit Objects; Quaternary Blast Injury – Exacerbation of Chronic Illness due to debris, dust, etc. Blast Lung Injury – characterized by respiratory difficulty and hypoxia. More likely in enclosed spaces or close proximity to explosion; may require early intubation but positive pressure ventilation may worsen injury, air transport may worsen their condition Intentional Explosion – Responders may be targets! Have a high index of suspicion, be on the lookout for secondary devices, watch out for your partners in Fire and Law Enforcement and keep your head on a swivel Blast Injury – Adult, Trauma 74 Trauma Protocols - Adult Trauma Protocols - Adult Go To Radiation Injury Protocol p90 Consider provider safety, number of patients and early notification of receiving facility Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS SAMPLE History OPQRST History Mechanism of Burn (heat, gas, chemical) Time of Injury Consider need for Airway Management EARLY Singed Facial Hair Wheezing, Hoarseness Subjective Throat Swelling Loss of Consciousness Differential Blast Injury Radiation Injury Electrical Injury Cyanokit Need? General Approach – Adult, Trauma Cellulitis Dermatitis Drug Reaction (Stevens-Johnson Syndrome) Indications of possible Cyanide Poisoning Exposure to fumes from burning Nitrile (polyurethane, vinyl) Seizures, coma, cardiac arrest, headache, vertigo and/or cherry red skin color from increased venous O2 concentration Minor Burn Serious Burn Critical Burn <5% TBSA, 1st – 2nd Degree Burn No inhalation Injury Normal BP, SpO2 5-15% TBSA, 2nd – 3rd Degree Burn Suspected Inhalation Injury Hypotension, Altered Mental Status >15% TBSA, 2nd – 3rd Degree Burn Burn with Trauma Burn with Airway Compromise Remove Rings, Bracelets and Constricting Items Remove Rings, Bracelets and Constricting Items Remove or Cool Heat Source (if not already done) Apply Dry Clean Sheet or Non-Adherent Dressing Apply Dry Clean Sheet or Non-Adherent Dressing Consider Pain Management – Adult, Trauma Protocol p89 Consider IV Access Protocol p49 A Remove or Cool Heat Source (if not already done) Consider Airway Management Protocol p27 Consider Pain Management – Adult, Trauma Protocol p89 Transport to Facility of Choice No Burn to Hands, Feet, Face or Perineum Yes A IV Access Protocol p49 A LR Preferred over NS, If available 500mL IV/IO Given over 1 hour Transport to Designated Burn Center Pearls REQUIRED EXAM: VS, GCS, Lung Sounds, HEENT, Posterior Pharynx Burns to face and eyes, remove contact lenses prior to irrigation Chemical burns require removal of contaminated clothing. Brush away dry powder before beginning irrigation. Flush with copious warm water on scene and continue irrigation en route. Early intubation is strongly recommended if suspicion of inhalation injury. Signs and symptoms include carbonaceous sputum, facial burns or edema, hoarseness, singed nasal hairs, agitation, hypoxia or cyanosis Burns – Adult, Trauma 75 Trauma Protocols - Adult Trauma Protocols - Adult Estimate TBSA Burned / Severity Legend EMT A-EMT A P Paramedic M Medical Control Differential Hypovolemic Shock -External Hemorrhage -Internal Hemorrhage -Unstable Pelvic Fracture Pertinent Positives and Negatives Age, if known Mechanism of Injury Events leading up to arrest Tension Pneumothorax Medical Condition Causing Trauma (i.e. Cardiac Arrest) General Approach – Adult, Trauma Injuries Incompatible With Life? (Incineration, Decapitation, Hemicorpectomy) Criteria for Death/Withholding Resuscitation Policy p9 Yes No Rigor Mortis, Dependent Lividity or Decomposition of Body Tissue? Yes Criteria for Death/Withholding Resuscitation Policy p9 Contact Law Enforcement and/or Medical Examiner Asystole OR PEA <40bpm Do Not Attempt Resuscitation Apply Continuous Cardiac Monitor Blunt Trauma Yes Yes No No Begin Resuscitation Continue CPR Throughout Transport to Closest Leveled Trauma Center (Preference to Level 1 Center, if possible) Full Spinal Immobilization with C-collar and Long Spine Board MANDATORY A IV Access Protocol p49 A NS Bolus 500mL IV/IO Return of Pulse No P Consider Chest Decompression Procedure p169 Go To Appropriate Trauma Protocol M Notify Receiving Facility, Contact Medical Control Yes Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Pupillary Light Reflex, Palpation of Pulses, Heart and Lung Auscultation Injuries incompatible with life include; decapitation, incineration, massively deforming head or chest injury, dependent lividity, rigor mortis As with all trauma patients, DO NOT delay transport Consider using medical cardiac arrest protocols if uncertainty exists regarding etiology of arrest Use of a long spine board will make chest compressions more effective; however, if spinal immobilization interferes with CPR use reasonable effort to limit patient and spine movement Be aware that these may be crime scenes: do your best to avoid disturbing forensic evidence If provider safety becomes a concern, transport of deceased patients to the hospital is acceptable Traumatic Cardiac Arrest – Adult, Trauma 76 Trauma Protocols - Adult Trauma Protocols - Adult No A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Type of exposure (heat, gas, chemical) Central and Peripheral Pulses Nausea, Vomiting, Diarrhea Chemical Name (if known) Time of Exposure (duration) Mechanism of secondary injury (blunt vs. penetrating) Voltage of Electrical Current (if known) Differential Thermal Injury Chemical Burn Electrical Injury Blast Injury Abrasion Contusion Laceration Compartment Syndrome General Approach – Adult, Trauma Consider need for Airway Management EARLY Chemical / Electrical Burn Patient Management Consider responder and Citizen Safety Yes Hazmat Scene Consider provider safety, number of patients and early notification of receiving facility Go To Hazmat, General Protocol p85 No Minor Burn Serious Burn Critical Burn <5% TBSA, 1st – 2nd Degree Burn No inhalation Injury Normal BP, SpO2 5-15% TBSA, 2nd – 3rd Degree Burn Suspected Inhalation Injury Hypotension, Altered Mental Status Preferred Transfer to Burn Center >15% TBSA, 2nd – 3rd Degree Burn Burn with Trauma Burn with Airway Compromise Preferred Transfer to Burn Center Continuous Cardiac Monitor for ALL Electrical Burns Consider Cardiac Dysrhythmia Protocol, As Appropriate Irrigate Involved Eye(s) with 2L NS or Sterile Water x 15 minutes Repeat as needed Yes Eye Involvement No Consider Burn, Trauma Protocol p75 Flush Contact Area with Normal Saline x 15 minutes Repeat as needed Consider Pain Management, Trauma Protocol p89 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Provider Safety is paramount! Ensure Chemical Source is not a hazard to responders and Electrical Sources are not contacting patient prior to assessment. Don’t allow yourself or your crew to become victims. Safety First! Assure a Chemical source of burn is NOT a hazard to responders. Assure an Electrical source of burn is OFF or no longer contacting pt. High Voltage Electrical Burns (>600 volts) require spinal immobilization, continuous cardiac monitor and immediate IVF regardless of external appearance of injury Chemical burns require removal of contaminated clothing, brush away dry powder before irrigation. Flush with copious warm water on scene and continue irrigation en route. Be sure to brush excess away and remove contaminated clothing BEFORE beginning irrigation Superficial appearance of Electrical Burns does NOT indicate severity of underlying tissue damage Attempt to locate contact points in Electrical Burns, generally contact point with source and where patient is grounded. Do not refer to them as entry or exit wounds. Surface appearance may belie the damage below Electrical Burns cause ventricular and atrial irritability and dysrhythmias; anticipate cardiac problems and treat accordingly Chemical / Electrical Burn – Adult, Trauma 77 Trauma Protocols - Adult Trauma Protocols - Adult Estimate TBSA Burned / Severity Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Respiratory Effort, Adequacy Abnormal Breath Sounds (unilateral vs. bilateral) SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Differential Simple Pneumothorax Tension Pneumothorax Pericardial Tamponade Aortic Root Disruption Bronchial Tree Injury Tracheal Disruption Great Vessel Laceration Cardiac Contusion Cardiac Laceration General Approach – Adult, Trauma Long Board Selective Spinal Immobilization Protocol p92 A IV Access Protocol p49 Mechanism Blunt Penetrating Stabilize Foreign Body if applicable, Assess Breath Sounds, SpO2 Assess Breath Sounds, SpO2 Clear and Equal Bilaterally Decreased Unilateral Breath Sounds Open OR Sucking Chest Wound Decreased Unilateral Breath Sounds Clear and Equal Bilaterally Assist Ventilations as Needed Support Ventilations, Monitor VS, watch for JVD, tracheal deviation Apply Occlusive Dressing and Assist Ventilations Support Ventilations, Monitor VS, watch for JVD, tracheal deviation Assist Ventilations as Needed Signs of Tension Pneumothorax Continuous Cardiac Monitor No Continuous Cardiac Monitor Yes Pain Management, Trauma Protocol p89 Consider Airway Management Protocol p27 P Chest Decompression Procedure p169 Notify Receiving Facility, Contact Medical Control As Necessary Pain Management, Trauma Protocol p89 Consider Airway Management Protocol p27 Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Consider tension pneumothorax in any patient with penetrating chest trauma, OR blunt chest trauma with decreased unilateral breath sounds, hypotension, tachycardia, hypoxia, tracheal deviation (late) or JVD (late) Aortic root injuries, bronchial disruption and tracheal disruptions are common with major deceleration injuries (i.e. MVC) Cardiac contusions are common with blunt chest trauma, and may present with ectopy, PVCs or even STEMI appearance on cardiac monitor Pericardial Tamponade is a surgical emergency and needs rapid transport. Look for muffled heart tones, hypotension, tachycardia Chest Injury – Adult, Trauma 78 Trauma Protocols - Adult Trauma Protocols - Adult Consider Pain Management, Trauma Protocol p89 Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS SAMPLE History OPQRST History Crushed under heavy load ≥30 min Building collapse, trench collapse, industrial accident, heavy equipment pinning Differential Compartment Syndrome Entrapment without Crush Fracture, Sprain, Strain General Approach – Adult, Trauma A Management of Crush Injury Patient Crush Injury should be suspected in prolonged pinnings >1 hour, AND proximal to the knee or elbow. IV Access Protocol p49 This protocol is NOT intended for hands or feet trapped in machinery or farm equipment Go To Long Board Selective Spinal Immobilization Protocol p92 A NS Bolus, 500mL 12-Lead ECG Procedure p139 (when possible) Abnormal ECG, Hemodynamically Unstable Abnormal ECG Peaked T-waves, QRS ≥0.12 sec QT ≥0.46 sec No Asystole, PEA, VF, VT No No Yes Yes Immediately Prior to Extrication Sodium Bicarbonate 50mEq IV/IO AND* Calcium Chloride 1g IV/IO over 3 min P HD Unstable Albuterol 2.5mg/3mL Neb P Sodium Bicarbonate 50mEq IV/IO P Sodium Bicarbonate 50mEq IV/IO AND* Calcium Chloride 1g IV/IO over 3 min Go To Trauma Pain Management Protocol p89 Go To Appropriate Cardiac Arrest Protocol Monitor and Reassess for Fluid Overload Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Vital Signs, GCS, Lung Sounds, Neuro Exam, Musculoskeletal Exam Structural Collapse, Crush Scenes are often full of hazards, provider safety is the most important consideration Patients may become hypothermic, even in warm environments -Hypothermia can lead to coagulopathy, which will increase bleeding times and have worse outcomes for the patient Crush injuries can result in hyperkalemia from shift of Potassium out of injured cells. Cardiac monitoring is required and 12-lead ECG preferred whenever possible (as dicated by the situation) Monitor extremities for signs of compartment syndrome after crush injury; Pain, Pallor, Paresthesias, Paralysis, Pulselessness and Poikilothermia (inability to regulate core body temperature) *Utilize different IV lines or flush between bicarb and calcium to prevent precipitation in the line Prolonged Crush Injury – Adult, Trauma 79 Trauma Protocols - Adult Trauma Protocols - Adult Continuous Cardiac Monitor Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Submersion in water regardless of depth SAMPLE History OPQRST History Temperature of water Mental Status Changes Degree of Water Contamination Vomiting Coughing, Wheezing, Rales, Rhonchi, Stridor Differential Spinal Trauma Pre-Existing Medical Condition Hypothermia Aspiration The Bends Pressure Injury o Barotrauma o Decompression Sickness Post-Immersion Syndrome General Approach – Adult, Trauma Long Board Selective Spinal Immobilization Protocol p92 Awake and Alert Awake but Altered Remove Wet Clothing Dry and Warm Patient Consider Airway Management Protocol p27 Unresponsive Yes Pulse Monitor and Reassess Encourage Transport and Evaluation even if asymptomatic Consider Altered Mental Status Protocol p45 No Remove Wet Clothing Dry and Warm Patient Go To Appropriate Adult MEDICAL Cardiac Arrest Protocol Monitor and Reassess Continuous Cardiac Monitor A Consider IV Access Protocol p49 Continuous Cardiac Monitor A IV Access Protocol p49 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Have a HIGH index of suspicion for possible spinal injuries. Any diving injury or submersion with unclear details should be fully immobilized Hypothermia is often associated with near-drowning and submersion injuries. Consider the Hypothermia Protocol as appropriate All patients with Near-Drowning / Submersion Injury should be transported for evaluation due to delayed presentation of respiratory failure With diving injuries (decompression / barotrauma) consider availability of a hyperbaric chamber; contact Medical Control early. Near-drowning patients who are awake and cooperative but with respiratory distress may benefit from CPAP / Positive Pressure Ventilation Near-Drowning / Submersion Injury – Adult, Trauma 80 Trauma Protocols - Adult Trauma Protocols - Adult Mental Status Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Mental Status SAMPLE History OPQRST History Time and length of exposure to hot environment Hot, dry or sweaty skin Seizures Nausea Hypotension, Shock, Fever Differential Alcohol Withdrawal (DTs) Hyperthyroidism (Thyroid Storm) Dehydration Cocaine or Sympathomimetic OD Sepsis CNS Lesion or Head Injury Abuse or Neglect (Elderly or disabled) Medication (Serotonin Syndrome, Malignant Hyperthermia) General Approach – Adult, Trauma If Evidence of Sympathomimetic OD Remove Patient from Hot Environment (if applicable) Consider Overdose, Sympathomimetic Protocol Heat Cramps Heat Exhaustion Heat Stroke Painful Spasms of Extremities and/or Abdominal Muscles Normal Mental Status Normal Vital Signs Dizziness, Lightheadedness, Headache, Irritability, Nausea Normal or Mildly Depressed Mental Status Mild Tachycardia (<150) Normal or Mildly Elevated Temp Marked Alteration in Level of Consciousness May Be Sweating OR Hot, Dry, Red Skin Extremely High Temp, >104oF Oral Fluids Sponge with Cool Water and Fan Keep Patient Supine Apply 100% Oxygen Sponge with Cool Water and Fan Semi-Reclining Position with Head Elevated Apply 100% Oxygen Rapid Cooling with Cold Packs, Sponge with Cool Water and Fan Tolerating Oral Fluids Yes Reassess and Document Mental Status, VS and ability to take PO Abnormal No Requires Transport IV Access Protocol p49 A NS 500mL IV/IO P Ondansetron 4mg IV/IO P If Shivering, Consider Midazolam 2mg IV/IO No A IV Access Protocol p49 A NS 500mL IV/IO P Consider Ondansetron 4mg IV/IO/ODT Normal Execute and Document Patient Refusal Protocol p65 A Notify Receiving Facility, Contact Medical Control As Necessary Yes Pearls REQUIRED EXAM: VS, GCS, Skin, HEENT, Neuro, Evidence of Intoxication, Mental Status Extremes of Age are more prone to heat emergencies due to inability to easily self-extricate from hot environments Patients on Tricyclic Antidepressants, Anticholinergics, Diuretics (i.e. Lasix) are more susceptible to heat emergencies due to medication effects Cocaine, amphetamines and salicylates all may elevate body temperature or interfere with the ability to auto-regulate Sweating generally disappears as body temperature rises above 104oF If Heat Cramps resolved without IV Access or Medications, patients may refuse transport, IF tolerating oral fluids and VS normal Environmental, Hyperthermia – Adult, Trauma 81 Trauma Protocols - Adult Trauma Protocols - Adult Estimate Severity of Symptoms Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Mental Status SAMPLE History OPQRST History Time and length of exposure to cold environment Cold or clammy skin Confusion Arrhythmias, J-waves on ECG Hypotension, Shock Differential Alcohol Intoxication Hypothyroidism (Myxedema Coma) Dehydration Sepsis CNS Lesion or Head Injury Abuse or Neglect (Elderly or disabled) Medication (beta blocker overdose, opiate overdose) General Approach – Adult, Trauma General Wound Care Do NOT Rub Skin To Warm PREVENT Refreezing A NS Warmed Fluids 500mL IV/IO over 30 minutes A IV Access Protocol p49 Remove Patient from Cold Environment (if applicable) Remove Wet Clothing Dry and Warm the Patient Localized Cold Injury (Frostbite) Yes No Blood Glucose Procedure p159 <70 Go To Diabetic Emergencies Protocol p47 >70 Estimate Severity of Symptoms Mild Hypothermia 90-95oF (32-35oC) Moderate Hypothermia 82-90oF (28-32oC) Severe Hypothermia <82oF (<28oC) Sympathetic Nervous System Excitation – Shivering, Hypertension, Tachycardia, Tachypnea Awake But May Be Confused Shivering more violent, ataxia and incoordination apparent. Stumbling pace and Moderate Confusion Appears pale as surface vessels constrict to retain heat. Heart rate, blood pressure and respiratory rate decrease. Disoriented, confused and combative Paradoxically may discard clothing External Rewarming Measures External Rewarming Measures 12-Lead ECG Procedure p139 12-Lead ECG Procedure p139 Consider Airway Management Protocol p27 A IV Access Protocol p49 A p49 Consider Altered Mental Status Protocol p45 NS Warmed Fluids 500mL IV/IO over 30 minutes A A NS Warmed Fluids 500mL IV/IO over 30 minutes Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Skin, HEENT, Neuro, Evidence of Intoxication, Mental Status Hypoglycemia is found in many hypothermic patients, because hypothermia may be a result of hypoglycemia Severe hypothermia may cause myocardial irritability and rough handling can theoretically cause V-fib. Please handle carefully. -Do not withhold intubation or CPR for this concern, but only the most experienced provider available should gently attempt intubation Below 86oF (30oC), antiarrhythmics may not be effective. If given, they should be given at reduced intervals. Do NOT attempt to pace below 86oF. If antiarrhythmics necessary for severely hypothermic patient, Contact Medical Control Extremes of age, malnutrition, ETOH and drug abuse and outdoor hobbies / employment all predispose to hypothermia Environmental, Hypothermia – Adult, Trauma 82 Trauma Protocols - Adult Trauma Protocols - Adult Consider Pain Management – Adult, Trauma Protocol p89 Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Central and Peripheral Pulses Neuro Function Distal to Injury Differential Vascular Disruption Amputation Fracture, Dislocation Sprain, Strain SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Abrasion Contusion Laceration Compartment Syndrome General Approach – Adult, Trauma Long Board Selective Spinal Immobilization Protocol p92 Laceration, Abrasion, Penetrating Injury Mechanism Wound Severity / Hemorrhage Control Palpate Pulses Evaluate Distal CMS Pulses Present Pad and Splint Extremity in Place Pulses Absent Mild-Moderate, Simple Wound Consider Pain Management, Trauma Protocol p89 if time allows Direct Pressure Severe-Exsanguinating, Complex Wound Gentle In-Line Traction Bleeding Controlled Reassess and Document CMS After Splinting A IV Access Protocol p49 No Tourniquet Procedure p177 Yes Consider Pain Management, Trauma Protocol p89 A IV Access Protocol p49 Consider Hemorrhage Control Protocol p87 A NS Bolus 500mL IV/IO If Signs of Hypovolemia Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Immobilization of bony injuries should include the joint above and below. Joint injuries require immobilization of bone above and below Palpate and document Circulation, Movement and Sensation both before and after splint application Tourniquets should remain in place once hemorrhage control is adequate. The tourniquet is tight enough when the bleeding stops! If active hemorrhage and bony/soft tissue deformity, priority should be put on hemorrhage control first, then splinting – remember A,B,C’s If amputated extremities available, seal in a plastic bag and place in cool water and bring to the hospital with the patient Extremity Injury – Adult, Trauma 83 Trauma Protocols - Adult Trauma Protocols - Adult Soft Tissue Swelling, Bony Deformity Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Visual Acuity SAMPLE History OPQRST History Time of Injury Involved Chemical MSDS Contact/Corrective Lens Use “Shooting” or “Streaking” Lights Rust Ring “Lowering Shade” in Vision Differential Globe Rupture Acute Closed Angle Glaucoma Stroke Retinal Artery Occlusion Chemical Burn Retinal Venous Thrombus General Approach – Adult, Trauma Pain / Vision Loss Non-Traumatic Nature of Complaint Traumatic Injury Assess Visual Acuity Go To Appropriate Trauma Protocol No Isolated to Eye(s) Yes Neuro Exam Focal Deficit Go To Stroke Protocol p69 Chemical Mechanism Blunt / Trauma Normal Unrecognized Chemical Agent Yes Assess Orbit for Stability Irrigate with 2L NS or Sterile Water No Cover and Protect Both Eyes Yes Shield and Protect Both Eyes Notify Receiving Facility, Contact Medical Control As Necessary A IV Access Protocol p49 P Ondansetron 4mg IV/IO/ODT Globe Rupture No Shield and Protect Both Eyes Assess Visual Acuity Consider Trauma Pain Management Protocol p89 Pearls REQUIRED EXAM: VS, GCS, Visual Acuity, Neuro Exam, Extraocular Movements Stabilize any penetrating objects. DO NOT remove any embedded / impaled objects If Long Spine Board not indicated, transport with head of stretcher elevated to 60 degrees to help reduce intraocular pressure Remove contact lenses when possible Always cover both eyes to prevent further injury Orbital fractures increase concern for globe or optic nerve injury; follow visual acuity and extraocular movements for changes Normal visual acuity can be present, even with severe injury Eye Pain – Adult, Trauma 84 Trauma Protocols - Adult Trauma Protocols - Adult Assess Pupils Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Mental Status SAMPLE History OPQRST History Time and length of exposure to toxic environment Differential Alcohol Intoxication Hyperthyroidism Drug Abuse, Intoxication Sepsis MSDS Sheet Info Mode of Release Number of Victims CNS Lesion or Head Injury Abuse or Neglect (Elderly or disabled) Medication (beta blocker overdose, opiate overdose) Scene Assessment Go To Appropriate Overdose and Poisoning Protocol p54 Contact Poison Control Center 1-800-222-1222 OD Step 1 – Site Control Respond to suspected Hazmat release from uphill and upwind Utilize binoculars for scene size-up Wear all appropriate PPE Control the scene by preventing entry into the area Toxic Exposure Or Overdose Toxic Exposure Step 2 – Identification of Products As soon as safely possible, ID product(s) involved If moderately or extremely hazardous, notify HIT Utilize ERG for ID of placards, containers or product(s) Hazmat Exposure Do NOT Use Water To Flush: Elemental metals (sodium, potassium, lithium) Phenols Step 3 – Hazard and Risk Assessment Utilize the ERG to make risk assessment If available, dilute these burns with (in order of effectiveness) Polyethylene Glycol Glycerol Vegetable Oil Inhalational Injury Yes Additional Helpful Numbers Chemtrec: 1-800-424-9300 Chemtell: 1-888-255-3924 Infotract: 1-800-535-5053 3E: 1-800-451-8346 No Albuterol 2.5mg/3mL Neb AND Ipratropium Bromide 0.5mg/2.5mL Neb 2.5mL Bicarb in 5mL NS, Neb P Inhaled Sodium Bicarb to neutralize the HCl formed in the lungs Yes Chlorine Gas OR Chloramine Gas No Notify Receiving Facility, Contact Medical Control As Necessary Step 4 – Personal Protective Equipment Use the ERG to determine PPE requirement Structural Firefighting Protective Clothing (SFPC) is not recommended for many Hazardous Materials Step 5 – Information and Resource Coordination Communicate with additional units as appropriate Update HIT Leader on their arrival Step 6 – Control Measures Confine and Contain product release as appropriate Consider additional resources as needed Step 7 – Decontamination Consider appropriate decon after Hazmat incident Confer with HIT Leader as necessary Step 8 – Termination Activities Before leaving the scene document all actions and equipment used Document possible parties names, addresses and phone numbers Turn the scene over to responsible party Pearls REQUIRED EXAM: VS, GCS, Skin, HEENT, Neuro, Evidence of Intoxication, Mental Status The most important factor in Hazmat response is provider safety – you can’t help anyone else if you’re a victim as well In any Hazmat situation, consider that the exposure may not be accidental; consider intentional releases, secondary devices and terrorism Always park upwind and uphill of any potential exposures, and be conscious of any symptoms you may begin to develop Communication is key; contact the appropriate Hazmat authority early and notify the Hazmat leader as well as the Comm Center of findings In a large-scale event, have the Comm Center activate Dane County Mass Casualty Plan and notify the Base Hospital to get prepared Inhaled bicarb is controversial but seems to help. Aslan S, Kandis H, Akgun M, Cakir Z, Inandi T, Görgüner M. The effect of nebulized NaHCO3 treatment on "RADS" due to chlorine gas inhalation. Inhal Toxicol. 2006 Oct. 18(11):895-900. Hazmat, General – Adult, Trauma 85 Trauma Protocols - Adult Trauma Protocols - Adult Consider Burns – Adult, Trauma Protocol p75 A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Loss Of Consciousness Vomiting, Altered Mental Status SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Differential Skull fracture Epidural hematoma Concussion, Contusion, Laceration, Hematoma Non-Accidental Trauma Spinal Cord Injury Subdural Hematoma Subarachnoid Hemorrhage General Approach – Adult, Trauma Elevate Head of Stretcher 15-30 degrees while maintaining Spinal Precautions Long Board Selective Spinal Immobilization Protocol p92 A <70 Blood Glucose >70 Seizure Yes Seizure Protocol p68 >8 Consider Airway Management Protocol p27 >5/10 OR Severe Pain Management, Trauma Protocol p89 No Airway Management Protocol p27 <8 If evidence of herniation, Goal EtCO2 is 30-35mmHg Document GCS Maintain SpO2 >93% Goal EtCO2 35-45mmHg Monitor and Reassess Frequent Airway and GCS Evaluations <5/10 Pain Notify Receiving Facility, Contact Medical Control As Necessary Document Response to Meds, Repeat GCS, SpO2, EtCO2 Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro If GCS <13 consider Air transport or Rapid Transport Airway interventions can be detrimental to patients with head injury by raising intracranial pressure, worsening hypoxia (and secondary brain injury) and increasing risk of aspiration. Whenever possible these patients should be managed in the least invasive manner to safely maintain O2 saturation >90% (ie. NRB, BVM with 100% O2) Acute herniation should be suspected when the following signs are present: acute unilateral dilated and non-reactive pupil, abrupt deterioration in mental status, abrupt onset of motor posturing, abrupt increase in blood pressure, abrupt decrease in heart rate. Only in suspected acute herniation – increase ventilatory rate (rate 20/minute) and target EtCO2 30-35mmHg Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushings response) Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively Most important vital sign to monitor and document is level of consciousness (GCS) Concussions are periods of confusion or loss of consciousness (LOC) associated with trauma which may have resolved by the time EMS arrives. Any confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be transported to an Emergency Department. Any questions or clarifications, contact Medical Control. Head Injury – Adult, Trauma 86 Trauma Protocols - Adult Trauma Protocols - Adult Diabetic Emergencies Protocol p47 IV Access Protocol Nasal Airways are CONTRAINDICATED in patients with significant Maxillofacial trauma – the cribriform plate may be broken and result in the NPA going into the patient’s brain A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Central and Peripheral Pulses Neuro Function Distal to Injury Time of Injury Deformity Diminished pulse / capillary refill Differential Vascular Disruption Amputation Fracture, Dislocation Sprain, Strain Abrasion Contusion Laceration Compartment Syndrome General Approach – Adult, Trauma Yes Signs / Symptoms of Shock, Poor Perfusion No Wound Severity / Hemorrhage Control Direct Pressure and Wound Management A IV Access Protocol p49 A Normal Saline Bolus 500mL IV/IO Repeat every 5 min., max 2L Severe-Exsanguinating, Complex Wound Direct Pressure SBP <100 Repeat and Document BP Bleeding Controlled SBP >100 Wound Severity / Hemorrhage Control No Extremity Yes Yes No Tourniquet Procedure p177 SBP <100 Reassess BP Improved? Hemostatic Dressing for Severe Hemorrhage, if available No M SBP >100 Dopamine 5-20mcg/kg/min IV/IO OR Epinephrine 0.1-0.5mcg/kg/min (1:10,000) IV/IO Titrate to SBP >100 Notify Receiving Facility, Contact Medical Control As Necessary A None OR Mild Consider IV Access Protocol p49 Pain Moderate OR Severe Consider Pain Management, Trauma Protocol p89 Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Hypotension in trauma needs blood products early, so minimize scene time. Goal for scene time in major trauma cases should be <10 min Multiple casualty incident or obvious life threatening hemorrhage, consider Tourniquet Procedure and/or Hemostatic Dressing FIRST Hemostatic Dressings are appropriate for hemorrhage that can’t be controlled with a tourniquet, such as abdominal and pelvic wounds Signs/Symptoms of Shock include: altered mental status, pallor, hypotension (SBP <100), cap refill >3 sec, faint/absent peripheral pulses Hemorrhage Control – Adult, Trauma 87 Trauma Protocols - Adult Trauma Protocols - Adult Mild-Moderate, Simple Wound Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Type of Strike (Direct, Splash, Contact) Central and Peripheral Pulses Nausea, Vomiting, Diarrhea Amnesia, Confusion, Neuro Deficits Duration of Unresponsiveness (if applicable) Time of Strike Wounds to Hands, Feet or Areas of Contact Differential Thermal Injury Electrical Injury Blast Injury Acute Myocardial Infarction Spine Fracture Rhabdomyolysis Cardiac Dysrhythmia Hypoglycemia General Approach – Adult, Trauma Stage, Call for Law Enforcement and/or Additional Resources Lightning Strike Patient Management Scene Safe Yes Yes Typically, patients victims of lightning strike who do not suffer cardiac or respiratory arrest survive; typical triage protocols do not apply under these circumstances, and resuscitation should be provided to those who are PNB Normal Mental Status ECG evidence of direct myocardial damage from lightning strike includes ST segment elevation, T-wave inversion and prolongation of the QT interval. No Most injuries occur outdoors, but contact with plumbing, phone lines, etc. that are struck can injure people indoors. Estimate Symptom Severity Cardiorespiratory Arrest A Altered Level of Consciousness A IV Access Protocol p49 Inadequate Respirations IV Access Protocol p49 A IV Access Protocol p49 Cardiac Arrest – Adult Protocol p33 Blood Glucose, SpO2, 12-Lead ECG, Full Spinal Immobilization Procedures Airway Management – Adult Protocol p27 Full Spinal Immobilization Procedure p174 Cardiac Arrhythmia – Adult Protocol, As Appropriate Full Spinal Immobilization Procedure p174 Go To Seizure, Adult Medical Protocol p68 Yes Seizure No Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro National lightning safety guidelines state that risk continues for 30 minutes after the last lightning is seen or thunder heard Lightning not striking twice is a myth; if there is continued risk to EMS providers, remove the patient to a safe place before treatment Full spinal immobilization should be performed in any patient with altered level of consciousness, as spinal injuries are common from the concussive force of the strike and/or involuntary muscle spasms There are reports of patients surviving prolonged periods of arrest after lightning strike. Treatment for cardiopulmonary arrest is per ACLS protocols, but decision to terminate resuscitation should be made in coordination with Medical Control. Lightning Strike – Adult, Trauma 88 Trauma Protocols - Adult Trauma Protocols - Adult Go to Appropriate Medical Protocol No Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS SAMPLE History OPQRST History History of chronic pain Differential Head injury Spine Injury Compartment Syndrome Fracture, Sprain, Strain Pneumo/hemo-thorax Pericardial effusion Aortic Dissection Internal organ injury General Approach – Adult, Trauma Patient Care per Appropriate Trauma Protocol None – Mild Pain (0-4) Moderate Pain (5-8) Consider IV Access Protocol p49 A A Severe Pain (9-10) IV Access Protocol p49 A Place patient on cardiac monitor, continuous SpO2 and EtCO2 SpO2 >93%, EtCO2 <45, SBP >120 P P Consider Ondansetron 4mg IV/IO/ODT Place patient on cardiac monitor, continuous SpO2 and EtCO2 SpO2 >93%, EtCO2 <45, SBP >120 Document VS (HR, BP, SpO2, EtCO2) Document VS (HR, BP, SpO2, EtCO2) SpO2 >93%, EtCO2 <45, SBP >90 Morphine 0.1mg/kg IV/IO (max single dose 5mg) May repeat x 2 IV Access Protocol p49 SpO2 >93%, EtCO2 <45, SBP >90 P P Fentanyl 1mcg/kg IV/IO/IM/IN (max single dose 100mcg) May repeat x 1 P Consider Ondansetron 4mg IV/IO/ODT P Morphine 0.1mg/kg IV/IO (max single dose 5mg) May repeat x 2 Consider Ondansetron 4mg IV/IO/ODT P Fentanyl 1mcg/kg IV/IO/IM/IN (max single dose 100mcg) May repeat x 1 P Consider Ondansetron 4mg IV/IO/ODT SBP >90 Reassess and Document VS, including Pain Scale Continue to Trauma Specific Protocol P Consider Ketamine 0.2mg/kg IV/IO (max 20mg) IFF patient still in severe pain Pearls REQUIRED EXAM: Vital Signs, GCS, Neuro Exam, Lung Sounds, abdominal exam, Musculoskeletal Exam Provider Discretion to be used for patients suffering from chronic pain related issues. Please note that history of chronic pain does not preclude the patient from treatment of acute pain related etiologies. If preference is to go directly to Ketamine, contact Medical Control for permission Ketamine major side effects: increased oral secretions, laryngospasm, emergence reaction Ketamine contraindications: suspected head or ocular globe injury (theoretical increase in intracranial and intraocular pressure) Pain Management – Adult, Trauma 89 Trauma Protocols - Adult Trauma Protocols - Adult Assess Pain 0-10 Pain Scale OR FACES Scale A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Type of exposure (heat, gas, chemical) Mechanism (blunt vs. penetrating) Central and Peripheral Pulses Nausea, Vomiting, Diarrhea Time of Exposure (duration) Distance from Radiation Source Shielding from Radiation Source Differential Thermal Injury Chemical Burn Electrical Injury Blast Injury Abrasion Contusion Laceration Compartment Syndrome General Approach – Adult, Trauma Consider Burn, Trauma Protocol p75 No Indication of Radiation Burn / Exposure Yes Consider provider safety, number of patients and early notification of receiving facility Responders should wear N95 mask, eye protection and gown to limit exposure to radiation Don Protective Gear Estimate TBSA Burned / Severity Minor Burn Serious Burn Critical Burn <5% TBSA, 1st – 2nd Degree Burn No inhalation Injury Normal BP, SpO2 5-15% TBSA, 2nd – 3rd Degree Burn Suspected Inhalation Injury Hypotension, Altered Mental Status Preferred Transfer to Burn Center >15% TBSA, 2nd – 3rd Degree Burn Burn with Trauma Burn with Airway Compromise Preferred Transfer to Burn Center Irrigate Involved Eye(s) with Normal Saline x 15 minutes Repeat as needed Yes Eye Involvement No Consider Burn, Trauma Protocol p75 Flush Contact Area with Normal Saline x 15 minutes Repeat as needed Consider Pain Management, Trauma Protocol p89 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Radiation exposures can be a frightening experience. Do not ignore the ABC’s; a dead but fully decon’d patient is not a good outcome Three methods for protecting yourself from radiation sources: limit time of exposure, distance from source, shield from radiation source Dirty bombs generally include previously used radioactive material combined with conventional explosives to distribute the material These events may require activation of the National Radiation Injury Treatment Network (RITN). Transport to the area RITN certified hospital Radiation Injury – Adult, Trauma 90 Trauma Protocols - Adult Trauma Protocols - Adult Consider need for Airway Management EARLY Radiation Incident Patient Management A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE History OPQRST History Situational Crisis Pyschiatric Illness / Medication History Medic Alert Bracelet, DM History Anxiety, Agitation or Confusion Suicidal / Homicidal Thoughts or History Evidence of Substance Use / Overdose Differential Illicit Drug Intoxication Drug/EtOH Withdrawal Primary Psychosis Hypoglycemia Hypoxia Head Injury Occult Trauma Cerebral Hypoperfusion Toxic Ingestion General Approach – Adult, Trauma Stage, Call for Law Enforcement AND/OR Additional Resources No Scene Safe Yes The TASER fires two small dart-like electrodes, which stay connected to the main unit by conductive wire as they are propelled by small compressed nitrogen charges Evidence of Exposure / Toxidrome Yes Begin Triage and Decontamination, As Appropriate Location of Electrodes ANY Electrodes Present In The Eye, Face, Neck, Groin, Spinal Column or Axilla Superficial Soft Tissues EXCLUDING Eye, Face, Neck, Groin, Spinal Column or Axilla DO NOT REMOVE ELECTRODES Stabilize in Place and Transport Place one hand flat on the patient around the probe and stabilize the skin surrounding the puncture site. Place your other hand/pliers firmly around the base of the probe Removed by Law Enforcement prior to EMS Evaluation In one fluid motion pull the probe straight out from the puncture site Repeat procedure with second probe Examine Site for Bleeding, Expanding Hematoma or Distal Neuro Deficit Examine Site for Bleeding, Expanding Hematoma or Distal Neuro Deficit Examine Site for Bleeding, Expanding Hematoma or Distal Neuro Deficit Consider Behavioral Emergencies – Adult, Medical Protocol p46 Refer to Police Custody Policy, As Appropriate p21 Notify Receiving Facility, Contact Medical Control As Necessary No Arrhythmia on Monitor Yes Go To Appropriate Cardiac Dysrhythmia, Adult Medical Protocol Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Safety first – for Providers, Police and Patients. Never restrain any patients in the prone (face down) position. Document the site of electrode penetration as well as whether the barb was completely intact or broken on removal Patients who require repeated deployments of the Electronic Control Device are at a significantly higher risk of cardiac dysrhythmias as well as in-custody death. Have a high index of suspicion and a low threshold to treat per the Behavioral Emergencies Protocol Patients who are actively restrained by Law Enforcement require an officer be present in the ambulance patient compartment during transport. It is a patient safety issue as well as a medicolegal liability for the EMS Provider. Electronic Control Device (a.k.a TASER) – Adult, Trauma 91 Trauma Protocols - Adult Trauma Protocols - Adult The Thomas A. Swift Electric Rifle (TASER) A Legend EMT A-EMT P Paramedic M Medical Control General Approach – Adult, Trauma Selective Spinal Immobilization Indication of Traumatic Mechanism This initiative aims to match the patients with a high likelihood of injury to the correct use of the rigid Long Spine Board. Yes The large majority of patients with traumatic injury SHOULD still be immobilized with a rigid C-collar until radiographically evaluated. Maintain Manual C-Spine Stabilization Until Evaluation and/or Immobilization Complete Mechanism of Injury ANY ‘Yes’ ALL ‘No’ ALL ‘No’ C-Spine Immobilization Appropriate by EMS Provider judgment Yes Apply Rigid Cervical Collar as per Standard Midline Thoracic or Lumbar Pain OR Tenderness to Palpation of Spine OR Neurologic Deficits OR Abnormal Sensation OR Anatomic Deformity of Spine OR Inability to Communicate OR Distracting Injury** Penetrating Yes Neurologic Deficits OR Abnormal Sensation No No Evidence of secondary injury (i.e. penetrating then fall from height) ANY ‘Yes’ Yes Immobilization with Rigid Cervical Collar AND Long Spine Board Indicated Evaluate per Blunt Algorithm THIS PAGE Evaluate and Treat per Appropriate Adult Trauma Protocol Notify Receiving Facility, Contact Medical Control As Necessary No Pearls REQUIRED EXAM: Motor Function both upper and lower extremities, Sensation of upper and lower extremities, subjective abnormal sensation, Tenderness to palpation of bony prominences OR paraspinal muscles *Clinical Intoxication – A transient condition resulting in disturbances in level of consciousness, cognition, perception, affect or behavior, or other psychophysiological functions and responses. Common examples include; ataxia, emotional instability, flight of ideas, tangential thought or motor incoordination. **Distracting Injury – Examples include, but are not limited to; long bone fracture, dislocations, large lacerations, deforming injuries, burns OR any condition preventing patient cooperation with history. ALL shallow water near drownings, diving injuries and high-voltage electrical injuries (lightning, ≥1000V AC or ≥1500V DC) MUST be fully immobilized If immobilization indicated but refused; advise the patient of risk of death, permanent disability or long term impairment. Clearly document the refusal and the conversation (re: risk); Apply a cervical collar, if allowed and transport in neutral alignment. Long spine boards have risks and benefits for patients. Spinal immobilization should always be applied when any doubt exists about the possibility of spinal trauma. It is always safer and better patient care to assume that a Cervical Spine injury has occurred and provide protection, and should be the standard of care in trauma patient management Long spine boards can be very useful for extricating patients, transferring locations, and providing a firm surface for chest compressions. Very thoughtful consideration should go into any decision to NOT use the rigid cervical collar OR long spine board. Long Board Selective Spinal Immobilization – Adult, Trauma 92 Trauma Protocols - Adult Trauma Protocols - Adult Blunt Altered level of consciousness OR (GCS < 15) OR Clinical Intoxication* OR Midline Neck Pain OR Midline Tenderness to Palpation of C-Spine OR Paraspinal Muscle Tenderness to Palpation OR Neurologic Deficits OR Abnormal Sensation OR ANY Anatomic Deformity OR Distracting Injury** OR Inability to Communicate OR Significant Mechanism of Injury OR Age >65 Go To Appropriate Adult Medical Protocol No A P M Legend EMT A-EMT Paramedic Medical Control Pertinent Positives and Negatives Age, VS, GCS Mechanism of Injury Events leading up to 9-1-1 Activation Relationship to and Location of Offender Strangling or Neck Injury SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Differential Hypovolemic Shock -External Hemorrhage -Internal Hemorrhage -Unstable Pelvic Fracture Abrasion Contusion Laceration Compartment Syndrome General Approach – Adult, Trauma Long Board Selective Spinal Immobilization Protocol p92 Consider Pain Management, Trauma Protocol p89 A IV Access Protocol p49 Go To Level 1 Trauma Center Steps 1 and 2 Destination Determination Protocol Rape Crisis Center: 608-251-5126 Crisis Line: 608-251-7273 Major Trauma Criteria Domestic Abuse Intervention Services DAIS Help Line: 608-251-4445 No Go To Head Injury, Trauma Protocol p86 Go To Extremity Injury, Trauma Protocol p83 Head Injury Extremity Injury Mechanism of Injury Chest Injury Sexual Assault Eye Injury Go To Chest Injury, Trauma Protocol p78 Go To Eye Injury, Trauma Protocol p84 Contact Law Enforcement for Scene and Provider Safety, if Not Already Present Provide Emotional Support, Do Not Judge The Victim Encourage Patient to Seek Evaluation While Respecting Autonomy Preserve Forensic Evidence, Wear Gloves, Use Burn Sheet To Collect Clothing Consider Pain Management, Trauma Protocol p89 When Possible, Help Guide the Patient in Collection of Belongings and Preservation of Evidence Work With Law Enforcement to Maintain Chain of Custody Transport to ED with SANE Nurse Capability Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Major Trauma Criteria – Step 1 and Step 2 in Destination Determination Protocol. GCS ≤13, SBP <90mmHg, Respiratory Rate <10 or >29 or need for ventilatory support Intimate Partner Violence is very difficult to disclose, and many victims call 9-1-1 with vague complaints; Have a HIGH index of suspicion Never judge a victim of intimate partner violence or sexual assault on the way they dress, act or present themselves Do not be afraid to involve Law Enforcement for assistance as needed, and have a low threshold to transport to a SANE Capable Emergency Department where Social Work, SANE Nurses, and Advocates can provide support and resources for these patients Sexual Assault / Intimate Partner Violence – Adult, Trauma 93 Trauma Protocols - Adult Trauma Protocols - Adult Dane County Rape Crisis Center Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Type of exposure (heat, gas, chemical) Central and Peripheral Pulses Nausea, Vomiting, Diarrhea Chemical Name (if known) Exposure to Chemical, Biologic, Nuclear or Radiologic Hazard Time of Exposure (duration) Pesticide Exposure Differential Thermal Injury Chemical Burn Blast Injury Nerve Agent Exposure Respiratory Irritant (Chlorine Gas, Ammonia, etc.) Vesicant (blistering agent) exposure Organophosphate Exposure General Approach – Adult, Trauma Stage, Call for Law Enforcement and/or Additional Resources Scene Safe WMD / Nerve Agent Exposure Patient Management Yes Consider provider safety, number of patients and early notification of receiving facility Evidence of Exposure / Toxidrome Yes Toxicity to the crew may occur from inhalation or topical exposure to the offending agent DuoDote AND/OR Mark-I Kit may be used for civilians IF cache released from the State of Wisconsin Estimate Symptom Severity A Consider IV Access Protocol p49 Go To Seizure, Adult Medical Protocol p68 Major Symptoms Altered Mental Status, Seizure, Respiratory Distress/Failure Minor Symptoms Respiratory Distress + SLUDGE Asymptomatic A IV Access Protocol p49 A IV Access Protocol p49 P Atropine 2mg IV/IO/IM Repeat Q5 min until symptoms resolve P Atropine 6mg IV/IO/IM Repeat Q5 min until symptoms resolve * DuoDote x 1 dose IM EMS Provider Use only May repeat x1 if symptoms return at 10 minutes * DuoDote x 3 doses IM EMS Provider Use only Seizure Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro *Each DuoDote Kit contains 600mg 2-PAM and 2.1mg of Atropine. The kits in the ambulance are intended for responder use only. If/When the emergency cache has been released by the State of Wisconsin, those kits may be used for the general public. SLUDGEM – Salivation, Lacrimation, Urination (Incontinence), Defecation (Incontinence), GI Upset, Emesis, Miosis For patients with major symptoms, there is no max dosing for Atropine; continue administering until salivation/secretions improved Follow all Hazmat procedures, strictly adhere to personal protective equipment for exposure prevention and begin decontamination early Patients who have been exposed to organophosphates are highly likely to off-gas; be sure to use all responder PPE and to avoid exposure to clothing or exhalations of victims. Helicopter EMS is generally NOT appropriate for these patients. WMD / Nerve Agent Exposure – Adult, Trauma 94 Trauma Protocols - Adult Trauma Protocols - Adult Begin Triage and Decontamination, As Appropriate No A Legend EMT A-EMT P Paramedic M Medical Control General Approach – Adult, Medical Log Member into Rehab Sector Assist in removal of all PPE Baseline Assessment Criteria for Rehab Infection Control Use of a 2nd 30-minute or 45-minute self-contained breathing apparatus (SCBA) cylinder, a single 60-minute SCBA cylinder or 40 minutes of intense work without SCBA are recommended as criteria mandating entry into the Rehab Sector. Members with direct involvement with patient care or exposure to bodily fluids must be decontaminated fully prior to entry into the Rehab Sector and accessing rehab supplies. Chest Pain OR Shortness of Breath not Improving with O2 OR Irregular HR and/or HR >160 OR ANY ‘Yes’ STEMI OR Syncope, Disorientation OR Confusion OR Member Requesting Transport For Any Reason Go To Appropriate Adult Medical Protocol Notify Incident Command, Begin ePCR and Initiate Transport to Hospital Special Operations Temp >100.5oF OR Systolic BP >160 OR Diastolic BP >100 OR Pulse >100 OR RR <12 or >20 OR SpO2 <93% OR ANY ‘Yes’ Consider Transport to Medical Facility Hydrate orally Begin temperature controls based on member temperature and environment Rest for at least 10 minutes Reassess Vital Signs at 10 minutes ALL ‘No’ Hydrate orally Begin temperature controls based on member temperature and environment Rest for at least 10 minutes Reassess Vital Signs at 10 minutes Abnormal VS (as Previous) Consider Transport to Medical Facility Continue temperature controls Orally hydrate, consider IV Fluids Rest for 10 minutes Reassess Vital Signs every 5 minutes ANY ‘Yes’ ALL ‘No’ Release Member From Rehab Division ALL ‘No’ Abnormal VS (as Previous) ANY ‘Yes’ Notify Receiving Facility, Contact Medical Control As Necessary Evaluate and Treat per Appropriate Adult Medical Protocol Pearls REQUIRED EXAM: Mental Status, Skin Condition, Temperature, Heart Rate, Respiratory Rate, Blood Pressure, SpO2, SpCO This Protocol was named “Public Safety Rehab”, and should be applied to any situation during which Firefighters, Law Enforcement Officers, Emergency Medical Services or ANY Emergency Response Personnel are exerting themselves for > 40 minutes. o This INCLUDES training operations, special events and non-emergency operations lasting longer than 40 minutes. Per NFPA 1584 Requirements, the Rehab Site should be set up in a location that provides shelter for the members, is far enough away from the active scene that the turnout gear, SCBA and protective equipment may be safety doffed, and provide protection from the environmental conditions. o Ideally, members should be shielded from view of the active scene, to reduce anxiety and to prevent members from trying to exit rehab inappropriately. The purpose of this Protocol is to protect the physical and mental condition of members operating at the scene of an emergency or a training exercise and to prevent decompensation of the individual. By keeping the individuals safe, it improves the safety and integrity of the team as well as the operation. At a minimum, turnout coat and nomex hood should be removed and turnout pants pushed down to the knees while seated in Rehab. Public Safety Personnel Rehab – Special Operations 95 Special Operations Notify Receiving Facility, Contact Medical Control As Necessary ALL ‘No’ A Legend EMT A-EMT P Paramedic M Medical Control Vital Signs In Children Age Newborn – 3mos 3mos – 2years 2years – 10years >10years Age Respiratory Rate (Breaths Per Minute) Age Minimum Systolic Blood Pressure Infant Toddler Preschooler School-Aged Child Adolescent 30-60 24-40 22-34 18-30 12-16 Term Neonates (0-28days) Infants (1-12mos) Children 1-10years Chilcren >10years >60 >70 >70 + (age in years x 2) >90 Heart Rate (Beats Per Minute) Awake Rate 85-205 100-190 60-140 60-100 Sleeping Rate 80-160 75-160 60-90 50-90 Wisconsin EMSC Recommended Weight Conversion (2.2lbs = 1kg -OR1lb = 0.45kg) Modified Glasgow Coma Scale for Infants and Children Infant Lbs. Score Eye Opening Spontaneous To Speech To Pain None Spontaneous To Speech To Pain None 4 3 2 1 Best Verbal Response Oriented, Appropriate Confused Inappropriate Words Incomprehensible Sounds None Coos and Babbles Irritable, Cries Cries in Response to Pain Moans in Response to Pain None 5 4 3 2 1 Best Motor Response Obeys Commands Localizes Painful Stimulus Withdraws in Response to Pain Flexion in Response to Pain Extension in Response to Pain None Moves Spontaneously and Purposely Withdraws in Reponse to Touch Withdraws in Response to Pain Abnormal Flexion Posture to Pain Abnormal Extension Posture to Pain None 6 5 4 3 2 1 Kgs. Lbs. Kgs. 5 lbs 2 kgs 20 lbs 9 kgs 6 3 21 10 7 3 22 10 8 4 23 10 9 4 24 11 10 lbs 5 kgs 25 lbs 11 kgs 11 5 26 12 12 5 27 12 13 6 28 13 14 6 29 13 15 lbs 7 kgs 30 lbs 14 kgs 16 7 31 14 17 8 32 15 18 8 33 15 19 9 34 15 www.chawisconsin.org Lbs. Kgs. 35 lbs 36 37 38 39 40 lbs 41 42 43 44 45 lbs 46 47 48 49 50 lbs 16 kgs 16 17 17 18 18 kgs 19 19 20 20 20 kgs 21 21 22 22 23 kgs PINK Small Infant 6-7kg RED Infant 6-9kg PURPLE Toddler 10-11kg YELLOW Small Child 12-14kg WHITE Child 15-18kg BLUE Child 19-23kg ORANGE Large Child 24-29kg GREEN Adult 30-36kg Resuscitation Bag Infant/Child Infant/Child Child Child Child Child Child Adult Oxygen Mask (NRB) Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric/ Adult Oral Airway (mm) 50 50 60 60 60 70 80 80 Laryngoscope Blade (Size) 1 Straight 1 Straight 1 Straight 2 Straight 2 Straight 2 Straight OR Curved 2 Straight OR Curved 3 Straight OR Curved Size 2.5 (Orange) Size 3 (Yellow) Size 3 (Yellow) Equipment GRAY 3-5kg King Airway NA NA NA NA LMA NA #1 #1 #1.5 #2 #2.5 #3 #3.5 #4 8 8 10 10 10 10 10 10-12 Infant/Child Infant/Child Child Child Child Child Child Small Adult IV Catheter (ga) 22-24 22-24 20-24 18-22 18-22 18-20 18-20 16-20 IO (ga) 18/15 18/15 15 15 15 15 15 15 NG Tube (French) 5-8 5-8 8-10 10 10 12-14 14-18 16-18 Suction Catheter (French) BP Cuff Neonatal #5/ Infant Size 2 (Green) Size 2 (Green) Quick Reference Page – Peds 96 Medical Protocols - Pediatric Medical Protocols - Pediatric Child A Legend EMT A-EMT P Paramedic M Medical Control Step One Any Airway Compromise not able to be managed by EMS should be taken to the CLOSEST FACILITY for stabilization immediately Measure Vital Signs and Level of Consciousness Glasgow Coma Scale Systolic blood pressure (mmHg) Respiratory rate ≤13 <70 + (age in years x 2)mmHG <10 or Inadequate Effort OR need for ventilation support Yes No Assess Severity of Illness Prolonged Seizure OR Status Epilepticus Cardiac Arrest OR Respiratory Arrest Severe Respiratory Distress (Cyanosis OR SpO2 <90%) Massive Gastrointestinal Bleeding Life Threatening Dysrhythmias Compromised Airway not relieved by EMS Signs or Symptoms of Sepsis or Shock No Step Three Yes Appearance Work of Breathing Tone Interactiveness Consolability Look/Gaze Speech/Cry Abnormal Breath Sounds Retractions Nasal Flaring Assess for Potential Time-Sensitive Problems Circulation to the Skin Pallor Mottling Cyanosis Altered Mental Status NOT Explained by Simple Hypoglycemia Significant Allergic Reaction Impending Cardiac OR Respiratory Collapse Multiple Medications Administered During Transport (Including Albuterol) Yes Transport to closest appropriate Pediatric ICU Capable Facility Yes Contact Medical Control; Consider Pediatric ICU Capable Facility OR Specialty Resource Center No Step Four Assess Special Patient or System Considerations Age <1 year Anticoagulation AND/OR history of bleeding disorder(s) Significant Toxic Ingestion / Poisoning / Overdose History (Proven OR Suspected) with deteriorating vital signs OR not responding to therapy Burns - without other trauma, transport to Burn Facility - with traumatic mechanism, transport to Trauma Center End Stage Renal Disease requiring Hemodialysis Medically complex patients requesting transport to non-PICU Facility EMS provider judgment No Transport according to Appropriate Medical Protocol Destination Determination – Peds 97 Medical Protocols - Pediatric Medical Protocols - Pediatric Step Two Transport to Pediatric ICU Capable Facility; Notify via Radio as early as possible A Legend EMT A-EMT General Approach – Peds, Medical P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Source of blood loss, if any (GI, vaginal, AAA, ectopic) Source of fluid loss, if any (vomiting, diarrhea, fever) Pregnancy history Mental Status Pale, Cool Skin Delayed Cap Refill Coffee Ground Emesis Tarry Stools Allergen Exposure Differential Cardiac Dysrhythmia Hypoglycemia Ectopic Pregnancy AAA Keep scene time to a minimum and notify receiving facility early of critical patient Assessment Scene Patient Safety Presentation OR Traumatic Mechanism Unsafe Insufficient Stage, Call for Law Enforcement and/or Additional Resources All Patients should remain Nothing By Mouth (NPO) Unless Specified by Treatment Protocol Yes Age <18 No Yes Go To Appropriate Peds Trauma Protocol Go To Appropriate ADULT Trauma Protocol No PPE Hazmat Pulseless, Apneic Pulse Sufficient Yes Notify Comm Center, Activate Hazmat Resources Fits Broselow Tape Present No Age >12 OR Signs of Puberty Yes Yes Go To Peds Cardiac Arrest Protocol p102 Go To ADULT Cardiac Arrest Protocol p33 Go To Appropriate ADULT Medical Protocol No Go To Peds Airway Management Protocol p99 Obstructed Airway, Ventilations Inadequate Exsanguinating Hemorrhage A,B,C’s Go To Peds Hemorrhage Control Protocol p135 Ventilations Adequate, BP and RR Adequate Support Airway, Support Oxygenation, Support Circulation M Contact Medical Control Doesn’t Fit Protocol, Exhausted Protocol Evaluate and Treat Per Appropriate Peds Medical Protocol Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Nature of Complaint Continuous Cardiac Monitor should be applied early for any non-traumatic pain complaint between the ear lobes and the umbilicus (belly button). Consider 12-Lead if concerning findings on Cardiac Monitor. Include Blood Glucose reading for any patient with weakness, altered mental status, seizure, loss of consciousness or known history of diabetes Measure and document SpO2, EtCO2 for ANY patient with complaint of weakness, altered mental status, respiratory distress, respiratory failure or EMS managed airway If hypotensive (Systolic BP100 p153 M Assess Air Movement and Chest Rise Poor Chest Rise OR Poor Air Exchange Good Chest Rise AND Good Air Exchange Document Response to Procedure Continuous EtCO2, SpO2 Monitoring Transport to PICU Capable Facility Contact Medical Control As Necessary Assess Air Movement and Chest Rise Poor Chest Rise OR Poor Air Exchange Poor Chest Rise OR Poor Air Exchange Good Chest Rise AND Good Air Exchange Consider Airway Obstruction Procedure p142 Go To Peds Failed Airway Protocol p100 Consider Midazolam 0.1mg/kg IV (max 2.0mg) If needed for CPAP compliance Assess Air Movement and Chest Rise Good Chest Rise AND Good Air Exchange Document Response to Procedure Continuous EtCO2, SpO2 Monitoring Transport to PICU Capable Facility Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Head, Neck, Blood Glucose Digital capnography is the standard of care and is to be used with all methods of advanced airway management and endotracheal intubation If Airway Management is adequately maintained with a Bag-Valve Mask and waveform SpO2 >93%, it is acceptable to defer advanced airway placement in favor of basic maneuvers and rapid transport to the hospital Always assume that patient reports of dyspnea and shortness of breath are physiologic, NOT psychogenic! Treatment for dyspnea is O2, not a paper bag! Gastric decompression with Oral Gastric Tube should be considered on all patients with advanced airways, if time and situation allow Once secured, every effort should be made to keep the advanced airway in the airway; commercially available tube holders and C-collars are good adjuncts For this protocol, an Attempt is defined as passing the tip of the laryngoscope blade or Advanced Airway past the teeth Airway Management - Peds 99 Medical Protocols - Pediatric Medical Protocols - Pediatric Evaluate and Treat Per Appropriate Peds, Medical Protocol Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of CHF, COPD, Asthma Failed Airway - Peds Lung Sounds before AND after intervention Allergen Exposure Toxic / Environmental Exposure Differential Head Injury Electrolyte Abnormality COPD Exacerbation CHF Exacerbation DM, CVA, Seizure, Tox Sepsis Asthma Exacerbation Drug Ingestion / Overdose Airway Management Protocol – Peds, Medical M Notify Medical Control (As Practical) P Needle Jet Insufflation Procedure p158 (>5 but <12 years old) P Cricothyrotomy (Open) Surgical Procedure p157 (>12 years old) One (1) unsuccessful attempts at BIAD Placement OR Anatomy Inconsistent with Continued Attempts AND Unable to Ventilate or Oxygenate adequately during or after one (1) unsuccessful BIAD Placement Attempt Call for additional resources as available Expedite Transport to CLOSEST Emergency Dept. Do NOT spend time on scene Bag-Valve Mask Airway Adjuncts Adjust Positioning Go To Appropriate Medical Protocol SpO2 >93% Unsuccessful Yes Significant Facial Trauma / Swelling / Airway Distortion No Blindly Inserted Airway Device (BIAD) Procedure p147 BIAD Successful Yes P Continue Ventilations and Support Airway Maintain SpO2 >93% Goal EtCO2 is 35-45mmHg M Notify Medical Control (If Not Already Done) No M Notify Medical Control (As Practical) P Needle Jet Insufflation Procedure p158 (>5 but <12 years old) P Cricothyrotomy (Open) Surgical Procedure p157 (>12 years old) P Continue Ventilations and Support Airway Maintain SpO2 >93% Goal EtCO2 is 35-45mmHg M Notify Medical Control (If Not Already Done) Continue Ventilations and Support Airway Maintain SpO2 >93%, Goal EtCO2 35-45mmHg Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Lung Sounds, RR, Skin, Neuro A patient with a “failed airway” is near death or dying, not stable or improving. Inability to place a BIAD airway or low SpO2 alone are not indications for surgical airway. Continuous digital capnography is the standard of care and is to be used with ALL methods of advanced airway management and endotracheal intubation. If a service does not have digital capnography capabilities and an Invasive Airway Device is placed, an intercept with a capable service MUST be completed If Airway Management is adequately maintained with a Bag-Valve Mask and waveform SpO2 >93%, it is acceptable to defer advanced airway placement in favor of basic maneuvers and rapid transport to the hospital Gastric decompression with Oral Gastric Tube should be considered on all patients with advanced airways, if time and situation allow Once secured, every effort should be made to keep the advanced airway in the airway; commercially available tube holders and C-collars are good adjuncts For this protocol, an Attempt is defined as passing the tip of the laryngoscope blade or advanced airway past the teeth Failed Airway - Peds 100 Medical Protocols - Pediatric Medical Protocols - Pediatric Each BIAD Placement Attempt should include change in approach and/or equipment NO MORE THAN TWO (2) ATTEMPTS TOTAL Legend EMT A-EMT A Wheezing / Asthma - Peds P Paramedic M Medical Control Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2 SAMPLE history OPQRST history Asthma, COPD, CHF history Home meds used prior to call (Nebs, Steroids, Theophylline) Wheezing, Rhonchi Accessory Muscle Use Decreased Ability to Speak History of CPAP/Intubation/ICU Admission from previous flares Smoke Exposure, Inhaled Toxins Differential Simple Pneumothorax Tension Pneumothorax Pericardial Tamponade STEMI, CHF Inhaled Toxins (CO, CN, etc.) Anaphylaxis Asthma/COPD General Approach – Peds, Medical Airway Patent, Respirations Adequate, SpO2 >93% No Go To Peds Airway Management Protocol Yes Go To Peds Allergic Reaction Protocol Yes Allergic Reaction/Anaphylaxis No A Consider Peds IV Access Protocol Wheezing / Lower Airway Lung Exam Albuterol 2.5mg/3mL Neb Ipratropium 0.5mg Neb * P Medical Protocols - Pediatric Medical Protocols - Pediatric Cardiac Monitor Stridor / Upper Airway 12 Lead ECG Procedure p139 Albuterol 2.5mg/3mL Neb * Consider Methylprednisolone 2mg/kg IV/IO (max 125mg) Improving Consider Peds Airway Management Protocol p99 No Albuterol 2.5mg/3mL Neb Ipratropium 0.5mg Neb * No Consider Epi 0.01mg/kg IM (1:1000) (max 0.3mg) P P No Nebulized Epinephrine 1mg Neb (1:1000) in 2 mL NS OR Racemic Epinephrine 2.25% 3mL/5mL Normal Saline Neb Yes Consider Mag Sulfate 50mg/kg IV/IO (max 2gm) Infuse over 10 minutes Improving Improving Yes Notify Receiving Facility, Contact Medical Control As Necessary Yes Pearls REQUIRED EXAM: VS, 12 Lead, GCS, RR, Lung Sounds, Accessory muscle use, nasal flaring Do not delay inhaled meds to get an extended history. Assessments and interviews may be carried out simultaneously with breathing treatments Supplemental O2 should be administered for all cases of hypoxia, tachypnea, and subjective air hunger Magnesium Sulfate is contraindicated if there is a history of renal failure Keep patient in position of comfort if partial obstruction EpiPen Jr. is 0.15mg and is indicated for patients <60lbs. The adult EpiPen is 0.30mg and is indicated for patients >60lbs Severe Asthma attacks may have such severe obstruction that they do NOT wheeze. Cases of “Silent Chest” need aggressive management with inhaled and IV medications. This is an ominous sign of impending respiratory failure. * Albuterol max 3 doses total, Ipratropium max 2 doses total. If pt. requires repeat dosing of either medication, contact Med Control AND/OR Activate ALS Wheezing / Asthma - Peds 101 A Legend EMT A-EMT P Paramedic M Medical Control Cardiac Arrest, General - Peds Pertinent Positives and Negatives Age (if known), Estimated Weight or Broselow Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Medications Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis CPR Quality Drug Therapy Shock Energy for Defibrillation First Shock 2 J/kg Second Shock 4 J/kg Subsequent Shocks >4 J/kg Maximum 10 J/kg or adult dose Reversible Causes Hypovolemia Hypoxia Hydrogen Ion (acidosis) Hypoglycemia Hypo- / Hyperkalemia Hypothermia Tension Pneumothorax Tamponade, Cardiac Toxins Thrombosis, Pulmonary Thrombosis, Coronary Epinephrine IV/IO Dose: 0.01mg/kg (0.1mL/kg of 1:10,000 concentration), max 1mg. Repeat every 3-5 minutes. Amiodarone IV/IO Dose 5mg/kg bolus during cardiac arrest, max 300mg. May repeat up to 2 times if refractory VF/Pulseless VT Advanced Airway Supraglottic advanced airway Waveform capnography to confirm and monitor airway placement Once advanced airway in place, give 1 breath every 6-8 seconds (8-10 breaths per minute) Return of Spontaneous Circulation (ROSC) Pulse and Blood Pressure check and documentation Spontaneous arterial pressure waves in the intra-arterial monitoring Pearls RECOMMENDED EXAM: Mental Status In order to successfully resuscitate a Pediatric patient, a cause of arrest must be identified and corrected Airway is the most important intervention. This should be addressed immediately. Survival is often dependent on successful airway management Airway management with BVM is often sufficient in the Pediatric patient. If evidence of tension pneumothorax - unilateral decreased or absent breath sounds, tracheal deviation, JVD, tachycardia, hypotension – consider needle thoracostomy. Chest decompression may be attempted at the 2nd intercostal space, mid clavicular line Cardiac Arrest, General - Peds 102 Medical Protocols - Pediatric Medical Protocols - Pediatric Push hard (>1/3 of anterior-posterior diameter of chest) and fast (at least 100/ min) and allow for complete chest recoil Minimize interruptions in compressions Avoid excessive ventilations Rotate compressors every 2 minutes If no advanced airway, 15:2 compressions:ventilations ratio. If advanced airway, 8-10 breaths per minute with continuous chest compression A Pulseless Electrical Activity (PEA) Arrest - Peds Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age (if known), Estimated Weight or Broselow Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis Medications Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect General Approach – Peds, Medical Start CPR Initiate Transport Immediately Existing Advanced Airway Give Oxygen Yes Ventilate at 8-10 breaths per minute with continuous compressions No 15:2 Ratio Compressions : Ventilations IF AT ANY TIME Return Of Spontaneous Circulation (ROSC) Go To Peds Post Resuscitation Protocol Expedite Transport to PICU Capable Facility Shockable Go To V-Fib / Pulseless V-Tach Arrest, Peds Protocol p105 Yes No Asystole, PEA Blood Glucose, Treat for <70 CPR Procedure x 2 Minutes (No Rhythm / No Pulse Check) p163 Consider Peds Airway Management Protocol p99 P A Peds IV Access Protocol p114 Epinephrine 0.01mg/kg (0.1mL/kg of 1:10,000) IV/IO Pulse Yes Peds Post Resuscitation Protocol p107 Treat Reversible Causes (Run the H’s and T’s) CPR x 2 Minutes (No Rhythm / Pulse Check) P Transport to PICU Capable Facility Contact Medical Control As Necessary No Epinephrine 0.01mg/kg (0.1mL/kg of 1:10,000) IV/IO every 3-5 min No Shockable Yes Go To V-Fib / Pulseless V-Tach Arrest, Peds Protocol p105 Pearls RECOMMENDED EXAM: Mental Status In order to successfully resuscitate a Pediatric patient, a cause of arrest must be identified and corrected Airway is the most important intervention. This should be addressed immediately. Survival is often dependent on successful airway management Airway management with BVM is often sufficient in the Pediatric patient. If evidence of tension pneumothorax - unilateral decreased or absent breath sounds, tracheal deviation, JVD, tachycardia, hypotension – consider needle thoracostomy. Chest decompression may be attempted at the 2nd intercostal space, mid clavicular line Pulseless Electrical Activity (PEA) Arrest - Peds 103 Medical Protocols - Pediatric Medical Protocols - Pediatric Attach Monitor / Defibrillator Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age (if known) Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Medications Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis Cardiac Arrest – Peds, Medical Shockable Continue Positive Pressure Ventilations AND Continue CPR Procedure p163 P Hypoxia – manage airway and ventilate Hypoglycemia – D10W 5mL/kg IV/IO Hyperkalemia – Sodium bicarbonate 2mEq/kg IV/IO - Calcium Chloride 1g IV/IO Hypothermia – Active Rewarming Calcium Channel and B-Blocker OD – Glucagon 3mg IV/IO Calcium Channel Blocker OD – Calcium Chloride 1g IV/IO (avoid if patient on Digoxin/Lanoxin) Tricyclic antidepressant OD – Sodium Bicarbonate 2mEq/kg IV/IO Possible Narcotic OD – Naloxone 0.1mg/kg IV/IO/IM Epinephrine 0.01mg/kg IV/IO (0.1mL/kg of 1:10,000) (max 1mg) Epinephrine 0.01mg/kg IV/IO (0.1mL/kg of 1:10,000) (max 1mg) P Pulse Shockable CPR x 2 Minutes (No Rhythm / Pulse Check) No Treat Reversible Causes (Run the H’s and T’s) Pulse Consider ALS Early IF AT ANY TIME Patient has Return of Spontaneous Circulation (ROSC) Go to Post Resuscitation Protocol Go To Post Cardiac Arrest Care Protocol p107 Yes Notify Receiving Facility, Contact Medical Control As Necessary No No Go To V-Fib / Pulseless V-Tach Peds, Adult Protocol p105 Yes Go To V-Fib / Pulseless V-Tach Arrest, Adult Protocol p105 Yes Go To Post Cardiac Arrest Care Protocol p107 No AND ACLS x 20min with >4 Epi Given Notify Receiving Facility, Contact Medical Control As Necessary Consider Termination of Resuscitation Policy p23 Consider Special Circumstances P M Contact Medical Control Consider Chest Decompression Procedure p169 Pearls RECOMMENDED EXAM: Mental Status In order to successfully resuscitate ANY cardiac arrest patient, a cause of arrest must be identified and corrected Airway is the most important intervention. This should be addressed immediately. Survival is often dependent on successful airway management Airway management with BVM is often sufficient in the Pediatric patient Do not prolong transport or scene time. If evidence of tension pneumothorax - unilateral decreased or absent breath sounds, tracheal deviation, JVD, tachycardia, hypotension – consider needle thoracostomy. Chest decompression may be attempted at the 2nd intercostal space, mid clavicular line Asystole Arrest - Peds 104 Medical Protocols - Peds Medical Protocols - Peds Consider Correctable Causes P Yes A Legend EMT A-EMT P Paramedic M Medical Control V-Fib / Pulseless V-Tach Arrest Peds Pertinent Positives and Negatives Age (if known), Estimated Weight or Broselow Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Medications Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis General Approach – Peds, Medical Start CPR Initiate Transport Immediately Existing Advanced Airway Give Oxygen 15:2 Ratio Compressions : Ventilations No Attach Monitor / Defibrillator IF AT ANY TIME Return Of Spontaneous Circulation (ROSC) Go To Peds Post Resuscitation Protocol Expedite Transport to PICU Capable Facility Shockable Ventilate at 8-10 breaths per minute with continuous compressions Go To Pulseless Electrical Activity (PEA) Arrest, Peds Protocol p103 No Yes Ventricular Fibrillation, Pulseless Ventricular Tachycardia Blood Glucose, Treat for <70 Defibrillate at 2J/kg Consider Peds Airway Management Protocol p99 CPR x 2 Minutes (No Rhythm / No Pulse Check) Shockable No Yes Pulse No Amiodarone 5mg/kg IV/IO (max single dose 300mg) May Repeat x 2 Defibrillate at 4J/kg Yes P Peds IV Access Protocol p114 Go To Pulseless Electrical Activity (PEA) Arrest, Peds Protocol p103 Yes Peds Post Resuscitation Care p107 Defibrillate at 4J/kg CPR x 2 Minutes (No Rhythm / Pulse Check) P A Epinephrine 0.01mg/kg (0.1mL/kg of 1:10,000) (max single dose 1mg) IV/IO every 3-5 min CPR x 2 Minutes (No Rhythm / Pulse Check) Shockable No Transport to PICU Capable Facility Contact Medical Control As Necessary Pearls RECOMMENDED EXAM: Mental Status In order to successfully resuscitate a Pediatric patient, a cause of arrest must be identified and corrected Airway is the most important intervention. This should be addressed immediately. Survival is often dependent on successful airway management Airway management with BVM is often sufficient in the Pediatric patient. Do not prolong transport or scene time. If evidence of tension pneumothorax - unilateral decreased or absent breath sounds, tracheal deviation, JVD, tachycardia, hypotension – consider needle thoracostomy. Chest decompression may be attempted at the 2nd intercostal space, mid clavicular line V-Fib / Pulseless V-Tach Arrest - Peds 105 Medical Protocols - Pediatric Medical Protocols - Pediatric Yes Legend EMT A-EMT A P Paramedic M Medical Control Neonatal Resuscitation - Peds Pertinent Positives and Negatives Time of Delivery, Estimated Weight or Broselow Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis Medications Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Newly Born – Adult, Medical Warm, Dry and Stimulate Infant Clear Mouth, then Nose As Needed Pulse Oximetry, Check Glucose, Continuous Cardiac Monitor Supplemental O2 via Blow-By Maintain SpO2 >94% Chest Compressions at 120/minute HR <60 Heart Rate BVM Assisted Ventilations with 10-15L O₂ At 60bpm X 30 seconds Medical Protocols - Pediatric Skin-To-Skin Contact With Mother If Situation Appropriate HR>60 BUT <100 Contact Medical Control AND Activate ALS BVM Assisted Ventilations with 10-15L At 60bpm X 30 seconds Notify Receiving Facility, Contact Medical Control As Necessary Pulse Oximetry, Check Glucose Continuous Cardiac Monitor Heart Rate BVM Assisted Ventilations with 10-15L At 60bpm X 30 seconds >60 <60 PM Quick Reference Chest Compressions at 120/minute, BVM at 3:1 Compressions:Breaths Naloxone, 0.1mg/kg IV/IO/IM Dextrose D10W, 5mL/kg IV/IO Dopamine 2-20mcg/kg/min IV/IO Epinephrine (1:10,000) 0.1-0.3mL/kg IV/IO Sodium Bicarb, 2mEq/kg IV/IO Normal Saline, 10mL/kg IV/IO M Contact Medical Control, Expedite Transport A Normal Saline Bolus, 10mL/kg (max 500mL) M Contact Medical Control, Expedite Transport P Sodium Bicarb 2mEq/kg IV/IO (max 50mEq) Yes A IV Access Protocol p114 P Epi (1:10,000) 0.1-0.3mL/kg IV/IO (max 1mg) every 5 minutes Hypovolemia <100 Heart Rate <60 >100 Heart Rate >100 Notify Receiving Facility, Contact Medical Control As Necessary No Yes EtCO2 >45mmHG No M Contact Medical Control, Expedite Transport Pearls REQUIRED EXAM: VS, GCS, Skin, Cardivascular, Pulmonary Normal blood sugar for birth to 72 hours of life is >30, and then >70 at >72 hours of life. If no IV Access in 3 attempts or 90sec (whichever comes first), move to IO Call early for ALS Intercept on neonates who are critically ill, and involve Medical Control so arrangements can be made at the receiving facility Transport rapidly to an OB Receiving Facility Consider hypoglycemia as etiology of neonatal arrest/peri-arrest situation. If not able to evaluate blood sugar, treat presumptively x 1 Neonatal Resuscitation - Peds 106 >60 BUT <100 Medical Protocols - Pediatric M Pulse Oximetry Continuous Cardiac Monitor HR >100 A Legend EMT A-EMT P Paramedic M Medical Control Post Resuscitation Care - Peds Medications Pertinent Positives and Negatives Age (if known), Estimated Weight or Broselow Events Surrounding Arrest Estimated Time of Arrest Past Medical History (if known) Concern for Foreign Body Aspiration Body Temperature History of Congenital Heart Defect Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Trauma Respiratory Failure -Foreign Body, Infectious, Epiglottitis Cardiac Arrest – Pediatric, Medical Consider Peds Airway Management Protocol p99 Persistent Signs of Shock Yes Cardiac History No A Peds IV Access Protocol p114 A Peds IV Access Protocol p114 A Normal Saline Bolus 20mL/KG IV/IO Repeat every 5 min. x 2 (max 60mL/kg) A Normal Saline Bolus 10mL/KG IV/IO Repeat every 5 min. x 2 (max 30mL/kg) Improved Repeat and Document BP Yes P Consider Ondansetron 0.1mg/kg (max 4mg) IV/IO No Hypovolemia Hypoxia Hydrogen Ion (acidosis) Hypoglycemia Hypo-/Hyperkalemia Hypothermia Tension Pneumothorax Tamponade (cardiac) Toxins Thrombosis (pulmonary) Thrombosis (cardiac) Trauma Improved Yes No M Fentanyl 1mcg/kg IV/IO (max 75mcg) AND Midazolam 0.2mg/kg IV/IO (max 4mg) May Repeat x 2 Possible Reversible Causes of Arrest Yes Repeat and Document BP P No Dopamine 5-20mcg/kg/min IV/IO OR Epinephrine 0.1-0.5mcg/kg/min IV/IO Titrate to Age Defined Minimum BP M Dopamine 5-20mcg/kg/min IV/IO Titrate to Age Defined Minimum BP Notify Receiving Facility, Contact Medical Control As Necessary Notify Receiving Facility, Contact Medical Control As Necessary Pearls RECOMMENDED EXAM: Mental Status Monitor and treat for agitation and seizures Monitor and treat hypoglycemia If patient remains unresponsive after resuscitation from cardiac arrest, contact Medical Control to discuss initiation of therapeutic hypothermia If evidence of tension pneumothorax - unilateral decreased or absent breath sounds, tracheal deviation, JVD, tachycardia, hypotension – consider needle thoracostomy. Chest decompression may be attempted at the 2nd intercostal space, mid clavicular line Hyperventilation is a significant cause of hypotension / recurrent cardiac arrest in post resuscitation phase; avoid at all costs Post Arrest Care - Peds 107 Medical Protocols - Pediatric Medical Protocols - Pediatric Titrate FiO2 to maintain SpO2 >93% Goal EtCO2 35-45mmHg Do Not Hyperventilate Airway Device Placed A Legend EMT A-EMT Bradycardia with a Pulse - Peds P Paramedic M Medical Control Pertinent Positives and Negatives Age (if known), Estimated Weight or Broselow Events Surrounding Rhythm Change Estimated Time of Events Past Medical History (if known) Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Sepsis Increased Intracranial Pressure (trauma, shunt, NAT) General Approach – Pediatric, Medical Identify and Treat Underlying Cause Go To Peds Airway Management Protocol p99 Patent Adequate GiveAirway, Supplemental O2Ventilations, via NRB SpO2 >93% No A Peds IV Access Protocol p114 Cardiopulmonary Compromise No Yes Start Pediatric CPR (C-A-B) if Heart Rate <60 At least 100 compressions per minute 15:2 Compressions:Breaths w/o airway 8-10 Breaths/min with advanced airway Support A,B,C’s Give O2 Monitor Closely for Change Bradycardia Persists No Yes, Severe P Epinephrine 0.01mg/kg IV/IO 1:10,000 (max 1mg) Repeat every 3-5 minutes While setting up to pace M Consider External Cardiac Pacing Procedure P Consider Sedation Before Initiation of Pacing P Midazolam 0.2mg/kg IM/IN (max 10mg) OR Lorazepam 0.05mg/kg IV/IO (max 2mg) OR Midazolam 0.05mg/kg IV/IO (max 2mg) Yes P P Transport to PICU Capable Facility Contact Medical Control As Necessary Epinephrine 0.01mg/kg IV/IO (max 1mg) Repeat every 3-5 minutes OR IF Bradycardia due to Vagal Tone Atropine, 0.02mg/kg IV/IO (min dose 0.1mg, max 0.5mg) may repeat ONCE Peds Cardiac Arrest Protocol p102 IF loss of pulses at any time Pearls RECOMMENDED EXAM: Mental Status Maintain patent airway throughout evaluation and treatment; assist breathing as necessary Cardiopulmonary Compromise – Hypotension, Acutely Altered Mental Status, Signs of Shock Don’t delay treatment to get 12-lead ECG if patient is unstable Pediatric patients ALWAYS get CPR; CCR is not appropriate for the pediatric patient Bradycardia with a Pulse - Peds 108 Medical Protocols - Peds Medical Protocols - Peds 12-Lead ECG Procedure If Situation Allows p139 A Legend EMT A-EMT Tachycardia with a Pulse - Peds P Paramedic M Medical Control Differential Hypoxemia, Hypovolemia, Hypotension, Acidosis Toxins, Tension Pneumo, Pericardial Tamponade Hypoglycemia, Sepsis Respiratory Distress -Foreign Body, Infectious, Epiglottitis Pertinent Positives and Negatives Age (if known), Estimated Weight or Broselow Events Surrounding Rhythm Change Estimated Time of Events Past Medical History (if known) General Approach – Pediatric, Medical Run the H’s and T’s (in Differential Above) Identify and Treat Underlying Cause Consider Peds Airway Management Protocol p99 Give Supplemental O2 via NRB Cardiac Monitor Consider Peds IV Access Protocol p114 Narrow (<0.09 sec) Evaluate QRS Wide (>0.09 sec) 12-lead ECG Procedure Possible Ventricular Tachycardia Infants <220 Children <180 Yes No Probable Sinus Tachycardia Probable SVT Search For and Treat Cause of Tachycardia (sepsis, dehydration, DKA, hypovolemia) P No Yes Consider Vasovagal Maneuvers No P Go To Appropriate Peds Medical Protocol Hemodynamic Instability Adenosine 0.1mg/kg IV/IO, (max 6mg) rapid push May repeat once at Adenosine 0.2mg/kg IV/IO, (max 12mg) rapid push Ineffective, Unavailable OR Unstable P Synchronized Cardioversion at 0.5-1 J/kg (May repeat ONCE at 2J/kg) Yes P Consider Pain Management – Peds, Medical Protocol p116 Effective Transport to PICU Capable Facility Contact Medical Control As Necessary Improved Rhythm regular and QRS monomorphic Adenosine 0.1mg/kg IV/IO, rapid (max 6mg) May repeat once at Adenosine 0.2mg/kg IV/IO, rapid (max 12mg) No Change M Consider Amiodarone 5mg/kg IV/IO (max 300mg) over 20-60 minutes Pearls RECOMMENDED EXAM: Mental Status Once Hemodynamically stable a 12-Lead ECG should be obtained Maintain patent airway throughout evaluation and treatment; assist breathing as necessary Probable Sinus tachycardia – P-waves present before every QRS, constant P-R interval. Infants usually <220/min, Children usually <180/min Probable SVT – history vague, nonspecific with abrupt rate change, P-waves absent / abnormal, HR not variable. Infants usually >220/min, Children >180/min Hemodynamic Instability – Hypotension, Acutely Altered Mental Status, Signs of Shock Don’t delay treatment to get 12-lead ECG if patient is unstable H’s & T’s – Hypovolemia, Hypoxia, Hydrogen Ion (acidosis), Hypoglycemia, Hypo-/Hyperkalemia, Tension Pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary), Trauma Tachycardia with a Pulse - Peds 109 Medical Protocols - Pediatric Medical Protocols - Pediatric A Legend EMT A-EMT A P Paramedic M Medical Control Allergic Reaction - Peds Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Onset and Location of Symptoms Lung Sounds before AND after intervention Allergen Exposure Toxic / Environmental Exposure Subjective throat “tightness” OR “closing” Differential Urticaria (Rash Only) Anaphylaxis (Systemic Effect) Shock (Vascular Effect) Angioedema Aspiration / Airway Obstruction Vasovagal Event Asthma / COPD CHF General Approach – Peds, Medical Mild Moderate Severe Imminent Cardiac Arrest Flushing, Hives, Itching, Erythema Normal BP, No Respiratory Involvement Flushing, Hives, Erythema PLUS Dyspnea, Wheezing Chest Tightness Derm symptoms may not be present, depending on perfusion Wheezing, Dyspnea, Hypoxia, Nausea/Vomiting PLUS Hypotension Altered Mental Status, Hypotension, Pallor, Diaphoresis, Weak Pulses A Consider Peds IV Access Protocol p114 P Consider Diphenhydramine 1mg/kg IV/IM/IO (max 50mg) M Consider Famotidine 0.5mg/kg IV/IO (max 20mg) Consider Epi 1:1,000 0.01mg/kg IM (max 0.3mg) <28kg, EpiPen Jr. (0.15mg) >28 kg, Adult EpiPen Consider Epi 1:1,000 0.01mg/kg IM (max 0.3mg) <28kg, EpiPen Jr. (0.15mg) >28kg, Adult EpiPen Epi 1:1,000 0.01mg/kg IM (max 0.3mg) <28kg, EpiPen Jr. (0.15mg) >28kg, Adult EpiPen Albuterol 2.5mg/3mL Neb May repeat Q10min, Max 3 A Peds IV Access Protocol p114 Normal Saline, 20mL/kg IV/IO Albuterol 2.5mg/3mL Neb May repeat Q10min, Max 3 A Peds IV Access Protocol p114 (If Not Already Done) M Contact Medical Control (As Practical) A Peds IV Access Protocol p114 A Normal Saline, 20mL/kg IV/IO (max 500mL) P Epi 1:10,000 0.005mg/kg IV/IO (Max 0.1mg) P Diphenhydramine 1mg/kg IV/IM/IO (max 50mg) P Diphenhydramine 1mg/kg IV/IM/IO (max 50mg) P Famotidine 0.5mg/kg IV/IO (max 20mg) P Famotidine 0.5mg/kg IV/IM/IO (max 20mg) P Methylprednisolone, 2mg/kg IV/IO (max 125mg) Yes Stable / Improving Response to Medications Worsening / Refractory Notify Receiving Facility, Contact Medical Control As Necessary Improving Worsening / Refractory Consider Peds Airway Management Protocol p99 M Epi Infusion 0.1-1mcg/kg/min IV/IO Pearls REQUIRED EXAM: VS, GCS, Skin, Cardivascular, Pulmonary Epinephrine Infusion: Mix 2mg (1:1,000) in 250mL NS. If worsening or refractory anaphylaxis, contact Med Control first. Start at 2mcg/min, titrate up. Famotidine: Mix 20mg in 100mL D5W. Infuse over 15 minutes In general, the shorter the time from allergen contact to start of symptoms, the more severe the reaction Consider the Airway Management Protocol early in patients with Severe Allergic Reaction or subjective throat closing Imminent Cardiac Arrest should be considered in patients with severe bradycardia, unresponsiveness, no palpable radial or brachial pulse If parents have administered diphenhydramine (Benadryl) prior to EMS arrival, confirm medication given as well as dose Allergic Reaction - Peds 110 Medical Protocols - Pediatric Medical Protocols - Pediatric Severity of Allergic Reaction A Legend EMT A-EMT P Paramedic M Medical Control Altered Mental Status - Peds Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of DM, medic alert bracelet Drug paraphernalia or report of illicit drug use Evidence of environmental toxin / ingested toxin Differential Head Injury Electrolyte Abnormality Psychiatric Disorder DM, CVA, Seizure, Tox Sepsis General Approach – Peds, Medical Blood Glucose Go To Appropriate Peds Cardiac Dyshrhythmia Protocol Abnormal <70 or >250 Continuous Cardiac Monitor Go To Peds Diabetic Emergencies Protocol p113 >70 and <250 Overdose Yes No Go To Stroke, Suspected Protocol, ADULT p69 Yes, Stroke Stroke or Seizure Yes, Seizure Go To Peds Seizure Protocol p118 >104oF (>40oC) Go To Peds Hyperthermia Protocol p130 No Go To Peds Hypothermia Protocol p131 <93o F (<34o C) Temperature >93o and <104oF (>35o and <40oC) Go To Appropriate Peds Cardiac Dysrhythmia Protocol Abnormal Cardiac Rhythm STEMI Go To STEMI Protocol, ADULT p39 Normal Rhythm Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Head, Neck, Blood Glucose Pay special attention to head and neck exam for bruising or signs of injury Altered Mental Status may be the presenting sign of environmental hazards / toxins. Protect yourself and other providers / community if concern. Involve Hazmat early Safer to assume hypoglycemia if doubt exists. Recheck blood sugar after dextrose/glutose administration and reassess Do not let EtOH fool you!! Intoxicated patients frequently develop hypoglycemia, Alcoholic Ketoacidosis (AKA) and often hide traumatic injuries! Altered Mental Status - Peds 111 Medical Protocols - Pediatric Medical Protocols - Pediatric Go To Peds Overdose and Poisoning, General Protocol p115 A Apparent Life-Threatening Episode (ALTE) - Peds Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history Events Leading up to 9-1-1 Pregnancy History Complications During Pregnancy/Delivery Mother’s GBS Status at Delivery Color, Tone and Appearance During Event Differential Hypoglycemia Hyponatremia Seizure Congenital Heart Defect Non-Accidental Trauma Inborn Error of Metabolism Periodic Apnea Reflux General Approach – Peds, Medical Blood Glucose Go To Appropriate Cardiac Dyshrhythmia, Peds Protocol Abnormal <70 or >250 Go To Diabetic Emergencies, Peds Protocol p113 Continuous Cardiac Monitor Normal Hives, Rash Skin Cyanotic Consider Airway Management, Peds Protocol p99 Yes Consider Airway Management, Peds Protocol p99 Limp, OR Poor Tone Consider Altered Mental Status, Peds Protocol p111 Yes Go To Appropriate Medical, Peds Protocol Normal Choking OR Gagging No Consider Seizure, Peds Protocol p118 Increased, OR Shaking Muscle Tone Normal Go To Appropriate Trauma, Peds Protocol Suspect Non-Accidental Trauma Signs or Symptoms of Illness No Notify Receiving Facility, Contact Medical Control As Necessary No Parents Refusing Yes M Contact Medical Control Pearls REQUIRED EXAM: VS, GCS, Skin, Cardivascular, Pulmonary An Apparent Life Threatening Event (ALTE) occurs in children <1 year of age and may be referred to as “Near-miss SIDS”; it is an episode that is frightening to the observer/caregiver and involves some combination of the following: Apnea, Color Change, Marked Change In Muscle Tone, and Choking or Gagging The incidence of ALTE was found to be 7.5% in one studied out-of-hospital infant population The overwhelming majority of ALTE patients (83%) appeared to be in no apparent distress by EMS assessment Nearly half of the patients assessed by EMS to be in no apparent distress (48%) were later found to have significant illness upon ED evaluation This is why the history of an apparent life-threatening event (ALTE) must always result in transport to an emergency department regardless of the infant’s appearance at the time of EMS assessment If the parent or guardian is refusing EMS transport, OLMC must be contacted prior to executing a refusal. Be supportive of parents as they may feel embarrassed for calling when the child now appears well Always have a high index of suspicion for Non-Accidental Trauma (NAT). It affects all ethnicities, socioeconomic statuses and family types. Apparent Life-Threatening Episode (ALTE) - Peds 112 Medical Protocols - Pediatric Medical Protocols - Pediatric Consider Allergic Reaction, Peds Protocol p110 Legend EMT A-EMT A P Paramedic M Medical Control Diabetic Emergencies - Peds Pertinent Positives/Negatives: Age, VS, Blood Glucose Reading SAMPLE History OPQRST History Last Meal, History of Skipped Meal Differential Toxic Ingestion Head Injury Sepsis Stroke/TIA Diaphoresis Siezures Abnormal Respiratory Rate History of DKA Seizure EtOH Abuse/Withdrawal Drug Abuse/Withdrawal General Approach – Peds, Medical Blood Glucose <70 >250 >70 and <250 Age-Defined Hypotension Mental Status Altered AND/OR Compromised Gag Glutose 15g PO One time Go To Appropriate Peds Medical Protocol Glucagon IM 0.5mg if <25kgs, 1mg if >25kgs One Time No Yes Clinically Dehydrated Yes A Consider Peds IV Access Protocol p114 A Consider Normal Saline Bolus, 20mL/kg (max 500mL) M Contact Medical Control for any Mental Status Changes or Additional NS No A IV Access Protocol p114 A Dextrose Dosing: D10 3mL/kg IV/IO (max 125mL) <70 Repeat Blood Glucose within 10 minutes Go To Appropriate Peds Medical Protocol >70 Mental Status Altered from Baseline OR Unknown Go To Peds Altered Mental Status Protocol p111 Baseline To Make D10 from D50 (IF D10 not available) Draw 4mL of D50 into a 20mL syringe, then draw 16mL of NS (This will give enough D10 to treat up to roughly 7kg (15lb) child under this protocol) Full Assessment Evaluate for Secondary Complaint Issue Discovered Go To Appropriate Peds Medical Protocol None Notify Receiving Facility, Contact Medical Control As Necessary Accepts Recommend Transport Parent/Guardian Declines M Contact Medical Control Pearls REQUIRED EXAM: VS, SpO2, Blood Glucose, Skin, Respiratory Rate and Effort, Neuro Exam Normal blood sugar for birth to 72 hours of life is >30, and then >70 at >72 hours of life. Do NOT administer oral glucose to patients that can’t swallow or adequately protect their airway Do NOT give Bicarb to patients with hyperglycemia suspected to be in DKA – This has been proven to result in WORSE outcomes for the patients Prolonged hypoglycemia may not respond to Glucagon; be prepared to start an IV and administer IV Dextrose Infants and patients with congenital liver diseases may not respond to Glucagon due to poor liver glycogen stores Patients on oral diabetes medications are at a very high risk of recurrent hypoglycemia and should be transported. Contact Medical Control for advice/ patient counseling if patient is refusing. See Refusal after Hypoglycemia Treatment Protocol for additional information as necessary. Always consider intentional insulin overdose, and ask patients / family / friends / witnesses about suicidal ideation, comments or gestures Diabetic Emergencies - Peds 113 Medical Protocols - Pediatric Medical Protocols - Pediatric Awake Protecting Airway Legend EMT A-EMT A P Paramedic M Medical Control IV Access - Peds General Approach – Peds, Medical First Access For Cardiac Arrest Yes A Go To Intraosseous Venous Access Procedure p180 No Emergent OR Potentially Emergent Medical OR Traumatic Condition No Yes A Consider Second IV Access Site for Critical Medical / Trauma Patients A Go To Extremity Venous Access Procedure p179 Go To Appropriate Peds Medical Protocol Successful Unsuccessful/ Peripherally Exhausted A Go To Intraosseous Venous Access Procedure p180 (Life Threatening Event) Success in <3 Total Attempts Monitor Access Site for Swelling, Pain, Redness, Evidence of Extravasation Yes A No Yes M Life Threatening Condition Monitor Infusion of IV Fluids No Notify Receiving Facility, Contact Medical Control As Necessary Contact Medical Control Pearls In the setting of CARDIAC ARREST ONLY, any preexisting dialysis shunt or central line may be used by paramedics For patients who are hemodynamically unstable or in extremis, Medical Control MUST be contacted prior to accessing any preexisting catheters Upper Extremity sites are preferred over Lower Extremity sites. Lower Extremity IVs are discouraged in patients with peripheral vascular disease or diabetes In post-mastectomy patients and patients with forearm dialysis fistulas, avoid IV attempts, blood draws, injections or blood pressures in the upper extremity on the affected side Saline Locks are acceptable in cases where access may be necessary but the patient is not volume depleted; having an IV does not mandate IV Fluid infusion The preferred order of IV Access is: Peripheral IV, Intraosseous IV, IN/IM access UNLESS medical acuity or situation dictate otherwise. IV Access - Peds 114 Medical Protocols - Pediatric Medical Protocols - Pediatric Consider IN/IM/PO Medications As Appropriate for Condition Legend EMT A-EMT A P Paramedic M Medical Control Overdose and Poisoning, General Peds Pertinent Positives/Negatives: Age, VS, SpO2, EtCO2, RR SAMPLE history OPQRST history History of Ingestion or Suspected Ingestion Dysrhythmias SLUDGEM DUMBELLS Time of Ingestion Type, Number and Dose of Pills Taken (if known) Seizures Mental Status Change Vomiting Differential Head Injury Hazmat Exposure Electrolyte Imbalance DM, CVA, Seizure Sepsis General Approach – Peds, Medical Call For Additional Resources, Stage Until Safe Yes Remember D.E.B. Do Everyone’s Blood Sugar!! Hazmat Scene A Assess Respirations, Ventilations and Oxygenation Adequate 12 Lead ECG Procedure p139 Pulse Inadequate Absent Go To Peds Cardiac Arrest Protocol p102 Peds IV Access Protocol p114 Present Blood Glucose Go To Peds Diabetic Emergencies Protocol p113 <70 Peds Airway Management Protocol p99 >70 Assess Mental Status Altered OR Not Protecting Airway Naloxone 0.1mg/kg IN (max 1mg per nare) OR Awake, Protecting Airway Potential Causes Pesticide or Nerve Gas Exposure SLUDGE Symptoms Go To Organophosphate OD Protocol, ADULT p55 Continuous Cardiac Monitor Regular Unchanged A Peds IV Access Protocol p114 Consider Opiate Overdose Protocol, ADULT p54 A Naloxone 0.1mg/kg IV/IO/IM (max 2mg) Improved Bradycardia, AV Block History of Beta Blocker Ingestion Consider Glucagon P 0.1mg/kg IV/IO (max 5mg) M Improved Bradycardia, AV Block History of Ca+ Channel Blocker Ingestion Consider Calcium P Chloride 20mg/kg IV/IO (max 1gm) Ventricular Dysrhythmia, Seizure History of TCA Ingestion Consider Sodium Bicarb P 1mEq/kg IV/IO (max 50mEq) Arrhythmia Go To Appropriate Peds Arrhythmia Protocol Altered Mental Status, Seizure Smoke Exposure Go To Cyanide OR Carbon Monoxide Poisoning Protocol, ADULT p58-59 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Mental Status, Skin, Blood Glucose Patients are unreliable historians in overdose situations, particularly in suicide attempts. Trust what they tell you, but verify (pill bottles, circumstances, etc.) Bring pill bottles, contents, emesis to the ED for evaluation and assessment Be careful of off-gassing in cases of inhalation of volatile agents Many intentional overdoses involve multiple substances, some with cardiac toxicity; a 12-Lead ECG should be obtained on all overdoses situation permitting Contact Poison Control for all non-opiate overdoses: 1-800-222-1222 SLUDGEM – Salivation, Lacrimation, Urination, Defecation, GI Upset, Emesis, Miosis DUMBBELLS – Diarrhea, Urination, Miosis/Muscle Weakness, Bronchorrhea, Bradycardia, Emesis, Lacrimation, Lethargy, Salivation/Sweating Overdose and Poisoning, General - Peds 115 Medical Protocols - Pediatric Medical Protocols - Pediatric No Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS SAMPLE History OPQRST History History of chronic pain Differential Head injury Spine Injury Compartment Syndrome Fracture, Sprain, Strain Pneumo/hemo-thorax Pericardial effusion Aortic Dissection Internal organ injury General Approach – Peds, Medical Patient Care per Appropriate Peds Medical Protocol None – Mild Pain (0-4) Consider Peds IV Access Protocol p114 A Moderate Pain (5-8) Severe Pain (9-10) Place patient on cardiac monitor, continuous SpO2 and EtCO2 Place patient on cardiac monitor, continuous SpO2 and EtCO2 P Consider IN Fentanyl 1.5mcg/kg (max 50mcg per nare) P Consider IN Fentanyl 1.5mcg/kg (max 50mcg per nare) A Consider Peds IV Access Protocol p114 A Consider Peds IV Access Protocol p114 Document response to meds, VS (HR, BP, SpO2, EtCO2) Document response to meds, VS (HR, BP, SpO2, EtCO2) SpO2 >93%, EtCO2 <45, SBP >90 Reassess Pain Unchanged OR Worsening P Fentanyl 1mcg/kg IV/IO/IM (max 75mcg) May repeat x 1 P Consider Ondansetron 0.1mg/kg IV/IO (max 4mg) M Consider Morphine 0.1mg/kg IV/IO (max 4mg) Improved Reassess and Document VS, including Pain Scale Continue to Peds Medical Specific Protocol Pearls REQUIRED EXAM: Vital Signs, GCS, Neuro Exam, Lung Sounds, Abdominal Exam, Musculoskeletal Exam, Area of Pain Provider Discretion to be used for patients suffering from chronic pain related issues. Please note that history of chronic pain does not preclude the patient from treatment of acute pain related etiologies. Pain severity (0-10) is a vital sign to be recorded pre- and post-medication delivery and at disposition As with all medical interventions, assess and document change in patient condition pre- and post-treatment Opiate naive patients can have a much more dramatic response to medications than expected; start low and titrate up as appropriate Allow for position of maximum comfort as situation allows Pain Management – Peds 116 Medical Protocols - Pediatric Medical Protocols – Pediatric Assess Pain 0-10 Pain Scale OR FACES Scale A Legend EMT A-EMT P Paramedic M Medical Control Refusal Protocol - Peds Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Mental Status Pale, Cool Skin Delayed Cap Refill Differential Cardiac Dysrhythmia Hypoglycemia Overdose Toxidrome Sepsis Occult Trauma Adrenal Insufficiency General Approach – Peds, Medical Parent or Legal Guardian is A&O x 4 and has capacity for decision making No Transport Required Under Implied Consent OR Police Protective Custody Yes Transport Required Under Implied Consent OR Police Protective Custody Contact On-Line Medical Control as necessary Yes Transport Required Under Implied Consent OR Police Protective Custody Contact On-Line Medical Control as necessary Parent/Guardian Condition: Altered mental status Impaired decision making ability Hallucinations or thought disorder Incapacitated or intoxicated Expresses Suicidal or Homicidal Ideation No <1 year old Vital Sign or Physical Exam abnormalities Reasonable concern that the parent/guardian decision poses a threat to the minor Advanced Life Support measures initiated and parent/ guardian refusing No Document assessment including mental status, physical exam, vitals, blood glucose and SpO2 Assure that the patient/parent/guardian understands the possible consequences of refusal Complete documentation of refusal and obtain signatures Pearls REQUIRED EXAM: VS, GCS, Nature of Complaint *Incapacitated definition: A person who, because of alcohol consumption or withdrawal, is unconscious or whose judgment is impaired such that they are incapable of making rational decisions as evidenced by extreme physical debilitation, physical harm or threats of harm to themselves, others or property. Evidence of incapacitation: inability to stand on ones own, staggering, falling, wobbling, vomit/urination/defecation on clothing, inability to understand and respond to questions, DTs, unconsciousness, walking or sleeping where subject to danger, hostile toward others. **Intoxicated definition: A person whose mental or physical functioning is substantially impaired as a result of the use of alcohol. If there is ANY question, do not hesitate to involve Law Enforcement to ensure the best decisions are being made on behalf of the patient. Refusal Protocol - Peds 117 Medical Protocols - Peds Medical Protocols - Peds Yes Legend EMT A-EMT A P Paramedic M Medical Control Bowel or Bladder Incontinence Tongue Biting Recent Fever History Evidence of Head Trauma Number of Seizures and Duration Pertinent Positives and Negatives Age, VS, GCS, SpO2, Blood Sugar SAMPLE History OPQRST History Seizure History, Med Compliance Environmental Cause or Toxic Exposure Subtle Indications of Peds Seizure: Persistent Gaze Deviation, Jaw Clenching, Rhythmic Mouth Movements, Focal Stiffening or Rhythmic Twitching of Extremity Notify Comm Center and Hazmat Team Ensure Responder and Public Safety Yes Go To Hazmat, General Protocol No Actively Seizing on EMS Arrival No Yes P Go To Peds Diabetic Emergencies Protocol p113 OR <70 >70 M <70 Midazolam 0.2mg/kg IM/IN (max 5mg) Blood Glucose If Peds Ketogenic Diet, Goal Blood Sugar >50 >70 Loosen Constrictive Clothing Protect Patient from Injury Consider Peds Airway Intervention Protocol p99 Consider Peds IV Access Protocol p114 A Monitor and Reassess Support Breathing Consider Peds Spinal Immobilization Protocol p138 Support Breathing Loosen Constrictive Clothing Protect Patient from Injury A Peds IV Access Protocol p114 P Lorazepam 0.05 mg/kg IV/IO (max 2mg) OR Midazolam 0.05mg/kg IV/IO (max 10mg) P IF IV Failed, Midazolam 0.2mg/kg IM/IN (max 5mg) Consider Peds Altered Mental Status Protocol p111 Seizure Returns No Notify Receiving Facility, Contact Medical Control As Necessary Yes No Status Epilepticus M Contact Medical Control Yes Pearls REQUIRED EXAM: Blood Sugar, SpO2, GCS, Neuro Exam Midazolam is effective in terminating seizures. Do not delay IM/IN administration to obtain IV access in an actively seizing patient. IN Midazolam is preferred to rectal Diazepam. Do not hesitate to treat recurrent, prolonged (>1 minute) seizure activity. Have a low threshold to give IN Midazolam rather than spend time on IV Access. Status epilepticus is a seizure lasting greater than 5 minutes OR >2 successive seizures without recovery of consciousness in between. This is a TRUE EMERGENCY requiring Airway Management and rapid transport to the most appropriate Pediatric ICU Capable facility Assess for possibility of occult trauma, substance abuse Active seizure in known or suspected pregnancy >20 weeks, give Magnesium 4gm IV/IO over 2-3 minutes Seizure – Peds 118 Medical Protocols - Pediatric Medical Protocols - Pediatric Drugs, EtOH Abuse Drugs, EtOH Withdrawal Occult Head Injury Non-Accidental Trauma Syncope General Approach – Peds, Medical Consider ALS Early Prolonged Seizures Are BAD for Neurologic Outcomes! Blood Glucose Differential Hypoxia Hypoglycemia Electrolyte Imbalance Eclampsia A Hypotension / Shock (NonTrauma) - Peds Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, BP, RR, SpO2 SAMPLE history OPQRST history Source of blood loss, if any (GI, vaginal, AAA, ectopic) Source of fluid loss, if any (vomiting, diarrhea, fever) Pregnancy history Mental Status Pale, Cool Skin Delayed Cap Refill Coffee Ground Emesis Tarry Stools Allergen Exposure Differential Cardiac Dysrhythmia Hypoglycemia Ectopic Pregnancy AAA Sepsis Occult Trauma Adrenal Insufficiency General Approach – Peds, Medical Blood Glucose Go To Appropriate Peds Cardiac Dyshrhythmia Protocol Arrhythmia/ STEMI 12 Lead ECG Procedure A Medical Protocols - Pediatric Consider Peds Airway Management Protocol p99 IV Access Protocol p114 History, Exam, Circumstances Suggest Etiology of Shock? Trauma Medical Hypovolemic (Dehydration, GI Bleed) A Distributive (Sepsis, Anaphalaxis) Cardiogenic (CHF, Congenital Heart Defect) Normal Saline Bolus 20mL/KG IV/IO Repeat every 5 min. x 2 (max 60mL/kg) A Obstructive (PE, Tamponade) Normal Saline Bolus 10mL/kg IV/IO Repeat at 5 min. if necessary (max 30mL/kg) SBP <70 + (2xage) SBP <70 + (2xage) Repeat and Document BP Improved Repeat and Document BP Yes Yes No M Improved No Dopamine 5-20mcg/kg/min IV/IO OR Epinephrine 0.1-0.5mcg/kg/min IV/IO Titrate to Age Defined Minimum BP M Dopamine 5-20mcg/kg/min IV/IO Titrate to Age Defined Minimum BP Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, RR, Lung sounds, JVD Shock may present with initially normal VS and progress insidiously; follow frequent blood pressures, particularly if the patient “looks sicker than Vital Signs” Tachycardia may be the first and only sign of shock in the pediatric population; remember – Peds patients compensate to a point, then crash quickly If evidence or suspicion of trauma (accidental OR non-accidental), move to Hypotension/Shock (Trauma) Protocol early Acute Adrenal Insufficiency – State where the body cannot produce enough steroids. Primary adrenal disease vs. recent discontinuation of steroids (Prednisone) after long term use. ** If Adrenal Insufficiency suspected, contact Medical Control and review case. Medical Control may authorize Methylprednisone 2mg/kg IV/IO Hypotension is a LATE finding in pediatric patients, and is an ominous sign that they are losing their ability to compensate Hypotension / Shock (Non-Trauma) - Peds 119 Medical Protocols - Pediatric Go To Peds Hemorrhage Control, Trauma Protocol p135 Go To Peds Diabetic Emergencies Protocol p113 <70 or >250 Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS SAMPLE History OPQRST History History of chronic pain History of Sickle Cell Anemia Signs of Infection Hypoxia Dehydration Painful Joint(s) Differential Dehydration Sepsis Pneumonia Fracture, Sprain, Strain Vaso-Occlusive Crisis Acute Chest Syndrome Splenic Sequestration Acute Stroke General Approach – Peds, Medical Supplemental O2 at 2LPM NC Titrate Up As Appropriate Warm Blanket if available None – Mild Pain (0-4) A Consider Peds IV Access Protocol p114 A If IV placed, consider Normal Saline 20mL/kg IV/IO (max 500mL) Reassess Pain Moderate Pain (5-8) Severe Pain (9-10) Place patient on cardiac monitor, continuous SpO2 and EtCO2 Place patient on cardiac monitor, continuous SpO2 and EtCO2 P Consider Fentanyl 1.5mcg/kg IN (max 50mcg per nare) P Consider Fentanyl 1.5mcg/kg IN (max 50mcg per nare) A Consider Peds IV Access Protocol p114 A Peds IV Access Protocol p114 A If IV placed, consider Normal Saline 20mL/kg IV/IO (max 500mL) A Normal Saline 20mL/kg IV/IO (max 500mL) Worsening Document response to meds, VS (HR, BP, SpO2, EtCO2) Document response to meds, VS (HR, BP, SpO2, EtCO2) Stable SpO2 >93%, EtCO2 <45, SBP >90 Reassess Pain Unchanged OR Worsening P Fentanyl 1mcg/kg IV/IO/IM (max 75mcg) May repeat x 1 P Consider Ondansetron 0.1mg/kg IV/IO (max 4mg) M Consider Morphine 0.1mg/kg IV/IO (max 5mg) Improved Reassess and Document VS, including Pain Scale Continue to Peds Medical Specific Protocol Pearls REQUIRED EXAM: Vital Signs, GCS, Neuro Exam, Lung Sounds, Abdominal Exam, Musculoskeletal Exam, Area of Pain Provider Discretion to be used for patients suffering from chronic pain related issues. Please note that history of chronic pain does not preclude the patient from treatment of acute pain related etiologies. Pain severity (0-10) is a vital sign to be recorded pre- and post-medication delivery and at disposition Sickle Cell Anemia is a chronic hemolytic anemia occurring almost exclusively in African Americans; pain crises result from the occlusion of blood vessels by masses of misshapen blood cells during times of crisis Sickle Pain Crises occur typically in the joints and back. Liver, Pulmonary and CNS involvement can present with RUQ pain, hypoxia or stroke Patients with sickle cell disease have a high incidence of life-threatening conditions at a very young age Sickle Cell Crisis – Peds 120 Medical Protocols - Pediatric Medical Protocols – Pediatric Assess Pain 0-10 Pain Scale OR FACES Scale A Legend EMT A-EMT P Paramedic M Medical Control Vital Signs In Children Age Newborn – 3mos 3mos – 2years 2years – 10years >10years Age Respiratory Rate (Breaths Per Minute) Age Minimum Systolic Blood Pressure Infant Toddler Preschooler School-Aged Child Adolescent 30-60 24-40 22-34 18-30 12-16 Term Neonates (0-28days) Infants (1-12mos) Children 1-10years Chilcren >10years >60 >70 >70 + (age in years x 2) >90 Heart Rate (Beats Per Minute) Awake Rate 85-205 100-190 60-140 60-100 Sleeping Rate 80-160 75-160 60-90 50-90 Wisconsin EMSC Recommended Weight Conversion (1 kg = 2.2 lbs -OR1 lb = 0.45 kgs) Child Infant Score Eye Opening Spontaneous To Speech To Pain None Spontaneous To Speech To Pain None 4 3 2 1 Best Verbal Response Oriented, Appropriate Confused Inappropriate Words Incomprehensible Sounds None Coos and Babbles Irritable, Cries Cries in Response to Pain Moans in Response to Pain None 5 4 3 2 1 Best Motor Response Obeys Commands Localizes Painful Stimulus Withdraws in Response to Pain Flexion in Response to Pain Extension in Response to Pain None Moves Spontaneously and Purposely Withdraws in Reponse to Touch Withdraws in Response to Pain Abnormal Flexion Posture to Pain Abnormal Extension Posture to Pain None 6 5 4 3 2 1 Lbs. Kgs. Lbs. Kgs. 5 lbs 2 kgs 20 lbs 9 kgs 6 3 21 10 7 3 22 10 8 4 23 10 9 4 24 11 10 lbs 5 kgs 25 lbs 11 kgs 11 5 26 12 12 5 27 12 13 6 28 13 14 6 29 13 15 lbs 7 kgs 30 lbs 14 kgs 16 7 31 14 17 8 32 15 18 8 33 15 19 9 34 15 www.chawisconsin.org Lbs. Kgs. 35 lbs 36 37 38 39 40 lbs 41 42 43 44 45 lbs 46 47 48 49 50 lbs 16 kgs 16 17 17 18 18 kgs 19 19 20 20 20 kgs 21 21 22 22 23 kgs PINK Small Infant 6-7kg RED Infant 6-9kg PURPLE Toddler 10-11kg YELLOW Small Child 12-14kg WHITE Child 15-18kg BLUE Child 19-23kg ORANGE Large Child 24-29kg GREEN Adult 30-36kg Resuscitation Bag Infant/Child Infant/Child Child Child Child Child Child Adult Oxygen Mask (NRB) Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric/ Adult Oral Airway (mm) 50 50 60 60 60 70 80 80 Laryngoscope Blade (Size) 1 Straight 1 Straight 1 Straight 2 Straight 2 Straight 2 Straight OR Curved 2 Straight OR Curved 3 Straight OR Curved Size 2.5 (Orange) Size 3 (Yellow) Size 3 (Yellow) Equipment GRAY 3-5kg King Airway NA NA NA NA LMA NA #1 #1 #1.5 #2.0 #2.5 #3 #3.5 #4 8 8 10 10 10 10 10 10-12 Infant/Child Infant/Child Child Child Child Child Child Small Adult IV Catheter (ga) 22-24 22-24 20-24 18-22 18-22 18-20 18-20 16-20 IO (ga) 18/15 18/15 15 15 15 15 15 15 NG Tube (French) 5-8 5-8 8-10 10 10 12-14 14-18 16-18 Suction Catheter (French) BP Cuff Neonatal #5/ Infant Size 2 (Green) Size 2 (Green) Quick Reference Page – Peds 121 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Modified Glasgow Coma Scale for Infants and Children A Legend EMT A-EMT P Paramedic M Medical Control Step One Measure Vital Signs and Level of Consciousness Glasgow Coma Scale Systolic blood pressure (mmHg) Respiratory rate ≤13 <70 + (age in years x 2)mmHG <10bpm or >upper normal (p.121) OR need for ventilation support Appearance Work of Breathing Tone Interactiveness Consolability Look/Gaze Speech/Cry Abnormal Breath Sounds Retractions Nasal Flaring Circulation to the Skin Yes Pallor Mottling Cyanosis No Assess Anatomy of Injury Penetrating Injury to head, neck, torso, extremities proximal to knee Chest wall instability or deformity ≥2 proximal long bone fractures Crushed, degloved, or mangled extremity Amputation proximal to wrist or ankle Pelvic fracture Open or depressed skull fracture Paralysis Yes Any Airway Compromise not able to be managed by EMS should be taken to the CLOSEST FACILITY for stabilization immediately No Step Three Assess Mechanism of injury and evidence of High Energy Impact Falls > 10 ft or twice the height of the child High Risk Auto Crash Auto vs. Pedestrian/Bicyclist thrown, run over or significant (>20 mph) impact Motorcycle crash >20 mph Yes Transport to closest appropriate PICU-Capable, Leveled Trauma Center Yes Contact Medical Control; Consider Trauma Center or Specialty Resource Center No Step Four Assess Special Patient or System Considerations Age <1 year Anticoagulation AND/OR history of bleeding disorder(s) Burns - without other trauma, transport to Burn Facility - with traumatic mechanism, transport to trauma center End Stage Renal Disease requiring Hemodialysis Pregnancy ≥20 weeks EMS provider judgment No Transport according to Appropriate Trauma Protocol Destination Determination – Peds, Trauma 122 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Step Two Transport to Level 1 Trauma Center; Notify via Radio as early as possible Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS Time of Injury, Mechanism of Injury DCAP-BTLS SAMPLE History Differential Stroke STEMI Overdose OPQRST History Pain / Swelling Mental Status Hypotension / Shock Elder Abuse Domestic Violence Non-Accidental Trauma Assessment Patient <18 years old Scene ≥5 Notify Comm Center, Activate MCI Incident <5 Consider Additional Resources, MCI if Necessary Multiple Patients Safety Unsafe Insufficient PPE Presentation OR Traumatic Mechanism No Go To Appropriate Peds Medical Protocol Pulseless, Apneic Go To Peds Traumatic Cardiac Arrest Protocol p102 Yes Sufficient Hazmat Primary Survey Yes Go To Peds Airway Management Protocol p99 Airway Patent, Poor Chest Compliance OR Unstable VS Consider Chest Decompression Procedure p169 P Notify Comm Center, Activate Hazmat Resources Obstructed Airway, Ventilations Inadequate Minimize Scene Time, Notify Receiving Facility of Trauma Patient Early A,B,C’s Exsanguinating Hemorrhage Go To Peds Hemorrhage Control Protocol p135 Ventilations Adequate, BP and HR Adequate Support Airway, Support Oxygenation, Support Circulation Consider Spinal Immobilization Transport Per Appropriate Peds Trauma Protocol Pearls REQUIRED EXAM: Vital Signs, GCS, Loss of Consciousness, Location of Pain (then targeted per Appropriate Trauma Protocol) Assess for major trauma criteria immediately upon patient contact -RR <10 or >upper normal (p.121 ); SBP <70 + (age in years x 2)mmHG; Pulse <50 or >upper normal (p.121 ); GCS <13; SpO2<93% -Transport to Trauma Center, minimize scene time to goal of <10 minutes Disability – assess for neuro deficits including paralysis, weakness, abnormal sensation Suspect Tension Pneumothorax when: -Mechanism consistent with Chest Trauma; Resp Distress; Decreased Breath Sounds; JVD; Low BP; Tachycardia; Tracheal Deviation -Signs and Symptoms of Tension Pneumothorax may be present with or without positive pressure ventilations -Needle Decompression should be performed with an 18-20ga needle at the 2nd intercostal space, midclavicular line -If repeat decompression necessary, continue to move laterally along the superior aspect of the 3rd rib General Approach – Peds, Trauma 123 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Safe Stage, Call for Law Enforcement and/or Additional Resources Legend EMT A-EMT A P Paramedic M Medical Control Differential Hypovolemic Shock -External Hemorrhage -Internal Hemorrhage -Unstable Pelvic Fracture Pertinent Positives and Negatives Age, if known Mechanism of Injury Events leading up to arrest Tension Pneumothorax Medical Condition Causing Trauma (i.e. Cardiac Arrest) General Approach – Peds, Trauma Injuries Incompatible With Life? (Incineration, Decapitation, Hemicorpectomy) Yes Criteria for Death/Withholding Resuscitation Policy No Yes No Contact Law Enforcement and/or Medical Examiner Continuous Cardiac Monitor Begin Resuscitation Continue CPR Throughout Transport to Closest Leveled Trauma Center (Preference to Level 1 Center, if possible) Full Spinal Immobilization with C-collar and Long Spine Board MANDATORY Go To Appropriate Trauma Protocol A Peds IV Access Protocol p114 A Normal Saline Bolus, 20mL/kg IV/IO Yes Return of Pulse No Notify Receiving Facility, Contact Medical Control As Necessary P Consider Chest Decompression Procedure p169 M Notify Receiving Facility, Contact Medical Control Pearls REQUIRED EXAM: Pupillary Light Reflex, Palpation of Pulses, Heart and Lung Auscultation This protocol is compliant with the Joint Position Statement of the ACS, ACEP, NAEMSP and AAP and can be referenced here: http://www.annemergmed.com/article/S0196-0644(14)00074-2/fulltext#sec6 Injuries incompatible with life include; decapitation, incineration, massively deforming head or chest injury, dependent lividity, rigor mortis As with all trauma patients, DO NOT delay transport Consider using medical cardiac arrest protocols if uncertainty exists regarding etiology of arrest Use of a long spine board will make chest compressions more effective; however, if spinal immobilization interferes with CPR use reasonable effort to limit patient and spine movement Be aware that these may be crime scenes: do your best to avoid disturbing forensic evidence If provider safety becomes a concern, transport of deceased patients to the hospital is acceptable Traumatic Cardiac Arrest – Peds, Trauma 124 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Rigor Mortis, Dependent Lividity or Decomposition of Body Tissue? Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Pulses distal to wound SAMPLE History OPQRST History Description or photo of offending creature Tetanus status Immunization History of Creature (if known) Domestic vs. Wild Animal Allergic Reaction Hypotension, Shock, Fever Differential Penetrating Trauma Dry Bite (Snake) Abscess/Cellulitis Non-Accidental Trauma General Approach – Peds, Trauma Offending Organism(s) Neutralized No Contact Dane Co. Animal Control 1-608-255-2345 Yes Yes Active Hemorrhage No Allergic Reaction Yes Go To Peds Allergic Reaction Protocol p110 No Evaluate Pain >5/10 OR Severe Consider Peds Pain Management – Trauma Protocol p136 None or Mild Spider, Bee, Wasp, Hornet Identification of Offending Organism Mammalian Bite (including Human) Snakebite Immobilize Injury, Remove jewelry distal to bite Immobilize Injury, Remove jewelry distal to bite Wound Care Procedure p183 Mark Edges of Erythema with Marking Pen Notify Receiving Facility, Contact Medical Control As Necessary Immobilize Injury, Remove jewelry distal to bite Muscle Spasms No A Peds IV Access Protocol p114 P Midazolam 0.02mg/kg IV/IO (max 10mg) OR Midazolam 0.1mg/kg IM/IN Pearls REQUIRED EXAM: VS, GCS, Evidence of Intoxication, Affected Extremity Neurovascular Exam Cat bites may not initially appear serious, but can progress rapidly to severe infection Human bites have higher rates of infection than animal bites and need to be evaluated in the Emergency Department for antibiotics Bites on the hands and lacerations over knuckles should be assumed to be “Fight Bites” until proven otherwise, and need evaluation Brown recluse spider bites are usually painless at the time of bite. Pain and tissue necrosis develops over hours to days Immunocompromised patients have higher risk of infection – Think: Diabetes, Chemotherapy, Organ Transplant Bites and Envenomations – Peds, Trauma 125 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Go To Peds Hemorrhage Control Protocol p135 Call For Resources, Stage Until Scene Safe Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS SAMPLE History OPQRST History Mechanism of Burn (heat, gas, chemical) Time of Injury Singed Facial Hair Wheezing, Hoarseness Subjective Throat Swelling Loss of Consciousness Consider need for Airway Management EARLY Differential Blast Injury Radiation Injury Electrical Injury Cyanokit Need? General Approach – Peds, Trauma Cellulitis Dermatitis Drug Reaction (Stevens-Johnson Syndrome) Indications of possible Cyanide Poisoning Exposure to fumes from burning Nitrile (polyurethane, vinyl) Seizures, coma, cardiac arrest, headache, vertigo and/or cherry red skin color from increased venous O2 concentration Minor Burn Serious Burn Critical Burn <5% TBSA, 1st – 2nd Degree Burn No inhalation Injury Normal BP, SpO2 5-15% TBSA, 2nd – 3rd Degree Burn Suspected Inhalation Injury Hypotension, Altered Mental Status >15% TBSA, 2nd – 3rd Degree Burn Burn with Trauma Burn with Airway Compromise Remove Rings, Bracelets and Constricting Items Remove Rings, Bracelets and Constricting Items Remove or Cool Heat Source (if not already done) Remove or Cool Heat Source (if not already done) Consider Peds Airway Management Protocol p99 Apply Dry Clean Sheet or Non-Adherent Dressing Apply Dry Clean Sheet or Non-Adherent Dressing Consider Pain Management – Peds, Trauma Protocol p136 Consider Peds IV Access Protocol p114 A Consider Pain Management – Peds, Trauma Protocol p136 Transport to Facility of Choice Trauma Protocols - Pediatric Trauma Protocols - Pediatric Estimate TBSA Burned / Severity No Burn to Hands, Feet, Face or Perineum Yes A Peds IV Access Protocol p114 A LR Preferred over NS, If available If <5 y/o, 125mL IV/IO If >5 and <14 y/o, 250mL IV/IO If >14 y/o, 500mL IV/IO Fluids given over 1 hour A=½ of Head Age 0 9½ Age 1 8½ Age 5 6½ Age 10 5½ Age 15 4½ B=½ of Thigh 2¾ 3¼ 4 4¼ 4½ C=½ of Leg 2½ 2½ 2¾ 3 3¼ Area Transport to Designated Burn Center Pearls REQUIRED EXAM: VS, GCS, Lung Sounds, HEENT, Posterior Pharynx Safety First! Assure a Chemical source of burn is NOT a hazard to responders. Assure an Electrical source of burn is OFF or no longer contacting pt. Never overlook the possibility that a burn injury may be the result of child abuse / non-accidental trauma. High Voltage Electrical Burns (>600 volts) require spinal immobilization, continuous cardiac monitor and immediate IVF regardless of external appearance of injury Chemical burns require removal of contaminated clothing, brush away dry powder before irrigation. Flush with copious warm water on scene and continue irrigation en route Burns to face and eyes, remove contact lenses prior to irrigation Early advanced airway is strongly recommended if suspicion of inhalation injury. Signs and symptoms include carbonaceous sputum, facial burns or edema, hoarseness, singed nasal hairs, agitation, hypoxia or cyanosis Burns – Peds, Trauma 126 A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Respiratory Effort, Adequacy Abnormal Breath Sounds (unilateral vs. bilateral) SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Differential Simple Pneumothorax Tension Pneumothorax Pericardial Tamponade Aortic Root Disruption Bronchial Tree Injury Tracheal Disruption Great Vessel Laceration Cardiac Contusion Cardiac Laceration General Approach – Peds, Trauma Peds Spinal Immobilization Protocol p138 Consider Pain Management, Peds Trauma Protocol p136 Peds IV Access Protocol p114 Mechanism Blunt Penetrating Stabilize Foreign Object Assess Breath Sounds, SpO2 Assess Breath Sounds, SpO2 Clear and Equal Bilaterally Decreased Unilateral Breath Sounds Open OR Sucking Chest Wound Decreased Unilateral Breath Sounds Clear and Equal Bilaterally Assist Ventilations as Needed Support Ventilations, Monitor VS, watch for JVD, tracheal deviation Apply Occlusive Dressing and Assist Ventilations Support Ventilations, Monitor VS, watch for JVD, tracheal deviation Assist Ventilations as Needed Signs of Tension Pneumothorax No Yes Pain Management, Peds Trauma Protocol p136 Consider Peds Airway Management Protocol p99 P Chest Decompression Procedure p169 Notify Receiving Facility, Contact Medical Control As Necessary Pain Management, Peds Trauma Protocol p136 Consider Peds Airway Management Protocol p99 Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Consider tension pneumothorax in any patient with penetrating chest trauma, OR blunt chest trauma with decreased unilateral breath sounds, hypotension, tachycardia, hypoxia, tracheal deviation (late) or JVD (late) Aortic root injuries, bronchial disruption and tracheal disruptions are common with major deceleration injuries (i.e. MVC) Cardiac contusions are common with blunt chest trauma, and may present with ectopy, PVCs or even STEMI appearance on cardiac monitor Pericardial Tamponade is a surgical emergency and needs rapid transport. Look for muffled heart tones, hypotension, tachycardia Chest Injury – Peds, Trauma 127 Trauma Protocols - Pediatric Trauma Protocols - Pediatric A Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS SAMPLE History OPQRST History Crushed under heavy load ≥30 min Differential Compartment Syndrome Entrapment without Crush Fracture, Sprain, Strain Building collapse, trench collapse, industrial accident, heavy equipment pinning Pelvic Fracture Hypothermia General Approach – Peds, Trauma A Go To Peds Spinal Immobilization Protocol p138 A Management of Crush Injury Patient Crush Injury should be suspected in prolonged pinnings >1 hours, AND proximal to the knee or elbow. Peds IV Access Protocol p114 This protocol is NOT intended for hands or feet trapped in machinery or farm equipment NS Bolus, 20mL/KG IV/IO (max 500mL) 12-Lead ECG Procedure (if possible) p139 Abnormal ECG, Hemodynamically Unstable Abnormal ECG Peaked T-waves, QRS ≥0.12 sec QT ≥0.46 sec HD Unstable No Asystole, PEA, VF, VT No No Yes Yes Immediately Prior to Extrication P Sodium Bicarbonate 1mEq/kg IV/IO* AND** P Calcium Chloride 20mg/kg IV/IO over 3 min, max 1g Albuterol 2.5mg/3mL Neb P Sodium Bicarbonate 1mEq/kg IV/IO* P Sodium Bicarbonate 1mEq/kg IV/IO* AND** P Calcium Chloride 20mg/kg IV/IO over 3 min, max 1g Consider Pain Management – Peds, Trauma Protocol p136 Go To Appropriate Cardiac Arrest Protocol Monitor and Reassess for Fluid Overload Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Vital Signs, GCS, Lung Sounds, Neuro Exam, Musculoskeletal Exam Structural Collapse, Crush Scenes are often full of hazards, provider safety is the most important consideration Patients may become hypothermic, even in warm environments -Hypothermia can lead to coagulopathy, which will increase bleeding times and have worse outcomes for the patient Crush injuries can result in hyperkalemia from shift of Potassium out of injured cells. Cardiac monitoring is required and 12-lead ECG preferred whenever possible (as dicated by the situation) Monitor extremities for signs of compartment syndrome after crush injury; Pain, Pallor, Paresthesias, Paralysis, Pulselessness and Poikilothermia (inability to regulate core body temperature) * Sodium Bicarb Infusion: 1mEq/kg added to 1L NS, administered 20mL/kg IV just prior to extrication **Utilize different IV lines or flush between bicarb and calcium to prevent precipitation in the line Prolonged Crush Injury – Peds, Trauma 128 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Continuous Cardiac Monitor Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Submersion in water regardless of depth SAMPLE History OPQRST History Temperature of water Mental Status Changes Degree of Water Contamination Vomiting Coughing, Wheezing, Rales, Rhonchi, Stridor Differential Spinal Trauma Pre-Existing Medical Condition Hypothermia Aspiration The Bends Pressure Injury Barotrauma Decompression Sickness Post-Immersion Syndrome General Approach – Peds, Trauma Peds Spinal Immobilization Protocol p138 Awake and Alert Awake but Altered Remove Wet Clothing Dry and Warm Patient Consider Peds Airway Management Protocol p99 Unresponsive Yes Pulse Monitor and Reassess Encourage Transport and Evaluation even if asymptomatic Consider Peds Altered Mental Status Protocol p111 No Remove Wet Clothing Dry and Warm Patient Go To Appropriate Peds MEDICAL Cardiac Arrest Protocol Monitor and Reassess Continuous Cardiac Monitor A Consider Peds IV Access Protocol p114 Continuous Cardiac Monitor A Peds IV Access Protocol p114 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Have a HIGH index of suspicion for possible spinal injuries. Any diving injury or submersion with unclear details should be fully immobilized Hypothermia is often associated with near-drowning and submersion injuries. Consider the Hypothermia Protocol as appropriate All patients with Near-Drowning / Submersion Injury should be transported for evaluation due to delayed presentation of respiratory failure With diving injuries (decompression / barotrauma) consider availability of a hyperbaric chamber; contact Medical Control early. Near-drowning patients who are awake and cooperative but with respiratory distress may benefit from CPAP / Positive Pressure Ventilation Near-Drowning / Submersion Injury – Peds, Trauma 129 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Mental Status Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Mental Status SAMPLE History OPQRST History Time and length of exposure to hot environment Hot, dry or sweaty skin Seizures Nausea Hypotension, Shock, Fever Differential Alcohol Withdrawal (DTs) Hyperthyroidism (Thyroid Storm) Dehydration Cocaine or Sympathomimetic OD Sepsis CNS Lesion or Head Injury Abuse or Neglect (Elderly or disabled) Medication (Serotonin Syndrome, Malignant Hyperthermia) General Approach – Peds, Trauma If Evidence of Sympathomimetic OD Consider Overdose, Sympathomimetic Protocol Remove Patient from Hot Environment (if applicable) Heat Cramps Heat Exhaustion Heat Stroke Painful Spasms of Extremities and/or Abdominal Muscles Normal Mental Status Normal Vital Signs Dizziness, Lightheadedness, Headache, Irritability, Nausea Normal or Mildly Depressed Mental Status Mild Tachycardia (age defined) Normal or Mildly Elevated Temp Marked Alteration in Level of Consciousness May Be Sweating OR Hot, Dry, Red Skin Extremely High Temp, >105oF Oral Fluids Sponge with Cool Water and Fan Keep Patient Supine Apply 100% Oxygen Sponge with Cool Water and Fan Semi-Reclining Position with Head Elevated Apply 100% Oxygen Rapid Cooling with Cold Packs, Sponge with Cool Water and Fan Yes Reassess and Document Mental Status, VS and ability to take PO Tolerating Oral Fluids Abnormal No Requires Transport Peds IV Access Protocol p114 A Normal Saline 20mL/kg IV/IO (max 500mL) P Ondansetron 0.1mg/kg IV/IO (max 4mg) P If shivering, consider Midazolam 0.04mg/kg IV/IO (max 2mg) No A Peds IV Access Protocol p114 A Normal Saline 20mL/kg IV/IO (max 500L) P Consider Ondansetron 0.1mg/kg IV/IO/ ODT (max 4mg) Normal Execute and Document Patient Refusal Protocol p117 A Notify Receiving Facility, Contact Medical Control As Necessary Yes Pearls REQUIRED EXAM: VS, GCS, Skin, HEENT, Neuro, Evidence of Intoxication, Mental Status Extremes of Age are more prone to heat emergencies due to inability to easily self-extricate from hot environments Patients on Tricyclic Antidepressants, Anticholinergics, Diuretics (i.e. Lasix) are more susceptible to heat emergencies due to medication effects Cocaine, amphetamines and salicylates all may elevate body temperature or interfere with the ability to auto-regulate Sweating generally disappears as body temperature rises above 104oF If Heat Cramps resolved without IV Access or Medications, patients may refuse transport, IF tolerating oral fluids and VS normal Environmental, Hyperthermia – Pediatric, Trauma 130 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Estimate Severity of Symptoms Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Mental Status SAMPLE History OPQRST History Time and length of exposure to cold environment Cold or clammy skin Confusion Arrhythmias, J-waves on ECG Hypotension, Shock Differential Alcohol Intoxication Hypothyroidism (Myxedema Coma) Dehydration Sepsis CNS Lesion or Head Injury Abuse or Neglect (Elderly or disabled) Medication (beta blocker overdose, opiate overdose) General Approach – Peds, Trauma Wound Care Procedure Do NOT Rub Skin To Warm PREVENT Refreezing p183 A Peds IV Access Protocol p114 A NS Warmed Fluids 20mL/kg IV/IO over 30 minutes Max 500mL Remove Patient from Cold Environment (if applicable) Remove Wet Clothing Dry and Warm the Patient Yes Localized Cold Injury (Frostbite) No Blood Glucose Procedure p159 Trauma Protocols - Pediatric <70 Go To Peds Diabetic Emergencies Protocol p113 >70 Estimate Severity of Symptoms Mild Hypothermia <93oF (<34oC) Moderate Hypothermia 86-93oF (30-34oC) Severe Hypothermia <86oF (<30oC) Sympathetic Nervous System Excitation – Shivering, Hypertension, Tachycardia, Tachypnea Awake But May Be Confused Shivering more violent, ataxia and incoordination apparent. Stumbling pace and Moderate Confusion Appears pale as surface vessels constrict to retain heat. Heart rate, blood pressure and respiratory rate decrease. Disoriented, confused and combative Paradoxically may discard clothing External Rewarming Measures External Rewarming Measures 12-Lead ECG Procedure p139 12-Lead ECG Procedure p139 Consider Peds Airway Management Protocol p99 A Peds IV Access Protocol p114 A Peds IV Access Protocol p114 Consider Peds Altered Mental Status Protocol p111 NS Warmed Fluids 20mL/kg IV/IO over 30 minutes (max 500mL) A A NS Warmed Fluids 20mL/kg IV/IO over 30 minutes (max 500mL) Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: VS, GCS, Skin, HEENT, Neuro, Evidence of Intoxication, Mental Status Hypoglycemia is found in many hypothermic patients, because hypothermia may be a result of hypoglycemia Severe hypothermia may cause myocardial irritability and rough handling can theoretically cause V-fib. Please handle carefully. -Do not withhold advanced airway or CPR for this concern, but only the most experienced provider available should gently attempt advanced airway Below 86oF (30oC), antiarrhythmics may not be effective. If given, they should be given at reduced intervals. Do NOT attempt to pace below 86oF. If antiarrhythmics necessary for severely hypothermic patient, Contact Medical Control Extremes of age, malnutrition, EtOH and drug abuse and outdoor hobbies / employment all predispose to hypothermia Environmental, Hypothermia – Peds, Trauma 131 Trauma Protocols - Pediatric Consider Pain Management – Peds, Trauma Protocol p136 Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Central and Peripheral Pulses Neuro Function Distal to Injury SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Differential Vascular Disruption Amputation Fracture, Dislocation Sprain, Strain Abrasion Contusion Laceration Compartment Syndrome General Approach – Peds, Trauma Consider Pain Management, Peds Trauma Protocol p136 Peds Spinal Immobilization Protocol p138 Mechanism Laceration, Abrasion, Penetrating Injury Wound Severity / Hemorrhage Control Palpate Pulses Evaluate Distal CMS Mild-Moderate, Simple Wound Pulses Absent Severe-Exsanguinating, Complex Wound Pulses Present Consider Pain Management Peds, Trauma Protocol if time allows p136 Pad and Splint Extremity in Place Direct Pressure Reposition to improve anatomic alignment, no more than 10 pounds pressure Bleeding Controlled Reassess and Document CMS After Splinting A Peds IV Access Protocol p114 No Tourniquet Procedure p177 Yes Consider Pain Management, Peds Trauma Protocol p136 A Peds IV Access Protocol p114 Consider Hemorrahge Control, Peds Trauma Protocol p135 Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Immobilization of bony injuries should include the joint above and below. Joint injuries require immobilization of bone above and below Palpate and document Circulation, Movement and Sensation both before and after splint application Tourniquets should remain in place once hemorrhage control is adequate. The tourniquet is tight enough when the bleeding stops! If active hemorrhage and bony/soft tissue deformity, priority should be put on hemorrhage control first, then splinting – remember A,B,C’s If amputated extremities available, seal in a plastic bag and place in cool water and bring to the hospital with the patient Extremity Injury – Peds, Trauma 132 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Soft Tissue Swelling, Bony Deformity Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, Visual Acuity SAMPLE History OPQRST History Time of Injury Involved Chemical MSDS Contact / Corrective Lens Use “Shooting” or “Streaking” Lights Rust Ring “Lowering Shade” in Vision Differential Globe Rupture Acute Closed Angle Glaucoma Stroke Retinal Artery Occlusion Chemical Burn Retinal Venous Thrombus General Approach – Peds, Trauma Pain / Vision Loss Non-Traumatic Nature of Complaint Traumatic Injury Go To Appropriate Peds Trauma Protocol Assess Pupils No Isolated to Eye(s) Yes Complete Neuro Exam Focal Deficit Go To Suspected Stroke Protocol, ADULT p69 Chemical Mechanism Blunt / Trauma Normal Unrecognized Chemical Agent Irrigate with 2L NS or Sterile Water Yes Assess Orbit for Stability No Shield and Protect Both Eyes Cover and Protect Both Eyes A Notify Receiving Facility, Contact Medical Control As Necessary P Yes Globe Rupture Peds IV Access Protocol p114 Ondansetron 0.1mg/kg IV/IO/ODT (max 4mg) No Shield and Protect Both Eyes Assess Visual Acuity Consider Peds Pain Management Trauma Protocol p136 Pearls REQUIRED EXAM: VS, GCS, Visual Acuity, Neuro Exam, Extraocular Movements Stabilize any penetrating objects. DO NOT remove any embedded / impaled objects If Long Spine Board not indicated, transport with head of stretcher elevated to 60 degrees to help reduce intraocular pressure Remove contact lenses when possible Always cover both eyes to prevent further injury Orbital fractures increase concern for globe or optic nerve injury; follow visual acuity and extraocular movements for changes Normal visual acuity can be present, even with severe injury Eye Pain – Peds, Trauma 133 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Assess Visual Acuity A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Loss Of Consciousness Vomiting, Altered Mental Status SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Differential Skull fracture Epidural hematoma Concussion, Contusion, Laceration, Hematoma Non-Accidental Trauma Spinal Cord Injury Subdural Hematoma Subarachnoid Hemorrhage General Approach – Peds, Trauma Elevate Head of Stretcher 15-30 degrees while maintaining Spinal Precautions Peds Spinal Immobilization Protocol p138 A <70 Peds IV Access Protocol p114 Blood Glucose >70 P Consider Midazolam 0.2mg/kg IM/IN (max 10mg) Peds Airway Management Protocol p99 If evidence of herniation, Goal EtCO2 is 30-35mmHg M Agitation Altered Mentation Seizure Peds Seizure Protocol p118 <8 Document GCS >8 Consider Peds Airway Management Protocol p99 Herniation No Maintain SpO2 >93% Goal EtCO2 35-45mmHg Pain <6/10 Monitor and Reassess Frequent Airway and GCS Evaluations Yes Increase Respiratory Rate <1 year of age, 35bpm >1 year of age, 25bpm Pain Management, Peds Trauma Protocol p136 >6/10 Notify Receiving Facility, Contact Medical Control As Necessary Document Response to Meds, Repeat GCS, SpO2, EtCO2 Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro If GCS <13 consider Air transport or Rapid Transport to Leveled Trauma Facility Airway interventions can be detrimental to patients with head injury by raising intracranial pressure, worsening hypoxia (causing secondary brain injury) and increasing risk of aspiration. Whenever possible these patients should be managed in the least invasive manner to safely maintain O2 saturation >90% (ie. NRB, BVM with 100% O2, etc.) Acute herniation should be suspected when the following signs are present: acute unilateral dilated and non-reactive pupil, abrupt deterioration in mental status, abrupt onset of motor posturing, abrupt increase in blood pressure, abrupt decrease in heart rate. Only in suspected acute herniation – increase ventilatory rate with target EtCO2 30-35mmHg Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushings response) Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively Most important vital sign to monitor and document is level of consciousness (GCS) Concussions are periods of confusion or loss of consciousness (LOC) associated with trauma which may have resolved by the time EMS arrives. Any confusion or mental status abnormality should be transported to an Emergency Department. Any questions or clarifications, contact Medical Control. Head Injury – Peds, Trauma 134 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Peds Diabetic Emergencies Protocol p113 Nasal Airways are CONTRAINDICATED in patients with significant Maxillofacial trauma – the cribriform plate may be broken and result in an NPA going into the patient’s brain A Legend EMT A-EMT P Paramedic M Medical Control Pertinent Positives and Negatives Type of injury Mechanism (blunt vs. penetrating) Central and Peripheral Pulses Neuro Function Distal to Injury Differential Vascular Disruption Amputation Fracture, Dislocation Sprain, Strain Time of Injury Deformity Diminished pulse / capillary refill Abrasion Contusion Laceration Compartment Syndrome General Approach – Peds, Trauma Yes Signs / Symptoms of Shock, Poor Perfusion No Wound Severity / Hemorrhage Control Direct Pressure and Wound Management A Peds IV Access Protocol p114 A Normal Saline Bolus 20mL/kg IV/IO May repeat every 5 min., max 60mL/kg Severe-Exsanguinating, Complex Wound Direct Pressure Hypotensive Repeat and Document BP Bleeding Controlled Normotensive Wound Severity / Hemorrhage Control Yes Reassess BP Tourniquet Procedure p177 Normotensive Hemostatic Dressing for Severe Hemorrhage, if available No Yes No M Extremity Yes Hypotensive Improved? No Contact Medical Control Notify Receiving Facility, Contact Medical Control As Necessary A None OR Mild Consider Peds IV Access Protocol p114 Pain >5/10 OR Severe Consider Pain Management, Peds Trauma Protocol p136 Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Hypotension in trauma needs blood products early, so minimize scene time. Goal for scene time in major trauma cases should be <10 min Multiple casualty incident or obvious life threatening hemorrhage, consider Tourniquet Procedure and/or Hemostatic Dressing FIRST Hemostatic Dressings are appropriate for hemorrhage that can’t be controlled with a tourniquet, such as abdominal and pelvic wounds Signs/Symptoms of Shock include: altered mental status, pallor, cap refill >3 sec, faint/absent peripheral pulses, hypotension (age defined) Hemorrhage Control – Peds, Trauma 135 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Mild-Moderate, Simple Wound Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS SAMPLE History OPQRST History History of chronic pain Differential Head injury Spine Injury Compartment Syndrome Fracture, Sprain, Strain Pneumo/hemo-thorax Pericardial effusion Aortic Dissection Internal organ injury General Approach – Peds, Trauma Patient Care per Appropriate Peds Trauma Protocol None – Mild Pain (0-4) Consider Peds IV Access Protocol p114 A Moderate Pain (5-8) Severe Pain (9-10) Place patient on cardiac monitor, continuous SpO2 and EtCO2 Place patient on cardiac monitor, continuous SpO2 and EtCO2 P Consider IN Fentanyl 1.5mcg/kg (max 100mcg) P Consider IN Fentanyl 1.5mcg/kg (max 100mcg) A Consider Peds IV Access Protocol p114 A Consider Peds IV Access Protocol p114 Document pain level after meds, VS (HR, BP, SpO2, EtCO2) Document pain level after meds, VS (HR, BP, SpO2, EtCO2) SpO2 >93%, EtCO2 <45, SBP >90 Reassess Pain P Fentanyl 1mcg/kg IV/IO/IM (max single dose 75mcg) After 5 min, may repeat x 1 P Consider Ondansetron 0.1mg/kg IV/IO (max 4mg) M Consider Morphine 0.1mg/kg IV/ IO (max 5mg) Unchanged OR Worsening Improved Reassess and Document VS, including Pain Scale Continue to Peds Trauma Specific Protocol Pearls REQUIRED EXAM: Vital Signs, GCS, Neuro Exam, Lung Sounds, abdominal exam, Musculoskeletal Exam Provider Discretion to be used for patients suffering from chronic pain related issues. Please note that history of chronic pain does not preclude the patient from treatment of acute pain related etiologies. As with all medical interventions, assess and document change in patient condition pre- and post-treatment Opiate naive patients can have a much more dramatic response to medications than expected; start low and titrate up as appropriate If not fully immobilized, allow patient to choose position of maximum comfort as situation allows Intranasal medication doses should be divided between nares, unless contraindications present Pain Management – Peds, Trauma 136 Trauma Protocols - Pediatric Trauma Protocols – Pediatric Assess Pain 0-10 Pain Scale OR FACES Scale Legend EMT A-EMT A P Paramedic M Medical Control Pertinent Positives and Negatives Age, VS, GCS Mechanism of Injury Events leading up to 9-1-1 Activation Relationship to and Location of Offender Strangling or Neck Injury SAMPLE History OPQRST History Evidence of Intoxication Evidence of Multi-System Trauma Differential Hypovolemic Shock -External Hemorrhage -Internal Hemorrhage -Unstable Pelvic Fracture Abrasion Contusion Laceration Compartment Syndrome General Approach – Peds, Trauma ALL Healthcare Providers are MANDATORY reporters, including EMS Peds Spinal Immobilization Protocol p138 If something doesn’t feel right, report it Consider Pain Management, Peds Trauma Protocol p136 A Peds IV Access Protocol p114 Go To Level 1 Trauma Center Steps 1 and 2 Destination Determination Protocol Rape Crisis Center: 608-251-5126 Crisis Line: 608-251-7273 Major Trauma Criteria Domestic Abuse Intervention Services DAIS Help Line: 608-251-4445 No Go To Head Injury, Peds Trauma Protocol p134 Go To Extremity Injury, Peds Trauma Protocol p132 Head Injury Extremity Injury Mechanism of Injury Chest Injury Sexual Assault Eye Injury Go To Chest Injury, Peds Trauma Protocol p127 Go To Eye Injury, Peds Trauma Protocol p133 Contact Law Enforcement for Scene and Provider Safety, if Not Already Present Provide Emotional Support, Do Not Judge The Victim Encourage Patient to Seek Evaluation While Respecting Autonomy Preserve Forensic Evidence, Wear Gloves, Use Burn Sheet To Collect Clothing Consider Pain Management, Peds Trauma Protocol p136 Discourage Patient from Voiding, Vomiting or Bathing to Preserve Evidence Work With Law Enforcement to Maintain Chain of Custody Transport to ED with SANE Nurse OR Child Abuse Evaluation Capability Notify Receiving Facility, Contact Medical Control As Necessary Pearls REQUIRED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro Major Trauma Criteria – Step 1 and Step 2 in Destination Determination Protocol. Intimate Partner Violence is very difficult to disclose, and many victims call 9-1-1 with vague complaints; Have a HIGH index of suspicion Never judge a victim of intimate partner violence or sexual assault on the way they dress, act or present themselves Do not be afraid to involve Law Enforcement for assistance as needed, and have a low threshold to transport to a SANE Capable Emergency Department where Social Work, SANE Nurses, and Advocates can provide support and resources for these patients Child Abuse Evaluation centers are also specialized units with specialized forensic capabilities, Child-Life Specialists and Social Work. Sexual Assault / Intimate Partner Violence – Peds, Trauma 137 Trauma Protocols - Pediatric Trauma Protocols - Pediatric Dane County Rape Crisis Center Legend EMT A-EMT A P Paramedic M Medical Control General Approach – Peds, Trauma Assess Mechanism of Injury (MOI) Blunt Significant mechanism of injury Penetrating Yes Yes No Neurologic Deficits Altered level of consciousness No (GCS < 15) OR Trauma Protocols - Pediatric Yes Yes Abnormal Sensation No No Distracting injury** OR Neurologic Deficits OR Abnormal Sensation Yes Fully Immobilize with Cervical Collar and Long Spine Board Yes Altered level of consciousness (GCS < 15) OR Clinical Intoxication * No No Tenderness to palpation of spine or Paraspinal muscles OR Anatomic Deformity of Spine Yes Go To Blunt Side of Algorithm Yes Evidence of Secondary Injury (i.e. fall after penetrating injury) No Pain with patient initiated range of motion No Yes No Spinal Immobilization not indicated Manage and Transport per Appropriate Peds Trauma Protocol Spinal Immobilization not indicated Pearls REQUIRED EXAM: Motor Function both upper and lower extremities, Sensation of upper and lower extremities, subjective abnormal sensation, Tenderness to palpation of bony prominences OR paraspinal muscles *Clinical Intoxication – A transient condition resulting in disturbances in level of consciousness, cognition, perception, affect or behavior, or other psychophysiological functions and responses. Common examples include; ataxia, emotional instability, flight of ideas, tangential thought or motor incoordination. **Distracting Injury – Examples include, but are not limited to: long bone fracture, dislocations, large lacerations, deforming injuries, burns OR any condition preventing patient cooperation with history. It is always safer and better patient care to assume that a Spinal Cord injury has occurred and provide protection, and should be the standard of care in trauma patient management Rigid cervical collars have risks and benefits for patients. Spinal immobilization should always be applied when any doubt exists about the possibility of spinal trauma. EXTREMELY thoughtful consideration and careful physical exam should be part of any decision to apply or not apply the spinal immobilization, and must be well documented. Spinal Immobilization – Peds, Trauma 138 Trauma Protocols - Pediatric Clinical Intoxication * OR Inability to communicate No A EMT A-EMT P Paramedic Procedure: 1. 2. 3. 4. Procedures Procedures 5. 6. 7. Prepare ECG monitor and connect patient cable to electrodes Expose chest and prep as necessary. Modesty of the patient should be respected. Apply chest leads and extremity leads using the following landmarks: (Distal to shoulder and distal to hip joint for most accurate ECG) RA: Right Arm LA: Left Arm RL: Right Leg LL: Left Leg V1: 4th intercostal space at right sternal border V2: 4th intercostal space at left sternal border V3: Directly between V2 and V4 V4: 5th intercostal space at midclavicular line V5: Level with V4 at left anterior axillary line V6: Level with V5 at left midaxillary line Instruct patient to remain still, minimize artifact as able (examples include stopping motion of ambulance and instructing patient to remain still) Press the brand specific button to acquire the 12-Lead ECG (complete age and gender questions correctly) Provide 12 Lead to hospital staff, transmit when appropriate Document the procedure, time, and results on/with the PCR 12 Lead ECG – Procedure 139 A EMT A-EMT P Paramedic To detect right ventricular STEMI associated with occlusion of the Right Coronary Artery, obtain a Right Sided ECG. Indications of a Right Ventricle Wall infarct may include: ST elevation in the inferior leads, II, III and aVF ST elevation that is greatest in lead III is especially significant ST elevation in V1 (the only precordial lead that faces the RV on standard 12-lead ECG) Right Bundle Branch Block, 2nd and 3rd Degree AV Blocks, ST elevation in V2 50% greater than the ST depression in aVF Procedure: 1. 2. 3. 5. 6. 7. Right Sided ECG – Procedure 140 Procedures Procedures 4. Prepare ECG monitor and connect patient cable to electrodes Expose chest and prep as necessary. Modesty of the patient should be respected. Apply chest leads and extremity leads using the following landmarks: (Distal to shoulder and distal to hip joint for most accurate ECG) V1R: 4th intercostal space, left sternal border V2R: 4th intercostal space, right sternal border V3R: halfway between V2R and V4R, on a diagonal line V4R: 5th intercostal space, right midclavicular line V5R: right anterior axillary line, same horizontal line as V4R and V6R V6R: right mid-axillary line, same horizontal line as V5R and V6R Instruct patient to remain still, minimize artifact as able (examples include stopping motion of ambulance and instructing patient to remain still) Press the brand specific button to acquire the 12-Lead ECG (complete age and gender questions correctly) Provide Right Sided ECG to hospital staff, transmit when appropriate Document the procedure, time, and results in the electronic Patient Care Report (ePCR) A EMT A-EMT P Paramedic To detect posterior STEMI associated with occlusion of the circumflex artery or dominant right coronary artery, obain a posterior ECG. Indications of a posterior wall infarction may include: Changes in V1-V3 on the standard 12-lead ECG predominantly, which include Horizontal ST depression A tall, upright T-wave A tall, wide R-wave R/S wave ratio greater than one Inferior or lateral wall MI (especially if accompanied by ST depression or prominent R waves in leads V1-V3) Procedure: 1. 2. 3. 5. 6. 7. 8. Posterior ECG – Procedure 141 Procedures Procedures 4. Prepare ECG monitor and connect patient cable to electrodes Expose chest and prep as necessary. Modesty of the patient should be respected. Place three additional ECG electrodes. TIP: start at V9 (the last electrode) and work forward V9: Left spinal border, same horizontal line as V4-6 V8: midscapular line, same horizontal line as V7 and V9 V7: posterior axillary line, same horizontal line as V4-6 Place ECG lead cables as follows (using standard 12-Lead) Lead cable V6 connects to electrode V9 Lead cable V5 connects to electrode V8 Lead cable V4 connects to electrode V7 Lead cables V1-V3 are connected the same way as when obtaining a standard 12-lead ECG Instruct patient to remain still, minimize artifact as able (examples include stopping motion of ambulance and instructing patient to remain still) Press the brand specific button to acquire the 12-Lead ECG (complete age and gender questions correctly) Provide Right Sided ECG to hospital staff, transmit when appropriate Document the procedure, time, and results in the electronic Patient Care Report (ePCR) A EMT A-EMT P Paramedic Procedure: Foreign Body Airway Obstruction – 1 Year Old Or Less, Conscious If coughing, wheezing and exchanging air, do not interfere with the victims efforts to expel the foreign body. If unable to cry or speak, weak or absent cough or no air exchange 1. Support the victim in the head down position with your non-dominant hand and forearm. 2. Perform 5 back slaps with the heel of your dominant hand between the should blades 3. Perform 5 chest thrusts with two fingers in the center of the chest 4. Repeat the steps above until the object is expelled or the victim becomes unresponsive Foreign Body Airway Obstruction – All Ages, Unconscious 1. If patient was responsive and then became unresponsive lower the victim to the ground and begin CPR, starting with compressions (do not check for a pulse) Every time you open the airway to give breaths, open the mouth wide and look for the object If you see an object that can easily be removed, remove it with your finger If you do not see an object, continue CPR 2. If a foreign body is visualized but cannot be removed with finger, attempt to remove it under direct visualization using the Laryngoscope blade and Magill forceps Assemble Laryngoscope and check bulb on blade Hold Laryngoscope in left hand, Place patient in sniffing position Using tongue-jaw lift or cross-finger technique to open mouth Insert laryngoscope blade into right corner of mouth and move to midline, sweeping tongue out of way Elevate mandible to visualize obstruction without using teeth or gums as a fulcrum Grasp Magill forceps in right hand and remove obstruction under direct visualization 3. Provide suction as needed 4. Resume appropriate CPR and airway management ACTIVATE ALS IF NOT ALREADY CONTACTED AND TRANSPORT RAPIDLY TO THE CLOSEST FACILITY! P Paramedic Paramedic: Move to FAILED AIRWAY MANAGEMENT PROTOCOL If the obstruction is not visualized or cannot be retrieved, attempt endotracheal intubation with appropriate size ET tube or 0.5 smaller if >12 years old If ETT cannot pass and patient is >12 years old perform cricothyrotomy with pertrach. If patient is >1year old but <12 years old perform needle jet insufflation TRANSPORT RAPIDLY TO THE CLOSEST FACILITY! Airway Obstruction – Procedure 142 Procedures Procedures Foreign Body Airway Obstruction – Greater Than 1 Year Old, Conscious If coughing, wheezing and exchanging air, do not interfere with the patient’s efforts to expel the foreign body. If unable to speak, weak or absent cough OR no air exchange, perform abdominal thrusts (Heimlich Maneuver). P Double Paramedic Indications: Contraindications: Age >18 unless specific permission given prior to procedure by medical control Need for invasive airway management in the setting of an intact gag reflex or inadequate sedation to perform nonpharmacologically assisted airway management Apnea Decreased LOC with respiratory failure (ie. Hypoxia O2 sat <90% not improved by 100% Oxygen, and/or respiratory rate <8) Poor ventilatory effort (with hypoxia not improved by 100% Oxygen) Unable to maintain patent airway by other means Burns with suspected significant inhalation injury Sensitivity to Succinylcholine or other RSA drugs Inability to ventilate via BVM Suspected hyperkalemia Myopathy or neuromuscular disease History of malignant hyperthermia Recent crush injury or major burn (>48 hours after injury End Stage Renal Disease Recent Spinal Cord Injury (72 hours – 6 months) SIMULTANEOUSLY CONTACT MEDICAL CONTROL TWO PARAMEDICS REQUIRED FOR THIS PROCEDURE PREPERATION ( T-8 minutes) Monitoring (continuous ECG, SPO2, Blood Pressure) 2 patent IV’s Functioning Laryngoscope and BVM with highflow O2 Endotracheal tube(s), stylet, syringe(s) LTA(s) and appropriate syringe(s) Alternative/Rescue Airway (LMA and surgical airway kit) immediately available All medications drawn up and labeled (including post-procedure sedation) Suction - turned on and functioning End Tidal CO2 device on and operational (colometric immediately available as backup only) Assess for difficult airway – LEMON PREOXYGENATE 100% O2 x5 minutes (NRB) or 8 vital capacity breaths with 100% Ox (BVM/NRB) PRETREATMENT ( T-3 minutes) Lidocaine 1.5mg/kg IV/IO (max 150mg) Begin cricoid pressure/Sellick’s maneuver PARALYSIS and INDUCTION ( T=0 ) Etomidate 0.3mg/kg (max 20mg) OR Ketamine 2mg/kg – must contact Medical Control for Ketamine Succinylcholine 2mg/kg (max 200mg) OR Rocuronium 1mg/kg (max 100mg) PLACEMENT with PROOF ( T + 30 seconds) Place LTA/ETT Confirm with EtCO2 waveform Auscultation Physical findings Secure Device, note position POST-PLACEMENT MANAGEMENT ( T + 1 minute) Sedation: Refer to Sedation Protocol, as needed. If additional needed and transport time >10 minutes: Rocuronium 1mg/kg IV/IO – UNLESS USED AS PRIMARY PARALYTIC Rapid Sequence Airway (RSA) – Procedure 143 Procedures Procedures Procedure: A EMT A-EMT P Paramedic Procedure: Apply probe to patient finger or toe, as recommended by the device manufacturer. Allow machine to register oxygen saturation level Record time and initial saturation percent on room air if possible on/with the PCR Verify pulse rate on machine or with actual manual pulse check of the patient Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary 6. Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to correct hypoxemia 7. In general, normal saturation is 97-99%. Below 93% suspect a respiratory compromise 8. Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data provided by the device 9. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain 10. Factors which may reduce the reliability of the pulse oximetry reading include: Poor peripheral circulation (blood volume, hypotension, hypothermia) Excessive pulse oximeter sensor motion Fingernail polish (may be removed with acetone pad) Carbon monoxide bound to hemoglobin Irregular heart rhythms (atrial fibrillation, SVT, etc.) Jaundice Placement of Blood Pressure cuff on same extremity as pulse ox probe ~ This Space Intentionally Left Blank ~ Pulse Oximetry – Procedure 144 Procedures Procedures 1. 2. 3. 4. 5. P Paramedic Procedure: 1. Maintain cervical alignment and immobilization, as necessary 2. Attach proper blade to laryngoscope handle and check light 3. Check endotracheal tube cuff, lubricate distal end of the tube 4. Confirm patient attached to cardiac monitor and oxygen saturation monitor 5. Ready ETCO2 detection device 6. Specify personnel to: Apply cricoid pressure Maintain cervical alignment and immobilization during procedure Watch cardiac and oxygen saturation monitors 7. Preoxygenate patient with 100% Oxygen (BVM or NRB) before intubation attempt to achieve O2 saturation >93% for 5 minutes or 8 vital capacity breaths. Have assistant apply cricoid pressure (Sellick’s Maneuver) during entire procedure. 8. Remove all foreign objects, such as dentures, Oropharyngeal Airways (OPA), etc., and suction the patients airway if needed. May leave an esophageal ETT if prior unsuccessful attempt to use as landmark for second attempt 9. Insert the blade into the right side of the patient’s mouth sweeping the tongue to the left side 10. Visualize the vocal cords while avoiding any pressure on the teeth 11. Insert the endotracheal tube until the cuff passes the vocal cords. Insert far enough so that balloon port tubing is even with the lips Typical depth = tube size (ID) x3 (example would be tube depth of 24 for a 8.0mm tube) 12. Remove the laryngoscope blade 13. Inflate the endotracheal cuff with the syringe with 5-10cc of air (low pressure cuff may require larger volume) and remove the syringe from inflation valve 14. Ventilate with BVM and confirm tube placement: Observe immediate (within 6 breaths) EtCO2 waveform and number with capnography Watch for chest rise AND Auscultate abdomen, listening for air movement in the stomach to ensure tube is not esophageal Auscultate bilateral breath sounds to confirm tube placement 15. Observe oxygen saturation Note: Regardless of apparent presence of lung sounds, tube misting, chest rise, AND/OR lack of gastric sounds: if EtCO2 does NOT indicate proper tube location (alveolar waveform), ETT must be removed. Intubation (1 of 2) – Procedure 145 Procedures Procedures When Considering Intubating Any Patient, Prepare Materials EARLY: Laryngoscope handle with appropriate size blade Proper Size Endotracheal Tube (ETT) PLUS Backup ETT 0.5-1.0mm smaller and BIAD Water-soluble lubrication gel, (lubricate distal end of tube at cuff) 10cc syringe (larger syringe if low pressure cuff) Stylet, (insert into ET tube and do no let stylet extend beyond tip of ET tube) – if not already incorporated into ETT Tape or ETT securing device Proper size oral pharyngeal airway BVM Oxygen Source Suction Device Stethoscope Continuous Digital Waveform Capnography Oxygen saturation monitor P Paramedic Procedure (continued): 16. If unilateral right sided breath sounds are heard, consider: Right mainstem intubation Deflate the cuff and withdraw tube 1-2cm Reinflate cuff and repeat auscultation procedure as above for breath sounds 17. If bowel sounds heard with bagging or EtCO2 device does not indicate proper ETT placement, deflate cuff, remove tube and ventilate with BVM for two minutes IF AND ONLY IF intubation attempted for medical reason AND unsuccessful on first attempt, may return to Step 7 of Procedure and repeat 18. If intubation attempt unsuccessful, refer to the next step in the Airway Management, Adult protocol. 19. 20. 21. 22. 23. 24. Secure tube using an endotracheal securing device Document depth of tube Reassess and document lung sounds, Vital Signs and patient clinical status Insert Oropharyngeal Airway (OPA), or use commercially available bite block with ET Tube holder (if available) Ensure Cervical Spine is immobilized to prevent accidental dislodgement of ETT during procedures or patient movement Continue ventilations at a rate of 8-10 breaths per minute; adjust rate to maintain SpO2 >93% and EtCO2 35-45mmHg, and as appropriate for patient condition 25. Document EtCO2 waveform and reading continuously at time of EACH patient movement, including waveform and reading at time of transfer of care at the Emergency Department. Video Assisted Laryngoscopy (VAL) Video Assisted Laryngoscopy (VAL) shall be performed in accordance with documented manufacturer recommendations. Follow Intubation procedure with the addition of VAL technology. It is essential that every operator of a VAL be competent in Direct Laryngoscopy (DL) in preparation for unsuccessful VAL operation or equipment malfunction. Intubation (2 of 2) – Procedure 146 Procedures Procedures IF successful intubation confirmed by Steps 13-15 above: A EMT A-EMT P Paramedic Prepare All Procedure Specific Materials: Correctly sized Laryngeal Tube Airway (LTA) – see chart below Bag Valve Mask Oxygen Reservoir Suction Device Bite Block AND/OR endotracheal tube holder (if available) Appropriately sized syringes for inflating cuff End Tidal CO2 and Oxygen Saturation Monitoring Devices OD/ID (mm) NA NA NA NA 18/10mm 18/10 18/10 Cuff Volume (ml) 10ml 20ml 25-35 30-40 45-60 60-80 70-90 Gastric Tube (Fr.) 10 10 16 16 Up to 18 Up to 18 Up to 18 Procedure: 1. Pre-oxygenate patient with 100% Oxygen via Bag Valve Mask or spontaneous ventilation to achieve O2 saturation of >93% if possible 2. Check the integrity of the cuff inflation system and pilot balloon 3. Fully deflate the cuff with the syringe 4. Lubricate the posterior distal tip of the device with a water soluble lubricant 5. Place patient in neutral sniffing position (if no Cervical Spine/Spinal Injury suspected) For patient with suspected Cervical Spine injury, perform two-person insertion technique One person maintains manual in-line cervical spine stabilization while the other person proceeds with procedure 6. Pull mandible down to open mouth 7. Insert uninflated device into oral cavity with midline or a lateral technique 8. Advance the tip behind the base of the tongue while rotating tube back to midline so that the blue orientation line faces the chin of the patient. 9. Without exerting excessive force, advance tube until base of the colored connector is aligned with teeth or gums 10. Inflate the King with the appropriate volume: If inflated King Airway insertion is difficult, perform jaw thrust, pulling the tongue forward. Alternately, a laryngoscope may be used to lift the jaw/mandible to facilitate insertion. 11. Attach the BVM to the King. 12. While bagging the patient, gently withdraw the tube until ventilation becomes easy and free flowing (large tidal volume with minimal airway pressure). 13. Adjust cuff inflation if necessary to obtain a seal of the airway at the peak ventilatory pressure employed. 14. Obtain End-tidal CO2 (waveform), auscultate breath sounds bilaterally, look for chest excursion, and check oxygen saturation 15. Secure in the midline to help maintain a good seal over the larynx. 16. Place bite block, oral airway or endotracheal tube holder (if available) between teeth to prevent biting tube 17. Place orogastric tube and attach to low continuous suction as directed in the applicable procedure to assist in gastric decompression 18. Ensure C-spine is still immobilized 19. If repeated attempts are made, oxygenate with 100% O2 for 2 minutes between attempts 20. **Follow manufacturers suggested guidelines at all times** 21. Document ETCO2 waveform and reading continuously at time of EACH patient movement, including waveform and reading at time of transfer of care at the Emergency Department. Note: regardless of the apparent presence of lung sounds, tube misting and chest rise, or lack of gastric sounds, if ETCO2 does NOT indicate proper tube location (alveolar waveform), Advanced Airway must be removed. King LTD & King LTS-D Laryngeal Tube Airway (1 of 2) – Procedure 147 Procedures Procedures Patient Airway Size Connector Color Height 0 Transparent <5kg 1 White 5-12kg 2 Green 12-25kg 2.5 Orange 41-51 inches 3 Yellow 4-5 feet 4 Red 5-6 feet 5 Purple >6 feet A EMT A-EMT P Paramedic Procedures Procedures 3. Without exerting force, advance tube until base of connector is aligned with the teeth or gums. Then inflate cuff with appropriate volume. King LTD & King LTS-D Laryngeal Tube Airway (2 of 2) – Procedure 148 P Paramedic Prepare All Procedure Specific Materials: Correctly sized laryngeal mask airway (see chart below) Bag valve mask or automatic ventilator Oxygen reservoir Suction device Bite block and/or endotracheal tube holder (if available) 25 and/or 35mL syringes for expanding cuff End Tidal CO2 and Oxygen saturation monitoring devices Mask Size 1 1.5 2 2.5 3 4 5 Patient weight (kg) <5kg 5-10 10-20 20-30 30-60 60-80 >80 Age (years) <0.5yrs .5-5 5-10 10-15 >15 >15 Length (cm) 10cm 10 11.5 12.5 19 19 19 Cuff volume (mL) 4 5-7 7-10 14 15-20 25-30 30-40 Largest ETT* 3.5mm 4.5 5 6 6.5 7 *Appropriately sized endotracheal tube (internal diameter) that can be passed through LMA for blind intubation if intubating LMA is inserted Procedure: 1. 2. 3. 4. 5. 6. Pre-Oxygenate patient with 100% Oxygen via bag valve mask to achieve O2 saturation of >93% if possible Remove the red tag from the balloon port Check the integrity of the cuff and pilot balloon Tightly deflate the cuff with the syringe – the deflated cuff should appear BOAT shaped Lubricate the posterior surface Place patient in neutral sniffing position (if no c-spine/spinal injury suspected) For patients with suspected c-spine injury, perform two person insertion technique: One person maintains manual in-line cervical spine stabilization while the other person proceeds with procedure as below 7. Pull mandible down to open mouth 8. Insert uninflated LMA into oral cavity with cuff facing away from hard palate 9. Guide LMA around curvature of the posterior pharynx into the hypopharynx until resistance is felt. Resistance is due to the tip of the LMA stopping at the upper esophageal sphincter 10. If uninflated LMA insertion is difficult: If the curvature of the posterior/hypopharynx is too acute, perform a jaw thrust, pulling the tongue forward. Alternately, a laryngoscope may be used to lift the jaw/mandible to facilitate insertion A slight inflation of the cuff to ⅓ to ½ of typical inflation volume may also increase ease of insertion Insert LMA with cuff facing hard palate, then rotate 180 degrees into the proper position after the angle around the posterior aspect of the tongue has been cleared. Continued on next page- Laryngeal Mask Airway (LMA) – Procedure 149 Procedures Procedures Laryngeal Mask Airway Sizes P Paramedic Procedure (continued): 11. Inflate cuff without holding the tube 12. Ensure that the black line running the length of the LMA shaft is in the midline of the upper lip and between the two central incisors (this will help maintain a seal) 13. Administer gentle positive pressure ventilation 14. Obtain End-tidal CO2 (waveform), listen for breath sounds bilaterally, look for chest excursion, and check oxygen saturation 15. Secure in the midline to help maintain a good seal over the Larynx 16. Place bite block, gauze or endotracheal tube holder (if available) between teeth to prevent biting tube 17. Ensure c-spine is still immobilized 18. If repeated attempts are made, oxygenate with 100% O2 for 2 minutes between attempts. Intubation using Intubating Laryngeal Mask Airway (ILMA): 1. 2. 3. Procedures Procedures 4. Select correct size ILMA Insert endotracheal tube into oropharynx at 90 degree angle (from corner of mouth) During insertion and passage through the ILMA rotate ET tube 90 degrees so that the tip of the ET tube will pass through the bars that traverse the distal opening of the ILMA Confirm placement as per endotracheal intubation procedure. ~ This Space Intentionally Left Blank ~ Laryngeal Mask Airway (LMA) – Procedure 150 A EMT A-EMT P Paramedic Procedure: 1. 2. 3. Ensure suction device is in proper working order with suction tip in place. Set mechanical suction device to appropriate setting (Adult: 120-150mmHg OR Pediatric: 80-100mmHg). Measure suction tip from corner of mouth to ear lobe and marks maximum insertion depth; OR ensure tip of catheter is always in sight during use. 4. Preoxygenate the patient. 5. Explain the procedure to the patient, if they are coherent. 6. Examine the oropharynx and remove any potential foreign bodies or material that may occlude the airway if dislodged by the suction device. 7. If applicable, remove ventilation devices (i.e. BVM, OPA) from the mouth and upper airway. 8. Insert into mouth without finger hole covered 9. Once inserted, cover the finger hole with a gloved finger to remove any secretions, blood, or other substances. The alert patient may assist with this procedure. Continue to cover the finger hole while removing. 9. Max suction time: Adult - 15 seconds Pediatric - 10 seconds Infant - 5 seconds 10. Reattach ventilation device (i.e. BVM) and resume ventilations or patient assistance, as applicable. 11. Record the time and result of the suctioning procedure in the electronic Patient Care Report (ePCR). Procedures Procedures ~ This Space Intentionally Left Blank ~ Suctioning (Basic) – Procedure 151 P Paramedic Procedure: 1. 2. 3. 4. Ensure suction device is in proper working order with suction tip in place. Preoxygenate the patient. Attach suction catheter to suction device, keeping sterile plastic covering over catheter. For all devices, use the suprasternal notch as the end of the airway. Measure the depth desired for the catheter (judgement must be used regarding the depth of suctioning with Endotracheal, Cricothyrotomy and Tracheostomy tubes). 5. If applicable, remove ventilation devices (i.e. BVM, OPA) from the airway. 6. With the thumb port of the catheter uncovered, insert the catheter through the airway device. 7. Once the desired depth (measured in #4 above) has been reached, use a gloved finger to occlude the thumb port and remove the suction catheter slowly. 8. A small volume (<10mL) of normal saline may be used to lavage secretions as needed, with supplemental oxygen and/or ventilations x 5 tidal volumes between lavages. 9. Reattach ventilation device (i.e. BVM) and ventilate or assist the patient as needed. 10. Record the time and result of the suctioning procedure in the electronic Patient Care Report (ePCR). Procedures Procedures Suctioning (ET tube and Stoma) – Procedure 152 A EMT A-EMT P Paramedic Prepare All Procedure Specific Materials: Medical Director approved Continuous Positive Airway Pressure (CPAP) Device as per manufacturer written procedure. Procedure: 1. 2. 3. 4. 5. 6. 7. 8. Consider CPAP protocol if 2 or more are present: Tachypnea, nasal flaring, subcostal/intercostal retractions, tracheal tugging Suspected bronchospasm on clinical exam Rales suggesting pulmonary edema and patient with history of congestive heart failure (CHF) or renal insufficiency Respiratory rate >25 per minute Oxygen saturation <93% on high flow Oxygen Contraindications Respiratory Arrest Agonal Respirations Unconsciousness or obtundation Shock associated with cardiac insufficiency Trauma Persistent nausea and vomiting Facial anomalies Inability to cooperate with the procedure Current tracheostomy ~ This Space Intentionally Left Blank ~ Continuous Positive Airway Pressure (CPAP) – Procedure 153 Procedures Procedures 9. Attach cardiac monitor, End-tidal CO2 (EtCO2) and continuous pulse oximetry (SpO2). Assemble device according to manufacturer procedure. Attach supplemental Oxygen per manufacturer procedure. Verbally instruct patient and coach breathing with the device. Patient must be able to follow commands and interact with EMS Provider to use this tool effectively. Instruct patient to slowly breathe in through the nose and exhale through the mouth. Inhalation to exhalation ratio should be roughly 4:1. Set positive end-expiratory pressure (PEEP) to 5cmH₂O. Secure mask in place with head strap. Reassess patient and titrate PEEP to desired effect, per protocol. Record and monitor vital signs, EtCO2, and SpO2 frequently. Changes in patient condition, patient complaint or clinical picture should all result in repeat of full VS and documentation. In the event of worsening respiratory status after initiation of CPAP: Evaluate patient compliance and offer reassurance, verbal coaching if appropriate. Remove CPAP mask and stop treatment if patient unable to tolerate CPAP OR if clinically deteriorating. Institute BLS and ALS care per appropriate protocol. Document adverse reactions, and reasons why CPAP was discontinued in electronic Patient Care Report (ePCR). P Paramedic Procedure: 1. 2. 3. 4. 5. 6. 7. 8. 9. 11. 12. 13. 14. ~ This Space Intentionally Left Blank ~ Bougie – Procedure 154 Procedures Procedures 10. Prepare, position, and oxygenate the patient with 100% Oxygen Select proper ET tube without stylette, test cuff and prepare suction Lubricate the distal end and cuff of the endotracheal tube (ETT) and the distal ½ of the endotracheal tube introducer (Bougie) Note: failure to lubricate the Bougie and the ETT may result in being unable to pass the ETT Using laryngoscopic techniques, visualize the vocal cords if possible using the Sellick’s/BURP as needed. Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or about the arytenoids if the cords cannot be visualized. Once inserted, gently advance the Bougie until you meet resistance (if you do not meet resistance you have a probable esophageal intubation and insertion should be re-attempted or the failed airway protocol implemented as indicated). Withdraw the Bougie ONLY to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie Gently advance the Bougie and loaded ET tube until you have resistance again, thereby assuring tracheal placement and minimizing the risk of accidental displacement of the Bougie While maintaining a firm grasp on the proximal Bougie, introduce the ET tube over the Bougie passing the tube to its appropriate depth IF you are unable to advance the ETT into the trachea and the Bougie and ETT are adequately lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER clockwise to turn the bevel of the ETT posteriorly. If this technique fails, to facilitate passing the ETT you may attempt a direct laryngoscopy while advancing the ETT (this will require an assistant to maintain the position of the Bougie and if so desired advance the ETT) Once the ETT is correctly placed, hold the ET tube securely and remove the Bougie Confirm tracheal placement with capnography according to the intubation protocol. Inflate the cuff, auscultate for equal breath sounds, and reposition accordingly When final position is determined secure the ET tube, continuously monitor, and record If there is any question regarding placement of ETT (Esophageal vs. Tracheal) remove immediately and ventilate with BVM A EMT A-EMT P Paramedic Nasal End-tidal CO2 (EtCO2) Procedure: 1. 2. 3. 4. Attach capnography tubing to device Attach tubing to patient (may supplement with NRB mask if needed) Record readings initially and throughout treatment as with other vital signs Document the procedure and results on/with the electronic Patient Care Report (ePCR) Advanced Airway End-tidal CO2 (EtCO2) Procedure: 1. 2. 3. 4. 6. http://kidocs.org/wp-content/uploads/2013/11/OESOPHAGEAL-INTUBATION.png http://kidocs.org/wp-content/uploads/2013/11/HYPOVENTILATION.png http://kidocs.org/wp-content/uploads/2013/11/ONSTRUCTION.png Capnography – Procedure 155 Procedures Procedures 5. Attach capnography sensor to Advanced Airway. Note CO2 level and waveform. Record readings on scene, en route to the hospital and upon patient delivery to receiving facility. Any loss of EtCO2 detection of waveform indicates an airway problem – recheck tube placement and remove if appropriate End-tidal CO2 goal is 40mmHg Above 45mmHg, increase ventilation rate Below 35mmHg, slow down ventilation rate Document the procedure and results on/with the Patient Care Report (PCR) P Paramedic Contact Medical Control Prior to Initiating Procedure, IF Time and Situation Permit When all airway interventions have failed and the patient needs a secure airway immediately, consider performing cricothyrotomy. The percutaneous approach is preferred to the open. If the patient is not able to be ventilated via BVM, ETT or BIAD and the Paramedic feels a surgical airway is necessary, Medical Control should be contacted first. If time and situation do not allow it, this Procedure may be completed prior to authorization by Medical Control. Prepare All Procedure Specific Materials: 14 gauge or larger IV catheter Needle 10 mL syringe Adapter from a 3.0mm ETT Saline Alcohol pad 4x4 gauze pad Tape Suction 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Position patient supine in the sniffing position with slight extension of the neck – identify landmarks of the cricothyroid membrane by palpation utilizing anatomical landmarks (below the thyroid cartilage and above the cricoid cartilage). Cleanse anterior neck Fill a 10mL syringe with 5mL of 0.9% Normal Saline Remove dilator from the package and sheath and advance into the tracheostomy tube Insert the splitting needle perpendicular to the skin and cricothyroid membrane while gently holding negative pressure and aspirating with the syringe. Upon entering the trachea there will be a loss of resistance and free flow of air with bubbles flowing easily into the syringe. Drop the angle of the needle > 45 degrees and aim the tip of the needle toward carina (toward the feet) and complete insertion of needle, while continuing to aspirate to ensure the needle remains in the trachea. While stabilizing the needle in place, disconnect the needle form the syringe and advance guidewire (attached to the dilator into the hub of the splitting needle until resistance is met. Squeeze wings of needle together. The needle should split in half and allow the guidewire/dilator to be advanced. When the dilator meets resistance at the skin, remove the needle by pulling in opposite directions, while securing the guidewire in the trachea and the dilator at the skin. Place thumb on dilator knob while first and second fingers are curved under flange of trachea tube. With gentle, continuous pressure, advance the dilator and tracheostomy tube into position until flange is secure against the skin. Remove dilator and inflate cuff until device is secure in the airway (max 5mL). Attach EtCO2 and BVM. Secure tube in place using the provided twill tape behind the neck of the patient. Confirm placement with gentle ventilation via BVM, continuous digital waveform capnography, and physical exam. Be sure air movement is fluid with bilateral symmetric chest rise and that no visible neck or soft-tissue distortion is noted If tracheal placement is unclear, remove device and transport immediately to the closest Emergency Department. Consider Sedation Protocol as appropriate. If not previously done, immediately contact receiving facility and Medical Control Cricothyrotomy – Procedure 156 Procedures Procedures Procedure: P Paramedic Clinical Indication: Failed airway management when standard airway procedures cannot be performed or have failed in an adult patient that requires airway management. Upper airway obstruction (eg. facial or neck trauma occluding airway patency, foreign body unable to be removed, angioedema) and inability to adequately oxygenate and ventilate using less invasive methods. If Possible Contact Medical Control Before Proceeding. If not possible, notify receiving hospital as soon as possible. Prepare All Procedure Specific Materials: Contraindications: Ability to oxygenate and ventilate using less invasive methods. Pediatric Patients Suspected fractured larynx and/or cricoid cartilage Suspected tracheal transection Inability to find anatomical landmarks Scalpel Antiseptic swab 6.0 mm endotracheal tube 10cmL syringe Tracheal hook (if available) Bougie device Continuous Digital Waveform Capnography 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Have suction and supplies available and ready. Position patient supine in the sniffing position with slight extension of the neck – identify landmarks of the cricothyroid membrane by palpation utilizing anatomical landmarks (below the thyroid cartilage and above the cricoid cartilage). Prep the area with an antiseptic swab. Using the non-dominant hand, spread the overlying skin taut with the thumb and fingers, and slightly depress the skin over the cricothyroid membrane with the index finger to mark the site of cricothyrotomy. Do not release the nondominant hand from the neck until the procedure is complete. Once the anatomy is found and defined, avoid movement of the anatomy to promote proper cricothyrotomy airway placement. Using a sterile scalpel, make a vertical incision in the mid-line of the neck extending from just above the lower edge of the thyroid cartilage to the middle of the cricoid cartilage. Make the depth of this incision sufficient to extend through the skin and fatty tissue underneath. Using the same scalpel, make a short horizontal incision in the middle of the cricothyroid membrane into the trachea. If a tracheal hook is available: prior to removing scalpel from incision, use a tracheal hook to pull anterior and inferior on the thyroid cartilage (lower edge of horizontal incision). Exercise caution when manipulating the tracheal hook into the incision – the tip of most tracheal hooks is particularly sharp-edged. If tracheal hook is not available: a bougie device should be used as introducer into the tracheal opening prior to passing the ET tube. Pass a 6.0mm Endotracheal Tube through the horizontal incision in the cricothyroid membrane, angling the tube inferior and posterior along the tracheal anatomy. Inflate the endotracheal cuff with 5-10mL of air and verify airway placement with EtCO2 (continuous digital capnography monitoring) and physical exam (chest rise, breath sounds). Confirm placement with gentle ventilation via BVM, continuous digital waveform capnography, and physical exam. Be sure air movement is fluid with bilateral symmetric chest rise and that no visible neck or soft-tissue distortion is noted If tracheal placement is unclear, remove device and transport immediately to the closest Emergency Department. Consider Sedation Protocol as appropriate. If not previously done, immediately contact receiving facility and Medical Control Continually monitor for respiratory changes during transport, especially after any patient movement/transfers. Monitor for complications (ie hemorrhage, expanding neck hematoma, dislodgement). Document procedure. Cricothyrotomy (Open) Surgical – Procedure 157 Procedures Procedures Procedure: P Paramedic Clinical Indications: Life threatening upper airway obstruction where all other BLS and ALS maneuvers and techniques have failed. Procedure: Use personal protective equipment, including gloves, gown and mask as indicated. Locate the cricothyroid membrane and prep the area with antiseptic wipe Extend the neck to bring the cricothyroid membrane anterior and as close to the skin as possible Insert the #10 gauge angiocath through the membrane at 90° to the skin until loss of resistance Use a 3mL syringe and apply negative pressure to confirm free aspiration of air and needle presence in the trachea Consider using a second angiocath through the same insertion site if first needle becomes occluded during procedure 5. Drop the angle of the needle to approximately 60° with the tip aimed toward the patient’s feet Continue negative pressure on the syringe to confirm continued placement in the trachea 6. Attach the 7.0 Endotracheal Tube BVM adapter to the end of the syringe 7. Ventilate at a ratio of 1:5 inhalation:exhalation 8. If the airway resistance continues to increase, disconnect the BVM to allow for exhalation Consider addition of second angiocath for use as an exhalation port 9. If subcutaneous emphysema develops, stop insufflation and remove angiocath Repeat steps 2-7 as above 10. Notify the receiving facility of Failed Airway Protocol use and need for Needle Jet Insufflation. 11. Document the procedure and patient response to care in the electronic Patient Care Report (ePCR). Needle Jet Insufflation – Procedure 158 Procedures Procedures 1. 2. 3. 4. A EMT A-EMT P Paramedic Prepare All Procedure Specific Materials: Glucometer Test Strip Lancet 2x2 gauze pad Alcohol prep pad Bandage Procedure: Select appropriate site. Blood samples for performing glucose analysis may be obtained simultaneously with intravenous access when possible. 3. Cleanse site appropriately with alcohol prep. 4. Puncture skin with lancet. 5. Dispose of sharps in proper container. 6. Wipe first drop of blood with 2x2 gauze. 7. Place correct amount of blood on reagent strip or site on glucometer per the manufacturers instructions. 8. Apply direct pressure and cover site with bandage as needed. 9. If result does not fit patient clinical picture: Consider presumptive management per Diabetic Emergencies Protocol while reassessing. Consider equipment error, may redraw sample and repeat analysis. 10. Record the time and result of the blood glucose analysis in the electronic Patient Care Report (ePCR). ~ This Space Intentionally Left Blank ~ Blood Glucose Analysis – Procedure 159 Procedures Procedures 1. 2. A EMT A-EMT P Paramedic Procedure: 1. 2. 3. 4. Apply probe to patient’s digit(s) as recommended by the manufacturer. If near strobe lights, cover the finger to avoid interference and/or move away from the lights if possible. Where the manufacturer provides a light shield it should be used. Allow machine to register percent circulating carboxyhemoglobin values Verify pulse rate on machine with palpated pulse of the patient Record levels in electronic Patient Care Report (ePCR) or on the scene rehabilitation form If CO <5%, assess for other possible illness or injury If CO >5% to <15% and symptomatic from Carbon Monoxide – treat per Carbon Monoxide Exposure Protocol If CO >15% - treat per Carbon Monoxide Exposure Protocol Signs and symptoms of Carbon Monoxide (CO) poisoning – altered mental status, dizziness, headache, nausea/vomiting, chest pain, respiratory distress, neurological impairments, vision problems, reddened eyes, tachycardia, tachypnea, arrhythmias, seizures and/or coma. 5. 6. 7. 9. CO poisoning can look a lot like influenza, particularly in the winter months. Have a high index of suspicion when seeing multiple patients from the same environment with flu-like illnesses and consider Carbon Monoxide. Carbon Monoxide Measurement – Procedure 160 Procedures Procedures 8. Monitor critical patients continuously with continuous pulse oximetry (SpO2) and SpCO until arrival at the hospital. Document percent of carboxyhemoglobin values every time vital signs are recorded during therapy for exposed patients. Use the SpO2 feature of the device as an added tool for patient evaluation. Treat the patient, not the data provided by the device. Utilize the relevant protocol for guidance. The SpO2 reading should never be used to withhold oxygen from a patient with respiratory distress or complaining of shortness of breath. Factors which may reduce the reliability of the reading include: Poor peripheral circulation (hypovolemia, hypotension, hypothermia). Excessive external lighting, particularly strobe/flashing lights Excessive sensor motion. Fingernail polish (should be removed with acetone pad). Irregular heart rhythms (atrial fibrillation, SVT, etc.). Jaundice. Placement of BP cuff on same extremity as SpO2 probe. P Paramedic Procedure: Ensure the patient is attached properly to a cardiac monitor/defibrillator capable of synchronized cardioversion. Have all equipment prepared for unsynchronized cardioversion/defibrillation, if the patient fails synchronized cardioversion and/or the clinical condition worsens. 3. Firmly apply defib pads to patients chest – assure it is clean, dry, with minimal chest hair. 4. Consider sedation: Midazolam 2-4mg IM/IN/IV/IO (max 4mg) OR Fentanyl 1.0mcg/kg IV/IO (max 75mcg) OR Lorazepam 0.04mg/kg IV/IO (max 2mg) 5. Set energy selection to the appropriate setting, per Protocol. 6. Set monitor/defibrillator to synchronized cardioversion mode, per manufacturer’s instructions. 7. Make certain all personnel are clear of the patient. 8. PRESS and HOLD the “Shock” button to deploy the charge and cardiovert. Stay clear of the patient until you are certain the energy has been delivered. NOTE: It may take the monitor/defibrillator several cardiac cycles to “synchronize”, so there may be a delay between activating the cardioversion and the actual delivery of energy. 9. Note patient response – immediately refer to Appropriate Cardiac Dysrhythmia Protocol. Document patient response to intervention, VS and clinical condition as situation permits. 10. Repeat per protocol until maximum setting or until efforts successful. 11. Note procedure, response, and times in electronic Patient Care Report (ePCR). ~ This Space Intentionally Left Blank ~ Cardioversion – Procedure 161 Procedures Procedures 1. 2. A EMT A-EMT P Paramedic Procedure: Check for responsiveness and feel for a carotid pulse. If compressions are ongoing on EMS arrival, evaluate rate and depth while attaching the AED OR Cardiac Monitor If compressions adequate, begin AED analysis OR charge the monitor for rhythm analysis and shock immediately If no compressions OR felt to be inadequate, initiate high quality chest compressions for two minutes 3. Open the airway with a head-tilt, chin-lift 4. Apply an airway adjunct (OPA or NPA) with NRB mask and O2 at 15Lpm 5. At first rhythm analysis: (Immediately after AED application if bystander compressions adequate, OR after 2 minutes) If shock advised by AED OR interpreted as V-fib OR pulseless V-tach, deploy charge and notify dispatch of first defibrillation time, Continue to #6 If no shock advised by AED OR interpreted to be non-shockable, discard shock and continue chest compressions, go to CPR Procedure 6. At every 2 minutes (200 chest compressions), perform a rhythm and pulse check Begin charging the monitor to prepare for defibrillation approximately 20 seconds before the 2 minute mark If adequate personnel present, rotate compressors every 1-2 minutes Electrical therapy and medications per Cardiac Arrest Protocol and specific rhythm protocols 7. Minimize interruptions in chest compressions 8. At 6 minutes (3 cycles of chest compressions), perform a rhythm and pulse check 9. If patient continues to be pulseless and apneic, begin positive pressure ventilations BVM with airway adjunct (OPA or NPA) OR Advanced Airway (BIAD or ETT) if situation and clinical presentation appropriate If situation dictates or unable to successfully place advanced airway, it is always acceptable to fall back to BVM with an airway adjunct (NPA or OPA) 10. Contact Medical Control for any additional orders or questions. Notes: This Procedure is NOT appropriate for patients <18 years of age, overdoses, hangings, drownings, traumatic arrests OR arrests suspected to be noncardiac in etiology. The Kellum and Barney article in 2008 evaluated CCR performed on witnessed arrests with initial shockable rhythm Dr. Ewy’s article in Circulation evaluated witnessed arrest due to V-fib in adults. http://circ.ahajournals.org/content/111/16/2134.full The protocols listed all have CCR for shockable rhythms only http://www.azdhs.gov/asshare/documents/EMSresponder.pdf ~ This Space Intentionally Left Blank ~ Cardio-Cerebral Resuscitation (CCR) – Procedure 162 Procedures Procedures 1. 2. A EMT A-EMT P Paramedic Procedure: Check for responsiveness and feel for a pulse Carotid pulse for adults and older children, brachial or femoral pulse for infant 2. If compressions are ongoing on EMS arrival, evaluate rate and depth while attaching the Cardiac Monitor OR AED If compressions adequate, charge the monitor for rhythm analysis and shock evaluation immediately if appropriate OR begin AED analysis If no compressions OR felt to be inadequate, initiate high quality chest compressions at >100 compressions per minute for two minutes. 3. Open the patient’s airway Head-tilt, chin-lift technique if no head or neck trauma suspected Jaw-thrust if head or neck trauma suspected or unknown 4. For arrests without advanced airway, perform compressions:breaths as age appropriate Once advanced airway established, transition to >100 compressions per minute uninterrupted with 8-10 breaths per minute. 5. At first rhythm analysis: If shock advised by AED or interpreted as V-fib / Pulseless V-tach, defibrillate and notify dispatch of first defibrillation time. If no shock advised by AED or interpreted to be non-shockable, discard shock and continue. 6. At 2 minutes if no response to resuscitation, consider advanced airway placement (BIAD or ETT) if situation and clinical presentation appropriate. If good chest rise and air exchange achieved, it is acceptable to continue BVM with an airway adjunct (NPA or OPA) 7. Begin charging the monitor to prepare for defibrillation approximately 20 seconds before the 2 minute mark 8. At every 2 minute mark (200 chest compressions) Rotate compressors (as allowed by personnel on scene) Perform a rhythm and pulse check. If V-fib / Pulseless V-tach, deliver shock as per Appropriate Cardiac Arrest Protocol Medications delivered after shock as per Appropriate Cardiac Arrest Protocol If no shockable rhythm, safely dump pending charge to prevent negligent discharge and/or responder injury. Medications delivered after decision as per Appropriate Cardiac Arrest Protocol 9. Resume compressions at 100 per minute, ventilations at 8-10 breaths per minute (as age appropriate if no advanced airway). Minimize interruptions in chest compressions as much as possible. 10. Repeat steps 7-9 until change in patient condition or decision made to terminate resuscitation after 20 minutes (4 rounds of ACLS medications) 11. Contact Medical Control as needed for orders or with any questions. Age Infant Child Adult Location Over sternum, between nipples (inter-mammary line), 2-3 fingers Over sternum, between nipples, heel of one hand Depth 1.5 inches (1/3 the anterior-posterior chest dimension 2 inches (1/3 the anteriorposterior chest dimension Over sternum, just above At least 2 inches (1/3 the the xyphoid process, anterior-posterior chest hadns with interlocked dimension fingers Rate At least 100/minute 15:1 At least 100/minute 15:1 At least 100/minute 30:2 Cardiopulmonary Resuscitation (CPR) – Procedure 163 Procedures Procedures 1. A EMT A-EMT P Paramedic Manual Procedure: 1. If multiple rescuers available, one rescuer should provide uninterrupted chest compressions while the Monitor is being prepared for use 2. Remove any medication patches on the chest and wipe off any residue 3. Apply defibrillator pads per manufacturer recommendations. Use alternate placement when implanted devices (pacemakers, AICDs) occupy preferred pad positions (front/back or shifted slightly to not rest on the implanted device). Refer to pictures for pediatric placement. 4. If necessary, connect defibrillator leads, per manufacturer recommendations 5. Charge the defibrillator per protocol. Continue chest compressions while the defibrillator is charging 6. Pause chest compressions and determine if shockable after reviewing rhythm for max of 5 seconds. 7. Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with the patient prior to defibrillation. 8. Defibrillate if appropriate by depressing the “shock” button. 9. If non-shockable discard the shock, per manufacturer recommendations 10. Continue to follow protocol 11. Record the time and result of the analysis in the patient care report (PCR). Procedures Procedures Automated Procedure: 1. If multiple rescuers available, one rescuer should provide uninterrupted chest compressions while the AED is being prepared for use 2. Remove any medication patches on the chest and wipe off any residue 3. Apply defibrillator pads per manufacturer recommendations. Use alternate placement when implanted devices (pacemakers, AICDs) occupy preferred pad positions (front/back or shifted slightly to not rest on the implanted device). 4. If necessary, connect defibrillator leads, per manufacturer recommendations 5. Activate AED for analysis of rhythm 6. Stop chest compressions and clear the patient for rhythm analysis. Keep interruption in chest compressions as brief as possible 7. Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with the patient prior to defibrillation. 8. Defibrillate if appropriate by depressing the “shock” button. Biphasic defibrillators will determine the correct joules accordingly 9. Continue to follow protocol 10. Record the time and result of the analysis in the electronic Patient Care Report (ePCR). Defibrillation Automated – Procedure 164 P Paramedic Procedure: 1. 2. Attach standard cardiac monitor. Apply defibrillation/pacing pads per manufacturer recommendations. One pad to left mid chest next to sternum, one pad to left mid posterior back next to spine. 3. Place monitor into pacing mode, as specified by manufacturer. 4. Adjust heart rate to 70bpm for an adult, 100bpm for pediatric patients. 5. Note pacer spikes on EKG screen. 6. Slowly increase output until capture of electrical rhythm is noted on the monitor. 7. If unable to capture while at maximum current output, stop pacing immediately. 8. If capture observed on monitor, check for corresponding pulse and assess vital signs. 9. Mechanical capture occurs when paced electrical spikes on the monitor correspond with palpable pulse. 10. Consider Sedation Protocol as appropriate. 11. Document the dysrhythmia and the response to external pacing with ECG strips in the electronic Patient Care Report (ePCR). Procedures Procedures ~ This Space Intentionally Left Blank ~ External Cardiac Pacing – Procedure 165 A EMT A-EMT P Paramedic Clinical Indications: May be used in patients 12 years of age or greater requiring chest compressions related to cardiac arrest. Contraindications: Patients <12 years Patients suffering traumatic cardiac arrest or patients with obvious signs of traumatic injury Patients who do not fit within the device: Too large and with whom you cannot press the pressure pad down 2 inches Too small and with whom you cannot pull the pressure pad down to touch the sternum Procedure: All therapies related to the management of cardiopulmonary arrest should be continued as currently defined. Initiate resuscitative measures following protocol – DO NOT DELAY MANUAL CPR FOR THE DEVICE. CONTINUE MANUAL CPR UNTIL THE DEVICE CAN BE PLACED Detailed instructions for LUCAS device follow: 1. While resuscitative measures are initiated, the LUCAS device should be removed from its carrying device and placed on the patient in the following manner 2. The Backplate should be centered on the nipple line and the top of the backplate should be located just below the patient’s armpits Procedures Procedures 3. 4. 5. In cases which the patient is already on the stretcher, place the backplate underneath the thorax. This can be accomplished by log-rolling the patient or raising the torso (placement should occur during a scheduled discontinuation of compressions [ie. After five cycles of 30:2 or two minutes of uninterrupted compressions]) Position the compressor Turn the LUCAS Device on (the device will perform a 3 second self test) 6. 7. Remove the LUCAS device from its carrying case using the handles provided on each side With the index finger of each hand, pull the trigger to ensure the device is set to engage the backplate. Once this is complete you may removed your index finger from the trigger loop 8. Approach the patient from the side opposite the person performing manual chest compressions 9. Attach the claw hook to the backplate on the side of the patient opposite that where compressions are being provided. 10. Place the LUCAS device across the patient, between the staff members’ arms who is performing manual CPR 11. At this point the staff member performing manual CPR stops and assists attaching the claw hook to the backplate on their side 12. Pull up once to make sure that the parts are securely attached Mechanical CPR Device – Procedure 166 A EMT A-EMT P Paramedic Procedure Continued: 16. To adjust the start position of the compression arm, manually push down the SUCTION CUP with two fingers onto the chest (without compressing the patient’s chest) 17. Once the position of the compression arm is satisfactory, push the green PAUSE button labeled #2 (This will lock the arm in this positon), then remove your fingers from the SUCTION CUP 18. If the position is incorrect, press the ADJUST MODE BUTTON and repeat the steps 19. Start Compressions 20. If the patient in not intubated and you will be providing compression to ventilation ratio of 30:2 push ACTIVE (30:2) button to start 21. If the patient is intubated and you will be providing continuous compressions push ACTIVE (continuous) button 22. Patient Adjuncts 23. Place the neck roll behind the patient’s head and attach the straps to the LUCAS device (this will prevent the LUCAS from migrating toward the patient's feet 24. Place the patient’s arms in the straps provided -Defibrillation can and should be performed with the LUCAS device in place and in operation -One may apply the defibrillation electrodes either before or after the LUCAS device has been put in position -The pads and wires should not be underneath the suction cup -If the electrodes are already in an incorrect position when the LUCAS is placed, you must apply new electrodes -If the rhythm strip cannot be assessed during compressions, one may stop the compressions for analysis by pushing the PAUSE BUTTON (The duration of interruption of compressions should be kept as short as possible and should not be > 10 seconds. There is no need to interrupt chest compressions other than to analyze the rhythm). -Once the rhythm is determined to require defibrillation, the appropriate ACTIVE BUTTON should be pushed to resume compressions while the defibrillator is charging and then the defibrillator should be discharged. Mechanical CPR Device – Procedure 167 Procedures Procedures 13. Adjust the height of the compression arm 14. Use the two fingers (V pattern) to make sure that the lower edge of the Suction Cup is immediately above the end of the sternum. If necessary, move the device by pulling the support legs to adjust the position 15. Press the Adjust Mode Button on the control pad labeled #1 (this will allow you to easily adjust the height of the compression arm) A EMT A-EMT P Paramedic Clinical Indications: ST Segment Elevation Myocardial Infarction Procedure: 1. 2. 4. 5. 6. Remote Ischemic Conditioning – Procedure 168 Procedures Procedures 3. Use personal protective equipment, including gloves, gown and mask as indicated. If patient condition is stable and all critical elements of the STEMI Protocol have been completed, explain to the patient the steps of this procedure The process involves a blood pressure cuff being inflated and held inflated for cycles of approximately 5 minutes There is some risk of discomfort to the limb with the blood pressure cuff, but otherwise it is well tolerated It is believed that this process will decrease the amount of heart muscle that dies and improve outcomes This will in no way interfere with the standard medical treatment for STEMI or Acute Coronary Syndrome The patient has the right to refuse the procedure or discontinue at any time If the patient agrees to the procedure A. Use a manual blood pressure cuff on a limb that is not the primary IV access point and does not have any contraindications to blood pressure cuff use (hemodialysis fistula, breast cancer history, prosthetic limb, etc.) Upper OR Lower Limbs may be used for this procedure, as long as the blood pressure cuff is of adequate size. B. Inflate the blood pressure cuff to >200mmHg and keep inflated for 5 minutes This will require a manual blood pressure cuff, as automatic cuffs are not able to sustain the elevated pressure C. Deflate the blood pressure cuff completely and allow rest for 5 minutes D. Repeat steps B-C for a total of four cycles while en route to the hospital, as permitted by transport time If the patient complains of pain related to the blood pressure cuff, consider the Pain Management, Adult Protocol If pain is not controlled or the patient does not wish to continue, remove the cuff and continue patient care per Protocol Notify the receiving facility of treatment with Remote Ischemic Conditioning Document the procedure and patient response to care in the electronic Patient Care Report (ePCR). P Paramedic Prepare All Procedure Specific Materials: 14 gauge 2–2.5 inch over the needle catheter Tape Sterile Gauze Pads Antiseptic swabs Occlusive dressing Procedure: Locate landmarks for needle decompression – Identify the 2nd intercostal space in the mid-clavicular line on the same side as the pneumothorax 2. Prepare the site with an antiseptic swab 3. Firmly introduce catheter immediately above superior edge of rib at selected site Remember: the neurovascular bundle (nerve, artery and vein) run under the inferior edge of the ribs) 4. Insert the needle perpendicular to the skin with downward pressure until there is a loss of resistance and a return of air. 5. Advance the needle another 1/8", to ensure the catheter is inside the thoracic cavity. Hold the catheter in place with one hand while removing the needle and disposing of sharps in container. 6. Secure the catheter taking care not to allow it to kink If time and situation allow, use an occlusive dressing to cover the catheter and tape on 3 sides to create a one-way valve. 7. Reassess lung sounds, pulses, tracheal deviation and patient clinical condition 8. Dress area with occlusive dressing then cover with sterile gauze pad 9. Reassess breath sounds and respiratory status 10. Document Procedure, patient response, VS and change in clinical condition in the electronic Patient Care Report Chest Decompression – Procedure 169 Procedures Procedures 1. A EMT A-EMT P Paramedic Procedure: 1. 2. 3. 4. 5. 6. 7. Procedures Procedures 8. 9. Assess and treat suspected stroke patients as per protocol The Cincinnati Stroke Screen should be completed for all suspected stroke patients Establish the “time last normal” for the patient. This will be the presumed time of onset. Perform the screen through physical exam: Look for facial droop by asking the patient to smile Have patient, while sitting upright or standing, extend both arms parallel to floor, close eyes, and turn their palms upward. Assess for unilateral drift of an arm. Have the person say, “you can’t teach an old dog new tricks”, or some other simple, familiar saying. Assess for the person to slur the words, get some words wrong, or inability to speak. If one of these exam components is “yes”, then the stroke screen is positive Evaluate Blood Glucose level If the “time last normal” is <12 hours, blood glucose is between 60 and 400, and at least one of the physical exam elements is positive, follow the Suspected Stroke Protocol, Alert the receiving hospital with Stroke Alert as early as possible. All sections of the Cincinnati screen must be completed. The complete screening should be documented in the electronic Patient Care Report (ePCR). Cincinnati Stroke Screen – Procedure 170 A EMT A-EMT P Paramedic 1. 2. 3. 4. 5. 6. 7. 8. Determine appropriate dose of medication per Protocol Draw medication into syringe and dispose of the sharps, do not administer more than 1ml per nostril. Attach intranasal device to syringe With one hand, control the patient’s head Gently introduce device into nare, stop when resistance is met. Aim slightly upwards and toward the ear on the same side Briskly compress the syringe to administer one half of the medication, repeat the procedure with the remaining medication on the other nare. It is important for the medication to be atomized or it will not be absorbed. Document the results in the electronic Patient Care Report (ePCR). ~ This Space Intentionally Left Blank ~ Intranasal – Procedure 171 Procedures Procedures Procedure: A EMT A-EMT P Paramedic Prepare All Procedure Specific Materials: Tube Lubricating Gel Securing device/Tape Suction Syringe for injecting Air Procedure: 1. 2. 3. 4. 5. Procedures Procedures 6. 7. 8. Measure the length of the tube from the tip of nose to earlobe to ziphoid process, mark maximum insertion depth. Lubricate the tube with water based lubricant prior to insertion. Insert lubricated tube through the gastric port of the BIAD or lift tongue/jaw anteriorly while passing tip lateral to endotracheal tube. Continue to advance the tube gently until the appropriate distance is reached. Confirm placement by injecting 20cc of air and auscultate for the whoosh or bubbling of the air over the stomach. If any doubt about placement, remove and repeat the insertion. Secure the tube. Decompress the stomach by connecting the tube to low continuous suction (50-150mmHg). Document the procedure, time, and result (success) on/with the electronic Patient Care Report (ePCR). ~ This Space Intentionally Left Blank ~ Orogastric Tube Insertion – Procedure 172 A EMT A-EMT P Paramedic Any patient who may harm himself, herself or others may be gently restrained to prevent injury to the patient or crew. This restraint must be in a humane manner and used only as a last resort. Other means to prevent injury to the patient or crew must be attempted first. These efforts could include reality orientation, distraction techniques, or other less restrictive therapeutic means. Physical or chemical restraint should be a last resort technique Procedure: The least restrictive means of managing the patient should always be employed first. Ensure that there are sufficient personnel available to restrain the patient safely. Restrain the patient in a lateral or supine position. No devices such as backboards, splints or other devices will be on top of the patient. 4. The patient will never be restrained in the prone position. 5. The patient must be under constant observation by the EMS crew at all times. This includes direct visualization of the patient as well as continuous cardiac, pulse oximetry and capnography monitoring as indicated. 6. The extremities that are restrained will have a circulation check at least every 15 minutes. The first of these checks should occur as soon after placement of the restraints as possible. This MUST be documented in the electronic Patient Care Report (ePCR). 7. If the above actions are unsuccessful, or if the patient is resisting the restraints, consider chemical restraint per protocol. 8. IF a patient is restrained by law enforcement personnel with handcuffs or other devices EMS personnel cannot remove, a law enforcement officer must accompany the patient to the hospital in the transporting EMS vehicle 9. Consider Behavioral Emergencies Protocol. 10. Restraining a patient in the prone position is never authorized. ~ This Space Intentionally Left Blank ~ Restraints – Procedure 173 Procedures Procedures 1. 2. 3. A EMT A-EMT P Paramedic Clinical Indications: Need for spinal immobilization, as per appropriate Trauma Protocol Utilization of the Long Spine Board should occur in consideration with the risks and benefits to the individual patient and the current circumstances Patients who should be immobilized with a Long Spine Board include: Blunt trauma with distracting injury Altered mental status Intoxication Neurologic complaint, including numbness and/or subjective weakness (even without finding on exam) Blunt trauma with spinal pain, tenderness to palpation of spine or paraspinal muscles, and spinal deformity Inability to communicate with the EMS Personnel Prepare All Procedure Specific Materials: Backboard Straps C-collar appropriate for patient size Tape and/or Head Rolls 1. 2. 3. 4. 5. 6. 7. Explain the procedure to the patient. Apply an appropriately sized c-collar while maintaining in-line stabilization of the c-spine. This stabilization, to be provided by a second rescuer, should not involve traction or tension but rather simply maintaining the head in a neutral, midline position while the first rescuer applies the collar. This may be performed by any credentialed responder if indicated by protocol. Once the collar is secure, the second rescuer should continue to maintain inline neutral position to ensure stabilization. The collar is helpful but will not do the job by itself. If the patient is supine or prone, consider the log roll technique. For the patient in a vehicle or otherwise unable to be placed prone or supine, place them on the backboard by the safest method available that maximizes maintenance of inline spinal stability Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is secured to the backboard, the second rescuer may release manual in-line stabilization. NOTE: some patients , due to size or age, will not be able to be immobilized through in-line stabilization with standard backboards and c-collars. Never force a patient into a non-neutral position to immobilize them. Such situations may require a second rescuer to maintain manual stabilization throughout the transport to the hospital. Document the time of the procedure in the electronic Patient Care Report (ePCR). ~ This Space Intentionally Left Blank ~ Spinal Immobilization – Procedure 174 Procedures Procedures Procedure: A EMT A-EMT P Paramedic EMS Providers must use extreme caution when evaluating and treating an injured player, especially when the extent of the injury remains unknown. Suspect any unconscious football player to have an accompanying spinal injury until proven otherwise. If the player isn’t breathing or the possibility of respiratory arrest exists, its essential that certified athletic trainers and EMS providers work quickly and effectively to remove the face mask and administer care. In most situations, the helmet should not be removed in the field. Proper management of head and neck injuries includes leaving the helmet and shoulder pads in place whenever possible, removing only the face mask from the helmet and developing a plan to manage head-and-neck injured players using well-trained sports medicine and EMS providers. The following guidelines and recommendations were developed by the Inter-Association Task Force for the appropriate Care of the Spine-Injured Athlete: 1. General Guidelines for Care Prior to Arrival of EMS The Emergency Medical Services system should be activated Any athlete suspected of having a spinal injury should not be moved and should be managed as though a spinal injury exists. The athlete’s airway, breathing and circulation, neurological status and level of consciousness should be assessed The athlete should NOT be moved unless absolutely essential to maintain airway, breathing and circulation If the athlete must be moved to maintain airway, breathing and circulation, the athlete should be placed in a supine position while maintaining spinal immobilization. When moving a suspected spine injured athlete, the head and trunk should be moved as a unit. One accepted technique is to manually splint the head to the trunk. 2. Face Mask Removal The face mask should be removed prior to transportation, regardless of current respiratory status (see figure 1) Those involved in the pre-hospital care of injured players must have the tools for face mask removal readily available. Indications for Helmet Removal: 1. The athletic helmet and chin straps should only be removed if: The helmet and chin strap do not hold the head securely, such that immobilization of the helmet does not also immobilize the head The design of the helmet and chin strap is such that even after removal of the face mask the airway cannot be controlled, or ventilation be provided. The face mask cannot be removed after a reasonable period of time The helmet prevents immobilization from transporting in an appropriate position. Helmet Removal: 1. If it becomes absolutely necessary, spinal immobilization must be maintained while removed the helmet Helmet removal should be frequently practiced under proper supervision by an EMS supervisor or Training Division staff Due to the varying types of helmets encountered, the helmet should be removed with close oversight by the team athletic trainers and/or sports medicine staff In most circumstances, it may be helpful to remove cheek padding and/or deflate air padding prior to helmet removal. Spinal Alignment: 1. Appropriate spinal alignment must be maintained during care and transport using backboard, straps, tape, head blocks or other necessary equipment. Be aware that the helmet and shoulder pads elevate an athlete’s trunk when in the supine position Should either be removed, or if only one is present, appropriate spinal alignment must be maintained. The front of the shoulder pads can be opened to allow access for CPR and defibrillation Spinal Immobilization of Athletes with Helmets – Procedure 175 Procedures Procedures Guidelines and Recommendations: A EMT A-EMT P Paramedic Clinical Indications: Immobilization of an extremity for transport due to suspected fracture, sprain or other traumatic injury Immobilization of an extremity for transport to secure medically necessary devices such as IV catheter Procedure: 1. 2. 3. 4. 5. 6. Procedures Procedures 7. 8. 9. Assess and document pulses, sensation and motor function prior to placement of the splint. If no pulses are present and a fracture is suspected, consider reduction of the fracture prior to placement of the splint. If extended scene time, prolonged extrication and pulseless extremity, contact Medical Control for recommendations Remove all clothing from the extremity. Select a site to secure the splint both proximal and distal to the area of suspected injury or the area where the medical device will be placed. Do not secure the splint directly over the injury. Place the splint and secure with Velcro, straps, or bandage material (ie. Kling, kerlex, cloth bandage, etc.) depending on the splint manufacturer and design. Document pulses, sensation and motor function after placement of the splint. If there has been a deterioration in any of these 3 parameters, reposition the splint and reassess. If no improvement, remove splint. IF a femur fracture is suspected and there is no evidence of pelvic fracture or instability, place a traction splint. Consider pain management per Pain Management Protocol. Document the time, type of splint, and the pre and post assessment of pulse, sensation and motor function in the electronic Patient Care Report (ePCR). ~ This Space Intentionally Left Blank ~ Splinting – Procedure 176 A EMT A-EMT P Paramedic Principles: Apply Tourniquet as proximal as possible to wound, minimum of 2" above hemorrhage site. Do not cross joints or bony prominences with the Tourniquet Secure Tourniquet in place and expedite transport. Document time and location of tourniquet deployment in electronic Patient Care Report (ePCR) and on device. Notify receiving center of tourniquet use, location of device and time placed. IF hemorrhage not controlled, a second tourniquet can be deployed, proximal to the first without overlap. 1. Route the self adhering band around the extremity and pass the free-running end of the band through the inside slit of the friction adapter buckle 2. Pass the band through the outside slit of the buckle, utilizing the friction adaptor buckle, which will lock the band in place. 3. Pull the self-adhering band tight and securely fasten the band back on itself. 4. Twist the rod until bright red bleeding has stopped. 5. Lock the rod in place with the Windlass Clip™ 6. Hemorrhage is now controlled. Secure the rod with the strap: Grasp the Windlass Strap™, pull it tight and adhere it to the opposite hook on the Windlass Clip™ Tourniquet (CAT- Combat Application Tourniquet) – Procedure 177 Procedures Procedures Procedure: P Paramedic Clinical Indications: Inability to obtain adequate alternative peripheral access Access of an existing catheter for medication or fluid administration Central venous access in a patient in cardiac arrest Only appropriate for critical patients Procedure: 1. 2. 3. 4. 5. 6. Use personal protective equipment, including gloves, gown and mask as indicated. Clean the port of the catheter with alcohol wipe Using sterile technique, withdraw 5-10mL of blood and place syringe in sharps box. Using 5mL normal saline, access the port with sterile technique and gently attempt to flush the saline. IF there is NO resistance with flush, no evidence of infiltration (i.e. No subcutaneous, collection of fluid), and no pain experienced by the patient, then proceed to step 5 IF there IS resistance with flush, evidence of infiltration, pain experienced by the patient, or any concern that the catheter may be clotted or dislodged, do not use the catheter. Begin administration of medications or IV fluids slowly. Observe for any signs of infiltration. If difficulties are encountered, stop the infusion and reassess. Document procedure, any complications, and fluids/medications administered in the electronic Patient Care Report (ePCR). Procedures Procedures ~ This Space Intentionally Left Blank ~ Accessing Peripherally Inserted Central Catheter (PICC) – Procedure 178 A A-EMT P Paramedic Prepare All Procedure Specific Materials: Appropriate tubing or IV lock #14-#24 catheter over the needle, or butterfly needle Venous tourniquet Antiseptic swab Gauze pad or adhesive bandage Tape or commercially available securing device Procedure: 1. 2. 3. 4. 6. 7. 8. ~ This Space Intentionally Left Blank ~ Extremity Venous Access – Procedure 179 Procedures Procedures 5. Saline locks may be used as an alternative to IV tubing and fluid under the authorization of the Service Medical Director and at the discretion of the provider. Intraosseous access can be used where threat to life exists as provided for in the Venous Access – Intraosseous Procedure. Use the largest catheter bore necessary based upon the patient’s condition and size of veins Fluid and set up choice is preferably: Normal Saline with macro drip (10 drops/mL) for medical/trauma conditions. Normal Saline with a micro drip (60 drops/mL) for medication infusions or for patients at risk of fluid overload. Assemble IV solution and tubing: Open IV bag and check for clarity, expiration date, etc. Verify correct solution Open IV tubing and assemble according to manufacturer's guidelines Insertion: Explain to the patient that an IV is going to be started Place the tourniquet around the patient’s arm proximal to the IV site, if appropriate Palpate veins for resilience Clean the skin with the antiseptic swab in an increasing sized concentric circle and follow it with an alcohol swab Stabilize the vein distally with the thumb/fingers Enter the skin with the bevel of the needle facing upward Enter the vein, obtain a flash, and advance the catheter into the vein while stabilizing the needle Remove the needle while compressing the proximal tip of the catheter to minimize blood loss Remove the tourniquet Connect IV tubing to the catheter, or secure the IV lock to the catheter to minimize blood loss Open the IV clamp to assure free flow (no infiltration, pain, etc) and set infusion rate Secure the IV: Secure the IV catheter and tubing Recheck IV drip rate to make sure it is flowing at appropriate rate. Trouble shoot the IV, (if the IV is not working well): Make sure the tourniquet is off Check the IV insertion site for swelling Check the IV tubing clamp to make sure it is open Check the drip chamber to make sure it is half full Lower the IV bag below IV site and watch for blood to return into the tubing A A-EMT P Paramedic Procedure: 1. Select the appropriate insertion site and palpate the appropriate bony landmarks to identify the site of insertion. The PROXIMAL HUMERUS is contraindicated in patients <18 years old, UNLESS authorized by Medical Control. Anterior Tibia Anteromedial aspect of the proximal tibia (bony prominence below the kneecap). The insertion location will be 1-2cm (2 finger widths) below this. Keeping the elbow flat on the floor and close to the side of the Proximal Humerus body, rotate the palm over the umbilicus (belly button) and palpate (Hand Over Umbilicus the greater tubercle of the humerus. The insertion location will be Technique) 1-2cm (2 finger widths) above the surgical neck. With the arm fully extended and tight to the body, rotate the hand Proximal Humerus medially (inward) until the palm is facing out. Palpate the greater (“Thumb-to-Bum” tubercle of the humerus approximately 1-2cm (2 finger widths) Technique) above the surgical neck. 4. 5. 6. 7. 8. 9. Cleanse the site with chlorhexidine, iodine or alcohol prep pad. Device insertion Manual devices (Cook or Jamshidi): Hold the intraosseous needle at a 90o degree angle to the bony surface, aimed away from the nearby joint and epiphyseal plate. Provide pressure to push the needle tip through the skin until resistance from the bone is felt. Twist the needle handle with a rotating grinding motion applying controlled downward force until a “pop” or loss of resistance is felt. Do not advance more than 1cm after the loss of resistance is felt. Powered Intraosseous Device (EZ-IO): Hold the intraosseous needle at a 90o degree angle to the bony surface, aimed away from the nearby joint and epiphyseal plate. Provide pressure to push the needle tip through the skin until resistance from the bone is felt. Power the driver until a “pop” or loss of resistance is felt. Do not advance more than 1cm after the loss or resistance is felt. Automatic Intraosseous Device (NIO): Rotate the cap 90° in either direction to unlock Place dominant hand over cap, and press device against patient. While pressing down on the device with palm, pull trigger wings upwards with fingers Gently pull the NIO up in a rotating motion while holding the needle stabilizer against the insertion site Continue holding the needle stabilizer in place and pull up the stylet to remove. Remove the stylet and place in an approved sharps container Attach a 10mL syringe filled with 5mL of Normal Saline; aspirate bone marrow to verify placement, then inject 5mL of Normal Saline to clear the lumen of the needle. Attach the IV line with fluids on a pressure bag. Paramedics may infuse 10-20mg of Lidocaine into the IO in adult patients who are awake and aware of pain. ½-1mL of 2% Lidocaine at 100mg/5mL concentration Allow the Lidocaine to sit in the marrow for approximately 30 seconds prior to fluid infusion through the line. Stabilize and secure the needle with dressings and tape Document the procedure, time, and procedure success (or failure) on the PCR Complications: ● Incorrect identification of landmarks ● A bent needle (more common with longer needles) ● Clogging of the needle with marrow, clot or bone spicules. -Can be avoided by flushing the needle or continuous infusion ● Through and through penetration of both anterior and posterior cortices caused by excess force after the needle has penetrated the cortex. ● Subcutaneous or subperiosteal infiltration, caused by incomplete placement or dislodgement of needle. ● Fractures caused by excess force or fragile bones. ● Compartment syndrome Contraindications: Fracture proximal to proposed intraosseous site History of Osteogenesis Imperfecta Current or prior infection at proposed intraosseous site Previous intraosseous insertion or joint replacement at the selected site IO Intraosseous Venous Access – Procedure 180 Procedures Procedures 2. 3. P Paramedic Clinical Indications: Medical patients who are awake and alert, and require IV access but are peripherally exhausted External jugular cannulation can be attempted initially in life threatening events when no obvious peripheral site is noted. Prepare All Procedure Specific Materials: Appropriate tubing or IV lock #14-#24 catheter over the needle or butterfly needle Antiseptic swab Gauze pad or adhesive bandage Tape or other securing device 1. Position yourself at the head of the patient. 2. Place the patient in a slight Trendelenburg (supine, head down) position if possible. This helps distend the vein and prevent air embolism. 3. Turn the patient’s head toward the opposite side if no risk of cervical injury exists. 4. Prep the site with antiseptic swab. 5. Align the catheter with the vein (insertion direction is away from the patient’s head, toward the patient’s same side shoulder). 6. Anchoring the vein lightly with one finger above the clavicle, puncture the vein at a superficial angle midway between the angle of the jaw and the clavicle and cannulate the vein. 7. Confirm placement with saline flush. 8. Attach the IV and secure the catheter (avoiding circumferential dressing or taping around the neck). 9. If unsuccessful, place occlusive dressing over site and do NOT go to other side of neck 10. Document the procedure appropriately. Contraindications: Patient combative or uncooperative with positioning (i.e. unable to hold still while procedure is being performed) Anterior neck hematoma/burn/cellulitis Anatomic landmarks not visible Medical appliance in place covering anterior neck (i.e. c-collar) External Jugular Monitor for complications Vein Expanding hematoma Internal Jugular Tracheal shift Vein Carotid Artery Difficulty breathing *PEARL: Superficial insertion angle is crucial as the carotid artery is in close proximity to the EJ. External Jugular Venous Access – Procedure 181 Procedures Procedures Procedure: A EMT A-EMT P Paramedic Frequently Asked Questions: What is a Ventricular Assist Device (VAD)? A ventricular assist device (VAD) is a mechanical pump that is used to support heart function and blood flow in people who have weakened hearts. Some common reasons for VAD implantation are MI, Heart Failure, myocarditis, cardiomyopathy and heart surgery. How does a VAD work? The device takes blood from a lower chamber of the heart and helps pump it to the body and vital organs, just as a healthy heart would. What are the parts of a VAD? The basic parts of a VAD include: a small tube that carries blood out of your heart into a pump; another tube that carries blood from the pump to your blood vessels, which deliver blood to your body; and a power source. What is the power source? The power source is either batteries or AC power. The power source is connected to a control unit that monitors the VAD functions. The batteries are carried in a case usually located in a holster in a vest around the patient’s shoulders. What does the control unit (or controller) do? The control unit gives warnings or alarms if the power is low or if it senses that the device isn’t functioning properly. Patient Management: 1. 2. Assess the patients airway and intervene per the Airway Management Protocol Auscultate heart sounds to determine if the device is functioning and what type of device it is. If it is a continuous flow device, you should hear a “whirling sound”. 3. Assess the device for any alarms. 4. Look on the controller located around the patient’s waist or in the VAD PAK and see what device it is. 5. Intervene appropriately based on the type of alarm and patient guide. You may follow the standard Cardiac Arrhythmia Protocols as per ACLS guidelines, EXCEPT: NO Chest Compressions NO Thrombolytics Defibrillation is the standard process 6. Start one large bore IV 7. Assess Vital Signs – use Mean BP with Doppler, if available. The first sound you will hear is the Mean Arterial Pressure (MAP) 8. If no Doppler available, use the Mean on the Non-Invasive BP cuff 9. Transport to the closest VAD Center. Call the number listed on the device for advice. 10. Bring all of the patient’s equipment and paperwork to the Emergency Department. 11. Allow the trained caregiver to ride in the patient compartment when possible. They may be able to serve as an expert on the device if the patient is unconscious or unable to answer for themselves. Quick Tips for Ventricular Assist Devices (VADs) Let the patient and/or caregiver take the lead; they will be your on-scene experts. Remember not to perform chest compressions because they could dislodge the pump, making the patient bleed to death. Use the assistance of the VAD coordinator before starting compressions in the case of obvious arrest and pump failure. Defibrillate / cardiovert as normal. Do NOT place the pads over the device that is under the patient’s skin. Keep in mind it may be difficult to obtain an accurate SpO2 because of little or no pulse. BE CAREFUL WHEN REMOVING / CUTTING CLOTHING so you don’t inadvertently dislodge or cut the drive line. Take the patient’s emergency travel bag when leaving the scene. It should have an extra controller batteries and the VAD Coordinator’s emergency contact number. http://www.uwhealth.org/health-professionals/emergency-education/preparing-ems-units-to-triage-and-care-for-vad-patients/ 30600 http://mylvad.com/sites/mylvadrp/files/EMS%20Field%20Guides/MCSO%20EMS%20GUIDE%202015%20.pdf http://www.jems.com/articles/print/volume-37/issue-2/patient-care/patients-ventricular-assist-device-need.html Ventricular Assist Device – Procedure 182 Procedures Procedures MOST patients have a tag located on the controller around their waist that lists the type of device, the institution that put it in and a number to call. A EMT A-EMT P Paramedic Clinical Indications: Skin and soft tissue wounds with associated bleeding and pain. Procedure: 1. 2. 3. 4. 6. 7. 8. 9. 9. ~ This Space Intentionally Left Blank ~ Wound Care – Procedure 183 Procedures Procedures 5. Use personal protective equipment, including gloves, gown and mask as indicated. If active bleeding, elevate the affected area if possible and hold direct pressure. Do not rely on compression bandage to control bleeding. Direct pressure is much more effective Consider tourniquet use early for extremity bleeding not controlled with direct pressure. Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate Consider Pain Management Protocol before beginning irrigation. Irrigation and decontamination are key to stopping ongoing tissue injury, preventing infection and promoting wound healing. Control bleeding and address life threats first. Irrigate thermal burns, chemical burns or contaminated wounds with Normal Saline, Lactated Ringer’s or sterile water. For chemical splashes to the eye, emergent irrigation is critical to preventing further tissue damage. If possible, have patient remove contact lenses as early as possible. Go to Eye Pain Protocol, as appropriate. Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to ensure the bandage is not too tight. Monitor wounds and/or dressing throughout transport for bleeding Bolster existing bandages as necessary if saturation or Consider tourniquet use as indicated in protocol/procedure If serious hemorrhage not controlled by other means: Apply approved non-heat generating hemostatic agent per manufacturer’s directions. Supplement hemostatic agent impregnated gauze with direct pressure and standard hemorrhage control techniques Apply additional hemostatic impregnated gauze and/or standard dressings as needed. Hemostatic impregnated gauze is contraindicated in wounds involving the thoracic cavity or violating the peritoneum of the abdominal cavity. Document the wound assessment and care in the electronic Patient Care Report (ePCR). A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Overview The purpose of this section is to serve as a drug information supplement and to provide a brief description of the out-of-hospital medications that are authorized by the State of Wisconsin for use in the Dane County EMS System. This document in no way represents the comprehensive pharmaceutical knowledge required for use of these medications by Emergency Medical Technicians providing field care. The comprehensive information about the use of these medications by practicing EMTs and paramedics, requires reference to other detailed sources. Medications are listed alphabetically based on generic names. Michael T. Lohmeier, MD, FACEP Medical Director, Dane County EMS Overview Overview ~ This Space Intentionally Left Blank ~ Pharmaceuticals 184 A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Adenosine Mechanism of Action Slows conduction through the AV node, can interrupt reentry pathways through the AV node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia; decreases cardiac oxygen demand, decreasing hypoxia Uses PSVT, as a diagnostic aid to assess myocardial perfusion defects in CAD, Wolff-Parkinson-White syndrome Unlabeled Uses: Wide-complex tachycardia diagnosis Dosage and Routes Antidysrhythmic Refer to specific protocol Side Effects CNS: Lightheadedness, dizziness, arm tingling, numbness, headache CV: Chest Pain, pressure, atrial tachydysrhthmias, sweating, palpitations, hypotension, facial flushing, AV block, cardiac arrest, ventricular dysrhythmias, atrial fibrillation GI: Nausea, metallic taste Resp: Dyspnea, chest pressure, hyperventilation, bronchospasm (asthmatics) Pharmacokinetics Cleared from plasma in <30sec, half-life 10sec, converted to inosine/adenosine monophosphate Interactions Increase: risk for higher degree of heart block – Carbamazepine Increase: risk for ventricular fibrillation – digoxin, verapamil Increase: effects of adenosine – dypridamole Decrease: activity of adenosine – theophylline or other methylxanthines (caffeine) EMT Considerations Assess cardiopulmonary status – BP, pulse, respiration, rhythm, ECG intervals (PR, QRS, QT); check for transient dysrhythmias (PVCs, PACs, sinus tachycardia, AV block) Assess respiratory status – rate, rhythm, lung fields for crackles; watch for respiratory depression; bilateral crackles may occur in CHF patient; increased respiration, increased pulse, product should be discontinued CNS effects – dizziness, confusion, psychosis, paresthesias, seizures; product should be discontinued Treatment of Overdose Defibrillation, vasopressor for hypotension, theophylline Pharmaceuticals 185 Adenosine Adenosine Contraindications Hypersensitivity, 2nd- or 3rd-degree AV block, sick sinus syndrome Precautions Pregnancy (C), breast-feeding, children, geriatric patients, asthma, atrial flutter, atrial fibrillation, ventricular tachycardia, bronchospastic lung disease, symptomatic bradycardia, bundle branch block, heart transplant, unstable angina, COPD, hypotension, hypovolemia, vascular heart disease, CV disease A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Albuterol Mechanism of Action Beta2-adrenergic agonist. Activates beta2 receptors on airway smooth muscle, increasing the cyclic AMP concentration, increasing activation of protein kinase A and lowers intracellular ionic calcium concentrations, leading to muscle relaxation. Uses Bronchospasm associated with asthma, exercise induced asthma, COPD Unlabeled Uses: Hyperkalemia Dosage and Routes Bronchospasm Refer to specific protocol Other Respiratory Conditions Refer to specific protocol Side Effects CNS: Tremors, anxiety, insomnia, headache, dizziness, stimulation, restlessness, hallucinations, flushing, irritability CV: Palpitations, tachycardia, angina, hypo/hypertension, dysrhythmias EENT: Dry nose, irritation of nose and throat GI: Heartburn, nausea, vomiting MS: Muscle cramps Resp: Cough, wheezing, dyspnea, parodoxical bronchospasm, dry throat Misc: Flushing, sweating, anorexia, bad taste/smell changes, hypokalemia, metabolic acidosis Pharmacokinetics Extensively metabolized in the liver and tissues, crosses placenta, breast mild, blood-brain barrier INH – onset 5-15min, peak 1-1.5hr, duration 3-6hr, half-life 4hr Interactions Increase: QTc prolongation – other drugs that increase QT prolongation Increase: ECG changes/hypokalemia – potassium wasting diuretics Increase: action of albuterol – tricyclics, MAOIs, other adrenergics; do not use together Decrease: effectiveness of albuterol – other β-blockers EMT Considerations Respiratory Function: vital capacity, forced expiratory volume, ABGs; lung sounds, hear rate and rhythm, BP, sputum (baseline and peak); whether patient has not received theophylline therapy before giving dose Evaluate: therapeutic response: absence of dyspnea, wheezing after 1hr, improved airway exchange, improved ABG Treatment of Overdose Administer β1-adrenergic blocker, IV Fluids Pharmaceuticals 186 Albuterol Albuterol Contraindications Hypersensitivity to sympathomimetics, tachydysrhythmias, severe cardiac disease, heart block Precautions Pregnancy (C), breast-feeding, cardiac/renal disease, hyperthyroidism, diabetes mellitus, hypertension, prostatic hypertrophy, angle-closure glaucoma, seizures, exercise-induced bronchospasm (aerosol) in children <12 y/o, hypoglycemia A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Amiodarone Mechanism of Action Prolongs duration of action potential and effective refractory period, noncompetitive a- and b-adrenergic inhibition; increases PR and QT intervals, decreases sinus rate, decreases peripheral vascular resistance Uses Hemodynamically unstable ventricular tachycardia, supraventricular tachycardia, ventricular fibrillation not controlled by 1st-line agents Unlabeled Uses: Atrial fibrillation treatment/prophylaxis, atrial flutter, cardiac arrest, cardiac surgery, CPR, heart failure, PSVT, Wolff-Parkinson-White (WPW) syndrome, supraventricular tachycardia Dosage and Routes Ventricular Dysrhythmias Refer to specific protocol Supraventricular Dysrhythmias (atrial fibrillation, atrial flutter, PSVT, WPW syndrome) Refer to specific protocol Side Effects CNS: Headache, dizziness, involuntary movement, tremors, peripheral neuropathy, malaise, fatigue, ataxia, paresthesia, insomnia CV: Hypotension, bradycardia, sinus arrest, CHF, dysrhythmias, SA node dysfunction, AV block, increased defibrillation energy EENT: Blurred vision, halos, photophobia, corneal microdepositis, dry eyes GI: Nausea, vomiting, diarrhea, abdominal pain, anorexia, constipation, hepatotoxicity MS: weakness, pain in extremities Resp: Pulmonary fibrosis/toxicity, pulmonary inflammation, ARDS; gasping syndrome if used with neonates Misc: Flushing, abnormal taste or smell, edema, abnormal salivation, coagulation abnormalities Pharmacokinetics Metabolized by liver (CYP3A4, CYP2C8), excreted by kidneys, 99% protein binding Interactions Increase: QT prolongation – azoles, fluoroquinolones, macrolides Increase: amiodarone concentration, possible serious dysrhythmias – protease inhibitors, reduce dose Increase: anticoagulation effects - warfarin Increase: bradycardia – b-blockers calcium channel blockers EMT Considerations Evaluate: therapeutic response: decreased in ventricular tachycardia, supraventricular tachycardia, fibrillation CNS Symptoms: confusion, psychosis, numbness, depression, involuntary movements; product should be discontinued Treatment of Overdose O2, artificial ventilation, ECG, administer dopamine for circulatory depression, administer diazepam for seizures Pharmaceuticals 187 Amiodarone Amiodarone Contraindications Black Box Warning – 2nd- and 3rd-degree AV block, bradycardia, severe hepatic disease, cardiac arrhythmias, pulmonary fibrosis Pregnancy (D), breastfeeding, neonates, infants, severe sinus node dysfunction, hypersensitivity to this product/iodine/a=benzyl alcohol, cardiogenic shock Precautions Children, goiter, Hashimoto’s thyroiditis, electrolyte imbalance, CHF, respiratory disease, torsades de pointes A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Aspirin Mechanism of Action Blocks pain impulses in CNS, reduces inflammation by inhibition of prostaglandin synthesis; antipyretic action results from vasodilation of peripheral vessels; decreases platelet aggregation Uses Mild to moderate pain or fever including RA, osteoarthritis, thromboembolic disorders; TIAs, rheumatic fever, post-MI, prophylaxis of MI, ischemic stroke, angina, acute MI Unlabeled Uses: Prevention of cataracts, Kawasaki disease, pericarditis, PCI Dosage and Routes Pain/Fever Refer to specific protocol MI, Stroke Prophylaxis Refer to specific protocol Side Effects CNS: Stimulation, drowsiness, dizziness, confusion, seizures, headache, flushing, hallucinations, coma CV: Rapid pulse, pulmonary edema EENT: Tinnitus, hearing loss Endocrine: Hypoglycemia, hyponatremia, hypokalemia GI: Nausea, vomiting, GI bleeding, diarrhea, heartburn, anorexia, hepatitis, GI ulcer Heme: Thrombocytopenia, agranulocytosis, leukopenia, neutropenia, hemolytic anemia, increased bleeding time Resp: Wheezing, hyperpnea, bronchospasm Skin: Rash, urticaria, bruising Syst: Reye’s syndrome (children), anaphylaxis, laryngeal edema Pharmacokinetics Enteric metabolism by liver; inactive metabolites excreted by kidneys; crosses placenta; excreted in breast mild; half-life 15-20min Interactions Increase: gastric ulcer risk – corticosteroids, anti-inflammatories, NSAIDs, alcohol Increase: bleeding – alcohol, plicamycin, thrombolytics, anticoagulants Increase: hypotension - nitroglycerin Decrease: effects of aspirin – antacids (high dose), urinary alkalizers, corticosteroids EMT Considerations Allergic reactions: rash, urticaria; if these occur, product may have to be discontinued; patients with asthma, nasal polyps allergies: severe allergic reaction may occur Ototoxicity: tinnitus, ringing, roaring in ears; audiometric testing needed before, after long-term therapy Treatment of Overdose Lavage, activated charcoal, monitor electrolytes, VS Pharmaceuticals 188 Aspirin Aspirin Contraindications Pregnancy (D) 3rd trimester, breastfeeding, children <12 y/o, children with flu-like symptoms, hypersensitivity to salicylates, GI bleeding, bleeding disorders, intracranial bleeding, nasal polyps, urticaria Precautions Abrupt discontinuation, acid/base imbalance, alcoholism, ascites, asthma, bone marrow suppression in elderly, G6PD deficiency, gout, heart failure, anemia, renal/hepatic disease, gastritis, pregnancy (C) 1st trimester A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Atropine Mechanism of Action Blocks acetylcholine at parasympathetic neuroeffector sites; increases cardiac output, heart rate by blocking vagal stimulation in heart; dries secretions by blocking vagus nerve stimulation Uses Bradycardia <40-50bpm, bradydysrhythmia, reversal of anticholinesterase agents, insecticide poisoning, blocking cardiac vagal reflexes, decreasing secretions before surgery, antispasmodic with GU, biliary surgery, bronchodilator, AV heart block Unlabeled Uses: Cardiac arrest, CPR, diarrhea, pulseless electrical activity, ventricular asystole, asthma Dosage and Routes Bradycardia / Bradydysrhythmias Refer to specific protocol Organophosphate poisoning Refer to specific protocol Side Effects CNS: Headache, dizziness, involuntary movement, confusion, psychosis, anxiety, coma, flushing, drowsiness, insomnia, delirium CV: Hypo/hypertension, paradoxical bradycardia, angina, PVCs, tachycardia, ectopic ventricular beats, bradycardia EENT: Blurred vision, photophobia, glaucoma, eye pain, pupil dilation, nasal congestion GI: Dry mouth, nausea, vomiting, abdominal pain, anorexia, constipation, paralytic ileus, abdominal distention, altered taste GU: Retention, hesitancy, impotence, dysuria Skin: Rash, urticaria, contact dermatitis, dry skin, flushing Misc: Suppression of lactation, decreased sweating, anaphylaxis Pharmacokinetics Half-life 2-3hr, terminal 12.5hr. Excreted by kidneys unchanged (70-90% in 24hr), metabolized in liver 40-50% crosses placenta Interactions Increase: mucosal lesions – potassium chloride tab Increase: anticholinergic effects – tricyclics, amantadine, antiparkinson agents Decrease: effect of atropine – antacids EMT Considerations Assess ECG for ectopic ventricular beats, PVCs, tachycardia. Assess for increased intraocular pressure; eye pain, nausea, vomiting, blurred vision, increased tearing Treatment of Overdose O2, artificial ventilation, ECG; administer dopamine for circulatory depression; administer diazepam for seizures; assess need for antidysrhythmics Pharmaceuticals 189 Atropine Atropine Contraindications Hypersensitivity to belladonna alkaloids, closed-angle glaucoma, GI obstructions, myasthenia gravis, thyrotoxicosis, ulcerative colitis, prostatic hypertrophy, tachycardia, asthma, acute hemorrhage, severe hepatic disease, myocardial ischemia Precautions Pregnancy ©, breastfeeding, children <6 y/o, geriatric patients, renal disease, CHF, hyperthyroidism, COPD, hypertension, Down Syndrome, spastic paralysis, gastric ulcer A P M Legend EMT A-EMT Paramedic Medical Control Pharmaceuticals Calcium Mechanism of Action Needed for maintenance of nervous, muscular, skeletal function; enzyme reactions; normal cardiac contractility; coagulation of blood; affects secretory activity of endocrine, exocrine glands Uses Prevention and treatment of hypocalcemia, hypermagnesemia, hypoparathyroidism, neonatal tetany, cardiac toxicity caused by hyperkalemia, lead colic, hyperphosphatemia, Vitamin D deficiency, osteoporosis prophylaxis, calcium antagonist toxicity Unlabeled Uses: Electrolyte abnormalities in cardiac arrest, CPR Dosage and Routes Refer to specific protocol Side Effects CV: Shortened QT, heart block, hypotension, bradycardia, dysrhythmias, cardiac arrest GI: Vomiting, nausea, constipation Hypercalcemia: Drowsiness, lethargy, muscle weakness, headache, constipation, coma, anorexia, nausea, vomiting, polyuria, Skin: Pain, burning at IV site, severe venous thrombosis, necrosis, extravasation Pharmacokinetics Crosses placenta, enters breast milk, excreted via urine and feces, half-life unknown, protein binding 40-50% Interactions Increase: dysrhythmias – digoxin glycosides Increase: toxicity - verpamil Decrease: effects of atenolol, verapamil EMT Considerations Assess: ECG for decreased QT and T-wave inversion; seizure precautions with padded side rails, decreased stimuli, place airway suction equipment Evaluate: therapeutic response with decreased twitching, paresthesias, muscle spasms; absence of tremor, seizure or dysrhythmia Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 190 Calcium Calcium Contraindications Hypercalcemia, digoxin toxicity, ventricular fibrillation, renal calculi Precautions Pregnancy (C), breastfeeding, children, respiratory/renal disease, cor pulmonale, patient in digoxin, respiratory failure, diarrhea A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Dextrose Mechanism of Action Needed for adequate utilization of amino acids; decreases protein, nitrogen loss; prevents ketosis Uses Increases intake of calories; increases fluids in patients unable to take adequate fluids, calories orally; acute hypoglycemia Contraindications Hyperglycemia, delirium tremens, hemorrhage (cranial/spinal), CHF, anuria, allergy to corn products Precautions Cardiac/renal/hepatic disease, diabetes mellitus, carbohydrate intolerance Side Effects CNS: confusion, loss of consciousness, dizziness CV: hypertension, CHF, pulmonary edema, intracranial hemorrhage Endo: Hyperglycemia, rebound hypoglycemia, hyperosmolar syndrome, hyperglycemic non-ketotic syndrome, aluminum toxicity, hypokalemia, hypomagnesium GI: Nausea GU: Glycosuria, osmotic diuresis Skin: Chills, flushing, warm feeling, rash, urticarial, extravasation necrosis Resp: Pulmonary edema Pharmacokinetics Metabolized at the cellular level to carbon dioxide and water. Oral – onset 10 minutes, peak 40 minutes; IV – onset immediate, peak 30 minutes Interactions Increase: fluid retention/electrolyte excretion—corticosteroids EMT Considerations Assess: Electrolytes (Potassium), blood glucose; Injection site for extravasation (redness along vein, edema at site, necrosis, pain/ tenderness), site should be changed immediately Evaluate: Therapeutic response Treatment of Overdose Insulin; discontinue product; supportive care Pharmaceuticals 191 Dextrose Dextrose Dosage and Routes Refer to specific protocol A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Diazepam Mechanism of Action Potentiates the actions of GABA, especially in the limbic system, reticular formation; enhances presympathetic inhibition, inhibits spinal polysynaptic afferent paths Uses Anxiety, EtOH withdrawal, seizure disorder, muscle relaxation Contraindications Pregnancy (D), hypersensitivity to benzodiazepines, closed -angle glaucoma, myasthenia gravis, EtOH intoxication, liver disease Precautions Breastfeeding, children <6 months, geriatric patients, COPD, CNS depression, labor, Parkinson’s disease, psychosis Side Effects CNS: Dizziness, drowsiness, confusion, headache, anxiety, tremors, fatigue, hallucinations, ataxia CV: Orthostatic hypotension, tachycardia, hypotension EENT: Blurred vision, tinnitus, mydriasis, nystagmus GI: Constipation, dry mouth, nausea, vomiting, anorexia, diarrhea Heme: Neutropenia Resp: Respiratory depression Pharmacokinetics Metabolized by the liver via CYP2C19, CYP3A4; excreted by kidneys, crosses the placenta, excreted in breast mild; crosses the blood-brain barrier; half life 20-50 hours. IM: Onset 15-30min, duration 1-1½ hour; IV: Onset immediate, duration 15 min-1 hour Interactions Increase: Diazepam effect – amiodarone, diltiazem, disulfiram, ketoconazole, nicardipine, verapamil, valproic acid Increase: toxicity – barbiturates, SSRIs, cimetidine, CNS depressants, valproic acid, CYP3A4 inhibitors Increase: CNS depression – EtOH Decrease: Diazepam metabolism – oral contraceptives, valproic acid, disulfiram, propranolol Decrease: Diazepam effect – CYP3A4 inducers (rifampin, barbiturates, carbamazepein, phenytoin, fosphenytoin), smoking EMT Considerations Assess BP (lying, standing), pulse; respiratory rate, Assess EtOH withdrawal symptoms, including hallucinations (visual, auditory), delirium, irritability, agitation, fine or coarse tremor Assess IV site for thrombosis or phlebitis, which may occur rapidly Evaluate therapeutic response – decreased anxiety, restlessness, muscle spasms Treatment of Overdose Discontinue product, supportive care, monitor VS Pharmaceuticals 192 Diazepam Diazepam Dosage and Routes Seizure Refer to specific protocol A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Diltiazem Mechanism of Action Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle, dilates coronary arteries, slows SA/AV node conduction times, dilates peripheral arteries Uses Angina pectoris due to coronary artery spasm, hypertension, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia Dosage and Routes Atrial fibrillation/flutter, paroxysmal supraventricular tachycardia Refer to specific protocol Rapid ventricular rate secondary to dysrhythmias (unlabeled) Refer to specific protocol Side Effects CNS: Headache, fatigue, drowsiness, dizziness, depression, weakness, insomnia, tremor, paresthesias CV: dysrhythmia, edema, CHF, bradycardia, hypotension, palpitations, heart block GI: Nausea, vomiting, diarrhea, gastric upset, constipation, increased LFTs GU: Nocturia, polyuria, acute renal failure Skin: Rash, flushing, photosensitivity, burning or itching at injection site Resp: Rhinitis, dyspnea, pharyngitis Pharmacokinetics Metabolized by the liver, excreted in the urine (96% as metabolites) IV – onset 30-60 min; peak 2-3 hours Interactions Increase: toxic effects – theophylline Increase: effects of -blockers, digoxin, lithium, carbamazepine, cyclosporine, anesthetics, HMG-CoA reductase inhibitorys, benzodiazepines, lovastatin, methylprednisolone Increase: effects of diltiazem – cimetidine EMT Considerations Assess for CHF – look for dyspnea, weight gain, edema, jugular venous distention, rales, Assess dysrhythmias – BP, pulse, respiratory rate, ECG and PR intervals, QRS and QT intervals Treatment of Overdose Discontinue product, atropine for AV block, vasopressors for hypotension Pharmaceuticals 193 Diltiazem Diltiazem Contraindications Sick sinus syndrome, AV heart block, hypotension <90mmHg systolic, acute MI, pulmonary congestion, cardiogenic shock Precautions Pregnancy (C), breastfeeding, children, geriatric patients, CHF, aortic stenosis, bradycardia, GERD, hepatic disease, hiatal hernia, ventricular dysfunction A P M Legend EMT A-EMT Paramedic Medical Control Pharmaceuticals Diphenhydramine Mechanism of Action Acts on blood vessels, GI, respiratory system by competing with histamine for H1-receptor site; decreases allergic response by blocking histamine Uses Allergy symptoms, rhinitis, motion sickness, antiparkinsonism, nighttime sedation, nonproductive cough Dosage and Routes Refer to specific protocol Side Effects CNS: Dizziness, drowsiness, poor coordination, fatigue, anxiety, euphoria, confusion, paresthesia, neuritis, seizures CV: hypotension, palpitations EENT: Blurred vision, dilated pupils, tinnitus, nasal stuffiness, dry nose, throat mouth GI: Nausea, anorexia, diarrhea GU: Retention, dysuria, frequency Heme: thrombocytopenia, agranulocytosis, hemolytic anemia Misc: Anaphylaxis Resp: Increased thick secretions, wheezing, chest tightness Pharmacokinetics Metabolized in liver, excreted by kidneys, crosses placenta, excreted in breast milk, half life 2-7 hours. IM – onset ½ hour, peak 14 hours, duration 4-7 hours. IV – onset immediate, duration 4-7 hours Interactions Increase: CNS depression – barbiturates, opiates, hypnotics, tricyclics, EtOH Increase: diphenhydramine effect – MAOIs EMT Considerations Assess for urinary retention, frequency, dysuria Assess respiratory status – rate, rhythm, increase in bronchial secretions, wheezing, chest tightness Treatment of Overdose Discontinue product, administer diazepam for seizures, vasopressors for hypotension, phenytoin for refractory seizures Pharmaceuticals 194 Diphenhydramine Diphenhydramine Contraindications Hypersensitivity to H1-receptor antagonist, acute asthma attack, lower respiratory tract disease, neonates Precautions Pregnancy (B), breastfeeding, children <2 years old, increased intraocular pressure, cardiac/renal disease, hypertension, bronchial asthma, seizure disorder, stenosed peptic ulcers, hyperthyroidism, prostatic hypertrophy, bladder neck obstruction A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Dopamine Mechanism of Action Causes increased cardiac output; acts on β1 and α- receptors, causing vasoconstriction in blood vessels; low dose causes renal and mesenteric vasodilation; β1 stimulation produces inotropic effects with increased cardiac output Uses Shock, increased perfusion, hypotension, cardiogenic/septic shock Unlabeled Uses: Bradycardia, cardiac arrest, CPR, acute renal failure, cirrhosis, barbiturate intoxication Contraindications Hypersensitivity, ventricular fibrillation, tachydysrhthmias, pheochromocytoma, hypovolemia Precautions: Pregnancy (C), breastfeeding, geriatric patients, arterial embolism, peripheral vascular disease, sulfite hypersensitivity, acute MI Black Box Warning: Extravasation Side Effects CNS: Headache, anxiety CV: Palpitations, tachycardia, hypertension, ectopic beasts, angina, wide QRS complex, peripheral vasoconstriction, hypotension GI: Nausea, vomiting, diarrhea Rash: Necrosis, tissue sloughing with extravasation, gangrene Resp: Dyspnea Pharmacokinetics IV: Onset 5 minutes, duration <10 min; metabolized in liver/kidney/plasma; excreted in urine (metabolites); half-life 2 min Interactions Do not use within 2 weeks of MAOIs; hypertensive crisis may result Increase: bradycardia, hypotension—phenytoin Increase: dysrhythmias—general anesthetics Increase: severe hypertension—ergots Increase: blood pressure—oxytocics Increase: pressor effect—tricyclics, MAOIs Decrease: dopamine action – β/α blockers EMT Considerations Assess: Hypovolemia, oxygenation/perfusion deficits (check BP, chest pain, dizziness, loss of consciousness), heart failure (dyspnea, neck venous distension, bibasilar crackles), ECG (monitor continuously, if BP increase consider decreasing dosing), parasthesias/coldness (peripheral blood flow may decrease), injection site Preform/Provide: Storage of reconstituted solution for up to 24 hour if refrigerated, do not use discolored solution; protect from light Evaluate: Therapeutic response (increase BP) Treatment of Overdose Discontinue IV, may give short-acting α-adrenergic blocker Pharmaceuticals 195 Dopamine Dopamine Dosage and Routes Refer to specific protocol A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals DuoDote Kit The DuoDote autoinjector provides a single intramuscular dose of the anti-nerve agent medications atropine and pralidoxime chloride in a self contained unit. The kits are only effective against the nerve agents tabun (GA), sarin (GB), soman (GD) and VX. It may also be used in cases of agricultural insecticide exposure, as organophosphates are a key component of the agent. Common examples of insecticides using organophosphates are malathion, parathion, diazinon, fenthion, dichlorvos, ethion and trichlorfon. Mechanism of Action Atropine counters the parasympathetic response from the muscarinic receptor overstimulation associated with organophosphate and nerve agent poisoning, and reverses the SLUDGEM symptoms. Pralidoxime chloride (“2-PAM”) binds to the organophosphate or nerve agent and changes the conformation of the molecule, which causes it to lose its binding to the acetylcholinesterase enzyme. The joined poison / antidote then releases from the site and regenerates the enzyme, allowing it to function again. Contraindications None in the emergency setting. Precautions Known hypersensitivity to the DuoDote or Mark I Kit and Pediatric patients under the age of 3 are relatively contraindicated. Dosage and Routes Each kit contains: Atropine 2.1mg and Pralidoxime chloride 600mg Minor initial symptoms – administer ONE DuoDote Kit via autoinjector (IM) Severe symptoms appearing within 10 minutes of first dose – administer ONE additional DuoDote Kit via autoinjector (IM) Severe symptoms present from the beginning – administer THREE DuoDote Kits via autoinjector (IM) Side Effects HEENT: Dry mouth Skin: Flushing CNS: Dilated pupils, Headache, Drowsiness CV: Tachycardia Interactions Morphine, theophylline, aminophylline and succinylcholine should be avoided in patients with organophosphate poisoning. Barbiturates are potentiated by the anticholinesterase enzyme and should be used cautiously when treating seizures in the poisoned patient. EMT Considerations The use of a DuoDote Kit offers no prophylactic protection and should be administered only if symptoms are present. There is a high potential for “off-gassing” from patients exposed to both organophosphates and nerve agents. In cases of “offgassing”, vapors are given off by chemically contaminated clothing or exhaled by poisoned individuals. EMS Providers should use all appropriate PPE including SCBA and be vigilant when monitoring for symptoms in themselves and other responders. These patients are generally NOT safe for transport by Helicopter EMS (HEMS). Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 196 DuoDote Kit DuoDote Kit Uses Organophosphate and nerve agent poisonings. A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Epinephrine Mechanism of Action β1- and β2-agonist causing increased levels of cAMP, thereby producing bronchodilation, cardiac and CNS stimulation; high doses cause vasoconstriction via alpha-receptors; low doses can cause vasodilation vai β2-vascular receptors Uses Acute asthma attacks, hemostasis, bronchospasm, anaphylaxis, allergic reactions, cardiac arrest, shock Dosage and Routes Anaphylaxis / Severe asthma exacerbation Refer to specific protocol Cardiac arrest Refer to specific protocol Hypotension Refer to specific protocol Side Effects CNS: Tremors, anxiety, insomnia, headache, dizziness, confusion, hallucinations, cerebral hemorrhage, weakness, drowsiness CV: Palpitations, tachycardia, hypertension, dysrhythmias, increased T wave GI: Anorexia, nausea, vomiting MISC: Sweating, dry eyes Resp: Dyspnea Pharmacokinetics Crosses placenta, metabolized in the liver. IM – onset variable, duration 1-4 hours; Inhaled - onset 1-5 minutes, duration 1-3 hours Interactions Do not use with MAOIs or tricyclics; hypertensive crisis may occur. Toxicity: other sympathomimetics Decrease: hypertensive effects – β-adrenergic blockers EMT Considerations Assess Asthma – auscultate lungs, pulse, BP, respiratory rate and effort, sputum ECG completed when continuous albuterol administered Sulfite sensitivity may be life-threatening Allergic reactions, bronchospasms Treatment of Overdose Discontinue product, administer α -blocker and β -blocker Pharmaceuticals 197 Epinephrine Epinephrine Contraindications Hypersensitivity to sympathomimetics, sulfites, closed-angle glaucoma, nonanaphylactic shock during general anesthesia Precautions Pregnancy (C), breastfeeding, cardiac disorders, hyperthyroidism, diabetes mellitus, prostatic hypertrophy, hypertension, organic brain syndrome, local anesthesia in certain areas, labor, cardiac dilation, coronary insufficiency, cerebral atherosclerosis, organic heart disease A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Etomidate Mechanism of Action Ultrashort-acting nonbarbiturate hypnotic used for rapid induction of anesthesia with minimal cardiovascular effects; modulates GABAA receptors to induce general anesthesia. Does NOT have any analgesic properties Uses Conscious sedation, anesthesia for rapid-sequence intubation Unlabeled uses: determine speech lateralization in patients prior to lobectomies to remove epileptogenic centers in the brain Dosage and Routes Induction of anesthesia Refer to specific protocol Side Effects Suppresses corticosteroid synthesis in the adrenal cortex by inhibiting 11-beta-hydroxylase, an enzyme important in adrenal steroid production. CV: Arrhythmias, bradycardia, HTN, hypotension GI: Nausea, vomiting on emergence from anesthesia MS: Pain at injection site Resp: Hiccups, laryngospasm, hypoventilation Pharmacokinetics Protein binding 76%, metabolized by hepatic and plasma esterases, excreted by kidneys, half life 1.25 hours IV – Onset in 30-60 seconds, peak within 1 minute, duration approximately 3-5 minutes Interactions No interactions listed on Lexi-Comp EMT Considerations Administer IV push over 30-60 seconds. Solution is highly irritating to small vessels Assess vital signs, note muscle tone prior to and after injection, drug history, hepatic or renal failure Assess for CNS changes – dizziness, somnolence, hallucinations, euphoria, LOC Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 198 Etomidate Etomidate Contraindications Hypersensitivity Precautions Renal impairment, Elderly patients, Pregnancy category (C), unknown if excreted in breast milk A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Famotidine Mechanism of Action Competitively inhibits histamine at histamine H2-receptor site, thus decreasing gastric secretion while pepsin remains at a stable level. Uses Short-term treatment of active duodenal ulcer, maintenance therapy for duodenal ulcer, Zollinger-Ellison syndrome, multiple endocrine adenomas, gastric ulcers; gastroesophageal reflux disease, heartburn Unlabeled uses: GI disorders in those taking NSAIDs; urticaria; prevention of stress ulcers, aspiration pneumonitis, inactivation of oral pancreatic enzymes in pancreatic disorders Dosage and Routes Allergic Reaction Refer to specific protocol Side Effects CNS: Headache, dizziness, paresthesia, depression, anxiety, somnolence, insomnia, fever, seizures in renal disease CV: Dysrhythmias, QT prolongation in impaired renal function EENT: Taste change, tinnitus, orbital edema Skin: Rash, toxic epidermal necrolysis, Stevens-Johnson syndrome MS: Myalgias, arthralgias Resp: Pneumonia Pharmacokinetics Plasma protein binding 15-20%, metabolized in liver 30% (active metabolites), 70% excreted by kidneys, half life 2½-3½ hours; IV – onset immediate, peak 30-60 minutes, duration 8-15 hours Interactions Decrease: absorption – ketoconazole, itraconazole, cefpodoxime, cefditoren Decrease: famotidine absorption – antacids Decrease: effect of – atazanavir, delavirdine EMT Considerations Assess for signs of ulcers – epigastric pain, abdominal pain, frank or occult blood in emesis Assess for signs of allergic reaction – redness, hives, itching Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 199 Famotidine Famotidine Contraindications Hypersensitivity Precautions Pregnancy (B), breastfeeding, children <12 years old, geriatric patients, severe renal/hepatic disease A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Fentanyl Mechanism of Action Inhibits ascending pain pathways in the CNS, increases pain threshold, alters pain perception by binding to opiate receptors Uses Controls moderate to severe pain; adjunct to general anesthetic, adjunct to regional anesthesia; conscious sedation Contraindications Hypersensitivity to opiates, myasthenia gravis Precautions Pregnancy (C), breastfeeding, geriatric patients, increased intracranial pressure, seizure disorders, severe respiratory disorders, cardiac dysrhythmias Side Effects CNS: Dizziness, euphoria, sedation CV: Bradycardia, arrest, hypo/hypertension EENT: Blurred vision, miosis GI: Nausea, vomiting, constipation Skin: Rash, diaphoresis MS: Muscle rigidity Resp: Respiratory depression, arrest, laryngospasm Fentanyl Fentanyl Dosage and Routes Moderate / Severe Pain Refer to specific protocol Pharmacokinetics Metabolized by liver, excreted by kidneys, crosses placenta, excreted in breast milk. Half-life IV: 2-4 hours IM: onset 7-8 minutes, peak 30 minutes, duration 1-2 hours. IV: Onset 1 minute, peak 3-5 minutes, duration ½ - 1 hour Interactions Increase: fentanyl effect (fetal respiratory depression) – cyclosporine, ketoconazole, cimetidine, fluconazole, nefazodine, zafrilukast Increase: hypotension – droperidol Increase: CV depression – diazepam Increase: fentanyl effect with other CNS depressants – EtOH, opioids, sedative/hypnotics, antipsychotics, skeletal muscle relaxants, protease inhibitors Decrease: fentanyl effect – CYP3A4 inducers (carbamazepine, phenytoin, phenobarbital, rifampin) EMT Considerations Assess vital signs, note muscle rigidity, drug history, hepatic or renal failure Assess for CNS changes – dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction Treatment of Overdose Discontinue product, naloxone Pharmaceuticals 200 A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Glucagon Mechanism of Action Increases in blood glucose, relaxation of smooth muscle of the GI tract, and a positive inotropic and chronotropic effect on the heart; increases in blood glucose are secondary to stimulation of glycogenolysis Uses Hypoglycemia, used to temporarily inhibit movement of GI tract as a diagnostic test Dosage and Routes Hypoglycemia Refer to specific protocol Glucagon Glucagon Contraindications Hypersensitivity, pheochromocytoma, insulinoma (insulin-secreting tumor) Side Effects CNS: Dizziness, headache, CV: Hypotension GI: Nausea, vomiting Pharmacokinetics IV: Onset immediate, peak 30 minutes, duration 1-1½ hours IM: Onset 5-10 minutes, peak 13-20 minutes, duration 12-30 minutes Interactions Increase: Bleeding risk – anticoagulants EMT Considerations Assess for hypoglycemia – monitor blood glucose levels before and after use; use other products to control hypoglycemia if patient is conscious Treatment of Overdose Discontinue product, supportive care Pharmaceuticals 201 A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Glucose Mechanism of Action Needed for adequate utilization of amino acids; decreases protein, nitrogen loss; prevents ketosis Uses Increases intake of calories; increases fluids in patients unable to take adequate fluids, calories orally; acute hypoglycemia Dosage and Routes Hypoglycemia Refer to specific protocol Side Effects CNS: confusion, loss of consciousness, dizziness CV: hypertension, CHF, pulmonary edema, intracranial hemorrhage Endo: Hyperglycemia, rebound hypoglycemia, hyperosmolar syndrome, hyperglycemic non-ketotic syndrome, aluminum toxicity, hypokalemia, hypomagnesium GI: Nausea GU: Glycosuria, osmotic diuresis Skin: Chills, flushing, warm feeling, rash, urticarial, extravasation necrosis Resp: Pulmonary edema Pharmacokinetics Metabolized at the cellular level to carbon dioxide and water Oral – onset 10 minutes, peak 40 minutes Interactions Increase: fluid retention/electrolyte excretion—corticosteroids EMT Considerations Assess: Mental status and appropriateness for oral medications, electrolytes (Potassium), blood glucose Evaluate: Therapeutic response Treatment of Overdose Insulin, IVF, discontinue product, supportive care Pharmaceuticals 202 Glucose (Oral) Glucose (Oral) Contraindications Inability to swallow effectively, impaired airway reflexes / inability to protect airway, hyperglycemia, delirium tremens, hemorrhage (cranial/spinal), CHF, anuria, allergy to corn products Precautions Cardiac/renal/hepatic disease, diabetes mellitus, carbohydrate intolerance A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Haloperidol Mechanism of Action Depresses cerebral cortex, hypothalamus, limbic system, which control activity and aggression; blocks neurotransmission produced by dopamine at synapse; exhibits, strong α-adrenergic, anticholinergic blocking action; mechanism for antipsychotic effects unclear Uses Psychotic disorders, control of tics, vocal utterances in Gilles de la Tourette’s syndrome, short-term treatment of hyperatcive children showing excessive motor activity, prolonged parenteral therapy in chronic schizophrenia, organic mental syndrome with psychotic features, hiccups (short-term), emergency sedation of severely agitated or delirious patients, ADHD Unlabeled uses: Intraoperative nausea, vomiting; autism; migraine Dosage and Routes Refer to specific protocol Side Effects CNS: EPS – pseudoparkinsonism, akathisia, dystonia, tardive dyskinesia, drowsiness, headache, seizures, neuroleptic malignant syndrome, confusion CV: Orthostatic hypotension, hypertension, cardiac arrest, ECG changes, tachycardia, QT prolongation, sudden death, torsades de pointes EENT: Blurred vision, glaucoma, dry eyes GI: Dry mouth, nausea, vomiting, anorexia, constipation, diarrhea, jaundice, weight gain, ileus, hepatitis GU: Urinary retention, dysuria, urinary frequency, enuresis, impotence, amenorrhea, gynecomastia Skin: Rash, photosensitivity, dermatitis Resp: laryngospasm, dyspnea, respiratory depression Pharmacokinetics Metabolized by liver, excreted in urine, bile; crosses placenta; enters breast mild; protein binding 92%; terminal half-life 12-36 hours (metabolites) IM: Onset 15-30 minutes, peak 15-20 minutes, half life 21 hours Interactions Increase: serotonin syndrome, neuroleptic malignant syndrome – SSRIs, SNRIs Increase: QT prolongation – class 1A, III antidysrhythmics, tricyclics, amoxapine, maprotiline, phenothiazines, pimozide, risperidone, sertindole, ziprasidone, β-blockers, chloroquine, clozapine, dasatinib, dolasetron, droperidol, dronedarone, flecainide, methadone, erythromycin, ondansetron, tacrolimus Increase: oversedation – other CNS depressants, EtOH, barbiturate anesthetics Increase: toxicity – epinephrine, lithium Decrease: effects – lithium, levodopa EMT Considerations Assess patient response to medications, scene safety, evaluate for dystonic reaction Treatment of Overdose Discontinue product, supportive care, ECG monitoring, diphenhydramine for dystonia Pharmaceuticals 203 Haloperidol Haloperidol Contraindications Hypersensitivity, coma, Parkinson’s disease Precautions Pregnancy (C), breastfeeding, geriatric patients, seizure disorders, hypertension, pulmonary/cardiac/hepatic disease, QT prolongation, torsades de pointes, prostatic hypertrophy, hyperthyroidism, thyrotoxicosis, children, blood dyscrasias, brain damage, bone marrow depression, EtOH and barbiturate withdrawal states, angina, epilepsy, urinary retention, closed angle glaucoma, CNS depression Black Box Warning: Increased mortality in elderly patients with dementia-related psychosis A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Hydroxocobalamin Mechanism of Action Precursor to cyanocobalamin (vitamin B12). Cyanocobalamin acts as a coenzyme for various metabolic functions including fat and carbohydrate metabolism and protein synthesis. In the presence of cyanide, each hydroxocobalamin molecule can bind one cyanide ion and form cyanocobalamin, which is then excreted in the urine. Uses Cyanide antidote, vitamin B12 deficiency, pernicious anemia, vitamin B12 malabsorption syndrome, increased requirements with pregnancy, thyrotoxicosis, hemolytic anemia, hemorrhage, renal/hepatic disease, nutritional supplementation Hydroxocobalamin Hydroxocobalamin Contraindications Hypersensitivity, optic nerve atrophy Precautions Pregnancy (A), breastfeeding, children Dosage and Routes Acute Cyanide Poisoning Refer to specific protocol Side Effects CNS: Flushing, optic nerve atrophy CV: CHF, peripheral vascular thrombosis, pulmonary edema GI: Diarrhea Skin: Itching, rash, pain at injection site Endo: Hypokalemia Systemic: Anaphylactic shock Pharmacokinetics Stored in liver/kidneys/stomach; 50%-90% excreted in urine; crosses placenta; excreted in breast milk Interactions Increase: absorption—prednisone Decrease: absorption—aminoglycosides, anticonvulsants, colchicine, chloramphenicol, aminosalicylic acid, potassium preparations, cimetidine EMT Considerations Assess: For vitamin B12 deficiency (red/beefy tongue, psychosis, pallor, neuropathy); For pulmonary edema, worsening of CHF in cardiac patients Perform/provide: Protection from light, heat Evaluate: Therapeutic response:, dyspnea on exertion, palpitations, paresthesias, psychosis, visual disturbances Treatment of Overdose Discontinue product, IVF, supportive care Pharmaceuticals 204 A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Ipratropium Mechanism of Action Inhibits interaction of acetylcholine at receptor sites on the bronchial smooth muscle, thereby resulting in decreased cGMP and bronchodilation Uses COPD, Asthma Dosage and Routes Wheezing / Dyspnea Refer to specific protocol Ipratropium Ipratropium Contraindications Hypersensitivity to this product, atropine, bromide, soybean or peanut products Precautions Breastfeeding, children <12 yr, angioedema, heart failure, surgery, acute bronchospasm, bladder obstruction, closed-angle glaucoma, prostatic hypertrophy, urinary retention, pregnancy (B) Side Effects CNS: Anxiety, dizziness, headache, nervousness CV: Palpitations EENT: Dry mouth, blurred vision, nasal congestion GI: Nausea, vomiting, cramps Skin: Rash RESP: Cough, worsening of symptoms, bronchospasms Pharmacokinetics 15% of dose reaches lower airways. Protein binding <9%, half-life elimination 2 hours INH – onset 15 minutes, peak 1-2 hours, duration 2-5 hours Interactions Increase: toxicity—other bronchodilators (INH) Increase: anticholinergic action—phenothiazines, antihistamines, disopyramide EMT Considerations Assess: Palpitations; respiratory status (rate, rhythm, auscultate breath sounds prior to and after administration Perform/provide: Storage at room temp Evaluate: Therapeutic response: ability to breathe adequately Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 205 A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Ketamine Mechanism of Action Produces a cataleptic-like state in which the patient is dissociated from the surrounding environment by direct action on the cortex and limbic system. Noncompetitive NMDA receptor antagonist that blocks glutamate in the brain. Low doses produce analgesia and modulate central sensitization, hyperalgesia and opioid tolerance. Reduces polysynaptic spinal reflexes. Uses Induction and maintenance of general anesthesia Unlabeled uses: Complex regional pain syndrome, analgesia, sedation Dosage and Routes Behavioral Emergencies Refer to specific protocol Analgesia Refer to specific protocol Side Effects CNS: Prolonged emergence, confusion, hallucinations, irrational behavior, increased CSF pressure, hypertonia (may resemble seizures), drug dependence CV: Bradycardia, arrhythmia, hypotension, HTN, tachycardia Derm: Erythema (transient), morbilliform rash (transient), rash at injection site Endo: Central diabetes insipidus GI: Anorexia, nausea, sialorrhea (drooling), vomiting EENT: Diplopia, increased intraocular pressure, nystagmus Resp: Airway obstruction, apnea, respiratory depression, laryngospasm Pharmacokinetics Metabolized in liver via hydroxylation and N-demehtylation, excreted primarily in the urine IV – onset 30 seconds, peak 5-10 minutes; IM – onset 3-4 minutes, peak 12-25 minutes. Half life 2.5 hours Interactions Increase: CNS depression – alcohol, buprenorphine, cannabis, magnesium sulfate, minocycline, mirtazapine, zolpidem, hydrocodone, antihistamines, thalidomide Increase: active metabolites – quazepam, stiripentol,memantine Ketamine may increase the toxic effects of – memantine, mifepristone, thiopental, SSRI antidepressants EMT Considerations Assess heart rate, blood pressure, respiratory rate, SpO2 Assess for emergence reaction Assess cardiac function continuously in patients with increased blood pressure or cardiac decompensation Treatment of Overdose Discontinue product; respiratory support for laryngospasm and respiratory depression, airway suctioning for increased salivation and secretions, supportive care for psychomotor agitation and hallucinations Pharmaceuticals 206 Ketamine Ketamine Contraindications Hypersensitivity, conditions in which increased blood pressure would be hazardous. Additional contraindications per American College of Emergency Physicians (ACEP) – Infants <3 months of age, known or suspected schizophrenia (even if currently stable or controlled with medications) Precautions Increased intracranial pressure, increased ocular pressure, thyroid disorders, cardiovascular disease, respiratory depression, airway complications, CNS depression, emergence reaction Ketamine crosses the placenta and can be detected in fetal tissue; it is not known if ketamine is excreted in breast milk A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Lidocaine Mechanism of Action Increases electrical stimulation threshold of ventricle, His-Purkinje system, which stabilizes cardiac membrane, decreases automaticity Uses Ventricular tachycardia, ventricular dysrhythmias during cardiac surgery, digoxin toxicity, cardiac catheterization Unlabeled uses: Attenuation of intracranial pressure increases during intubation/endotracheal tube suctioning Contraindications Hypersensitivity to amides, severe heart block, supraventricular dysrhythmias, Adams-Stokes syndrome, Wolff-Parkinson-White syndrome Precautions: Pregnancy (B), breastfeeding, children, geriatric patients, renal/hepatic disease, CHF, respiratory depression, malignant hyperthermia, myasthenia gravis, weight <50 kg Side Effects CNS: Headache, dizziness, involuntary movement, confusion, tremor, drowsiness, euphoria, seizures, shivering CV: Hypotension, bradycardia, heart block, CV collapse, arrest EENT: Tinnitus, blurred vision GI: Nausea, vomiting, anorexia Hematology: Methemoglobinemia Skin: Rash, urticaria, edema, swelling, petechiae, pruritus Misc: Febrile response, phlebitis at injection site Resp: Dyspnea, respiratory depression Pharmacokinetics Half-life 8 min, 1-2 hr (terminal); metabolized in liver; excreted in urine; crosses placenta IV: Onset 2 minutes, duration 20 min Interactions Increase: cardiac depression, toxicity—amiodarone, phenytoin, procainamide, propranolol Increase: hypotensive effects—MAOIs, antihypertensives Increase: neuromuscular blockade—neuromuscular blockers, tubocurarine Increase: lidocaine effects—cimetidine, beta blockers, protease inhibitors, ritonavir Decrease: lidocaine effects—barbiturates, ciprofloxacin, voriconazole Decrease: effect of—cyclosporine Decrease: effect—coltsfoot EMT Considerations Assess: ECG continuously to determine increased PR or QRS segments; if these develop, discontinue or reduce rate; watch for increased ventricular ectopic beats, may have to re-bolus; Blood pressure; Malignant hyperthermia (tachypnea, tachycardia, changes in BP, increased temp); Respiratory status (rate, rhythm, lung fields for crackles, watch for respiratory depression); CNS effects (dizziness, confusion, psychosis, paresthesias, convulsions-- product should be discontinued) Evaluate: Therapeutic response: decreased dysrhythmias Treatment of Overdose Discontinue product, O2, artificial ventilation, ECG; administer Dopamine for circulatory depression, diazepam for seizures Pharmaceuticals 207 Lidocaine Lidocaine Dosage and Routes Cardiac Arrhythmia Refer to specific protocol Increased Intracranial Pressure Refer to specific protocol A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Lorazepam Mechanism of Action Potentiates the actions of GABA, especially in the limbic system and the reticular formation Uses Anxiety, irritability with psychiatric or organic disorders, preoperatively; insomnia; adjunct for endoscopic procedures, status epilepticus Unlabeled uses: Antiemetic prior to chemotherapy, rectal use, alcohol withdrawal, seizure prophylaxis, agitation, insomnia, sedation maintenance Dosage and Routes Anxiolysis Refer to specific protocol Seizure Refer to specific protocol Side Effects CNS: Dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation, fatigue, depression, insomnia, hallucinations, weakness, unsteadiness CV: Orthostatic hypotension, ECG changes, tachycardia, hypotension; apnea, cardiac arrest (IV, rapid) EENT: Blurred vision, tinnitus, mydriasis GI: Constipation, dry mouth, nausea, vomiting, anorexia, diarrhea Skin: Rash, dermatitis, itching Misc: Acidosis Pharmacokinetics Metabolized by liver; excreted by kidneys; crosses placenta, excreted in breast milk; half-life 14 hr IM: Onset 15-30 min, peak 1-1.5 hours; duration 6-8 hours IV: Onset 5-15 min, peak unknown, duration 6-8 hours Interactions Increase: Lorazepam effects—CNS depressants, alcohol, disulfiram, oral contraceptives Decrease: Lorazepam effects—valproic acid EMT Considerations Assess: Anxiety (decrease in anxiety; mental status); Physical dependency (withdrawal symptoms: headache, nausea, vomiting, muscle pain, weakness, tremors, seizures) Perform/provide: Assistance with ambulation during beginning therapy, since drowsiness, dizziness occurs; Refrigerate parenteral form Evaluate: Therapeutic response: decreased anxiety, restlessness Treatment of Overdose GI lavage, VS, supportive care, flumazenil Pharmaceuticals 208 Lorazepam Lorazepam Contraindications Pregnancy (D), breastfeeding, hypersensitivity to benzodiazepines, benzyl alcohol; closed-angle glaucoma, psychosis, history of drug abuse, COPD, sleep apnea Precautions: Children <12 yr, geriatric patients, debilitated, renal/hepatic disease, addiction, suicidal ideation, abrupt discontinuation A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Magnesium Mechanism of Action When taken orally, promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity. Parenteral infusion decreases acetylcholine in motor nerve terminals and acts on myocardium by slowing rate of SA node impulse formation and prolonging conduction time. Magnesium is necessary for the movement of calcium, sodium and potassium into and out of the cells as well as stabilizing excitable membranes. Uses Anticonvulsant for preeclampsia/eclampsia Unlabeled uses: persistent pulmonary hypertension of the newborn (PPHN), cardiac arrest, CPR, digitoxin/digoxin toxicity, premature labor, seizure prophylaxis, status asthmaticus, torsades de pointes, ventricular fibrillation/tachycardia Dosage and Routes Preeclampsia / Eclampsia Refer to specific protocol Torsades de Pointes Refer to specific protocol Side Effects CNS: Muscle weakness, flushing, sweating, confusion, sedation, depressed reflexes, flaccid paralysis, hypothermia CV: Hypotension, heart block, circulatory collapse, vasodilation GI: Nausea, vomiting, anorexia, cramps, diarrhea Hematology: Prolonged bleeding time Metabolic: Electrolyte, fluid imbalances Resp: Respiratory depression/paralysis Pharmacokinetics Protein binding 30% to albumin, excreted in the urine as magnesium IM – onset 1 hour, duration 3-4 hours; IV – onset immediate, duration 30 min Interactions Increase: effect of neuromuscular blockers Increase: hypotension—antihypertensives Decrease: absorption of tetracyclines, fluoroquinolones, nitrofurantoin Decrease: effect of digoxin EMT Considerations Assess: Eclampsia (seizure precautions, BP, ECG) Evaluate: Therapeutic response (absence of seizures, stabilization of dysrhythmia, improvement in respiratory status) Treatment of Overdose Discontinue product; support respirations with positive pressure ventilation, supportive care Pharmaceuticals 209 Magnesium Magnesium Contraindications Hypersensitivity, abdominal pain, nausea/vomiting, obstruction, acute surgical abdomen, rectal bleeding, heart block, myocardial damage Precautions: Pregnancy (A), renal/cardiac disease A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Mark 1 Kit Mark I NAAK (“Nerve Agent Antidote Kit”) is a dual-chamber autoinjector with two anti-nerve agent drugs. The kits are only effective against the nerve agents tabun (GA), sarin (GB), soman (GD) and VX. It may also be used in cases of agricultural insecticide exposure, as organophosphates are a key component of the agent. Common examples of insecticides using organophosphates are malathion, parathion, diazinon, fenthion, dichlorvos, ethion and trichlorfon. Mechanism of Action Atropine counters the parasympathetic response from the muscarinic receptor overstimulation associated with organophosphate and nerve agent poisoning, and reverses the SLUDGEM symptoms. Pralidoxime chloride (“2-PAM”) binds to the organophosphate or nerve agent and changes the conformation of the molecule, which causes it to lose its binding to the acetylcholinesterase enzyme. The joined poison / antidote then releases from the site and regenerates the enzyme, allowing it to function again. Uses Organophosphate and nerve agent poisonings. Mark I Kit Dosage and Routes Each kit contains: Atropine 2mg and Pralidoxime chloride 600mg Minor initial symptoms – administer ONE Mark I Kit via autoinjector (IM) Severe symptoms appearing within 10 minutes of first dose – administer ONE additional Mark I Kit via autoinjector (IM) Severe symptoms present from the beginning – administer THREE Mark I Kits via autoinjector (IM) Tube one (atropine) is always administered before tube two (2-PAM) Side Effects HEENT: Dry mouth Skin: Flushing CNS: Dilated pupils, Headache, Drowsiness CV: Tachycardia Interactions Morphine, theophylline, aminophylline and succinylcholine should be avoided in patients with organophosphate poisoning. Barbiturates are potentiated by the anticholinesterase enzyme and should be used cautiously when treating seizures in the poisoned patient. EMT Considerations The use of a Mark I Kit offers no prophylactic protection and should be administered only if symptoms are present. There is a high potential for “off-gassing” from patients exposed to both organophosphates and nerve agents. In cases of “offgassing”, vapors are given off by chemically contaminated clothing or exhaled by poisoned individuals. EMS Providers should use all appropriate PPE including SCBA and be vigilant when monitoring for symptoms in themselves and other responders. These patients are generally NOT safe for transport by Helicopter EMS (HEMS). Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 210 Mark I Kit Contraindications None in the emergency setting. Precautions Known hypersensitivity to the Mark I or DuoDote Kit and Pediatric patients under the age of 3 are relatively contraindicated. A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Methylprednisolone Mechanism of Action In a tissue-specific manner, corticosteroids regulate gene expression subsequent to binding specific intracellular receptors and translocation into the nucleus. Corticosteroids exert a wide array of physiologic effects including modulation of musculoskeletal, endocrine and neurologic physiology are influenced by corticosteroids. Decreases inflammation by suppression of migration of polymorphonuclear leukocytes, reversal of increased capillary permeability, and lysosomal stabilization Uses Anaphylaxis, Asthma, COPD. Used primarily as an anti-inflammatory or immunosuppressant agent in the treatment of a variety of diseases. Unlabeled uses: bronchiolitis, cadaveric organ recovery, COPD exacerbation Dosage and Routes Wheezing / Dyspnea Refer to specific protocol Side Effects CNS: Sedations, fatigue, restlessness, headache, sleeplessness, dystonia, dizziness, suicidal ideation, seizures, neuroleptic malignant syndrome, tardive dyskinesia (>3 months at high doses) CV: hypotension, SVT GI: Dry mouth, constipation, nausea, vomiting, diarrhea, anorexia GU: Decrease libido, amenorrhea, galactorrhea Hematology: Neutropenia, leukopenia, agranulocytosis Skin: urticaria , rash Pharmacokinetics Metabolized by the liver, excreted in urine Half-life 2.5-6 hours IV: onset 1-2 minutes, duration 1-2 hours Interactions Avoid use with MAOIs Increase: sedation- alcohol, other CNS depressants Increase: risk of EPS- haloperidol, phenothiazines Decrease: action of metoclopramide, anticholinergics, opiates EMT Considerations Assess: respiratory status (rate, rhythm, auscultate breath sounds prior to administration) Evaluate: therapeutic response, ability to breathe adequately Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 211 Methylprednisolone Methylprednisolone Contraindications Hypersensitivity, neonates Precautions Pregnancy (C), breastfeeding, diabetes mellitus, glaucoma, osteoporosis, seizure disorders, ulcerative colitis, CHF, myasthenia gravis, renal disease, esophagitis, peptic ulcer, viral infection, TB, trauma. A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Midazolam Mechanism of Action Binds to BZD receptors on the postsynaptic receptors on the postsynaptic GABA neuron at several sites within the CNS, including the limbic system, reticular formation. Enhancement of GABA on neuronal excitability results in hyperpolarization (less excitable state) and stabilization. BZD receptors and effects appear to be linked to GABAA receptors, BZDs do not bind GABAB receptors. Uses Seizure, anxiolysis, pre-sedation for intubation, anesthesia Unlabeled uses: Status epilepticus Dosage and Routes Anxiolysis Refer to specific protocol Sedation Refer to specific protocol Seizure Refer to specific protocol Side Effects CNS: retrograde amnesia, euphoria, confusion, headache, anxiety, insomnia slurred speech, paresthesia, tremors, weakness, chills, agitation, paradoxical reactions CV: hypotension, PVCs, tachycardia, bigeminy, nodal rhythm, cardiac arrest EENT: blurred vision, nystagmus, diplopia, loss of balance GI: nausea, vomiting, increased salivation, hiccups Skin: urticaria, pain/swelling/pruritus at injection site, rash Resp: coughing, apnea, bronchospasm, laryngospasms, dyspnea, respiratory depression Pharmacokinetics Protein binding 97%, half-life 1.8-6.4 hr, metabolized in liver; metabolites excreted in urine; crosses placenta and the blood brain barrier IV – onset 3-5 minutes, duration <2 hours (6 hours in liver failure); IM – onset 15 minutes, duration 6 hours; IN – onset 4-8 minutes, duration 41 minutes Interactions Increase: hypotension- antihypertensives, opiates, alcohol, nitrates Increase: extended half-life—CYP3A4 inhibitors (cimetidine, erythromycin, ranitidine) Increase: respiratory depression—other CNS depressants, alcohol, barbiturates, opiate analgesics, verapamil, ritonavir, indinavir Decrease: midazolam metabolism—CYP3A4 inducers (azole antifungals, theophylline) EMT Considerations Assess: BP, pulse, respirations during IV; Injection site for redness, pain and swelling; Degree of amnesia in geriatric patients; may be increased; Anterograde amnesia; Vital signs during recovery period in obese patients, since half-life may be extended Preform/Provide: Assistance with ambulation until drowsy period ends; Storage at room temp, protect from light; Immediate availability of resuscitation equipment, O2 to support airway, do NOT give by rapid bolus Evaluate: Therapeutic response Treatment of Overdose Discontinue product, supportive care, flumazenil (may induce seizures if used in patients with chronic benzodiazepine use), O2 Pharmaceuticals 212 Midazolam Midazolam Contraindications Pregnancy (D), hypersensitivity to benzodiazepines, acute closed-angle glaucoma Precautions Breastfeeding, children, geriatric patients, COPD, CHF, chronic renal failure, chills, debilitated, hepatic disease, shock, coma, alcohol intoxication, status asthmaticus A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Morphine Mechanism of Action Binds to opioid receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of and response to pain; produces generalized CNS depression Uses Moderate to severe pain Contraindications Hypersensitivity, addition (opioid), hemorrhage, bronchial asthma, increase intracranial pressure, paralytic ileus, hypovolemia, shock Side Effects CNS: Drowsiness, dizziness, confusion, headache, sedation, euphoria, insomnia, seizures CV: Palpitations, bradycardia, change in BP, shock, cardiac arrest, chest pain, hypo/hypertension, edema, tachycardia EENT: Tinnitus, blurred vision, miosis, diplopia GI: Nausea, vomiting, anorexia, constipation, cramps, biliary tract pressure GU: Urinary retention Heme: Thrombocytopenia Skin: Rash, urticarial, bruising, flushing, diaphoresis, pruritus Resp: Respiratory depression, respiratory arrest, apnea Pharmacokinetics Metabolized by liver, crosses placenta, excreted in urine/breast milk IV – onset 5-10 minutes, duration patient dependent. Half-life 1.5-2 hours Interactions Unpredictable reaction, avoid use - MAOIs Increase: effects with other CNS depressants- alcohol, opiates, sedative/hypnotics, antipsychotics, skeletal muscle relaxants Decrease: morphine action- rifampin EMT Considerations Assess: Pain: location, type, character; give dose before pain becomes severe; BP, pulse, respirations (character, depth, rate); CNS changes: dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction; Allergic reactions: rash, urticarial Preform/Provide: Storage in light-resistant container at room temp; Assistance with ambulation; Safety measures Evaluate: Therapeutic response; decrease in pain intensity Treatment of Overdose Discontinue product, supportive care, naloxone (Narcan): 0.2-0.8 mg IV, O2, IV fluids, vasopressors Pharmaceuticals 213 Morphine Morphine Dosage and Routes Analgesia Refer to specific protocol A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Naloxone Mechanism of Action Pure opioid antagonist that competes and displaces opioids at opioid receptor sites Uses Opiate overdose, respiratory depression induced by opioids, pentazocine, propoxyphene Unlabeled uses: opiate-induced pruritis Contraindications Hypersensitivity Precautions Pregnancy (C), breastfeeding, children, neonates, CV disease, opioid dependency, seizure disorder, drug dependency Side Effects CNS: Drowsiness, nervousness, seizures, tremor CV: Rapid pulse, increase systolic BP (high doses), ventricular tachycardia/fibrillation, hypo/hypertension, cardiac arrest, sinus tachycardia GI: Nausea, vomiting, hepatotoxicity Resp: Tachypnea, pulmonary edema Pharmacokinetics Metabolized by liver, crosses placenta; excreted in urine/breast milk IV – onset 1 minute, duration 45 min. Half-life 30-81 minutes Interactions Increase: seizures - tramadol Decrease: effect of opioid analgesics EMT Considerations Assess: Withdrawal: cramping, hypertension, anxiety, vomiting; signs of withdrawal in drug-dependent individuals may occurs <2 hours after administration; Vital Signs q3-5 minutes; Cardiac Status: tachycardia, hypertension, monitor ECG ; Respiratory Function: respiratory depression, character, rate, rhythm, if respiration <10/min, administer naloxone; probably due to opioid overdose; monitor LOC; Pain: duration, intensity, location before and after administration Preform/Provide: Dark storage at room temp Evaluate: Therapeutic Response: reversal of respiratory depression; change in level of consciousness Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 214 Naloxone Naloxone Dosage and Routes Opiate Overdose Refer to specific protocol Altered Mental Status Refer to specific protocol A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Nitroglycerin Mechanism of Action Produces a vasodilator effect on the peripheral veins and arteries with more prominent effects on the veins. Primarily reduces cardiac oxygen demand by decreasing preload (left ventricular end-diastolic pressure). May modestly reduce afterload. Dilates coronary arteries and improves collateral flow Uses Unstable angina, Hypertension, Flash Pulmonary Edema Unlabeled use: esophageal spasms, uterine relaxation, short-term management of pulmonary hypertension Dosage and Routes Chest Pain Refer to specific protocol Hypertension Refer to specific protocol Nitroglycerin Nitroglycerin Contraindications Known hypersensitivity, increased intracranial pressure, cerebral hemorrhage Precautions Used with caution in postural hypotension, pregnancy, breastfeeding, children, renal disease, hepatic injury, inferior STEMI Side Effects CNS: Headache, flushing, dizziness CV: Hypotension, tachycardia, collapse, syncope, palpitations GI: Nausea, vomiting Skin: Pallor, sweating, rash Pharmacokinetics Metabolized by liver, excreted in urine Half-life 1-4 min. Sublingual – onset 1-3 minutes, duration 30 minutes. IV – onset 1-2 minutes, duration 3-5 minutes Interactions Severe hypotension, CV collapse: alcohol Increase: effects of beta-blockers, diuretics, antihypertensives, calcium channel blockers Increase: erectile dysfunction meds (fatal hypotension - sildenafil, tadalafil, vardenafil; do not use together) Increase: nitrate level - aspirin Decrease: heparin - IV nitroglycerin EMT Considerations Assess: Orthostatic BP, pulse; Pain: duration time started, activity being preformed, character; Tolerance: if taking over long period of time; Headache, lightheadedness, decreased BP Perform/Provide: Storage protected from light, moisture; store in cool environment Evaluate: Therapeutic response: decrease in anginal pain Treatment of Overdose Discontinue product, IV fluids, supportive care Pharmaceuticals 215 A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Ondansetron Mechanism of Action Selective 5-HT3-receptor antagonist, blocking serotonin both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone Uses Chemotherapy associated nausea and vomiting, radiotherapy associated nausea and vomiting, postoperative nausea and/or vomiting Unlabeled use: Hyperemesis gravidarum (severe or refractory), breakthrough nausea and/or vomiting associated with chemotherapy Dosage and Routes Abdominal Pain Refer to specific protocol Antiemetic Refer to specific protocol Side Effects CNS: Headache, dizziness, drowsiness, fatigue, EPS GI: Diarrhea, constipation, abdominal pain, dry mouth Misc: Rash, bronchospasm (rare), musculoskeletal pain, wound problems, shivering, fever, hypoxia, urinary retention Pharmacokinetics Metabolized in the liver, excreted primarily in urine Half-life 3.5-4.7 hr Interactions Decrease: ondansetron effect- rifampin, carbamazepine, phenytoin EMT Considerations Assess: Hypersensitivity reaction: rash, bronchospasm (rare); EPS: shuffling gait, tremors, grimacing, period rigidity Perform/Provide: Storage at room temp Evaluate: Therapeutic response: absence of nausea/vomiting Treatment of Overdose Evaluate QT for prolongation; monitor for dysrhythmias; discontinue product; supportive care Pharmaceuticals 216 Ondansetron Ondansetron Contraindications Hypersensitivity, congenital OR acquired prolonged QT, history of Torsades de Pointes Precautions Pregnancy (B), breastfeeding, children, geriatric patients A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Rocuronium Mechanism of Action Blocks acetylcholine from binding to receptors on motor endplate inhibiting depolarization. Inhibits transmission of nerve impulses by binding with cholinergic receptor sites, antagonizing action of acetylcholine Uses Facilitation of endotracheal intubation; skeletal muscle relaxation during mechanical ventilation Unlabeled use: preinduction to blunt defasciculation Dosage and Routes Paralysis Refer to specific protocol Side Effects CV: Bradycardia, tachycardia, change in BP, edema GI: Nausea, vomiting Skin: Rash, flushing, pruritus, urticarial MSK: Myopathy Resp: Prolonged apnea, bronchospasm, cyanosis, respiratory depression, dyspnea, pulmonary vascular resistance Pharmacokinetics Metabolized in liver Half-Life 30 min, duration 60-70 min Interactions Theophylline increases risk of dysrhythmias Increase: neuromuscular blockade caused by amphotericin B, verapamil, aminoglycosides, clindamycin, enflurane, isoflurane, lincomcin, lithium, opiates, local anesthetics, polymyxin, anti-infectives, quinidine, thiazides EMT Considerations Assess: Vital Signs: BP, pulse, respirations, airway until fully recovered; Allergic reactions: rash, fever, respiratory distress, pruritus Preform/Provide: Storage in light-resistant area, stable at room temp for 30 days Evaluate: Therapeutic response Treatment of Overdose Discontinue product, Edrophonium or Neostigmine, Atropine, Monitor VS Pharmaceuticals 217 Rocuronium Rocuronium Contraindications Hypersensitivity Precautions Pregnancy (C), breastfeeding, children, geriatric patients, electrolyte imbalances, dehydration, respiratory/neuromuscular/cardiac/ renal/hepatic disease A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Sodium Bicarbonate Mechanism of Action Increase plasma bicarbonate which buffers hydrogen ion concentrations and reverses acidosis Uses Acidosis (metabolic), cardiac arrest, salicylate poisoning, tricyclic antidepressant overdose Dosage and Routes Cardiac Arrest Refer to specific protocol ASA Poisoning Refer to specific protocol TCA overdose Refer to specific protocol Side Effects CNS: Irritability, confusion, headache, stimulation, tremors, hyperreflexia, weakness, seizures of alkalosis CV: Irregular pulse, cardiac arrest, water retention, edema, weight gain GI: Flatulence, belching, distension MSK: Muscular twitching, tetany, irritability Pharmacokinetics Excreted in urine Onset 15 minutes. Duration 1-2 hours Interactions Increase: effects- amphetamines, mecamylamine, quinine, quinidine, pseudophedrine, flecainide, anorexiants, sympathomimetics Increase: sodium and decrease potassium- corticosteroids Decrease: effects- lithium, chlorpropamide, barbiturates, salicylates, benzodiazepines, ketoconazole, corticosteroids EMT Considerations Assess: Respiratory and pulse rate/rhythm; Fluid balance: edema, crackles, shortness of breath; Alkalosis: irritability, confusion, twitching, hyperreflexia, slow respirations, cyanosis, irregular pulse; Milk-Alkali Syndrome: confusion, headache, nausea, vomiting, anorexia, urinary stones, hypercalcemia Treatment of Overdose Discontinue product; ventilatory support to exhale excess CO2; supportive care Pharmaceuticals 218 Sodium Bicarbonate Sodium Bicarbonate Contraindications Metabolic/respiratory alkalosis, hypochloremia, hypocalcemia Precautions Pregnancy (C), children, CHF, toxemia, renal disease, hypertension, hypokalemia, breastfeeding, hypernatremia, Cushing’s syndrome, hyperladosteronism A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Succinylcholine Mechanism of Action Acts similar to acetylcholine, producing depolarization of the motor endplate at the myoneural junction which causes sustained flaccid skeletal muscle paralysis. Uses Facilitation of endotracheal intubation Dosage and Routes Side Effects CV: Bradycardia, tachycardia, hypo/hypertension, sinus arrest, dysrhythmias, edema EENT: Increased secretions, Increased intraocular pressure Heme: Myoglobinemia Skin: Rash, flushing, pruritus, urticaria MSK: Weakness, muscle pain, fasciculations, prolonged relaxation, myalgia, rhabdomyolysis Resp: Prolonged apnea, bronchospasm, cyanosis, respiratory depression, wheezing, dyspnea Systemic: anaphylaxis, angioedema, malignant hyperthermia Pharmacokinetics Hydrolyzed in blood, excreted in urine IV - onset 1 min, peak 2-3 min, duration 6-10 min Interactions Dysrhythmias: theophylline Increase: neuromuscular blockade- aminoglycosides, beta-blockers, cardiac glycosides, clindamycin, lincomycin, procainamide, quinidine, local anesthetics, polymyxin antibiotics, lithium, opiates, thiazides, enflurane, isoflurane, magnesium salts, oxytocin EMT Considerations Assess: Electrolyte imbalances (potassium, magnesium); may lead to increase action of product; Vital Signs: BP, pulse, respirations, airway; Recovery: decreased paralysis; Allergic Reactions: rash, fever, respiratory distress, pruritus Perform/Provide: Storage in refrigerator powder at room temp Evaluate: Therapeutic response: paralysis of jaw, eyelid, head, neck rest of body Treatment of Overdose Discontinue product, supportive care, Neostigmine, Atropine Pharmaceuticals 219 Succinylcholine Succinylcholine Contraindications Hypersensitivity, malignant hyperthermia, trauma (crush injuries) Precautions Pregnancy (C), breastfeeding, geriatric or debilitated patients, cardiac disease, severe burns, fractures (fasciculations may increase damage), electrolyte imbalances (hyperkalemia), dehydration, neuromuscular disease, respiratory/cardiac/renal/hepatic disease, collagen disease, glaucoma, eye surgery A Legend EMT A-EMT P Paramedic M Medical Control Pharmaceuticals Vasopressin Mechanism of Action Increases water permeability at the renal tubule resulting in decreased urine volume and increased intravascular volume. Direct vasoconstrictor without inotropic or chronotropic effects. Increases systemic vascular resistance and mean arterial blood pressure, decreases heart rate and cardiac output. Uses Cardiac arrest, vasodilatory shock, diabetes insipidus Unlabeled uses: cadaveric organ recovery, gastroesophageal variceal hemorrhage Dosage and Routes Cardiac Arrest Refer to specific protocol Side Effects CNS: Drowsiness, headache, lethargy, flushing, vertigo CV: Increased BP, dysrhythmias, cardiac arrest, shock, chest pain, MI EENT: Nasal irritation, congestion, rhinitis GU: Nausea, heartburn, cramps, vomiting, flatus Misc: Tremor, sweating, vertigo, urticarial, bronchial constriction Pharmacokinetics Metabolized by the liver and kidneys, excreted in the urine IV – onset <15 minutes, duration 20 minutes Interactions Increase: antidiurectic effects- tricyclics, carbamazepine, chloropromide, fludrocortisone, clofibrate, urea Decrease: antidiuretic effect- lithium, demeclocycline EMT Considerations Assess: Vital Signs: BP and pulse Evaluate: Therapeutic response: return of spontaneous circulation, change in BP Treatment of Overdose Discontinue product; supportive care Pharmaceuticals 220 Vasopressin Vasopressin Contraindications Hypersensitivity, chronic nephritis Precautions Pregnancy (C), breastfeeding, CAD, asthma, vascular/renal disease, migraines, seizures Approved Abbreviations A&O x 3 A&O x 4 Alert and Oriented to Person, Place and Time Alert and Oriented to Person, Place, Time and Events C/O Complains Of CA Cancer A-Fib Atrial Fibrillation CABG Coronary Artery Bypass Graft AAA Abdominal Aortic Aneurysm CAD Coronary Artery Disease ABC’s Airway, Breathing and Circulation CATH Coronary Catheter ABD Abdomen CC Chief Complaint ACLS Advanced Cardiac Life Support CCR Cardiocerebral Resuscitation AKA Above The Knee Amputation CHF Congestive Heart Failure ALS Advanced Life Support CMS Circulation, Motor, Sensation AMA Against Medical Advice CNS Central Nervous System AMS Altered Mental Status COPD Chronic Obstructive Pulmonary Disease AMT Amount CP Chest Pain APPROX Approximately CPAP Continuous Positive Airway Pressure ASA Aspirin CPR Cardiopulmonary Resuscitation ASSOC Associated CSF Cerebrospinal Fluid BG Blood Glucose CT Computed Tomography (CAT Scan) BILAT BIlateral CVA Cerebrovascular Accident (Stroke) BKA Below The Knee Amputation D5W 5% Dextrose in Water BLS Basic Life Support DKA Diabetic Ketoacidosis BM Bowel Movement DNR Do Not Resuscitate BP Blood Pressure DOA Dead on Arrival BS Breath Sounds DOB Date of Birth BVM Bag-Valve Mask Ventilations DOE Dyspnea on Exertion C-SECTION Caesarean Section DT Delirium Tremens C-SPINE Cervical Spine DVT Deep Vein Thrombosis 221 Approved Abbreviations Dx Diagnosis HTN Hypertension ECG Electrocardiogram Hx History ED Emergency Department ICP Intracranial Pressure EEG Electroencephelogram ICU Intensive Care Unit EMT-B EMT Basic IDDM Insulin-Dependent Diabetes Mellitus EMT- A Advanced EMT IM Intramuscular EMT-P Paramedic IN Intranasal ET Endotracheal IO Intraosseous EtOH Ethanol (alcohol) IV Intravenous ETT Endotracheal Tube JVD Jugular Vein Distention EXT External (extension) kg kilogram °F Farenheit KVO Keep Vein Open FB Foreign Body L-SPINE Lumbar Spine FLEX Flexion L/S-SPINE Lumbarsacral Spine Fx Fracture L&D Labor and Delivery g gram(s) LAT Lateral GERD Gastroesophageal Reflux Disease lb pound GI Gastrointestinal LLQ Left Lower Quadrant GSW Gunshot Wound LMP Last Menstrual Period gtts “Guttae” (Latin for drops) LOC Level of Consciousness / Loss of Consciousness GU Genitourinary LR Lactated Ringers GYN Gynecology (gynecological) LUQ Left Upper Quadrant H/A Headache MAST Military Anti-Shock Trousers HEENT Head, Eyes, Ears, Nose, Throat mcg microgram(s) HR Heart Rate MD Medical Doctor 222 Approved Abbreviations MED Medicine Peds Pediatric mg miligram(s) PERRL Pupils Equal, Round, Reactive to Light MI Myocardial Infarction (heart attack) PMHx Past Medical History min minimum/minute PO Per Os (By Mouth) MRI Magnetic Resonance Imaging PRN Pro Re Nata (As Needed) MS Mental Status PT Patient MVA Motor Vehicle Accident PVC Premature Ventricular Contraction MVC Motor Vehicle Crash RLQ Right Lower Quadrant N/V Nausea/Vomiting RN Registered Nurse N/V/D Nausea/Vomiting/Diarrhea RUQ Right Upper Quadrant NAD No Apparent Distress Rx Medicine NG Nasogastric Tube S/P Status Post NC Nasal Cannula SOB Shortness of Breath NEB Nebulizer SQ Subcutaneous NIDDM Non Insulin-Dependent Diabetes Mellitus ST Sinus Tachycardia NKDA No Known Drug Allergies SVT Supraventricular Tachycardia NRB Non-Rebreather Sx Symptom NS Normal Saline SZ Seizure NSR Normal Sinus Rhythm T-SPINE Thoracic Spine O2 Oxygen TB Tuberculosis OB/GYN Obstectrics/Gynecology Temp Temperature PA Physician Assistant TIA Transient Ischemic Attack PALP Palpation TKO To Keep Open PAC Premature Atrial Contraction Tx Treatment PE Pulmonary Embolus UOA Upon Our Arrival 223 Approved Abbreviations American College of Surgeons Committee on Trauma American College of Emergency Physicians Society of Academic Emergency Medicine URI Upper Respiratory Infection ACS-COT UTI Urinary Tract Infection ACEP VF Ventricular Fibrillation SAEM VS Vital Signs NAEMSP National Association of EMS Physicians VT Ventricular Tachycardia NREMT National Registry of EMTs WAP Wandering Atrial Pacemaker AAP American Academy of Pediatrics WNL Within Normal Limits AHA American Heart Association YO (YOA) Years Old (Years of Age) ILCOR International Liaison Committee on Resuscitation + Positive - Negative ? Questionable ~ Approximately > Greater Than < Less Than = Equal 224 INDEX 12-Lead ECG 139 Capnography 155 Abdominal Pain 43 Carbon Monoxide 160 Acute Coronary Syndrome (ACS) 37 Cardiac Arrest 33 Airway Management 27 Cardiac Arrest - Traumatic 76 Airway Obstruction 142 Cardioversion 161 Airway Orotracheal Intubation 145 CCR – Cardiocerebral Resuscitation 162 Airway Suctioning 151 Chemical Burns 77 Airway Video Laryngoscopy 146 Chest Decompression 169 Allergic Reaction 44 Chest Injury 78 Altered Mental Status 45 Chest Pain 38 Anticholinergic 55 CHF – Congestive Heart Failure 32 Antidepressants 63 Child Abuse 8 Antipsychotics 60 Child Birth 52 Asthma 31 Cincinnati Stroke Scale 170 Asystole 35 Cocaine 62 Atrial Fibrillation/Flutter 40 Conducted Electrical Device (TASER) 91 Behavioral 46 COPD – Chronic Obstructive Pulmonary Disease 31 Beta Blocker 56 CPAP 153 Bites 73 CPR – Cardiopulmonary Resuscitation 163 Blast Injury 74 Cricothyrotomy 156 Blood Glucose Analysis 159 Cricothyrotomy – Open (Surgical) 157 Bradycardia 42 Criteria for Death 9 Bougie 154 Crush Injury 79 Burns 75 Cyanide Poisoning 59 Calcium Channel Blockers 57 Defibrillation (Manual and AED) 164 225 INDEX Destination 4 Interhospital 13 Diabetic Emergencies 47 Intranasal 171 DNR – Do Not Resuscitate 7 Intravenous Access - IV Documentation 10 Intubation 145 Domestic Violence 12 King Airway 147 Drowning (Near) 80 Labor (Imminent Delivery) 52 Lightning Strike 88 ECG 139,140,141 49,179 Elder Abuse 8 Lights/Sirens During Patient Transport 14 Electrical Burns 77 LMA – Laryngeal Mask Airway 149 Envenomations 73 Long Board Selective Spinal Immobilization 92 Excited Delirium 46 Narrow Complex Tachycardia 40 External Cardiac Pacing 165 Needle Jet Insufflation 158 Extremity Injury 82 Nerve Agent 94 Eye Pain 84 Newly Born 53,106 Failed Airway 30 OB General 50 GI Bleeding 43 Opiate OD 61 Hazardous Materials 85 Organophosphates 55 Head Injury 86 Orogastric Tube Insertion 172 Hemorrhage Control 87 Overdose 54 HEMS – Helicopter EMS 5,6 Pain 64 Hypertension 48 Pain - Traumatic 89 Hyperthermia 81 Paramedic / Non-Paramedic 15 Hypotension 67 Patient Without a Protocol 18 Hypothermia 82 Patient Care During Transport 17 Intercept 16 Pediatrics 96 226 INDEX Pediatric – Airway Management 99 Pediatric - Pain 116 Pediatric – Allergic Reactions 110 Pediatric – Pain (Trauma) 136 Pediatric – Altered Mental Status 111 Pediatric – Post Resuscitation 107 Pediatric – Apparent Life-Threatening Episode (ALTE) 112 Pediatric – Pulseless Electrical Activity PEA 103 Pediatric - Asthma 101 Pediatric - Refusal 117 Pediatric - Asystole 104 Pediatric - Seizure 118 Pediatric - Bradycardia 108 Pediatric – Sexual Assault 137 Pediatric – Bites/Envenomations 125 Pediatric – Sickle Cell Crisis 120 Pediatric – Burns 126 Pediatric – Spinal Immobilization 138 Pediatric – Cardiac Arrest 102 Pediatric – Tachycardia with a pulse 109 Pediatric – Cardiac Arrest (Traumatic) 124 Pediatric – Vfib/Pulseless Vtach Arrest 105 Pediatric – Chest Injury 127 Pediatric - Wheezing 101 Pediatric – Crush Prolonged 128 Pharmaceuticals 184 Physician on Scene 19 Pediatric - Destination 97,122 Pediatric – Diabetic Emergencies 113 Poison Control 20 Pediatric – Drowning (Near) 129 Police Custody 21 Pediatric – Eye Pain 133 Posterior ECG 140 Pediatric – Failed Airway 100 Post-Resuscitation 37 Pediatric – Head Injury 134 Post RSA 29 Pediatric – Hemorrhage Control 135 Pulmonary Edema 32 Pediatric – Hypotension / Shock (non-trauma) 119 Pulse Oximetry 144 Pediatric - Hyperthermia 130 Pulseless Electrical Activity PEA 34 Pediatric – IV Access 114 Radiation Injury 90 Pediatric – Overdose and Poisoning 115 Radio Report 22 Pediatric – Neonatal Resuscitation 106 Rapid Sequence Airway RSA 28 227 INDEX Rehab – Public Safety Personnel Refusal 95 65,66 Venous Access - Extremity 179 Venous Access – Intraosseous (IO) 180 Remote Ischemic Conditioning 168 Ventricular Assist Device (VAD) 182 Restraints 173 V Fib / Pulseless V Tach 36 Right Sided ECG 141 Wide Complex Tachycardia 41 Seizure 68 WMD (Weapons of Mass Destruction) 94 Sexual Assault 93 Wound Care 183 Shock (Non-Trauma) 67 Spinal Immobilization 174 Spinal Immobilization - Athletes 175 Splinting 176 STEMI – ST Elevation Myocardial Infarction 39 Stroke 69 Suctioning 151,152 Sympathomimetic 62 TASER 91 Termination of Resuscitation 23 Thrombolytic Screening 70 Tourniquet 177 Transfer of Care 24 Trauma General 71 Tricyclic 63 Vaginal Bleeding 51 Venous Access – EJ (External Jugular) 181 Venous Access – Existing PICC, etc. 178 228