12-lead ecg, stemi, and transmission bls airway management...

12-Lead ECG, STEMI, and TransmissionBLS Airway ManagementKey ProceduresNon-Invasive ETCO2 MonitoringOxygen TherapyOxygen Titration and Pulse OximetryPain Assessment and ManagementPain Assessment ToolsPediatric AssessmentPediatric Vital Signs and GCS ScoringPediatric Medication Administration Rule of 9s – Burn Surface Area Sepsis ScreeningSpinal ImmobilizationVascular AccessVentricular Assist Devices (VAD)

Procedures andPatient CareReference

12-LEAD ACQUISITION AND LEAD PLACEMENTLimb Lead Placement:Place limb leads on distal extremities if possibleConfirm correct lead placement for each limbMay be moved to proximal if needed (if motion artifact)

Chest Lead Placement:To begin placement of chest leads, locate sternal angle (2nd ribs are adjacent) then count down to 4th interspace (below 4th rib)

V1 – 4th intercostal space at the right sternal borderV2 – 4th intercostal space at the left sternal borderV4 – 5th intercostal space at left midclavicular lineNote: Place V4 lead first to aid in correct placement of V3V3 – Directly between V2 and V4V5 – Level of V4 at left anterior axillary lineV6 – Level of V4 at left mid-axillary line

Note: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG

Sternal angle

LOCALIZING SITE OF INFARCT

• Localization of an infarct pattern adds to the accuracy of ECG interpretation

• A STEMI will have 1 mm or more ST-segment elevation in 2 or more contiguous leads (which means findings noted in the same anatomical location of the infarct)o Contiguous leads for inferior infarction include II, III, and aVFo Contiguous leads for anterior infarction include V1-V4 (V1-V2 elevation also called septal infarction)o Contiguous leads for lateral myocardial infarction include Leads I, aVL, V5, and V6o Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or

inferolateral)

I – LATERAL aVR V1 – SEPTALor ANTERIOR

V4 – ANTERIOR(V4R – RVMI)

II - INFERIOR aVL – LATERAL V2 – SEPTALor ANTERIOR V5 – LATERAL

III – INFERIOR aVF - INFERIOR V3 – ANTERIOR V6 – LATERAL

STEMI RECOGNITION AND DESTINATION

STEMI RECOGNITION

• Patients who have ECGs of acceptable quality with the following messages are candidates for transport to STEMI Receiving Centers:o ***Acute MI*** (Zoll)o ***Acute MI Suspected*** (LIFEPAK 12)o ***Meets ST-Elevation MI Criteria*** (LIFEPAK15)

• The 12-lead ECG should be inspected prior to initiation of a STEMI Alert – a steady baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation

• Causes of artifact include patient motion or tremor, poor lead contact, or electrical interference

• Good skin preparation is essential for optimal lead contact and clear 12-lead tracings• If artifact is noted the ECG should be repeated• Paced rhythms may cause false readings – the pacemaker spike is not always detected

by the computer algorithm. Inform facility if patient has a pacemaker during report.

STEMI REPORT

If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon as possible following completion of the ECG

DESTINATION POLICY

Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC)• Patients shall be transported to the closest SRC unless they request another facility• A SRC that is not the closest facility is an acceptable destination if estimated additional

transport time does not exceed 15 minutes• Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after

arrest shall be transported to the closest SRC• Patients with unmanageable airway en route shall be transported to the closest available

emergency department

STEMI REPORT• A patient with a computer interpretation of ***Acute MI*** (Zoll) or ***Acute MI Suspected*** (LP-12) or

***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center • Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have

significant baseline artifact or other deficit before initiating a STEMI Alert

SITUATION

• Identify the call as a “STEMI Alert”• Estimated time of arrival (ETA) in minutes• Patient age and gender• Report ECG computer interpretation has a STEMI message (as listed above)• Report if subsequent ECG findings are variable or if ECG quality not optimal (e.g., if no

***Acute MI*** findings noted in tracings without significant artifact)• Verify that 12-lead ECG Transmission has been completed and received

BACKGROUND• Presenting chief complaint and symptoms• Pertinent past cardiac history• History of pacemaker (important – paced rhythms may give false ECG interpretations)

ASSESSMENT

• General assessment• Pertinent vitals (especially heart rate and BP) and physical exam• Cardiac rhythm• Pain level

RX – RECAP • Prehospital treatments given• Patient response to prehospital treatments

TRANSMISSION OF MONITOR DATA• 12-Lead ECG transmission is an enhancement to the STEMI system that allows facilities to interpret 12-lead data prior to

patient arrival, appropriately prepare, and appropriately activate resources when indicated• Transmission of cardiac arrest monitor data and data related to treatment of dysrhythmias and patient intubations allows

appropriate documentation and review of care provided in those situations12-Lead ECG Transmission

12-LEAD TRANSMISSION

• All 12-Lead ECGs are to be transmitted• Any 12-Lead that indicates that the patient is having an STEMI should be transmitted to the STEMI receiving

center where the patient is being transported• All other 12-Leads should be transmitted to the destination hospital site listed on the monitor

IDENTIFIERS At a minimum, 12-Lead ECG labeling should include initials of the first and last name of the patient Provider agencies may require additional labeling

HOSPITAL NOTIFICATION

Once a STEMI 12-Lead has been transmitted to a STEMI receiving facility, that facility should be notified as soon as possible following the transmission of the ECG to verify receipt and to complete STEMI alert

REVIEW Not all hospitals have ability to review transmitted ECGs and some may filter out normal or non-acute appearing ECGs. Hard copies of ECGs also must be left at all receiving facilities.

Transmission of Cardiac Arrest and Other Monitor Data

INDICATIONS FOR TRANSMISSION

• Cardiac arrests• Any calls that involve the treatment of a cardiac dysrhythmia (medication, cardioversion or pacing)• Any call involving monitoring of intubated patients• Any other call in which the paramedic believes data review may add to PCR documentation of events

TRANSMISSION • Transmit these calls to the Arrest/Rhythm site listed on the monitor

REVIEW • This data is transmitted to the provider agency and to EMS for review but does not go to hospitals for immediate access. Code summaries should be printed and left at receiving facilities.

Note: Optimally, a single monitor should be used to gather data, particularly with regard to cardiac arrest or continuous monitoring of intubated patients

BLS AIRWAY MANAGEMENT

GOALS The goal of airway management is to ensure adequate ventilation and oxygenation. Initial airway management should always begin with BLS Maneuvers

VENTILATION RATES AND DELIVERY

Avoid excessive ventilation. In non-arrest patients, ventilation rates:Adults – 10 / minuteChildren – 20 / minuteInfants – 30 / minute

Deliver ventilations over one second to produce visible chest rise and to avoid distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary based on patient size.

PREFERRED MANEUVERS

Two-person technique is the preferred method to ventilate patients using bag-valve mask device

Maneuvers – Use “JAWS”

J—Jaw thrust maneuvers to open airway

A—Airway - Use oral or nasal airway

W—Work together - Ventilation using a bag-valve mask should include two rescuers – one to hold mask and other to deliver ventilations

S—Slow and small ventilations to produce visible chest rise

AIRWAY POSITIONING

Position the patient to optimize airway opening and facilitate ventilations (see below)• Use the sniffing position with head extended (A) and neck flexed forward (B)

unless suspected spinal injury• Position with head/shoulders elevated – anterior ear should be at the same

horizontal level as the sternal notch (C). This is especially advantageous in larger or morbidly obese patients.

A

C

KEY PROCEDURESSkill Indication / Comment Contraindication

12-LEAD ECG

• Chest pain or suspected Acute Coronary Syndrome (ACS)

• Atypical ACS or anginal equivalents:o Symptoms include shortness of breath,

diaphoresis, syncope, dizziness, weakness, and altered level of consciousness

o Elderly patients, females and diabetics are more likely to present atypically

• Arrhythmias (both pre- and post-conversion)• Suspected cardiogenic shock• Cardiac arrest after return of spontaneous

circulation

• Uncooperative patient

• Any condition in which delay to obtain ECG would compromise immediately needed care (e.g. arrhythmia requiring immediate shock)

Autopulse(SRVFPD) • Cardiac Arrest in Adults

• Pediatric patients • Trauma patients• Patients too small or large for

the compression band

Blood Glucose Testing

• Altered level of consciousness• Patients with signs and symptoms of

hypoglycemia (may include diaphoresis, weakness, hunger, shakiness, anxiety)

• Patients not meeting any indication


ContinuousPositiveAirwayPressure (CPAP)

Patient has 2 or more findings:• RR >25• Pulse ox <94%• Use of accessory muscles

and patient is awake, able to maintain airway & follow commands

• Unconscious or unable to follow commands

• Respiratory arrest / apnea• Pneumothorax• Vomiting• Major head, facial or chest trauma

Endotracheal Intubation

• Patient with decreased sensorium (GCS less than or equal to 8) and apneic (adults)

• Patient with decreased sensorium (GCS less than or equal to 8) and ventilation unable to be maintained with BLS airway

Note: In non-arrest patients, allow no more than 2 interruptions of ventilation lasting up to 30 seconds during laryngoscopy or intubation attempts Monitor intubated patients continuously using end-tidal carbon dioxide waveform capnography (ETCO2)

• Pediatric patients under 40 kg• Suspected hypoglycemia or narcotic

overdose• Maxillo-facial trauma with unrecognizable

facial landmarks• Seizures• Patients with an active gag reflexNote: Patients with perfusing pulses should be managed with BLS airways unless unable to successfully ventilate (e.g. trauma, respiratory insufficiency)

EndotrachealTube Introducer (Bougie)

Helpful in situations with limited neck mobility, short neck, or immobilized patients

Note: Do not force introducer as it can perforate pharynx or trachea

Cannot be used with endotracheal tubes smaller than 6.0 mm


External Cardiac Pacing

Symptomatic bradycardia

Note: Use careful titration with midazolam or morphine if required for relief of discomfort

• Cardiac arrest• Hypothermia• Pediatric Patients

Helmet Removal

Helmet should be removed if:• Interferes with airway management or spinal

immobilization•Improper fit, allowing head to move within helmet•Patient in cardiac arrest

Face mask of sports helmets can be removed to facilitate easy airway access. If helmet removed, shoulder pads (if worn) must also be removed to maintain neutral spinal alignment.

• Patient airway and spinal immobilization can be addressed without helmet removal

Impedance Threshold Device (ITD) - ResQPOD (SRVFPD)

•Patients ≥ 9 years of age in cardiac arresto Remove if patient resumes spontaneous

breathing or regains perfusing pulse

Note: If secretions encountered, clear device by removing and shaking

•Age below 9 years•Perfusing pulse or spontaneously

breathing•History of traumatic cardiac arrest

due to blunt chest trauma• Flail chest


IntranasalNaloxone

• Patient with altered mental status, respiratory rate less than 12 and suspected opiate overdose

Note: May be less effective in patients with prior nasal mucosal damage

• Shock• Copious nasal secretions or bleeding• Patients with established vascular access

King Airway

• Cardiac arrest

• Inability to ventilate non-arrest patient (with BLS airway maneuvers) in a setting in which endotracheal intubation is not

successful or unable to be done

• Presence of gag reflex• Caustic ingestion• Known esophageal disease (e.g. cancer, varices,

stricture)• Laryngectomy with stoma (place ET tube in stoma)• Height less than 4 feet

LUCAS Chest Compression System

Patients with medical cardiac arrest who properly fit device.

• Traumatic arrest• Pregnant Patients• Improper fit of deviceo Too small – suction cup pad does not touch

chest when lowered as far as possibleo Too large – support legs of LUCAS cannot be

locked to back plate without compressing patient


Needle Thoracostomy

Signs and symptoms of tension pneumothorax:• Altered level of consciousness• Decreased BP• Increased pulse and respirations• Absent breath sounds, hyperresonance to

percussion on affected side• Jugular venous distention• Difficulty ventilating• Tracheal shift

Any condition without signs and symptoms of tension pneumothorax

Oral Glucose

• Altered level of consciousness with known history of diabetes. Patient is conscious and should be able to sit in an upright position.

• Administer up to 30 grams in the patient’s mouth. Optimally the patient will self-administer.

• Unconscious patient or unable to sit upright

• If patient has difficulty swallowing, discontinue procedure and assure open airway

Stomal Intubation

Patients requiring intubation who have mature stoma and do not have a replacement tracheostomy tube available

Note: Pass tube until cuff is just past stoma. If inserted further, mainstem bronchus intubation may occur as carina is only around 10 cm from stoma.

Patients without mature stoma


Tourniquet

(Combat Application Tourniquet)

• External hemorrhage from extremity that cannot be controlled with application of dressings with direct pressure

• May be appropriate for use for hemorrhage control in multi-casualty settings

•Hemorrhage that can be controlled with pressure or dressings

TracheostomyTubeReplacement

•Dislodged tracheostomy tube (decannulation)

• Tracheostomy tube obstruction not resolved by suction

•Recent tracheostomy surgery (less than 1 month)

• Inadequately sized tract or stoma for insertion of new tube (use endotracheal tube instead)

NON-INVASIVE MONITORING OF END-TIDAL CO2

Non-Invasive ETCO2Monitoring

• In patients without shock (normal perfusion), use of non-invasive end-tidal carbon dioxide mea-surement (ETCO2) can be valuable in monitoring respiratory rate and ventilation

• ETCO2 measurements are an earlier indicator of respiratory depression than pulse oximetry

Indications For ETCO2 Monitoring

• Patients at risk for inadequate ventilation may include:

o Patients with borderline respiratory rates (8-12) from overdose or other cause (may help determine if naloxone appropriate)

o Patients who have received medications such as morphine or midazolam that may de-press respiratory rate.

o Patients with chronic lung disease and chronic hypoxia - many patients have elevated ETCO2 levels to begin with and rapidly increasing levels may indicate that a patient has decreased respirations due to oxygen therapy (loss of hypoxic drive)

ETCO2 Findings

• ETCO2 readings may be unreliable if there is shock or poor perfusion

• Normal ETCO2 levels range from 32-36, but this may vary based on the patient’s underlying respiratory and metabolic status

• ETCO2 levels that rise from a normal baseline to above 40 generally indicate hypoventilation is occurring

• Patient stimulation, use of BVM, or use of naloxone may be appropriate based on the situation

OXYGEN THERAPY

Oxygen Safety

• Oxygen has the potential to be harmful to patients – the general goal is to have normal oxygen levels (nor-moxemia) – high levels are not better than normal levels. When pulse oximetry can be used, an sPO2 of 94% is considered adequate.

• Conditions in which high levels may be dangerous include stroke, patients who have return of circulation following cardiac arrest, and patients with severe chronic lung disease

Initial Indications for Oxygen

Supplemental oxygen is indicated in the following conditions:• Altered Level of Consciousness (e.g. overdose, seizure, stroke)

• Cardiac Arrest

• Chest Pain or other suspected cardiac problem (rapid or irregular pulse)

• Obstetric complication (e.g. breech, prolapsed cord, bleeding or pain)

• Respiratory Distress / Respiratory Depression or Apnea

• Shock

• Smoke or other chemical Inhalation

• Suspected carbon monoxide exposure

• Trauma (major)

Follow specific treatment guidelines where applicable

BLS Oxygen Administration

In general, patients in distress should receive high-flow oxygen initially• Chest pain and stroke patients without respiratory distress or shock should receive low-flow oxygen

Oxygen Delivery

Low flow – Use nasal cannula with 4 L/min initial flowHigh-flow – Non-rebreather mask with 15 L/min flowSupplement with BVM if patient is apneic or has shallow respirations

OXYGEN TITRATION AND PULSE OXIMETRY MONITORING

Pulse Oximetry

• Utilize pulse oximetry in all patients with oxygen therapy or suspected hypoxia

• Pulse oximetry is a tool to measure oxygenation, but must be combined with other assess-ments and skills to determine best patient care

Pulse Oximetry Pitfalls

• Pulse oximetry readings can be misleading with poor perfusion (shock) or cold extremities, hypothermia, anemia or in carbon monoxide poisoning.

• Readings may be difficult to obtain or unreliable during with excessive patient movement (e.g.seizures) or if nail polish is present.

ALS Oxygen Titration

• High flow oxygen should be maintained in patients with shock and in those with severe respira-tory distress or profound hypoxia

• In most conditions, titration of oxygen should occur to assure an sPO2 of at least 94%

• Titration may involve decreasing the oxygen flow for either nasal cannula or non-rebreather masks, or switching from high to low flow devices

• Stable patients without distress who have sPO2 readings of 94% or greater without therapy do not need supplemental oxygen

• Some patients with chronic lung problems will not be able to attain an sPO2 of 94% and in fact may be at baseline with readings of 90% or less

o The patient’s level of distress is an important finding in these cases –patients may be with-out distress at lower baseline levels and do not require high-flow oxygen

PAIN ASSESSMENT AND MANAGEMENTRelief of pain and suffering is an important component of quality EMS field care. Pain assessment is the 5th vital sign and should be performed on each patient using an age appropriate pain scale. Pain is a subjective experience for the patient and should be treated following the appropriate pain treatment guideline.

Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts should be made to alleviate pain using both pharmacologic (e.g, Morphine, Nitroglycerin for cardiac cases) and non-pharmacologic (e.g., splinting, immobilization) measures.

Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5 minutes after every medication administration

Assess pain using the same pain scale before and after pain administration and document

Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved. Administer medication cautiously and monitor patient.

Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional narcotic administration.

PAIN ASSESSMENT TOOLS

FACES Pain Rating Scale(Ages 3 to adult)

See pain scale and English/Spanish chart on back cover of field manual• Point to each face using the words to describe the pain intensity • Ask the patient to choose the face that best describes how they are feeling. A

person does not have to be crying to have the worst pain.

0-10 Numeric Pain Rating Scale(Ages > 9 yo)

Explain scale (0 means no pain and 10 is the most severe pain they have ever had). Ask patients what number on a scale of 0-10 they would give as the level of pain currently.

Pain Assessment in the Very Young, Non-Verbal Infant and Child

Pain assessment in infants, non-verbal young children or developmentally delayed children is more complex and presents special challenges. Despite this, pain medication should be considered in cases where the infant or child is in severe pain. This includes evidence of painful mechanisms such as burns, limb fractures or other events. Using pain medication in these children requires judgment and caution. Signs and symptoms of pain in non-verbal young or developmentally delayed children include: Inconsolable crying, screaming that cannot be distracted from by a caregiver High pitched crying Any pain face expression that is continual, such as grimace or quivering chin Constant tense/stiff body tone and/or guarding

“Whatever is painful to adults, is painful to children until proven otherwise”

PEDIATRIC ASSESSMENTBegin interventions immediately and transport promptly if life-threatening conditions are identified in general visual assessment or primary assessment

PEDIATRIC ASSESSMENT TRIANGLE - GENERAL VISUAL ASSESSMENTAssessment Abnormal

Appearance Assess TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry Any abnormality

Work of Breathing Assess effort Increased or decreased effort or abnormal

soundsCirculation Assess for skin color Abnormal skin color or external bleeding

PREHOSPITAL PRIMARY ASSESSMENT Assessment Signs of Life-Threatening Condition

Airway Assess patency Complete or severe airway obstruction

BreathingAssess respiratory rate and effort, air movement, airway and breath sounds, pulse oximetry

Apnea, slow respiratory rate, very fast respiratory rate or significant work of breathing

CirculationAssess heart rate, pulses, capillary refill, skin color and temperature, blood pressure

Tachycardia, bradycardia, absence of detectable pulses, poor blood flow (increased capillary refill, pallor, mottling, or cyanosis), hypotension

Disability Assess AVPU response, pupil size and reaction to light, blood glucose

Decreased response or abnormal motor response (posturing) to pain, unresponsiveness

Exposure Assess skin for rash or traumaHypothermia, rash (petichiae/purpura) consistent with septic shock, significant bleeding, abdominal distention

PEDIATRIC VITAL SIGNS / GLASGOW COMA SCALEAge Normal RR Normal HR Hypotension by systolic blood pressure

Term Neonate 30-60 100-205Neonate: Less than 60 mmHg or weak pulsesInfant: Less than 70 mmHg or weak pulses1-10 yrs: Less than 70 mmHg + (age in yrs x 2) Over 10: Less than 90 mmHg

Infant (<1 yr) 30-60 100-190Toddler (1-3 yr) 24-40 90-150Preschooler (4-5 yr) 22-34 80-140School Age (6-12yr) 18-30 70-120Adolescent (13-18 yr) 12-20 60-100

Pediatric GCS Infant Score Child Score

Motor Response

Spontaneous movements 6 Obeys commands 6Withdraws to touch 5 Localizes 5Withdraws to pain 4 Withdraws 4

Flexion 3 Flexion 3Extension 2 Extension 2

No response 1 No response 1

Verbal Response

Coos and babbles 5 Oriented 5Irritable cry 4 Confused 4

Cries to pain 3 Inappropriate 3Moans to pain 2 Incomprehensible 2No response 1 No response 1

Eye Response

Opens spontaneously 4 Opens spontaneously 4Opens to speech 3 Opens to speech 3

Opens to pain 2 Opens to pain 2No response 1 No response 1

PEDIATRIC MEDICATION ADMINISTRATION

Patient safety in medication administration is paramount. Accurate administration of pediatric medications requires multiple steps. Follow each of these steps in every case.

Assess Patient Remember the 6 Rights – Right patient, right drug (and indication), right dose, right route of administration, right timing and frequency, right documentation

Obtain Weight Estimate In Kg

• Use Broselow tape in every child of appropriate height to determine color range of weight o Broselow applies to patients less than 147 cm tall (4 feet 10 inches)

• If taller than Broselow tape, estimate weight by patient/parent history or paramedic estimate and ALWAYS convert to kg using conversion table

Determine Volume On Drug Chart

• Consult drug chart based on medication name to determine volume in ml• If 50 kg or greater, utilize adult dosages

Draw Up Medication

• Verify drug being administered• Utilize smallest syringe for volume (e.g. 1 ml or less, use tuberculin syringe)• When giving IM or intranasal medication, load syringe only with amount to be

administered

Double Check To Confirm Volume

• Double-check volume and dose with drug chart in hand –verbalize name of medication, volume, dosage and route to another paramedic or EMT on scene

Administer Medication

• Administer by appropriate route• Observe patient for any signs of adverse reaction

Documentation • Always document drug dosages in chart by mg (if dextrose, in grams)• Document response to medication and any observed adverse reaction

RULE OF NINES – BURN SURFACE AREA

SEPSIS SCREENING• Sepsis is a life-threatening condition that can occur when a systemic reaction known as Systemic Inflammatory

Response Syndrome (SIRS) develops and is related to an infection • The inflammatory response may be the result of exposure to infectious agents in the blood, urine, lungs, skin, or

other organs

RISK FACTORS

Common risk factors for sepsis include elderly age, diabetes, and immunocompromised states. Other risk factors include cancer, renal disease, alcoholism, injection drug use, malnutrition, hypothermia, or recent surgery or invasive procedure.

INDICATIONS FOR SCREENING

Sepsis screening should be done in adults when a patient is suspected of an infection. Examples include patients with the following:• Fever;• Respiratory symptoms such as tachypnea, shortness of breath, cough, sputum production;• Abdominal symptoms such as vomiting, diarrhea, or abdominal pain;• Urinary symptoms such as flank pain or painful / frequent urination;• Skin infections (cellulitis or abscess);• General weakness, altered level of consciousness or lethargy, especially in the elderly

ASSESSMENTSepsis screening includes assessment of pulse rate, respiratory rate and temperature. It is important to note that an elevated temperature may not be seen in sepsis, particularly in elderly patients or advanced stages.

CRITERIA FOR POSITIVE SCREEN

A positive sepsis screen in adults occurs in the setting of suspected infection when 2 of 3 conditions are met:• Heart rate/pulse greater than 90;• Respiratory rate greater than 20;• Temperature above 100.4 or below 96.

HOSPITAL REPORTING

If a positive sepsis screen is encountered, the receiving facility should be notified as part of the report from the field. Report the finding as a “positive sepsis screen.” Not all patients with a positive screen will have sepsis but alerting the facility may assist in calling attention to time-sensitive steps in evaluation and care that are needed to be taken upon hospital arrival.

INDICATIONS FOR SPINAL IMMOBILIZATIONPenetrating Injury (Trauma to head, neck or torso)

• Presence of neurologic complaint or deficit – paralysis, weakness, numbness, tingling, priapism or neurogenic shock, loss of consciousness

• Anatomic deformity of spine

Blunt Injury (Regardless of mechanism)

• Altered level of consciousness (GCS < 15)• Presence of spinal pain or tenderness• Anatomic deformity of spine• Presence of neurologic complaint or deficit – paralysis, weakness,

numbness, tingling, priapism or neurogenic shock

Blunt Injury (When mechanism of injury is concerning)

• Presence of alcohol or drugs or acute stress reaction / anxiety• Distracting injury (e.g. long bone fracture, large laceration, crush or

degloving injury, large burns)• Inability to communicate (e.g. speech or hearing impaired, language gap,

small children, developmental or psychiatric conditions)

Concerning mechanisms of injury include but are not limited to:• Violent impact to head, neck, torso, or pelvis (e.g. assault, entrapment in structural collapse)• Sudden acceleration, deceleration or lateral bending forces to neck or torso (e.g., moderate- to high-

speed MVC, pedestrian struck, explosion)• Falls (especially in elderly patients)• Ejection from motorized or other transportation device (e.g. scooter, skateboard, bicycle, motor

vehicle, motorcycle, recreational vehicle, or horse)• Victims of shallow-water diving incident

*** USE CLINICAL JUDGMENT – IF IN DOUBT, IMMOBILIZE ***

VASCULAR ACCESSSkill Indication / Comment Contraindication

Saline Lock When medication alone is being given or a potential for medication is anticipated

No anticipated need for prehospital medication or fluid

Arm IVWhen fluids or medications needed and patient not in shock or arrest. Antecubital site not ideal unless no other vein available.


Antecubital IV

• Shock • Adenosine (rapid IV bolus)• Cardiac arrest if IO cannot be obtained• Other peripheral sites not available and

medications or fluids indicated


IntraosseousAccess (IO)

• Cardiac arrest• Profound shock or unstable dysrhythmia

when rapid IV access or suitable vein cannot be rapidly locatedo Use lidocaine for pain control in non-

arrest patients PRIOR to IO flush, fluid or medication (Infusion is painful!)

• If no medication or fluid is being administered (do not use for prophylactic vascular access)

• If patient stable• When other routes for medications

available (IM, IN)

External Jugular IV

Unstable patient needs emergent IV medication or fluids AND no peripheral site is available AND IO not appropriate (e.g. very alert patient)

• Contraindicated in cardiac arrest unless IO and antecubital IV cannot be started (interrupts CPR)

• When other routes for medications available (IM, IN) – e.g. naloxone or use of glucagon instead of dextrose

VENTRICULAR ASSIST DEVICES (VAD)

BACKGROUND INFORMATION

• A Ventricular Assist Device (VAD) is an implanted device used to partially or completely replace the pumping function of a failing heart. VADs are used both as a bridge device while patients are awaiting heart transplant, and now increasingly are used permanently in patients who are not transplant candidates (referred to as destination therapy).

• VAD patients and their families/caretakers have been given training for their devices and they should be capable of basic troubleshooting of the device. Hospitals that implant VADs have 24-hour on-call coverage (VAD Coordinators) for families or responders to contact in case of any issues. The contact phone number should be present on the patient’s equipment and this person may be able to help the family or responding personnel in assessing the device.

ASSESSMENT

• Depending on the type of VAD, a patient may or may not present with a palpable pulse, and blood pressure may not be detected, particularly with automatic measurements. Most newer VADs work without generating a pulse. The pulse, if present, may not correspond to the patient’s heart rate on the monitor.

• In the absence the ability to detect pulse and blood pressure, patient evaluation of skin signs, level of consciousness, oxygen saturation, non-invasive end-tidal carbon-dioxide, and general appearance may give the best clues as to the patient’s clinical status.

TREATMENT

• Patients may be cardioverted or defibrillated if symptomatic, but asymptomatic dysrhythmias do not require treatment

• VAD devices may become dislodged with chest compressions and this may lead to massive hemorrhage. Do not perform chest compressions on patients with VADs, even if the patient is unconscious.

• Treatment should otherwise follow appropriate treatment guidelines. Medical direction is provided by the base hospital (VAD coordinators cannot provide medical direction).

DESTINATIONANDDISPOSITION

• In most circumstances, when transport is indicated the appropriate destination for the patient is the hospital where the VAD was implanted and the patient is managed.

• For very minor conditions (e.g. small laceration repair) local transport may be appropriate.

• Contact the base hospital if there are questions concerning destination. • If possible, the patient’s family member or caregiver should accompany the patient

in the ambulance, and all related VAD equipment (e.g. spare batteries) should also be transported with the patient.

• In arrest situations, determine if DNR/POLST or advance directives are available. Many VAD patients have made end-of-life care decisions.

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