2018 adult and pediatric statewide ems treatment protocols
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Calhoun County EMS System Protocols – Adult and Pediatric
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CALHOUN COUNTY EMS
SYSTEM WIDE PROTOCOLS
2018
2018 Adult and Pediatric Statewide EMS Treatment Protocols IOWA DEPARTMENT OF PUBLIC HEALTH BUREAU OF EMERGENCY AND TRAUMA SERVICES MARCH 2018
Calhoun County EMS System Protocols – Adult and Pediatric
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Table of Contents Table of Contents ........................................................................................................................... - 1 -
Introduction .................................................................................................................................. - 6 -
IOWA ADMINISTRATIVE CODE 641 - CHAPTER 132: EMERGENCY MEDICAL SERVICES—SERVICE PROGRAM
AUTHORIZATION ....................................................................................................................................... - 6 -
2018 PROTOCOL APPROVAL – SERVICE LEVEL - MEDICATIONS ........................................................................ - 7 -
2018 PROTOCOL APPROVAL ...................................................................................................................... - 8 -
IOWA EMS TREATMENT PROTOCOLS ..................................................................................................9
INITIAL PATIENT CARE PROTOCOL-ADULT AND PEDIATRICS ............................................................................... 10
AIRWAY PROTOCOLS .............................................................................................................................. 16
ADVANCED AIRWAY PLACEMENT / CONFIRMATION / MANAGEMENT ............................................................ 17
CARDIAC PROTOCOLS ............................................................................................................................. 18
ACUTE CORONARY SYNDROME / CHEST PAIN .............................................................................................. 19
ASYSTOLE / PEA ..................................................................................................................................... 22
ATRIAL FIBRILLATION ............................................................................................................................... 23
BRADYCARDIA ........................................................................................................................................ 24
CARDIAC ARREST BLS - AED .................................................................................................................... 25
CONGESTIVE HEART FAILURE / PULMONARY EDEMA.................................................................................... 26
POST RESUSCITATION .............................................................................................................................. 28
TACHYCARDIA: NARROW COMPLEX .......................................................................................................... 30
TACHYCARDIA: WIDE COMPLEX................................................................................................................ 32
TERMINATION OF RESUSCITATIVE EFFORTS ................................................................................................. 33
VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA ........................................................... 34
MEDICAL PROTOCOLS ............................................................................................................................ 36
ABDOMINAL PAIN (NON-TRAUMATIC) ....................................................................................................... 37
ALTERED MENTAL STATUS ........................................................................................................................ 37
APPARENT DEATH-DETERMINATION OF DEATH-WITHHOLDING RESUSCITATIVE EFFORTS .................................. 40
ALLERGIC REACTION ................................................................................................................................ 42
ASTHMA AND COPD ............................................................................................................................... 44
BEHAVIORAL EMERGENCIES ...................................................................................................................... 46
DIABETIC EMERGENCY ............................................................................................................................. 48
EPISTAXIS ............................................................................................................................................... 50
FEVER/INFECTION CONTROL ..................................................................................................................... 51
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HYPERTENSIVE EMERGENCY ...................................................................................................................... 53
HYPOTENSION ........................................................................................................................................ 54
NAUSEA & VOMITING ............................................................................................................................. 55
OVERDOSE / TOXIC INGESTION ................................................................................................................. 56
PAIN CONTROL ....................................................................................................................................... 59
RESPIRATORY DISTRESS ............................................................................................................................ 61
SEIZURE ................................................................................................................................................. 62
SEPSIS ................................................................................................................................................... 64
STROKE .................................................................................................................................................. 65
SYNCOPE / WEAKNESS............................................................................................................................. 68
OB PROTOCOLS ....................................................................................................................................... 70
CHILDBIRTH / LABOR ............................................................................................................................... 71
NEWBORN ............................................................................................................................................. 73
OBSTETRICAL EMERGENCY ........................................................................................................................ 75
PRE-ECLAMPSIA / ECLAMPSIA................................................................................................................... 76
PEDIATRIC PROTOCOLS .......................................................................................................................... 78
INITIAL PATIENT CARE PROTOCOL-ADULT AND PEDIATRICS ........................................................................... 79
Pediatric Airway ................................................................................................................................. 85
PEDIATRIC ALLERGIC REACTION ................................................................................................................. 86
PEDIATRIC ALTERED MENTAL STATUS ........................................................................................................ 87
PEDIATRIC ASTHMA ................................................................................................................................. 88
PEDIATRIC BEHAVIORAL EMERGENCIES....................................................................................................... 89
PEDIATRIC BURNS ................................................................................................................................... 90
PEDIATRIC CARDIAC ARRHYTHMIA ............................................................................................................. 93
PEDIATRIC DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS ............................................. 95
PEDIATRIC NAUSEA AND VOMITING ........................................................................................................... 96
PEDIATRIC NEAR DROWNING .................................................................................................................... 97
PEDIATRIC PAIN CONTROL ........................................................................................................................ 99
PEDIATRIC POISONING ........................................................................................................................... 100
PEDIATRIC SEIZURE ................................................................................................................................ 101
PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION ......................................................................................... 102
PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION CONTINUED ........................................................................ 103
PEDIATRIC SHOCK ................................................................................................................................. 104
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SUSPECTED CHILD ABUSE ....................................................................................................................... 105
PEDIATRIC TRAUMA .............................................................................................................................. 106
ENVIRONMENTAL PROTOCOLS ............................................................................................................ 108
BITES AND ENVENOMATION ................................................................................................................... 109
FROSTBITE ............................................................................................................................................ 111
HYPERTHERMIA .................................................................................................................................... 112
HYPOTHERMIA...................................................................................................................................... 113
TRAUMA PROTOCOLS .......................................................................................................................... 114
ABDOMINAL / PELVIC TRAUMA .............................................................................................................. 115
BURNS ................................................................................................................................................. 116
ELECTRICAL INJURIES ............................................................................................................................. 118
EXTREMITY TRAUMA ............................................................................................................................. 119
HEAD TRAUMA ..................................................................................................................................... 121
MULTI-SYSTEMS TRAUMA ...................................................................................................................... 122
SHOCK - TRAUMA ................................................................................................................................. 123
THORACIC TRAUMA ............................................................................................................................... 124
SELECTIVE SPINAL IMMOBILIZATION ......................................................................................................... 125
SEXUAL ASSAULT .................................................................................................................................. 127
IOWA EMS TREATMENT APPENDICES .......................................................................................................... 128
Appendix A - EMS Out-of-Hospital Do-Not-Resuscitate Protocol .................................................. 129
Appendix B: Adult Out-Of-Hospital Trauma Triage Destination Decision Protocol ....................... 130
Pediatric Out-Of-Hospital Trauma Triage Destination Decision Protocol ...................................... 131
Appendix C: Physician on Scene ...................................................................................................... 132
Appendix D: Air Medical Transport - Utilization Guidelines for Scene Response .......................... 133
Appendix E: Intentionally Left Blank ............................................................................................... 134
Appendix F: Reperfusion Therapy Screening Not Limited to Paramedic Level .............................. 135
Fibrinolytic Checklist ........................................................................................................................ 136
Appendix G: Strategies for Reperfusion Therapy: Acute Stroke .................................................... 137
Appendix H: Simple Triage and Rapid Treatment (START) ............................................................. 139
Simple Triage and Rapid Treatment – Pediatric JumpSTART ......................................................... 140
Appendix I: Suspected Abuse/Assault/Neglect/Maltreatment ..................................................... 141
Appendix J: Guidelines for EMS Provider Initiating Organ and Tissue Donation at the Scene of the Deceased ........................................................................................................................................... 142
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Appendix K: Guidelines for EMS Providers Responding to a patient with special needs .............. 143
Appendix L: EMS Approved Abbreviations...................................................................................... 144
Appendix M: Guidelines for New Protocol Development .............................................................. 145
Appendix N: Rapid Sequence Induction .......................................................................................... 146
Appendix O: Continuous Positive Airway Pressure (CPAP) ............................................................ 148
Appendix P: PEEP Valve Guidelines ................................................................................................. 150
Appendix Q: Special Events .............................................................................................................. 151
Appendix R: Swiss Mountain Society Stages of Hypothermia ........................................................ 152
APGAR Score ..................................................................................................................................... 153
Cincinnati Stroke Scale ..................................................................................................................... 154
Pediatric Glasgow Coma Scale ......................................................................................................... 155
Wong-Baker Faces Pain Rating Scale ............................................................................................... 156
Pediatric Assessment Triangle ......................................................................................................... 157
Rule of Nines ..................................................................................................................................... 158
Dopamine Chart ............................................................................................................................... 159
MEDICATION REFERENCES .......................................................................................................................... 160
ADENOSINE (Adenocard) ................................................................................................................. 160
ALBUTEROL (PROVENTIL, VENTOLIN) .............................................................................................. 160
AMIODARONE .................................................................................................................................. 161
ASPIRIN ............................................................................................................................................. 161
ATROPINE ......................................................................................................................................... 161
CALCIUM CHLORIDE ......................................................................................................................... 162
DEXTROSE (D50W, D25W, D10W) ................................................................................................... 162
DILTIAZEM (CARDIZEM) ................................................................................................................... 162
DIPHENHYDRAMINE (BENADRYL) .................................................................................................... 163
DOPAMINE (INTROPIN) .................................................................................................................... 163
EPINEPHRINE (ADRENALIN) ............................................................................................................. 164
FENTANYL CITRATE (SUBLIMAZE) .................................................................................................... 164
GLUCAGON ....................................................................................................................................... 164
GLUCOSE (ORAL) ............................................................................................................................... 165
Haloperidol (Haldol) ......................................................................................................................... 165
KETAMINE (KETALAR) ....................................................................................................................... 165
LIDOCAINE ........................................................................................................................................ 166
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Lorazepam (Ativan) .......................................................................................................................... 166
MAGNESIUM SULFATE ..................................................................................................................... 167
METHYLPREDNISOLONE (SOLU-MEDROL) ....................................................................................... 167
MIDAZOLAM (VERSED) ..................................................................................................................... 168
Morphine Sulfate.............................................................................................................................. 168
NALOXONE (NARCAN) ...................................................................................................................... 168
NITROGLYCERIN (NTG) ..................................................................................................................... 170
ONDANSETRON HCL (ZOFRAN) ........................................................................................................ 170
OXYGEN ............................................................................................................................................ 170
ROCURONIUM BROMIDE (ZEMURON) ............................................................................................ 171
SODIUM BICARBONATE (BICARB) .................................................................................................... 171
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Introduction Iowa Administrative Code 641 - Chapter 132: Emergency Medical Services—Service Program Authorization 132.8(3) Service program operational requirements. Ambulance and non-transport service programs shall:
b. Utilize department protocols as the standard of care. The service program medical director may make changes to the department protocols provided the changes are within the EMS provider’s scope of practice and within acceptable medical practice. A copy of the changes shall be filed with the department.
132.9(2) The medical director’s duties include, but need not be limited to:
a. Developing, approving and updating protocols to be used by service program personnel that meet or exceed the minimum standard protocols developed by the department.
Purpose
The completed protocol approval page allows for a physician medical director to implement the use of the 2017 Iowa Statewide EMS Treatment Protocols for one or more service programs where they serve as the program’s medical director.
Instructions
Print or type the service name in the space provided. Next select each service’s corresponding service type and level of authorization. If the medical director makes any additions, subtractions, or other changes to the 2017 protocols the changes will need to be noted in the Protocol Revisions space and filed with the Department. This would include the addition, subtraction, or change of any medication listed within the 2017 protocols. If no changes are made to the 2017 protocols check the box for no changes.
Scope of Practice
The Iowa Emergency Medical Care Provider Scope of Practice document outlines the skills each level of certified EMS provider can perform. Some skills will require the approval of the service program’s physician medical director as well as documentation of additional training. Iowa EMS providers may not perform skills outside of their identified scope of practice as documented in the Iowa Emergency Medical Care Provider Scope of Practice. The most current version of the Iowa Emergency Medical Care Provider Scope of Practice document can be viewed and downloaded from the Bureau’s website at: http://idph.iowa.gov/bets/ems/scope-of-practice.
Recommendations
It is recommended that each service program maintain records that document the review/education of all staff members on the program’s most current protocols and the most current version of the Iowa Emergency Medical Care Provider Scope of Practice document.
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2018 Protocol Approval – Service level - Medications
Service(s) Name
Calh
oun
Coun
ty
EMS
– Ro
ckw
ell
City
Ca
lhou
n Co
unty
EM
S –
Lake
City
Calh
oun
Coun
ty
EMS
- Man
son
Lohr
ville
EM
S
Farn
ham
ville
EM
S
Service Type Ambulance X X X X X Non transport
Service’s Level of Authorization
EMR EMT X X AEMT X Paramedic X X
Pharmaceuticals Check All Medications Carried by the Service
Medication kit should contain only medications approved by the service’s Medical Director OTC Medications Medications
Aspirin � Adenosine � Lorazepam Glucose Paste � Albuterol � Magnesium Sulfate � Amiodarone � Midazolam Patient Assisted Medications � Atropine � Morphine Sulfate � Auto-injector Epinephrine � Dextrose � Naloxone � Nitroglycerin � Diphenhydramine � Nitroglycerin � Inhaler � Dopamine � Ondansetron
IV Fluids � Epinephrine � Oxygen � Normal Saline � Fentanyl � Sodium Bicarbonate � Ringer’s Lactate � Glucagon � � Dextrose 10% � Lidocaine �
� Medications Added by Service’s Medical Director
Acetaminophen Ketamine Burn Cream Rocuronium Calcium Chloride Methylprednisolone Diltiazem Triple Antibiotic Ointment Haldol
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2018 Protocol Approval � No changes were made to the 2018 Iowa Statewide EMS Treatment Protocols
OR List below or attach copies of all changes made by the physician medical director to the 2018 Iowa
Statewide EMS Treatment Protocols Page Protocol Name Changes Made
All Complete format change
Additional Skills for the EMR, EMT, AEMT
Approval of these additional skills must be within the Service Program’s Level of Authorization and the Iowa EMS Provider’s Scope of Practice
Mark “Yes” if the skill is approved by the medical director to be performed by the identified certification level
Certification Level
Yes
No
Pulse oximetry EMR X Glucose monitor EMT X Service carries auto-inject epi EMT X Central line access AEMT X CPAP EMT, AEMT X
NOTE: Iowa’s Scope of Practice document requires medical director approval and documentation of additional training for these skills. Service program must maintain documentation of the additional training
Medical Director Statement of Approval As the physician medical director I have reviewed both the 2018 Iowa Statewide EMS Treatment Protocols and the Iowa Emergency Medical Care Provider Scope of Practice document and approve the use of the skills, medications, and protocols with revisions as documented above for the authorized Iowa EMS program(s) listed within this document.
Medical Director’s Printed Name Signature Date Dr. James Comstock
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IOWA EMS TREATMENT PROTOCOLS
Initial Patient Care Protocol
Airway Protocols
Cardiac Protocols
Medical Protocols
OB Protocols
Pediatric Protocols
Environmental Protocols
Trauma Protocols
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Initial Patient Care Protocol-Adult and Pediatrics Revised 2018 - This protocol serves to reduce the need for extensive reiteration of basic assessment and other considerations in every protocol.
Assessment
1. Assess scene safety
a. Evaluate for hazards to EMS personnel, patient, bystanders
b. Determine number of patients
c. Determine mechanism of injury
d. Request additional resources if needed and weigh the benefits of waiting for additional resources against rapid transport to definitive care
e. Consider declaration of mass casualty incident if needed
2. Use appropriate personal protective equipment (PPE)
3. Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g. operations at night
or in darkness, on or near roadways) 4. Consider cervical spine stabilization and/or spinal care if trauma
Primary Survey
1. Airway, Breathing, Circulation is cited below; (although there are specific circumstances where Circulation, Airway, Breathing may be indicated such as cardiac arrest or major arterial bleeding) a. Airway (assess for patency and open the airway as indicated)
i. Patient is unable to maintain airway patency—open airway 1. Head tilt chin lift 2. Jaw thrust 3. Suction 4. Consider use of the appropriate airway management adjuncts and devices:
• oral airway, • nasal airway, • blind insertion, or supraglottic airway device, • laryngeal mask airway, • endotracheal tube
5. For patients with laryngectomies or tracheostomies, remove all objects or clothing that may obstruct the opening of these devices, maintain the flow of prescribed oxygen, and reposition the head and/or neck
b. Breathing
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i. Evaluate rate, breath sounds, accessory muscle use, retractions, patient positioning ii. Administer oxygen as appropriate with a target of achieving 94-98% saturation for most acutely ill patients iii. Apnea (not breathing) – open airway-see #4 above
c. Circulation
i. Control any major external bleeding (see Extremity Trauma/External Hemorrhage Management guideline) ii. Assess pulse
1. If none – go to Cardiac Arrhythmia Protocol 2. Assess rate and quality of carotid and radial pulses
iii. Evaluate perfusion by assessing skin color and temperature
1. Evaluate capillary refill
d. Disability i. Evaluate patient responsiveness: AVPU scale (Alert, Verbal, Pain, Unresponsive) ii. Evaluate gross motor and sensory function in all extremities iii. Check blood glucose in patients with altered mental status iv. If acute stroke suspected – go to Stroke Protocol
e. Expose patient as appropriate to complaint
i. Be considerate of patient modesty ii. Keep patient warm
Secondary Survey
1. The performance of the secondary survey should not delay transport in critical patients. Secondary surveys should be tailored to patient presentation and chief complaint. Secondary survey may not be completed if patient has critical primary survey problems a. Head
i. Pupils ii. Naso-oropharynx iii. Skull and scalp
b. Neck
i. Jugular venous distension ii. Tracheal position iii. Spinal tenderness
c. Chest i. Retractions
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ii. Breath sounds iii. Chest wall deformity
d. Abdomen/Back
i. Flank/abdominal tenderness or bruising ii. Abdominal distension
e. Extremities
i. Edema ii. Pulses iii. Deformity
e. Neurologic i. Mental status/orientation ii. Motor/sensory
2. Obtain Baseline Vital Signs (An initial full set of vital signs is required: pulse, blood pressure,
respiratory rate, neurologic status assessment) (see chart below) a. Neurologic status assessment: establish a baseline and note any change in patient neurologic status
i. AVPU (Alert, Verbal, Painful, Unresponsive) or ii. Glasgow Coma Score (GCS)
b. Patients with cardiac or respiratory complaints
i. Pulse oximetry ii. 12-lead EKG should be obtained early in patients with cardiac or suspected cardiac complaints iii. Continuous cardiac monitoring, if available iv. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry
c. Patient with altered mental status
i. Check blood glucose ii. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry
d. Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should be taken shortly before arrival at receiving facility
e. Critical patients should have pertinent vital signs frequently monitored
3. Obtain OPQRST history:
a. Onset of symptoms (circumstances surrounding onset such as gradual, or sudden onset) b. Provocation – location; any exacerbating or alleviating factors c. Quality of pain d. Radiation of pain e. Severity of symptoms – pain scale
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f. Time of onset and circumstances around onset
4. Obtain SAMPLE history:
a. Symptoms b. Allergies – medication, environmental, and foods c. Medications – prescription and over-the-counter; bring containers to ED if possible d. Past medical history
i. look for medical alert tags, portable medical records, advance directives ii. look for medical devices/implants (some common ones may be dialysis shunt, insulin pump, pacemaker, central venous access port, gastric tubes, urinary catheter)
e. Last oral intake f. Events leading up to the 911 call
Treatment and Interventions
1. Administer oxygen as appropriate with a target of achieving 94-98% saturation
2. Tier with an appropriate service if advanced level of care or assistance is needed and can be accomplished in a timely manner
3. Place appropriate monitoring equipment as dictated by assessment, within scope of practice – these may include:
a. Continuous pulse oximetry b. Cardiac rhythm monitoring c. Waveform capnography or digital capnometry d. Carbon monoxide assessment
4. If within scope of practice, establish vascular access if indicated or in patients who are at risk for
clinical deterioration. a. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of lidocaine 0.1mg/mL with slow push through IO needle to a maximum of 40 mg to mitigate pain from IO medication administration
5. Monitor pain scale if appropriate
6. Reassess patient
Patient Safety Considerations
1. Routine use of lights and sirens without documented indication is not warranted
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2. Even when lights and sirens are in use, always limit speeds to level that is safe for the emergency vehicle being driven and road conditions on which it is being operated
3. Be aware of legal issues and patient rights as they pertain to and impact patient care (e.g.
patients with functional needs or children with special healthcare needs)
4. Be aware of potential need to adjust management based on patient age and comorbidities, including medication dosages
5. The maximum weight-based dose of medication administered to a pediatric patient should not
exceed the maximum adult dose except where specifically stated in a patient care guideline
6. Direct medical control should be contacted when mandated or as needed Key Considerations Pediatrics: Use an accurate weight or length-based assessment tool (length-based tape or other system) to estimate patient weight and guide medication therapy and adjunct choices.
a. The pediatric population is generally defined by those patients who weigh up to 40 kg or up to 14-years of age, whichever comes first b. Consider using the pediatric assessment triangle (appearance, work of breathing, circulation) when first approaching a child to help with assessment.
Geriatrics: The geriatric population is generally defined as those patients who are 65 years old or more.
a. In these patients, as well as all adult patients, reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease)
Co-morbidities: reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease).
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Normal Vital Signs
Age Pulse Respiratory Rate
Systolic BP
Preterm less than 1 kg 120-160 30-60 36-58 Preterm 1 kg 120-160 30-60 42-66 Preterm 2 kg 120-160 30-60 50-72 Newborn 120-160 30-60 60-70 Up to 1 year 100-140 30-60 70-80 1-3 years 100-140 20-40 76-90 4-6 years 80-120 20-30 80-100 7-9 years 80-120 16-24 84-110 10-12 years 60-100 16-20 90-120 13-14 years 60-90 16-20 90-120 15 years or older 60-90 14-20 90-130
Glasgow Coma Scale
ADULT GLASGOW COMA SCALE PEDIATRIC GLASGOW COMA SCALE Eye Opening (4) Eye Opening (4) Spontaneous 4 Spontaneous 4 To Speech 3 To Speech 3 To Pain 2 To Pain 2 None 1 None 1 Best Motor Response (6) Best Motor Response (6) Obeys Commands 6 Spontaneous
Movement 6
Localizes Pain 5 Withdraws to Touch
5
Withdraws from Pain
4 Withdraws from Pain
4
Abnormal Flexion 3 Abnormal Flexion 3 Abnormal Extension
2 Abnormal Extension
2
None 1 None 1 Verbal Response (5) Verbal Response (5) Oriented 5 Coos, Babbles 5 Confused 4 Irritable Cry 4 Inappropriate 3 Cries to Pain 3 Incomprehensible 2 Moans to Pain 2 None 1 None 1 Total Total
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AIRWAY PROTOCOLS
Advanced Airway Placement/Confirmation/Management
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ADVANCED AIRWAY PLACEMENT / CONFIRMATION / MANAGEMENT
ADVANCED CARE GUIDELINES
1. If Advanced Airway Placement is necessary a. Perform Orotracheal Intubation
2. If successful confirm with at least 3 methods. One must be ETCO2/waveform monitoring.
b. Secure the tube c. Ventilatory rate should initially 10-12 BPM. Adjust to maintain an ETCO2 of 35-45. d. Consider Midazolam 2mg IV, or Ketamine 1-2 mg/Kg IV, repeat as necessary to sedate the
patient if needed to maintain airway.
3. If unsuccessful, refer to RSI Protocol.
4. If still cannot ventilate, perform needle cricothyrotomy
CONSIDERATIONS:
o Confirmation of intubation include: 1. Visualization of the ETT protruding adequately past the vocal cords and into the trachea 2. ETCO2 / waveform monitoring 3. Auscultation of all lung fields to confirm adequate air exchange 4. Bilateral, symmetrical expansion of the thorax
o Document the following: tube size, depth at the lips/nares, clinical signs of improved oxygenation & ventilation, tube confirmation methods and confirmation at destination.
o Minimally, reconfirmation should occur once the patient is prepared for transport; anytime the patient is moved; anytime dislodgement of the tube is suspected; any changes in patient condition and when responsibility for care is transferred to another provider.
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CARDIAC PROTOCOLS
ACUTE CORONARY SYNDROME/CHEST PAIN
ASYSTOLE/PEA
ATRIAL FIBRILLATION
BRADYCARDIA
CARDIAC ARREST/BLS-AED
CONGESTIVE HEART FAILURE/PULMONARY EDEMA
POST RESUSCITATION
TACHYCARDIA NARROW COMPLEX
TACHYCARDIA WIDE COMPLEX
VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA
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ACUTE CORONARY SYNDROME / CHEST PAIN
HISTORY:
o Age o Medications o Viagra, Levitra, Cialis o Past medical history (MI,
Angina, Diabetes, post-menopausal)
o Allergies (ASA, Morphine) o Palliation/Provocation o Quality (crampy, constant,
sharp, dull, etc.) o Region/Radiation/Referred o Severity (1-10) o Time
(onset/duration/repetition)
SIGNS AND SYMPTOMS:
o Chest pain (pain, pressure, aching, vice-like tightness)
o Location (substernal, epigastric, arm, jaw, neck, shoulder)
o Radiation of pain o Pale, diaphoresis o Shortness of
breath/cough o Nausea, vomiting,
dizziness o Time of Onset
DIFFERENTIAL:
o Trauma vs. Medical o Angina vs. Myocardial
infarction o Pericarditis o Pulmonary embolism o Asthma / COPD o Pneumothorax o Aortic dissection or
aneurysm o GERD or hiatal hernia o Esophageal spasm o Chest wall injury or pain o Pleural pain o Overdose (Cocaine) or
Methamphetamine
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Place patient in position of comfort, loosen tight clothing and provide reassurance. If patient is complaining of shortness of breath, has signs of respiratory distress or pulse oximetry of less than 94%, titrate oxygen to symptom improvement or to maintain saturation of 94-99%.
b) If capability exists, obtain a 12-lead EKG and transmit to the receiving facility and/or medical control for interpretation as soon as possible. An initial management goal is to identify STEMI and transport the patient with cardiac symptoms to the facility most appropriate to needs.
c) If patient is alert and oriented and expresses no allergy to aspirin have patient chew non-enteric coated aspirin 324-325 mg.
d) Evaluate if erectile dysfunction or pulmonary hypertension medications have been taken in the past 48 hours including: Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn), or Avanafil (Stendra), Tadalafil (Cialis, Adcirca).
e) If the patient has not taken any of the medications in (d) in the last 48 hours and has a systolic blood pressure of 90 mmHg or above, have the patient self-administer one dose of nitroglycerin (patient’s nitro only).
f) Repeat one dose of nitroglycerin in 3-5 minutes if pain continues, systolic blood pressure is 90 mmHg or above, up to a maximum of three doses.
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g) Reassess patient and vital signs following each dose of nitroglycerin.
h) Reperfusion Checklist
ADVANCED CARE GUIDELINES
i) Monitor EKG and treat dysrhythmias.
j) Establish IV access at TKO rate unless otherwise ordered or indicated.
k) Administer nitroglycerin 0.4 mg sublingually if systolic blood pressure 90 mmHg or above for symptoms of chest pain or atypical cardiac pain. Repeat dose every 5 minutes if pain continues and systolic blood pressure is 90 mmHg or above.
l) If pain continues after administration of three doses of nitroglycerin and systolic blood pressure remains above 90 mmHg administer: Morphine 2-4 mg IV may repeat every 5 minutes
OR Fentanyl 25-50 mcg IV may repeat every 5 minutes
m) Consider NS Bolus for Inferior MI
n) Use Protocols as needed
Nausea and Vomiting Protocol Hypotension Protocol
CONSIDERATIONS:
o Chest pain, or “discomfort”, is present in two out of three patients with acute myocardial ischemia/infarction. Atypical presentations (commonly seen in diabetics, females and geriatric patients) include the following angina equivalents: respiratory distress, syncope, unexplained weakness, diaphoresis, palpitations, epigastric pain and nausea.
o Cardiac Risk Factors include: Major-tobacco (packs per day x years), hypertension, hyperlipidemia, genetics (mother, father, brother, or sister had MI or CABG prior to age 55), cocaine use; Minor-obesity, male, physical inactivity, post-menopausal, age > 45
o Assess 12-Lead ECG early – Goal within 10 minutes of first patient contact o Avoid Nitroglycerin in any patient who has used Viagra, Levitra, Cialis, or other ED medications in
the past 48 hours due to potential severe hypotension—contact Medical Control o Patient with STEMI (ST-Elevation Myocardial Infarction) should be transported to the appropriate
destination based on the EMS System STEMI Plan. o If the patient has taken nitroglycerin without relief, consider potency of the medication.
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Dysrhythmia Protocols
o Treat life threatening arrhythmias per the appropriate protocol before initiating the Acute Coronary Syndrome protocol.
POSITIVE ACUTE MI (STEMI = 1 mm ST Segment Elevation in 2 Contiguous Leads)
Transport based on EMS System STEMI Plan with Early Notification. Goal -SCENE TIME < 10 MINUTES
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ASYSTOLE / PEA
HISTORY:
o Events leading to arrest o End stage renal disease o Estimated downtime o Bystander CPR? o Suspected hypothermia o Suspected overdose o DNR, IPOLST
SIGNS AND SYMPTOMS:
o Pulseless o Apneic o Cyanosis o Livor mortis or Rigor
mortis?
DIFFERENTIAL:
o Trauma vs. Medical o Hypoxia o Potassium (hypo / hyper) o Drug overdose o Acidosis o Hypothermia o Device (lead) error o Death
1. Follow initial patient care protocol 2. Withhold Resuscitation as per Apparent Death or Termination of Resuscitation protocol
BASIC CARE GUIDELINES a) Perform high quality CPR immediately, apply AED and follow device prompts
b) Compression-only CPR is appropriate if unable to support airway while applying and using AED
c) May place appropriate airway if unable to adequately ventilate patient noninvasively, if does not
interrupt compressions, or after return of spontaneous circulation
d) May apply mechanical compression device (if available) after ensuring high quality compressions/ventilations and application of AED. Emphasis on minimizing interruption of compressions.
ADVANCED CARE GUIDELINES e) Perform high quality CPR immediately, apply monitor and check rhythm as soon as possible
f) When IV/IO established, give Epinephrine 1 mg every 3-5 minutes following cycle checks
g) Evaluate and treat for underlying causes
h) If pulse returns, go to Post Resuscitation Protocol
CONSIDERATIONS:
• Initial efforts should be concentrated on high quality CPR with minimal interruptions. This has a greater impact on patient outcome than any intervention. Deliver continuous chest compressions (minimum 100 and no more than 120 per minute)
• Once high-quality CPR has been initiated only then shall airway management be attempted. Ventilations with oral airway and BVM is acceptable as long as tidal volume is being delivered. Advanced airway procedures shall only be done when other means do not work. Ventilations should be no more than 10 – 12 per minute. AVOID HYPERVENTILATION!
• IV/IO is the preferred routes of medication administration and initiation of IV/IO takes precedence over intubating. ETT is no longer an acceptable route for medication administration.
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ATRIAL FIBRILLATION HISTORY:
o Medications (Aminophylline, Diet pills, Thyroid supplements, decongestants, Digoxin)
o Diet (caffeine, chocolate)
o Drugs (nicotine, cocaine, methamphetamine)
o Past medical history o History of palpitations /
heart racing
SIGNS AND SYMPTOMS:
o HR > 130/min o QRS < 0.12 sec o Dizziness, chest pain, SOB o Potential presenting
rhythm Sinus tachycardia Atrial fibrillation / flutter Multifocal atrial tachycardia
DIFFERENTIAL:
o Heart disease (WPW, Valvular) o Sick Sinus Syndrome o Myocardial Infarction o Electrolyte imbalance o Exertion, pain, emotional stress o Fever o Hypoxia o Hypovolemia or anemia o Drug effect / overdose (see Hx) o Hyperthyroidism o Pulmonary embolus
1. Follow initial patient care protocol BASIC CARE GUIDELINES
a) Obtain 12 lead ECG and transmit to receiving facility
ADVANCED CARE GUIDELINES b) History of WPW (Wolff-Parkinson-White)? Follow Tachycardia: Narrow Complex
Protocol
c) Asymptomatic, monitor for changes
d) Symptomatic (Chest pain, Altered Mental Status, etc.) Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min (Max = 20 mg)
e) Pre-Arrest (severely altered mental status, no palpable BP)
Consider sedation for Cardioversion with Versed 2-5 mg IV Synchronized Cardioversion 100 J x 1, then 200 J. Repeat PRN Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min (Max = 20 mg)
f) After rate control or cardioversion obtain repeat 12 Lead ECG
CONSIDERATIONS:
• Exam: Mental Status, Skin, Heart, Lung, Extremities • Adenosine may not be effective in identifiable atrial fibrillation/flutter, yet is not harmful • Monitor for hypotension after administration of Cardizem • Document all rhythm changes with monitor strips. • Continuous Pulse Oximetry is required for all Atrial Fibrillation Patients
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BRADYCARDIA HISTORY:
o Past medical history – cardiac, thyroid problem
o Pacemaker o Medications Beta-Blockers Calcium channel
blockers Clonidine Digoxin
SIGNS AND SYMPTOMS:
o HR < 60/min with hypotension, acute altered mental status, chest pain, acute CHF, seizures, syncope or shock secondary to bradycardia
o Respiratory distress
DIFFERENTIAL:
o Acute myocardial infarction o Hypoxia o Pacemaker failure o Hypothermia o Sinus bradycardia o Athletes o Head injury (elevated ICP) or
stroke o Spinal cord lesion o Sick Sinus Syndrome o AV Blocks (1˚, 2˚, or 3˚) o Overdose
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Obtain 12 Lead ECG and transmit to receiving facility 3. If asymptomatic continue to monitor and reassess
ADVANCED CARE GUIDELINES 4. If symptomatic, administer atropine 0.5 mg IV or IO every 3-5 minutes as needed to maximum
dose of 3.0 mg. If in the setting of myocardial infarction, do not give atropine if there is a wide complex rhythm.
5. Consider transcutaneous pacing early in the unstable patient (especially in 2nd or 3rd degree heart block)
6. Consider administering dopamine 5-20 mcg/kg/min IV or IO if patient still hypotensive 7. Consider administering Glucagon 0.5 mg/kg if patient still bradycardic and on beta blockers 8. Consider Calcium Chloride 0.5-1 gram over 10 minutes if patient still bradycardic and on calcium
channel blockers or dialysis patient. CONSIDERATIONS:
• Symptomatic bradycardia is defined as a pulse rate of < 60 bpm with a SBP < 90 mmHg, shortness of breath, altered mental status, and/or other signs of hypoperfusion
• Treatment of choice for 2˚ type II and 3˚ AV heart blocks with serious signs/symptoms is external pacing. Consult Medical Control if serious signs/symptoms do not exist
• Pharmacological treatment of Bradycardia is based upon the presence or absence of symptoms. If symptomatic treat, if asymptomatic, monitor only
• In wide complex slow rhythm consider hyperkalemia. Contact Medical Control. • Transplanted hearts will not respond to Atropine: external pacing is treatment of choice • If hypotension exists, treat bradycardia first. If hypotension persists once HR is normalized,
treat hypotension • Consider treatable causes for Bradycardia (Beta Blocker OD, Calcium Channel Blocker OD,
etc.) • A 12-Lead ECG is essential in assessing for cardiac ischemia
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CARDIAC ARREST BLS - AED
HISTORY:
o Estimated down time o Events leading to arrest o Cardiac history o Renal failure / dialysis o DNR or IPOST o SAMPLE
SIGNS AND SYMPTOMS:
o Unresponsive, apneic, pulseless
o Ventricular fibrillation or ventricular tachycardia on ECG
DIFFERENTIAL:
o Asystole/VF/VT o Artifact / Device failure o Endocrine / Metabolic o Drugs o Pulmonary
1. Follow initial patient care protocol 2. Withhold Resuscitation as per Apparent Death or Termination of Resuscitation protocol 3. Request ALS unit if not already enroute
BASIC CARE GUIDELINES
4. Initiate high quality compressions 5. Connect AED and Analyze and follow the prompts 6. If shock advised, defibrillate and immediately start compressions for 2 minutes 7. If no shock advised, recheck pulse, if remains pulseless, continue compressions for 2 minutes 8. Consider placement of KING Airway if BVM with oral airway ineffective 9. Once AED has been applied and analyzed consider LUCAS compression device placement 10. At any time Return of Spontaneous Circulation ROSC – Go to Post Resuscitation Protocol
CONSIDERATIONS: • Initial Patient Care incorporates checking responsiveness, airway management including
positive pressure ventilations and high-quality CPR • Initial efforts should be concentrated on high quality CPR with minimal interruptions. This has
a greater impact on patient outcome than any intervention. Deliver continuous chest compressions (minimum 100 and no more than 120 per minute)
• Once high-quality CPR has been initiated only then shall airway management be attempted. Ventilations with oral airway and BVM is acceptable as long as tidal volume is being delivered. Advanced airway procedures shall only be done when other means do not work. Ventilations should be no more than 10 – 12 per minute. AVOID HYPERVENTILATION!
• Reassess rhythm after 2 minutes of CPR and shock indicated. Each shock should be immediately followed by two minutes of effective CPR
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CONGESTIVE HEART FAILURE / PULMONARY EDEMA
HISTORY:
o Congestive heart failure o Past medical history o Medications (digoxin,
Lasix) o Cardiac history – past
myocardial infarction
SIGNS AND SYMPTOMS:
o Respiratory distress, bilateral rales
o Apprehension, orthopnea o Jugular vein distention o Pink, frothy sputum o Peripheral edema,
diaphoresis o Hypotension, shock o Chest pain
DIFFERENTIAL:
o Myocardial infarction o Congestive heart failure o Asthma o Anaphylaxis o COPD o Pleural effusion o Pneumonia o Pulmonary embolus o Pericardial tamponade o Toxic exposure
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Obtain 12 Lead ECG and transmit to receiving facility 3. Obtain and record pulse oximetry and EtCO2 if available 4. Airway Protocol if needed 5. Consider CPAP Procedure 6. If patient is prescribed Nitroglycerin, contact Medical Control to assist with Nitroglycerin
0.4 mg SL q 5 minutes if BP is > 90 systolic. Up to three times (patient Nitro only) Evaluate if Erectile Dysfunction or Pulmonary Hypertension medications taken in the past 48 hours including: Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn), or Avanafil (Stendra), Tadalafil (Cialis, Adcirca). Hold nitrates for 48 hours following the last dose.
ADVANCED CARE GUIDELINES 7. If rales or flash pulmonary edema administer Nitroglycerin 0.4 mg SL q 5 minutes if BP >
90 systolic. 8. Consider Lorazepam 0.5-1.0 mg IV if needed to better tolerate CPAP. May repeat once
as needed. 9. If CPAP contraindicated due to hypotension, consider Dopamine infusion then CPAP.
CONSIDERATIONS:
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• Avoid Nitroglycerin in any patient who has used Viagra, Levitra, Cialis, or other ED medications in the past 48 hours due to potential severe hypotension—contact Medical Control
• Lasix and Narcotics have NOT been shown to improve the outcomes of EMS patients with pulmonary edema, it is no longer recommended.
• If patient has taken nitroglycerin without relief, consider potency of the medication • Contraindications to narcotics include severe COPD and respiratory distress. Monitor the
patient closely. • Consider myocardial infarction in all these patients. Diabetics and geriatric patients often
have atypical pain, or only generalized complaints • Carefully monitor the level of consciousness, BP and respiratory status with the above
interventions • Allow the patient to be in their position of comfort to maximize their breathing effort.
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POST RESUSCITATION
HISTORY:
o Respiratory arrest o Cardiac arrest
SIGNS AND SYMPTOMS:
o Return of pulse
DIFFERENTIAL:
o Continue to address specific differentials associated with the original dysrhythmia
1. Repeat Primary Assessment
BASIC CARE GUIDELINES
2. Continue ventilatory support as needed to maintain oxygen saturation >94%. Do not hyperventilate.
3. Follow Airway Protocol 4. Obtain 12 Lead ECG and transmit to receiving facility
ADVANCED CARE GUIDELINES 5. Continue anti-arrhythmic if
return of spontaneous circulation was associated with its use
6. If Hypotensive, consider fluid bolus. If remains hypotensive after bolus, consider Dopamine.
7. If Significant Ectopy, treat per Tachycardia: Wide Complex Protocol
8. If Bradycardia, treat per Bradycardia protocol
9. If arrest reoccurs, revert to appropriate protocol and/or initial successful treatment
CONSIDERATIONS:
• Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase and must be avoided
• Most patients immediately post ROSC will require ventilatory assistance
Dose/Details Ventilation/Oxygenation: • Avoid excessive ventilation. • Start at 10-12 breaths/min & titrate to target
PETCO2 of 35-40 mmHg • When feasible, titrate FIO2 to minimum
necessary to achieve SpO2 >94% IV Bolus: • 500cc-1L normal saline. Dopamine IV Infusion: • 5-10 mcg/kg/min
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• The condition of post-resuscitation patients fluctuates rapidly and continuously and requires close monitoring. Appropriate post-resuscitation management may be best planned in consultation with medical control.
• Common causes of post-resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax and medication reaction to ALS drugs
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TACHYCARDIA: NARROW COMPLEX
1. Follow initial patient care protocol
BASIC CARE GUIDELINES 2. Obtain 12 Lead ECG and transmit to receiving facility
ADVANCED CARE GUIDELINES 3. If Heart Rate < 150 bpm – monitor and consider etiology 4. If Heart Rate >150 bpm:
o Stable (no serious signs/symptoms) • Regular rhythm
- Vagal Maneuver - Consider Adenosine 6mg IV/IO rapid IV push - May repeat with Adenosine 12 mg IV/IO rapid IV push - Consider Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) - If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min
(Max = 20 mg) • Irregular rhythm
- (Symptomatic Atrial Fib or Flutter with rapid ventricular response?)
- Consider Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) - If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min
(Max = 20 mg) o Unstable (Hypotensive, chest pain, altered level of consciousness)
• Synchronized Cardioversion 100 joules • Repeat at 200 joules each subsequent shock
HISTORY:
o Medications (Digoxin, Aminophylline, Diet pills, Thyroid supplements, Decongestants)
o Diet (caffeine, chocolate) o Drugs (nicotine, cocaine) o History of
palpitations/heart racing
o Syncope/near syncope
SIGNS AND SYMPTOMS:
o Heart rate > 150/min o QRS < 0.12 Sec o Palpitations o Dizziness, CP, SOB, COPD o Altered level of consciousness o Hypotension o S/S of shock, CHF, pulmonary
edema o Potential presenting rhythm:
-Sinus Tachycardia -Atrial fibrillation/flutter -Multifocal atrial tachycardia
DIFFERENTIAL:
o Heart disease (WPW, Valvular)
o Sick sinus syndrome o Myocardial infarction o Electrolyte imbalance o Exertion, Pain, Emotional
stress o Fever o Hypoxia o Hypovolemia or Anemia o Drug effect / overdose o Hyperthyroidism o Pulmonary embolus
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CONSIDERATIONS:
o If you are unable to determine whether the rhythm is regular or irregular and the QRS is < 0.12, administer Adenosine as a diagnostic tool to slow the rate
o If delta wave is present, consider WPW and withhold Cardizem o Withhold Cardizem for heart rate < 150 or blood pressure less than 90 mm HG
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TACHYCARDIA: WIDE COMPLEX
HISTORY:
o Syncope/near syncope o Palpitations o Pacemaker o Allergies:
lidocaine/Novocain o SAMPLE
SIGNS AND SYMPTOMS:
o Ventricular tachycardia on ECG (runs or sustained)
o Conscious, rapid pulse o Chest pain, SOB o Dizziness o Rate usually 150-180 bpm
for sustained V-Tach
DIFFERENTIAL:
o Artifact/Device Failure o Cardiac o Endocrine / Metabolic o Drugs o Pulmonary
1. Follow initial patient care protocol 2. If at any time, no pulse follow the ventricular fibrillation/pulseless ventricular tachycardia
protocol
BASIC CARE GUIDELINES
3. Obtain 12 Lead ECG and transmit to receiving facility ADVANCED CARE GUIDELINES
4. If stable: o Polymorphic
• Consider Magnesium Sulfate 1-2 g IV/IO, delivered over 5-20 minutes • If doesn’t convert, consider Amiodarone 150 mg IV/IO.
o Monomorphic • If possible Tricyclic Toxicity administer Sodium Bicarb 50 mEq IV/IO • If not Tricyclic Toxicity administer Adenosine 6mg IV/IO rapid push. • May repeat with Adenosine 12 mg IV/IO rapid push. • If unsuccessful, consider Amiodarone 150 mg IV/IO over 10 min
5. If unstable: o Synchronized cardioversion 100 joules (consider 200 joules if polymorphic) o May repeat at 200 joules
CONSIDERATIONS:
o When uncertain about the rhythm (narrow vs. wide), treat according to this Tachycardia – Wide Complex Protocol and contact Medical Control early
o In the case of an AICD discharging, treat the underlying rhythm as per protocol
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TERMINATION OF RESUSCITATIVE EFFORTS Revised 2018
Indications to consider termination of resuscitation: 1. Advanced level care (Paramedic level) has been instituted to include rhythm analysis
and defibrillation if indicated, airway management, and medications given per protocol 2. No return of spontaneous circulation or respiration 3. Correctable causes or special resuscitation circumstances have been considered and
addressed 4. Patient does not have profound hypothermia 5. Patient has no other signs of life (no response to pain, non-reactive pupils, no
spontaneous movement) Termination of resuscitation:
1. A valid DNR order, such as IPOST, is obtained by the EMS provider at any level OR
2. Patient meets all criteria under ‘indications’ above and as applicable to scope of practice
a. On-line medical direction is contacted (while advanced care continues) to discuss any further appropriate actions.
b. Advanced care may be discontinued if physician on-line medical direction authorizes.
Other considerations:
1. Documentation must reflect that the decision to terminate resuscitation was determined by physician on-line medical direction.
2. An EMS/health care provider must attend the deceased until the appropriate authorities arrive.
3. All IVs, tubes, etc. should be left in place until the medical examiner authorizes removal.
4. Implement survivor support plans related to coroner notification, funeral home transfer, leaving the body at the scene, and death notification/grief counseling for survivors.
5. See Appendix J -EMS Provider Initiating Organ and Tissue Donation at the Scene of the Deceased.
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VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA
HISTORY:
o Estimated down time o Events leading to
arrest o Renal failure / dialysis o DNR / IPOST o SAMPLE
SIGNS AND SYMPTOMS:
o Unresponsive, apneic, pulseless
o Ventricular fibrillation or ventricular tachycardia on ECG
o Preceding signs/symptoms of ACS
DIFFERENTIAL:
o Asystole o Artifact/Device Failure o Endocrine / Metabolic o Drugs o Pulmonary
1. Follow initial patient care protocol 2. Withhold Resuscitation as per Apparent Death or Termination of Resuscitation protocol
BASIC CARE GUIDELINES
3. Perform high quality CPR immediately, apply AED and follow device prompts 4. Compression-only CPR is appropriate if unable to support airway while applying and using AED 5. May place appropriate airway if unable to adequately ventilate patient noninvasively, if does not
interrupt compressions, or after return of spontaneous circulation 6. May apply mechanical compression device (if available) after ensuring high quality
compressions/ventilations and application of AED. Emphasis on minimizing interruption of compressions.
ADVANCED CARE GUIDELINES 7. Perform high quality CPR immediately, apply monitor and check rhythm as soon as possible 8. Defibrillate at manufacturer’s specification, immediately resume CPR for two minutes 9. Evaluate and treat for underlying causes 10. Administer epinephrine 1:10,000 concentration 1 mg IV/IO every 3-5 minutes 11. Consider amiodarone for refractory pulseless V-Tach or V-Fib 300 mg IV/IO push, repeat
150 mg IV/IO push in 3-5 minutes 12. At any time ROSC, go to Post Resuscitation Protocol 13. At any time rhythm converts to a non-shockable, pulseless rhythm go to Asystole/PEA
Protocol
CONSIDERATIONS:
• Initial Patient Care incorporates checking responsiveness, airway management including positive pressure ventilations and high-quality CPR
• Initial efforts should be concentrated on high quality CPR with minimal interruptions. This has a greater impact on patient outcome than any intervention. Deliver continuous chest compressions (minimum 100 and no more than 120 per minute)
• Once high-quality CPR has been initiated only then shall airway management be attempted. Ventilations with oral airway and BVM is acceptable as long as tidal volume is being delivered. Advanced airway procedures shall only be done when other means do not work. Ventilations should be no more than 10 – 12 per minute. AVOID HYPERVENTILATION!
• Reassess rhythm after 2 minutes of CPR and shock indicated. Each shock should be immediately followed by two minutes of effective CPR
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• IV/IO are the preferred routes of medication administration and initiation of IV/IO takes precedence over securing an advanced airway. ETT is no longer an acceptable route for medication administration.
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MEDICAL PROTOCOLS
ABDOMINAL PAIN (NON-TRAUMATIC)
ALLERGIC REACTION
ALTERED MENTAL STATUS
APPARENT DEATH-DETERMINATION OF DEATH-WITHHOLDING RESUSCITATIVE EFFORTS
ASTHMA – COPD
BEHAVIORAL
DIABETIC EMERGENCY
EPISTAXIS
FEVER / INFECTION CONTROL
HYPERTENSIVE EMERGENCY
HYPOTENSION
NAUSEA / VOMITING
OVERDOSE/TOXIC INGESTION
PAIN CONTROL
RESPIRATORY DISTRESS
SEIZURE
SEPSIS
STROKE
SYNCOPE / WEAKNESS
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ABDOMINAL PAIN (NON-TRAUMATIC)
HISTORY:
o Age o Onset o Palliation / Provocation o Quality (crampy,
constant, sharp, dull, etc.)
o Region / Radiation / Referred
o Severity (0-10) o Time (duration /
repetition) o Fever o Last meal eaten o Last bowel movement o Menstrual history o SAMPLE
SIGNS AND SYMPTOMS:
o Pain o Tenderness o Nausea / Vomiting o Diarrhea / Constipation o Dysuria o Vaginal bleeding /
discharge o Pregnancy o Associated symptoms:
(Helpful to localize source) Fever, headache, weakness, malaise, myalgias, cough, mental status changes, rash
o Absent femoral pulses o Pertinent negatives
DIFFERENTIAL:
o Myocardial infarction o Abdominal aneurysm o Pulmonary embolus or
Pneumonia o Pelvic (PID, Ectopic
pregnancy, cyst) o Gallbladder o Pancreatitis o Kidney stone o Appendicitis o Bladder / Prostate disorder o Spleen enlargement o Diverticulitis o Bowel Obstruction o Gastroenteritis (infectious)
1. Follow initial patient care protocol 2. AT ANY TIME if relevant signs / symptoms found go to appropriate protocol
BASIC CARE GUIDELINES a) Give nothing by mouth b) Obtain 12 lead ECG and transmit
ADVANCED CARE GUIDELINES c) Consider a fluid bolus if indicated. d) Evaluate the need for pain and nausea control. Go to appropriate protocol e) Cardiac monitoring
CONSIDERATIONS:
• Over 25% of acute myocardial infarctions present with ANGINAL EQUIVALENT symptoms, including abdominal pain/discomfort.
• Elderly patients with hypotension and/or major cardiac risk factors should be evaluated for possible Abdominal Aortic Aneurysm (AAA) with dissection and STEMI.
• The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50 years old. • Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise. • Patients over 40 years old with 3 or more major cardiac risk factors i.e. tobacco, hypertension, hyperlipidemia,
genetics, cocaine use, should have a 12 lead ECG performed.
• Advanced treatment is generally not required for patients < 40 years of age who have a soft and non-tender abdomen, are without fever, have stable vital signs, and are not complaining of nausea, vomiting, and/or diarrhea.
• Abdominal assessment may be more accurate when pain control is initiated
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1. Follow initial patient care protocol BASIC CARE GUIDELINES
a) Obtain blood glucose b) If blood sugar < 60 mg/dl, patient is conscious & able to swallow, administer glucose 15 gm by
mouth c) Evaluate the need for naloxone 4 mg prefilled intranasal if suspect overdose. Follow
Overdose/Toxic Ingestion Protocol d) Obtain 12 lead and transmit e) Monitor airway. Follow Airway Protocol
ADVANCED CARE GUIDELINES f) If blood sugar less than 60 mg/dL, patient is symptomatic, administer D10 IV in incremental
doses until mental status improves or blood glucose level is > 60 mg/dl. g) If no vascular access, administer glucagon 1 mg IM h) Evaluate the need for naloxone 1-2 mg IV/IO or 4 mg IN. May repeat dosage in 3 minutes i) Cardiac monitoring j) Evaluate the need for intubation per Airway Protocol
CONSIDERATIONS:
• Adequate breathing is defined as an acceptable rate and depth of breathing (chest rise and fall)
ALTERED MENTAL STATUS
HISTORY:
o Diabetes o Substance ingested,
route, quantity and time of ingestion
o Reason (suicidal, accidental, criminal)
o Trauma o Seizure o Fever o Organic brain disorder o Available medications
in home o SAMPLE
SIGNS AND SYMPTOMS:
o Mental status changes o Hypotension /
hypertension o Decreased respiratory
rate o Tachycardia,
dysrhythmias o Seizures or Focal motor
or sensory deficit o Nausea, vomiting,
abdominal pain, defecation, urination
o Hypoxia/CO2 retention o Fever o Abnormal blood glucose o Positive Stoke Findings o Pertinent negatives
DIFFERENTIAL:
o Diabetes (Hyper / Hypoglycemia)
o Head trauma o CNS (stroke, tumor, seizure,
infection) o Cardiac (MI, CHF) o Infection o Thyroid (hyper / hypo) o Shock (septic, metabolic,
hypovolemic) o Toxicological (drug, ETOH,
poison) o Acidosis / Alkalosis o Environmental exposure o Respiratory – Hypoxia, CO, CO2
retention o Psychiatric disorder
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• Naloxone is preferentially administered intranasal even in the presence of established venous access. Side effects such as nausea, vomiting and combativeness are significantly decreased with IN administration. Only give Naloxone for possible opiate overdose or unknown cause of mental status changes.
• Consider mnemonic AEIOU-TIPS • Consider CO poisoning. Use Masimo Carbon Monoxide detector on ZOLL X. • Because an intubated patient has a definitive airway in place, and because naloxone administration
may cause combativeness and vomiting as the patient begins to respond, hold naloxone in order to maintain effective airway management.
• Contact Poison Control if necessary at 1-800-222-1222.
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APPARENT DEATH-DETERMINATION OF DEATH-WITHHOLDING RESUSCITATIVE EFFORTS
HISTORY:
o Person encountered by EMS who meets criteria for obvious death
o Patient with DNR in place who is pulseless and apneic
o Patient with other approved advanced directive requiring no CPR be administered who is pulseless and apneic
o Patient for whom resuscitative efforts are cease on scene
KEY INFORMATION:
o Name of primary care physician
o Known medical conditions
o Last time know to be alive
DIFFERENTIAL:
o Attended Death ( a patient with a primary care physician who apparently died of natural causes (aka “natural death”)
o Unattended Death (a patient without a primary care physician who apparently dies of natural causes (aka “natural death”)
o Suspicious Death (Law Enforcement)
o Traumatic Death
1. Follow initial patient care protocol
Resuscitation should be started on all patients who are found apneic and pulseless unless the following medical cause, traumatic injury or body condition clearly indicating biological death (irreversible brain death) such as:
Signs of trauma are conclusively incompatible with life o Decapitation o Transection of the torso o 90% of the body surface area with full thickness burns o Massive crush injury o Apneic, pulseless and without other signs of life (movement, EKG
activity, pupillary response) Cardiac and respiratory arrest with obvious signs of death including
o Rigor mortis o Dependent lividity
Physical decomposition of the body
OR A valid DNR order (form, card, bracelet) or other actionable medical order (e.g. I-POLST form) present, when it:
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Conforms to the state specifications Is intact: it has not been cut, broken or shows signs of being repaired Displays the patient’s name and the physician’s name
If apparent death is confirmed, continue as follows:
a) The county Medical Examiner and law enforcement shall be contacted 712-297-7583. b) When possible, contact Iowa Donor Network at 1-800-831-4131. c) At least one EMS provider should remain at the scene until the appropriate authority is
present d) Provide psychological support for grieving survivors e) Document the reason(s) no resuscitation was initiated f) Preserve the crime scene if applicable
In all other circumstances (except where “NO CPR/DNR” protocol applies; see appendix A) full resuscitation must be initiated
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ALLERGIC REACTION
HISTORY:
o Onset and location o Insect sting or bite o Food allergy / exposure o Medication allergy /
exposure o New clothing, soap,
detergent o Past history of reactions o SAMPLE
SIGNS AND SYMPTOMS:
o Itching or hives o Coughing / wheezing or
respiratory distress o Chest or throat constriction o Difficulty swallowing o Hypotension or shock o Edema o Facial or oral mucosal
swelling o Pertinent negatives
DIFFERENTIAL:
o Urticaria (rash only) o Anaphylaxis (systemic effect) o Shock (vascular effect) o Angioedema (drug induced) o Aspiration / Airway
obstruction o Vasovagal event o Asthma or COPD o CHF
1. Follow initial patient care protocol
BASIC CARE GUIDELINES 2. Assess severity
a. If mild reaction (hives/rash with no respiratory component or hypotension) i. Monitor airway
b. If moderate or severe (wheezing/stridor/impending respiratory failure or shock) i. Administer epinephrine auto injector 0.3 mg IM
ii. Oxygen as needed to maintain spo2 94-99% iii. Obtain 12 lead ECG and transmit
Advanced care guidelines 3. Establish IV/IO access 4. Cardiac monitoring 5. If mild reaction:
a. Administer diphenhydramine 50 mg IV/IM b. Administer methylprednisolone 125 mg IV/IM
6. If moderate/severe: a. Administer epinephrine 1mg/ml (1:1,000) concentration 0.5mg IM b. For severe reactions administer epinephrine 1mg/ml (1:10,000) concentration 0.5 mg
IV c. Administer diphenhydramine 50 mg IV/IM d. Administer methylprednisolone 125 mg IV/IM e. Administer albuterol 5.0 mg via nebulizer. Repeat as indicated. f. Fluid bolus as necessary. Follow Hypotension protocol.
7. Prepare for intubation if necessary
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CONSIDERATIONS:
Use caution when administering epinephrine in patients who are > 50 years of age, have a history of cardiac disease, or if the patient’s heart rate is > 150. Epinephrine may precipitate cardiac ischemia. These patients should receive a 12 lead ECG.
Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine and methylprednisolone IV/IM.
The shorter the onset from contact to symptoms, the more severe the reaction.
When the use of an epinephrine auto injector is indicated and the patient weighs less than 30 kg (66 lbs.), the pediatric auto injector should be used
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ASTHMA AND COPD
HISTORY:
o Asthma o COPD: chronic
bronchitis, emphysema o Congestive heart failure o Home treatment
(oxygen, nebulizer) o Medications
(Theophylline, steroids, inhalers)
o Toxic exposure, smoke inhalation
o SAMPLE
SIGNS AND SYMPTOMS:
o Shortness of breath o Pursed lip breathing o Tripod positioning o Use of accessory muscles o Decreased ability to
speak o Increased respiratory
rate and effort o Wheezing, rhonchi o Fever, cough o Tachycardia o Pertinent negatives
DIFFERENTIAL:
o Asthma o Anaphylaxis o Aspiration o COPD (Emphysema, Bronchitis) o Pleural Effusion o Pneumonia o Pulmonary Embolus o Pneumothorax o Cardiac (MI or CHF) o Pericardial Tamponade o Hyperventilation o Inhaled toxin (Carbon
Monoxide, etc.)
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) If patient has a physician prescribed hand-held metered dose inhaler: Assist patient in administering a single dose if they have not done so already Reassess patient and assist with second dose if necessary per medical direction
b) Evaluate the need for CPAP c) Obtain 12 lead ECG and transmit
ADVANCED CARE GUIDELINES
d) Administer albuterol up to 5.0 mg via nebulizer, repeat as needed e) Evaluate the need for epinephrine 1 mg/ml (1:1,000) concentration 0.3 mg IM. f) Cardiac monitoring g) Vascular access h) Administer methylprednisolone 125 mg IV/IM i) Consider Magnesium Sulfate 2 grams in 50 cc NS over 10-15 minutes for severe asthma j) Evaluate the need for CPAP k) Evaluate the need for intubation
CONSIDERATIONS:
• WHEN IN DOUBT about the cause of the respiratory distress, support, transport and contact Medical Control.
• Patients > 50 years of age with a cardiac history, COPD, and/or renal failure should not be given Magnesium Sulfate without consultation with Medical Control
• CPAP is not indicated when wheezing is secondary to allergic reaction or anaphylaxis.
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• Mild distress is associated with shortness of breath without any accessory muscle use. Moderate distress includes wheezing, accessory muscle use and nasal flaring. Severe distress includes little or no movement of air, tripod position, nasal flaring and diaphoresis.
• Waveform capnography should be used to assist with a differential diagnosis and to evaluate the effectiveness of treatment.
• Maintain oxygen saturation 94-99%.
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BEHAVIORAL EMERGENCIES
HISTORY:
o Situational crisis o Psychiatric
illness/mediations o Injury to self or threat to
others o Medic alert tag o Diabetes o SAMPLE o Any weapons
SIGNS AND SYMPTOMS:
o Anxiety, agitation, confusion o Affect change, hallucinations o Delusional thoughts, bizarre
behavior o Combative, violent o Expression of suicidal /
homicidal thoughts o Pertinent negatives
DIFFERENTIAL:
o Alcohol intoxication o Toxin / Substance abuse o Medication effect /
overdose o Depression o Bipolar (manic-
depressive) o Schizophrenia o Anxiety disorders
1. Follow initial patient care protocol 2. If there is evidence of immediate danger, protect yourself and others by summoning law
enforcement to help ensure safety
BASIC CARE GUIDELINES
a) Rule out Medical Causes. Treat suspected medical or trauma problems per appropriate protocol
b) Psychiatric Risk Assessment c) Remove patient from stressful environment d) Verbal techniques (reassurance, calm, establish rapport)
ADVANCED CARE GUIDELINES
e) Consider the cause of agitation i) Behavioral: Administer Ketamine 1 mg/kg IV or 2 mg/kg IM
OR Midazolam 2mg IV/IM or 5-10 mg IN may repeat
every 5 minutes as needed OR
Haloperidol 5 – 10 mg IM ii) For excited delirium: Ketamine 4 mg/kg IM/IV
OR Midazolam 2mg IV/IM or 5-10 mg IN may repeat
every 5 minutes as needed Consider cooling measures
Psychiatric Risk Assessment
Is the patient presenting with or has presented with any of the following in
recent past?
o Aggressive or agitated behavior o Affect changes or hallucinations o Delusional thoughts or
bizarre behavior o Suicidal or homicidal ideations o Easily agitated o Verbal outbursts o Required handcuffs or
restraints prior arrival
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Consider ETCO2 monitoring f) Be alert for a dystonic reaction if patient is on Reglan, Phenergan or Compazine at
home. If present give diphenhydramine 25-50 mg IV/IM
CONSIDERATIONS:
• Perform Psychiatric Risk Assessment early. If the patient presents with any of the findings, contact law enforcement. YOUR SAFETY FIRST!
• DO NOT be fooled by the patient’s current demeanor, it can change rapidly. • In the case of threat in the unit. Stop. Exit. Open the side door. Stand with partner.
Communicate. • Keep it simple. Psychotic & stressed patients do not process complicated messages. • Try to have same sex provider in back as patient. Consider third person for safety. • Do not irritate the patient with a prolonged exam. • Be sure to consider all possible medical/trauma causes for behavior. Consider mnemonic
AEIOU-TIPS. • The presence of irrational behavior, hallucinations, and alternating periods of lethargy
followed by excitement, screaming and kicking following ketamine administration may be associated with emergence phenomena and will likely respond better to midazolam instead of additional ketamine.
• Patients in handcuffs cannot be transported without law enforcement in the back with the patient.
• If restraints needed for safety, documentation of distal Pulse, Motor and Sensory is required every 5 minutes with continuous monitoring of the airway.
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DIABETIC EMERGENCY
HISTORY:
o Known diabetic, medic alert tag
o Medications (Insulin, Diabinese, Orinase, Micronase, etc.)
o Last dose of diabetic medications
o Report of illicit drug use or toxic ingestion
o History of trauma o Onset; duration o Seizure activity o Fever o SAMPLE
SIGNS AND SYMPTOMS:
o Sudden decrease in mental status
o Bizarre behavior; intoxicated appearance
o Cool, diaphoretic skin or
o Flushed, dry skin o Hunger o Anxiety o Combativeness o Lethargy o Headache o Tremors o Faintness o Seizures, coma
DIFFERENTIAL:
o Diabetes (hyper / hypoglycemia) o Head trauma o CNS (stroke, tumor, seizure,
infection) o Cardiac (MI, CHF) o Infection o Thyroid (hyper / hypo) o Shock (septic, metabolic,
traumatic) o Toxicologic o Acidosis / Alkalosis o Environmental exposure o Respiratory-Hypoxia, CO, CO2
retention o Psychiatric disorder
1. Follow Initial Patient care protocol BASIC CARE GUIDELINES 2. Obtain blood glucose level 3. If blood glucose is < 60 mg / dl and the patient is symptomatic, able to swallow, administer 15 gm of
oral glucose 4. Obtain 12 lead ECG and transmit if capability exists ADVANCED CARE GUIDELINES If Patient is unable to swallow with blood glucose less than 60 mg/dl: 5. Obtain vascular access 6. If blood sugar less than 60 mg/dL, patient is symptomatic, administer Dextrose D10W IV in incremental doses until mental status improves or blood glucose level is > 60 mg.dl. 7. If IV access unsuccessful administer Glucagon 1mg IM 8. Cardiac monitoring If blood glucose is > 250 mg / dl consider fluid bolus. 9. S/S DKA or HHNK administer NS or LR 500 cc fluid bolus. Reassess and repeat bolus as needed.
CONSIDERATIONS:
• Hypoglycemia secondary to oral hypoglycemic medications and longer acting insulin is risky; transport is critical because of the potential for recurrence of hypoglycemia
• Pre-hospital treatment of hypoglycemia is a bridge to get the patient to the ER or physician and not considered definitive therapy
• The duration of dextrose and glucagon is relatively short. Reassess the patient and repeat as needed.
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• A blood glucose level > 250 mg/dl does not mean the patient is in DKA. A blood glucose level alone is only indicative of hyperglycemia. Common s/s associated with DKA includes: abdominal pain or cramping, altered LOC, thirsty, deep rapid respirations, dyspnea, frequent urination, nausea, vomiting.
• It is very common for a patient that has received medication for hypoglycemic event to refuse transport once their LOC improves.
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EPISTAXIS
HISTORY:
o Age o Past Medical history o Medications (HTN,
anticoagulants, Aspirin, NSAIDS)
o Previous episodes of epistaxis
o Trauma o Duration of bleeding o Quantity of bleeding o SAMPLE
SIGNS AND SYMPTOMS:
o Bleeding from nasal passage
o Pain o Nausea o Vomiting o HTN o Pertinent negatives
DIFFERENTIAL:
o Trauma o Infection (viral URI or
Sinusitis o Allergic rhinitis o Lesions (polyps, ulcers) o Hypertension
1. Follow Initial Patient Care Protocol
BASIC CARE GUIDELINES
2. Compress Nostrils and hold for at least 5-15 minutes 3. Ice packs 4. Tilt head forward, be prepared to suction
ADVANCED CARE GUIDELINES
5. Consider vascular access 6. For Hypertension cause also follow the Hypertension Protocol
CONSIDERATIONS: o It is very difficult to quantify the amount of blood loss with epistaxis o Bleeding may also be occurring posteriorly. Evaluate for posterior blood loss by examining the
posterior pharynx o Anticoagulants include aspirin, Coumadin, non-steroidal anti-inflammatory medications
(Ibuprofen, Naproxen), and many over the counter headache relief powders or tablets.
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FEVER/INFECTION CONTROL
HISTORY:
o Age o Duration of fever o Immunocompromised
(transplant, HIV, diabetes, cancer)
o Environmental exposure o Last Acetaminophen or
Ibuprofen o SAMPLE
SIGNS AND SYMPTOMS:
o Warm o Flushed o Sweaty o Chills/Rigor o Malaise, cough, chest pain,
headache, dysuria, abdominal pain, mental status changes, rash/petechial, stiff neck
o Pertinent negatives
DIFFERENTIAL:
o Cocaine/stimulant intoxication
o Heat Stroke o Medication or drug
reaction o Connective tissue disease o Arthritis o Vasculitis o Hyperthyroidism o Cancer / Tumors /
Lymphomas o Meningitis
1. Follow Initial Patient Care Protocol
BASIC CARE GUIDELINES
2. Consider Droplet, Airborne or Contact Precautions 3. Temperature Assessment 4. Cooling Measures
ADVANCED CARE GUIDELINES 5. Consider IV 6. Consider Fluid Bolus
CONSIDERATIONS:
• Temperature may be decreased by a combination of 4 methods: • Radiation: Heat loss to air (unwrap or remove clothing) • Evaporation: Heat loss through the evaporation of sweat or liquid from the skin (tepid water
bath to skin) • Convection: Heat loss through the movement of air currents over the skin (fan air over the
skin) • Conduction: Heat loss through the contact with solid substances (with heat stroke use cool
packs per protocol) • Re-hydration with fluids increases the patient’s ability to sweat and improves heat loss. • Droplet precautions include standard PPE plus a standard surgical mask for providers who
accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplet are suspected
• Airborne precautions include standard PPE plus an N-95 mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient.
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This level of precaution should be used when TB, measles, varicella or other infections that are spread by droplet nuclei are suspected.
• Contact precautions include standard PPE plus utilization of a gown.
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HYPERTENSIVE EMERGENCY
HISTORY:
o History of HTN o Related diseases:
o Diabetes o CVA o Renal failure o Cardiac
o Medications (compliance?)
o Viagra, Levitra or Cialis use
o Pregnancy o SAMPLE
SIGNS AND SYMPTOMS:
o Systolic BP 200 or greater o Diastolic BP 120 or greater o Headache o Epistaxis o Blurred Vision o Dizziness o Pertinent Negative
DIFFERENTIAL:
o Hypertensive encephalopathy o Primary CNS Injury (Cushing’s
response = bradycardia with hypertension), Stroke
o Myocardial Infarction o Aortic dissection (aneurysm) o Pre – eclampsia/Eclampsia
1. Follow Initial Patient Care Protocol
BASIC CARE GUIDELINES
2. Obtain 12 lead ECG and transmit 3. Monitor and Reassess vital signs every 5 minutes 4. Appropriate protocol based on patient signs & symptoms
ADVANCED CARE GUIDELINES
5. Obtain vascular access, TKO rate 6. Cardiac monitor 7. Nitroglycerin 0.4 mg SL every 5 minutes if SBP is > 200 or DBP is > 120 or MAP is > 145 and the
patient is symptomatic (Consult Medical Advice prior to administration if positive stroke assessment or Head Injury)
CONSIDERATIONS:
o NEVER TREAT ELEVATED BLOOD PRESSURE BASED ON ONE SET OF VITALS o ASYMPTOMATIC HYPERTENSIVE PATIENTS DO NOT REQUIRE TREATMENT IN THE
PREHOSPITAL SETTING. o All symptomatic patient should be transported with their head elevated o Attention in the prehospital setting should be on:
o CNS (Central Nervous System ) – Altered LOC, decreased vision, focal motor deficits, seizure and headaches o CVS (Cardiovascular System) – Angina, acute CHF, and aortic dissection.
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HYPOTENSION
HISTORY:
o Past medical history o Medications o Blood loss – AAA, ectopic
pregnancy, vaginal or gastrointestinal bleeding
o Fluid loss – vomiting &/or diarrhea
o Infection – fever o Pregnancy o History of poor oral
intake o SAMPLE
SIGNS AND SYMPTOMS:
o Restlessness, confusion o Weakness, dizziness o Weak, rapid pulse o Pale, cool, clammy skin o Delayed capillary refill o SBP < 90 o Hematemesis (blood or
coffee-ground) o Hematochezia (blood or
tarry stools) o Pertinent Negatives
DIFFERENTIAL:
o Shock o Hypovolemia o Cardiogenic o Septic o Neurogenic o Anaphylactic
o Ectopic pregnancy o Dysrhythmias o Pulmonary Embolus o Tension Pneumothorax o Medication effect/overdose o Vasovagal o Physiologic (pregnancy)
1. Follow Initial Patient Care Protocol
BASIC CARE GUIDELINES
2. Obtain 12 lead ECG and transmit 3. Monitor and Reassess vital signs every 5 minutes 4. Appropriate protocol based on patient signs & symptoms (Trauma, Cardiac, Anaphylaxis, OB)
ADVANCED CARE GUIDELINES 5. Obtain vascular access, if no signs of CHF/Pulmonary Edema infuse NS 500 ml bolus and
reassess. 6. Cardiac monitor 7. In non – cardiac and non- trauma, consider 2nd 500 ml bolus. 8. Consider Dopamine 5-20 mcg/kg/min IV/IO infusion
Considerations:
• Hypotension is defined as systolic blood pressure of less than 90 mmHg • Consider all possible causes of shock and treat per appropriate protocol
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NAUSEA & VOMITING
HISTORY:
o Age o Time of last oral intake o Last bowel
movement/emesis o Improvement or
worsening with food or activity
o Duration of event o Other sick contacts o Past medical & surgical hx o Medications o Menstrual history
(pregnancy) o Travel history o Bloody emesis/diarrhea o SAMPLE
SIGNS AND SYMPTOMS:
o Pain (OPQRST) o Associated Symptoms:
Fever, headache, blurred vision, weakness, malaise, myalgias, cough, dysuria, mental status changes, rash
o Pertinent Negatives
DIFFERENTIAL:
o CNS (increased pressure headache, stroke, CNS lesions, trauma or hemorrhage)
o Migraine o Myocardial infarction o Drugs/medications o GI or Renal disorder o Diabetic ketoacidosis o Gynecologic disease
(ovarian cyst, PID) o Infections (pneumonia,
influenza) o Electrolyte abnormalities o Food or toxin induced o Pregnancy o Psychologic
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Give nothing by mouth b) Obtain 12 lead ECG and transmit c) Check blood glucose level
ADVANCED CARE GUIDELINES
d) Consider fluid bolus IV/IO if evidence of hypovolemia and lung sounds are clear e) Cardiac monitor f) Administer ondansetron (Zofran) 4 mg IV/IO, may repeat in 15 minutes x 1 dose. g) Consider intubating patients with altered mental status who are vomiting and cannot
protect their airway
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OVERDOSE / TOXIC INGESTION HISTORY:
o Ingestion or suspected ingestion of a potentially toxic substance
o Substance ingested, route, quantity
o Time of ingestion o Reason (suicidal,
accidental, criminal) o Available medications
in home o SAMPLE
SIGNS AND SYMPTOMS:
o Mental status changes o Hypotension /
hypertension o Decreased RR o Tachycardia, dysrhythmias o Seizures o Nausea, vomiting,
abdominal pain, diarrhea o Sweating, tearing, rash o Decreased oxygen
saturation / CO2 retention o Pupil response
DIFFERENTIAL:
o Acetaminophen (Tylenol) o Narcotics/depressants o Tricyclic antidepressants
(TCAs) o Stimulants-cocaine,
amphetamines o Anticholinergic-Benadryl o Cardiac medications o Solvents, Alcohols, Cleaning
agents o Insecticides
(organophosphates)
1. Follow initial patient care protocol
2. Identify contaminate and call Poison Control and follow directions given to provide care: 1-800-222-1222
3. Contact Medical Direction as soon as possible with information given by Poison Control and care given
BASIC CARE GUIDELINES
1. Attempt to identify substances ingested or exposed by interviewing witnesses. Try to establish the exact time of ingestion, as well as the amount and type of ingestion. Medication containers or chemical labels should be taken with you.
2. Consider Narcan for respiratory depression 4 mg IN
ADVANCED CARE GUIDELINES
Bradycardia with Unknown Overdose: a. Consider Atropine 0.5 mg IV every 5 minutes as needed up to total dose of 3 mg. b. Consider dopamine (Intropin) 5-15 mcg/kg/min c. Consider transcutaneous pacemaker
Tachycardia with Unknown Overdose:
a. Provide IV fluid bolus with normal saline 1 Liter
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b. Consider benzodiazepine FOR agitation/Seizure such as: 1. Midazolam 0.5-2.5 mg IV/IM/IO repeated every 5 minutes as needed to a
maximum of 5 mg OR
2. Lorazepam 2mg IV/IO, repeated every 30 minutes as needed to a maximum of 4 mg. Use for long transports
c. Consider Sodium Bicarbonate 1 mEq/kg IV for dysrhythmias refractory to benzodiazepines (especially those with a wide QRS complex or prolonged QT).
d. Cool patients presenting with agitation, delirium, seizure and elevated body temperature
Suspected Opioid Overdose:
e. Support ventilations via bag-valve-mask and oxygen while preparations are made for Naloxone (Narcan) administration
f. Initial dose of Naloxone (Narcan) is 1 to 2 mg IV/IO over 15-30 seconds or 2 to 4 mg IM, SQ or 4 mg IN. Repeated doses may be required
Calcium Channel Blocker (Norvasc, Cardizem) or Beta Blocker (Atenolol, Lopressor, Inderal) Overdose:
g. Consider Calcium Chloride 10% 0.5-1 gram IV over 10 minutes i. May repeat x 1 in 5 minutes if persistent EKG changes ii. Calcium therapy is contraindicated for patients taking digitalis
h. Consider Glucagon 1 mg slow IV push over 1-2 minutes. Digitalis Overdose:
i. Consider normal saline IV j. Consider Atropine 0.5 mg IV every 5 minutes as needed up to total dose of 3 mg k. Consider transcutaneous pacemaker
Tricyclic Antidepressants (Elavil, Tofranil) Overdose:
l. Consider Sodium bicarbonate 50 mEq IV for wide complex QRS m. Be cautious for seizures
Considerations
• Naloxone is preferentially administered intranasal even in the presence of established venous access. Side effects such as nausea, vomiting and combativeness are significantly decreased with IN administration.
• Do not rely entirely on patient history of ingestion, especially in suicide attempts • Bring bottles, contents, emesis to ED • Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental
status or coma; be aware of rapid progression from alert mental status to death.
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• Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure
• Depressants: decreased HR, decreased BP, deceased temperature, decreased respirations, non-specific pupils
• Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures • Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes • Cardiac Meds: Hypotension, dysrhythmias and mental status changes • Solvents: nausea, vomiting, and mental status changes • Insecticides: SLUDGE-Salivations, Lacrimation, Urination, Defecation, GI distress & Emesis
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PAIN CONTROL
HISTORY:
o Age o Location o Duration o Severity (0-10) o Past medical history o Recent pain medication
usage o Medications o Allergies o SAMPLE
SIGNS AND SYMPTOMS:
o Onset o Provocation / Palliation o Quality (Sharp, dull, etc.) o Radiation o Severity o Relation to movement,
inspiration o Increased with palpation o Pertinent Negatives o Pupil response
DIFFERENTIAL:
o Per the specific protocol o Musculoskeletal o Visceral (abdominal) o Cardiac o Pleural/Respiratory o Neurogenic o Renal (colic)
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) First, attempt to manage all painful conditions: Splint extremity injuries Place the patient in a position of comfort
b) Appropriate Protocol per patient’s complaint c) Record pain severity score d) Monitor and Assess vital signs
ADVANCED CARE GUIDELINES
b) Consider administration of pain medications for patients that have significant pain, do not have a decreased level of consciousness, are hemodynamically stable, and have oxygen saturations above 93% . Morphine 2-4 mg via IV/IO, repeated in 5 min, to a maximum of 10 mg
OR Fentanyl 25 to 50 mcg slow IV/IO every 5 minutes as needed to a maximum of
200 mcg Ketamine 0.1-0.3 mg/kg IV/IO or 0.5 mg/kg IM/IN
c) Administer naloxone 2 mg IV for respiratory depression from narcotics. May repeat. d) For severe pain consider anxiolytic medication
Midazolam 1-2 mg slow IV/IO/IM repeated every 5 minutes as needed to a maximum of 5 mg OR
Lorazepam 1-2 mg slow IV, repeated every 30 minutes as needed to a maximum of 4 mg
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e) Monitor ECG and O2 saturations f) The patient must have vital signs taken prior to each dose, after each dose, and be
monitored closely. g) After drug administration, reassess the patient using the appropriate pain scale.
Considerations:
• Pain severity is a vital sign to be recorded pre and post IV/IO medication delivery and at disposition
• Vital signs should be obtained pre, 15 min post and at disposition with all pain medications • Pain meds are contraindicated in patients with hypotension. Consider carefully use in
patients with AMS, head injury, or respiratory distress. • If at any time there is a decreased level of consciousness, decrease in oxygen saturation
below 94%, or blood pressure drops to 90 mmHg or less, administration of narcotic medication must stop
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RESPIRATORY DISTRESS
HISTORY:
o Asthma; COPD; chronic bronchitis, emphysema, congestive heart failure
o Home treatment (oxygen, nebulizer)
o Medications (theophylline, steroids, inhalers)
o Toxic exposure, smoke inhalation
o SAMPLE
SIGNS AND SYMPTOMS:
o Shortness of breath o Pursed lip breathing o Decreased ability to
speak o Increased respiratory rate
and effort o Wheezing, rhonchi, rales,
stridor o Use of accessory muscles o Tripod positioning o Fever, cough o Tachycardia o Pertinent Negatives
DIFFERENTIAL:
o Asthma o Anaphylaxis o Aspiration o COPD (Emphysema,
Bronchitis) o Pleural effusion o Pneumonia o Pulmonary Embolus o Pneumothorax o Cardiac (MI or CHF) o Pericardial Tamponade o Hyperventilation o Inhaled Toxin
1. Follow the Initial Patient Care Protocol
BASIC CARE GUIDELINES
2. If Respiratory Insufficiency follow the Airway – Adult Protocol 3. If no respiratory insufficiency place patient in position of comfort 4. Obtain 12 lead ECG and transmit 5. Monitor and assess vital signs 6. If signs/symptoms found go to the appropriate protocol i.e. Allergic Reaction, Asthma/COPD,
Chest Pain, and Pulmonary Edema. 7. Consider CPAP
ADVANCED CARE GUIDELINES 8. Obtain vascular access 9. Cardiac monitoring 10. Consider Albuterol up to 5.0 mg via nebulizer. May repeat if indicated 11. Consider Epinephrine 0.5 mg 1:1,000 IM 12. Consider methylprednisolone 125 mg IV
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SEIZURE
HISTORY:
o Reported / witnessed seizure activity
o Previous seizure history
o Medic Alert tag information
o Seizure medications o History of trauma o History of diabetes o History of pregnancy o Recent fever/viral
illness o SAMPLE
SIGNS AND SYMPTOMS:
o Decreased mental status o Lethargy o Incontinence o Observed seizure activity o Evidence of trauma o Unconsciousness o In children, fever, hot dry
skin, altered mental status
o Pertinent Negatives
DIFFERENTIAL:
o CNS (Head) trauma o Tumor o Metabolic, Hepatic or Renal
Failure o Electrolyte abnormality (NA,
CA, Mg) o Drugs, Medications, Non-
compliance o Infection/fever o Alcohol withdrawal o Eclampsia o Stroke o Hyperthermia o Hypoglycemia o Overdose
1. Follow initial patient care protocol 2. If Associated with Pregnancy, see Eclampsia Protocol
ACTIVE SEIZURE
BASIC CARE GUIDELINES
a) Protect airway
ADVANCED CARE GUIDELINES
b) Administer benzodiazepine such as: Lorazepam 2 mg IV/IO push, continue with 2 mg increments every 2 minutes
until the seizure stops or until maximum dose of 10 mg is given OR Midazolam 2 mg IV/IO push, continue with 2 mg increments every 2 minutes
until the seizure stops or until maximum dose of 10 mg is given OR Midazolam 5 mg IN. May repeat x 1 after 2 minutes.
c) Check blood glucose level, if available, and treat hypoglycemia if present d) Cardiac monitoring, 12 lead ECG
POSTICTAL
BASIC CARE GUIDELINES
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a) Protect airway b) Check blood sugar, if available, and treat hypoglycemia if present per diabetic protocol c) Follow Altered Mental Status protocol if indicated d) If associated with Pregnancy follow Eclampsia Protocol
ADVANCED CARE GUIDELINES
e) Consider monitoring ETCO2
CONSIDERATIONS
• Status Epilepticus is defined as a prolonged seizure greater than 5 minutes or two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment and transport.
• Grand mal seizures (generalize tonic-clonic) are associated with loss of consciousness, incontinence and possible tongue trauma.
• Focal seizures affect only a part of the body and are not usually associated with a loss of consciousness.
• Jacksonian seizures are seizures which start as a focal seizure and become generalized. • Be prepared for airway problems and continued seizures • Assess possibility of trauma, substance abuse, or alcohol/benzo withdrawal. • Be prepared to assist ventilations, especially if midazolam is used. Midazolam can cause
hypotension and respiratory depression. • For any seizure in a pregnant patient, follow the PRE-ECLAMPSIA/ECLAMPSIA Protocol • If febrile, remove clothing and sponge with room temperature water. • In an infant, a seizure is most commonly a febrile seizure, but may be the only evidence of a
closed head injury.
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SEPSIS
HISTORY:
o Age o Duration of Illness o Past medical history o Medications o Immunocompromised
(transplant, HIV, diabetes, cancer)
o Environmental exposure o Last acetaminophen or
ibuprofen administration o SAMPLE
SIGNS AND SYMPTOMS:
o Warm o Flushed o Diaphoretic o Chills/Rigor o Associated symptoms:
Myalgia’s, cough, chest pain, headache, dysuria, abdominal pain, mental status changes, rash.
o Pertinent Negatives
DIFFERENTIAL:
o Shock o Hypovolemic o Cardiogenic o Neurogenic o Anaphylactic o Fever o Cancer / Tumors /
Lymphomas o Medication / drug reaction o Hyperthyroidism o Heat Stroke o Meningitis
1. Follow Initial Patient Care Protocol
BASIC CARE GUIDELINES
2. Assess skin temperature 3. Obtain blood glucose 4. Obtain 12 lead ECG and transmit
ADVANCED CARE GUIDELINES
5. Obtain vascular access 6. Consider NS or LR bolus to reach target of SBP > 90 7. Consider Dopamine 5-20 mcg/kg/min to reach SBP > 90 8. Two or more SIRS criteria and a suspected source of infection &
ETCO2 < 25 probable SEPSIS ALERT
CONSIDERATIONS • If available, report the patient’s actual temperature. Temperatures of >
38˚C (100.4˚F) or < 36˚C (96.8˚F) are positive SIRS criteria • Sepsis is a rapidly progressing, life threatening condition due to
systemic infections. Sepsis must be recognized early and treated aggressively to prevent progression to shock and death
• Hypotension is defined as a SBP <90 • In the presence of hypotension, administer 500 ml bolus of fluid (unless
contraindicated) prior to dopamine administration • In cases of suspected right sided heart failure, contact medical control
for fluid order.
Systemic Inflammatory Response Syndrome (SIRS)
Two or more of the following symptoms
o Pulse > 90 BPM o Respirations > 20 or
mechanically ventilated o Elevated temperature o Altered Mental Status o Hyperglycemia (BS >
120 mg/dl)
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STROKE
HISTORY:
o Previous CVA, TIA’s o Previous cardiac /
vascular surgery o Associated diseases:
diabetes, hypertension, CAD
o Atrial fibrillation o Medications (blood
thinners) o History of trauma o SAMPLE
SIGNS AND SYMPTOMS:
o Altered mental status o Weakness / Paralysis o Blindness or other sensory loss o Aphasia / Dysarthria o Syncope o Vertigo / Dizziness o Vomiting o Headache o Seizures o Respiratory pattern change o Hypertension / Hypotension o Pertinent Negatives
DIFFERENTIAL:
o See Altered Mental Status
o TIA (transient ischemic attack)
o Seizure o Hypoglycemia o Stroke
Thrombotic ( ̴85%) Hemorrhagic ( ̴15%)
o Tumor o Trauma
1. Follow Initial Patient Care Protocol
BASIC CARE GUIDELINES
2. Prehospital Stroke Screen 3. If positive and Symptoms < 5 hours, transport to the destination as per the EMS System Stroke
Plan. Goal: Scene Time 10 minutes or less and Provide Early Notification. 4. Obtain Blood Glucose If < 60 and the patient is symptomatic and able to swallow administer 15
gm oral glucose 5. Obtain 12 lead ECG and Transmit 6. Consider other protocols as indicated: Altered Mental Status; Hypertension, Seizure,
Overdose/Toxic Ingestion ADVANCED CARE GUIDELINES
7. IV/IO 8. Cardiac Monitoring 9. If Blood Glucose < 60 mg/dl and patient is unable to swallow, See Diabetic Emergency protocol 10. If no vascular access administer Glucagon 1 mg IM
REPORT TO RECEIVING FACILITY o Time of onset/last seen at baseline o Stroke scale findings o Vital signs including Glasgow Coma Scale o Blood Glucose o Any seizure? o Terminal condition exist?
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CONSIDERATIONS
• Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro, Stroke Scale • Items in Red Text are key performance measures used in the EMS Acute Stroke Care • The reperfusion checklist should be completed for any suspected stroke patient. With a durations of
symptoms of less than 5 hours, scene times should be limited to 10 minutes, early destination notification/activations should be provided and transport times should be minimized based on the EMS System Stroke Plan
• Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke symptoms would be defined as an onset time of the previous night when the patient was symptom free)
• The differential listed on the Altered Mental Status Protocol should also be considered • Elevated blood pressure is commonly present with stroke. See Hypertensive Emergency Protocol • Be alert for airway problems (swallowing difficulty, vomiting / Aspiration • Hypoglycemia can present as a localized neurologic deficit, especially in the elderly • Document the Stroke Screen results in the PCR
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MEND EXAM
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SYNCOPE / WEAKNESS
HISTORY:
o Cardiac history, stroke, seizure
o Occult blood loss (GI, ectopic)
o Females: LMP, vaginal bleeding
o Fluid loss: nausea, vomiting, diarrhea
o Past medical history o Medications o Syncope history:
exertional/vasovagal o Anxiety/psychiatric illness o SAMPLE
SIGNS AND SYMPTOMS:
o Loss of consciousness with recovery
o Lightheadedness, dizziness o Palpitations, slow or rapid
pulse o Irregular pulse o Decreased blood pressure o Weakness o “Fainting” o Pertinent Negatives
DIFFERENTIAL:
o Vasovagal o Orthostatic hypotension o Cardiac syncope o Micturition / defecation
syncope o Psychiatric o Stroke o Hypoglycemia o Seizure o Shock (see Shock
Protocol) o Toxicologic (Alcohol,
drugs) o Medication effect (i.e.
beta-blocker)
1. Follow Initial patient care protocol
BASIC CARE GUIDELINES
2. Obtain blood glucose, if < 60 mg/dl and the patient is symptomatic and able to swallow, administer 15 gm glucose orally
3. Obtain 12 lead ECG and transmit 4. If relevant signs / symptoms are found go to the appropriate protocol: Altered Mental Status,
Hypotension, Diabetic Emergency, and Dysrhythmia. ADVANCED CARE GUIDELINES
5. VASCULAR ACCESS 6. CARDIAC MONITOR 7. IF SYSTOLIC BP < 90 CONSIDER FLUID BOLUS UP TO 500 ML NORMAL SALINE IF NO CONTRAINDICATIONS 8. IF BLOOD GLUCOSE , 60 MG/DL AND PATIENT IS SYMPTOMATIC AND UNABLE TO SWALLOW,
FOLLOW THE DIABETIC EMERGENCY PROTOCOL
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CONSIDERATIONS
• Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro
• Assess for signs and symptoms of trauma if associated or questionable fall with syncope • Consider dysrhythmias, GI bleed, ectopic pregnancy and seizure as possible causes of syncope • More than 25% of geriatric syncope is cardiac dysrhythmia based.
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OB PROTOCOLS
CHILDBIRTH / LABOR
NEWBORN
OBSTETRICAL EMERGENCY
PRE-ECLAMPSIA / ECLAMPSIA
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CHILDBIRTH / LABOR
HISTORY:
o Age o Gravida/para/due date o Time contractions started
/ how often o Rupture of membranes o Time / amount of any
vaginal bleeding o Sensation of fetal activity o Color of fluid discharge o Social history (drugs,
smoking, alcohol) o SAMPLE
SIGNS AND SYMPTOMS:
o Spasmodic pain o Vaginal discharge of
bleeding o Crowning or urge to push o meconium
DIFFERENTIAL:
o Abnormal presentation Buttock Foot Hand
o Prolapsed cord o Placenta Previa o Abruptio placenta o Braxton Hicks contractions o Uterine rupture
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Put patient in left lateral position 3. Inspect perineum (no digital vaginal exam) 4. No crowning – monitor, reassess, document frequency and duration of contractions 5. Normal Delivery –crowning, > 36 weeks gestation
a) If delivery is imminent with crowning, commit to delivery on site and contact medical control.
b) If the amniotic sac does not break, or has not broken, use a clamp to puncture the
sac and push it away from the infant’s head and mouth as they appear.
c) Clamp cord with 2 clamps and cut the cord between the clamps.
d) For newborn management, see newborn protocol.
6. Abnormal Delivery (crowning, < 36 weeks gestation, abnormal presentation, severe vaginal bleeding, multiple gestation) IMMEDIATE TRANSPORT
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Breech Delivery (Buttocks Presentation) a) Allow spontaneous delivery. b) Support infant's body as it’s delivered. c) If head delivers spontaneously, proceed as in (Normal Delivery). d) If head does not deliver within 3 minutes, insert gloved hand into the
vagina, keeping your palm toward baby's face; form a "V" with your fingers and push wall of vagina away from baby's face, thereby creating an airway for baby. Do not remove your hand until relieved by advanced EMS or hospital staff.
Prolapsed Cord
a) Insert gloved hand into the vagina, keeping your palm toward baby's face; form a "V" with your fingers and push wall of vagina away from baby's face, thereby creating an airway for baby. Do not remove your hand until relieved by advanced EMS or hospital staff.
Contact medical control for any other issues.
CONSIDERATIONS
• Document all times (delivery, contraction frequency and length • If maternal seizures occur, refer to the Obstetrical emergency protocol • After delivery, massaging the uterus will promote uterine contraction and help to control
post-partum bleeding • some perineal bleeding is normal with any childbirth. large quantities of blood > 500 ml is
abnormal
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NEWBORN
HISTORY:
o Due date and gestational age
o Multiple gestation o Meconium o Delivery difficulties o Congenital disease o Medications (maternal) o Maternal substance
abuse & smoking
SIGNS AND SYMPTOMS:
o Respiratory distress o Peripheral cyanosis or
mottling (normal) o Central cyanosis (abnormal) o Altered level of
consciousness o Bradycardia o Tachycardia o Tachypnea
DIFFERENTIAL:
o Airway failure Secretions Respiratory drive
o Infection o Maternal medication effect o Hypovolemia o Hypoglycemia o Congenital defect o Hypothermia
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Suction the airway using a bulb syringe as soon as the head is delivered and before delivery of the body. Suction the mouth first, then the nose
3. Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the baby in a thermal blanket or dry towel. Cover the scalp to preserve warmth
4. Open and position the airway. Suction the airway again using a bulb syringe. Suction the mouth first, then the nose
5. Assess breathing and adequacy of ventilation
6. If ventilation is inadequate, stimulate by gently rubbing the back and flicking the soles of the feet
7. If ventilation is still inadequate after brief stimulation, begin assisted ventilation at 40 to 60 breaths per minute using a bag-valve-mask device with room air. If no improvement after 30-60 seconds, apply 100% oxygen
8. If ventilation is adequate and the infant displays central cyanosis, administer oxygen at 5 L via blow-by. Hold the tubing 1/2 to 1 inch from the nose
9. If the heart rate is slower than 60 beats per minute after 30 seconds of assisted ventilation with high-flow, oxygen:
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a) Begin chest compressions at a combined rate of 120/minute (three compressions to each ventilation)
ADVANCED CARE GUIDELINES
10. If there is no improvement in heart rate after 30 seconds. Perform endotracheal intubation
11. If there is no improvement in heart rate after intubation and ventilation, administer Epinephrine 1:10,000 concentration at 0.01 mg/kg (maximum individual dose 1.0
mg) IV/IO Repeat epinephrine at the same dose every 3 to 5 minutes as needed
k) Initiate transport. Reassess heart rate and respirations enroute
If the heart rate is between 60 & 80 beats per minute, initiate the following actions: a) Continue assisted ventilation with high-flow, 100% concentration oxygen. If there is no
improvement in heart rate after 30 seconds, initiate management sequence described in step H above, beginning with chest compressions
b) Initiate transport. Reassess heart rate and respirations enroute If the heart rate is between 80 & 100 beats per minute, initiate the following actions:
a) Continue assisted ventilation with high-flow, 100% concentration oxygen. Stimulate as previously described
b) Initiate transport. Reassess heart rate after 15 to 30 seconds If the heart rate is faster than 100 beats per minute, initiate the following actions:
a) Assess skin color. If central cyanosis is still present, continue blow by oxygen. Initiate transport. Reassess heart rate and respirations enroute
If thick meconium is present: a) Initiate endotracheal intubation before the infant takes a first breath. Suction the airway
using an appropriate suction adapter while withdrawing the endotracheal tube. Repeat this procedure until the endotracheal tube is clear of meconium. If the infant’s heart rate slows, discontinue suctioning immediately and provide ventilation until the infant recovers
Note: If the infant is already breathing or crying, this step may be omitted
CONSIDERATIONS
• Maternal sedation or narcotics will sedate newborn (Naloxone effective) • Consider hypoglycemia in newborn • Document 1 and 5 minute APGAR scores (see appendix)
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OBSTETRICAL EMERGENCY
HISTORY:
o Hypertension meds o Prenatal care o LMP / Gestational age o Previous complicated
pregnancies o Gravid / Para o SAMPLE o MVC with seatbelt use
/ air bag deployment
SIGNS AND SYMPTOMS:
o Vaginal bleeding / discharge / mucous plug/ ruptured membranes
o Abdominal pain o Seizures o Hypertension o Severe headache o Visual changes o Edema of hand and face
DIFFERENTIAL:
o Pre-eclampsia/Eclampsia o Placenta previa o Placenta abruptio o Spontaneous abortion o Gestational diabetes o Uterine rupture o Trauma
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. If Hypertension – go to Pre-eclampsia / Eclampsia Protocol 3. Vaginal bleeding / abdominal pain / contraction?
Known pregnancy / missed period Estimate gestation 1st or 2nd trimester consult medical control 3rd trimester place in left lateral position and immediate transport. Be
prepared to follow Childbirth Protocol No known pregnancy or missed period
Go to Abdominal Pain protocol
CONSIDERATIONS
• Severe headache, vision changes, or RUQ pain may indicate pre-eclampsia • In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or
greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) blood pressure.
• Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome • Ask patient to quantify bleeding - number of pads used per hour • Any pregnant patient involved in a MVC should be seen immediately by a physician for
evaluation and fetal monitoring
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PRE-ECLAMPSIA / ECLAMPSIA
HISTORY:
o Hypertension meds o Prenatal care o LMP / Gestational age o Previous complicated
pregnancies o Gravid / Para o SAMPLE o MVC with seatbelt use
/ air bag deployment
SIGNS AND SYMPTOMS:
o Vaginal bleeding / discharge / mucous plug/ruptured membranes
o Abdominal pain o Seizures o Hypertension o Severe headache o Visual changes o Edema of hand and face
DIFFERENTIAL:
o Pre-eclampsia/Eclampsia o Placenta previa o Placenta abruptio o Spontaneous abortion o Gestational diabetes o Uterine rupture o Trauma
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Active Labor – go to Childbirth Labor Protocol 3. If not hypertensive – go to Obstetrical Emergency Protocol
ADVANCED CARE GUIDELINES
4. If hypertensive
Pre-eclampsia place patient in left lateral position
Eclampsia If Seizure or seizure-like activity
o Administer Magnesium sulfate 4 grams IV over 3 minutes o Consider midazolam 2mg IV if no termination of seizure, may
repeat in 2 mg increments to a maximum of 10 mg o Obtain blood glucose
- Go to Diabetic Emergency Protocol if indicated If no seizure activity place patient in left lateral position
CONSIDERATIONS
• Eclampsia seizures may occur up to 2 months post-partum. Always consider in pregnant / recently pregnant seizing patient
• If no IV and unable to secure an IV/IO due to seizure activity, do not delay administration of midazolam via IN/IM route
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• Severe headache, vision changes, or rug pain may indicate pre-eclampsia • In the setting of pregnancy, hypertension is defined as a bp greater than 140
systolic or greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) blood pressure.
• Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome
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PEDIATRIC PROTOCOLS
PEDIATRIC INITIAL CARE PROTOCOL
PEDIATRIC AIRWAY
PEDIATRIC ALLERGIC REACTION
PEDIATRIC ALTERED MENTAL STATUS
PEDIATRIC ASTHMA
PEDIATRIC BEHAVIORAL EMERGENCIES
PEDIATRIC BURNS
PEDIATRIC CARDIAC ARRHYTHMIA
PEDIATRIC DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS
PEDIATRIC NAUSEA AND VOMITING
PEDIATRIC NEAR DROWNING
PEDIATRIC PAIN CONTROL
PEDIATRIC POISONING
PEDIATRIC SEIZURE
PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION
PEDIATRIC SHOCK
SUSPECTED CHILD ABUSE
PEDIATRIC TRAUMA
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INITIAL PATIENT CARE PROTOCOL-ADULT AND PEDIATRICS Revised 2018 - This protocol serves to reduce the need for extensive reiteration of basic assessment and other considerations in every protocol.
Assessment
1. Assess scene safety
a. Evaluate for hazards to EMS personnel, patient, bystanders
b. Determine number of patients
c. Determine mechanism of injury
d. Request additional resources if needed and weigh the benefits of waiting for additional resources against rapid transport to definitive care
e. Consider declaration of mass casualty incident if needed
2. Use appropriate personal protective equipment (PPE)
3. Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g. operations at night
or in darkness, on or near roadways) 4. Consider cervical spine stabilization and/or spinal care if trauma
Primary Survey
1. Airway, Breathing, Circulation is cited below; (although there are specific circumstances where Circulation, Airway, Breathing may be indicated such as cardiac arrest or major arterial bleeding) a. Airway (assess for patency and open the airway as indicated)
i. Patient is unable to maintain airway patency—open airway 1. Head tilt chin lift 2. Jaw thrust 3. Suction 4. Consider use of the appropriate airway management adjuncts and devices:
• oral airway, • nasal airway, • blind insertion, or supraglottic airway device, • laryngeal mask airway, • endotracheal tube
5. For patients with laryngectomies or tracheostomies, remove all objects or clothing that may obstruct the opening of these devices, maintain the flow of prescribed oxygen, and reposition the head and/or neck
b. Breathing
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i. Evaluate rate, breath sounds, accessory muscle use, retractions, patient positioning ii. Administer oxygen as appropriate with a target of achieving 94-98% saturation for most acutely ill patients iii. Apnea (not breathing) – open airway-see #4 above
c. Circulation
i. Control any major external bleeding [see Extremity Trauma/External Hemorrhage Management guideline] ii. Assess pulse
1. If none – go to Pediatric Cardiac Arrhythmia Protocol 2. Assess rate and quality of carotid and radial pulses
iii. Evaluate perfusion by assessing skin color and temperature 1. Evaluate capillary refill
d. Disability
i. Evaluate patient responsiveness: AVPU scale (Alert, Verbal, Pain, Unresponsive) ii. Evaluate gross motor and sensory function in all extremities iii. Check blood glucose in patients with altered mental status iv. If acute stroke suspected – go to Stroke Protocol
e. Expose patient as appropriate to complaint
i. Be considerate of patient modesty ii. Keep patient warm
Secondary Survey
1. The performance of the secondary survey should not delay transport in critical patients. Secondary surveys should be tailored to patient presentation and chief complaint. Secondary survey may not be completed if patient has critical primary survey problems a. Head
i. Pupils ii. Naso-oropharynx iii. Skull and scalp
b. Neck
i. Jugular venous distension ii. Tracheal position iii. Spinal tenderness
c. Chest
i. Retractions ii. Breath sounds iii. Chest wall deformity
d. Abdomen/Back
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i. Flank/abdominal tenderness or bruising ii. Abdominal distension
e. Extremities i. Edema ii. Pulses iii. Deformity
e. Neurologic i. Mental status/orientation ii. Motor/sensory
2. Obtain Baseline Vital Signs (An initial full set of vital signs is required: pulse, blood pressure,
respiratory rate, neurologic status assessment) (see chart below) a. Neurologic status assessment: establish a baseline and note any change in patient neurologic status
i. Glasgow Coma Score (GCS) (see chart below) or ii. AVPU (Alert, Verbal, Painful, Unresponsive)
b. Patients with cardiac or respiratory complaints
i. Pulse oximetry ii. 12-lead EKG should be obtained early in patients with cardiac or suspected cardiac complaints iii. Continuous cardiac monitoring, if available iv. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry
c. Patient with altered mental status
i. Check blood glucose ii. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry
d. Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should be taken shortly before arrival at receiving facility
e. Critical patients should have pertinent vital signs frequently monitored
3. Obtain OPQRST history:
a. Onset of symptoms b. Provocation – location; any exacerbating or alleviating factors c. Quality of pain d. Radiation of pain e. Severity of symptoms – pain scale f. Time of onset and circumstances around onset
4. Obtain SAMPLE history:
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a. Symptoms b. Allergies – medication, environmental, and foods c. Medications – prescription and over-the-counter; bring containers to ED if possible d. Past medical history
i. Look for medical alert tags, portable medical records, advance directives ii. Look for medical devices/implants (some common ones may be dialysis shunt, insulin pump, pacemaker, central venous access port, gastric tubes, urinary catheter)
e. Last oral intake f. Events leading up to the 911 call
In patients with syncope, seizure, altered mental status, or acute stroke, consider bringing the witness to the hospital or obtain their contact phone number to provide to ED care team
Treatment and Interventions
1. Administer oxygen as appropriate with a target of achieving 94-98% saturation
2. Tier with an appropriate service if advanced level of care or assistance is needed and can be accomplished in a timely manner
3. Place appropriate monitoring equipment as dictated by assessment and scope of practice – these may include:
a. Continuous pulse oximetry b. Cardiac rhythm monitoring c. Waveform capnography or digital capnometry d. Carbon monoxide assessment
4. If within scope of practice establish vascular access if indicated or in patients who are at risk for
clinical deterioration. a. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of lidocaine 0.1mg/mL with slow push through IO needle to a maximum of 40 mg to mitigate pain from IO medication administration
5. Monitor pain scale if appropriate
6. Reassess patient
Patient Safety Considerations
1. Routine use of lights and sirens is not warranted
2. Even when lights and sirens are in use, always limit speeds to level that is safe for the emergency vehicle being driven and road conditions on which it is being operated
3. Be aware of legal issues and patient rights as they pertain to and impact patient care (e.g.
patients with functional needs or children with special healthcare needs)
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4. Be aware of potential need to adjust management based on patient age and comorbidities,
including medication dosages
5. The maximum weight-based dose of medication administered to a pediatric patient should not exceed the maximum adult dose except where specifically stated in a patient care guideline
6. Direct medical control should be contacted when mandated or as needed
Key Considerations Pediatrics: ALWAYS use a weight-based assessment tool (length-based tape or other system) to estimate patient weight and guide medication therapy and adjunct choices.
a. The pediatric population is generally defined by those patients who weigh up to 40 kg or up to 14-years of age, whichever comes first b. Consider using the pediatric assessment triangle (appearance, work of breathing, circulation) when first approaching a child to help with assessment.
Geriatrics: The geriatric population is generally defined as those patients who are 65 years old or more.
a. In these patients, as well as all adult patients, reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease)
Co-morbidities: reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease). Normal Vital Signs
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Age Pulse Respiratory Rate
Systolic BP
Preterm less than 1 kg 120-160 30-60 36-58 Preterm 1 kg 120-160 30-60 42-66 Preterm 2 kg 120-160 30-60 50-72 Newborn 120-160 30-60 60-70 Up to 1 year 100-140 30-60 70-80 1-3 years 100-140 20-40 76-90 4-6 years 80-120 20-30 80-100 7-9 years 80-120 16-24 84-110 10-12 years 60-100 16-20 90-120 13-14 years 60-90 16-20 90-120 15 years or older 60-90 14-20 90-130
Glasgow Coma Scale
ADULT GLASGOW COMA SCALE PEDIATRIC GLASGOW COMA SCALE Eye Opening (4) Eye Opening (4) Spontaneous 4 Spontaneous 4 To Speech 3 To Speech 3 To Pain 2 To Pain 2 None 1 None 1 Best Motor Response (6) Best Motor Response (6) Obeys Commands 6 Spontaneous
Movement 6
Localizes Pain 5 Withdraws to Touch
5
Withdraws from Pain
4 Withdraws from Pain
4
Abnormal Flexion 3 Abnormal Flexion 3 Abnormal Extension
2 Abnormal Extension
2
None 1 None 1 Verbal Response (5) Verbal Response (5) Oriented 5 Coos, Babbles 5 Confused 4 Irritable Cry 4 Inappropriate 3 Cries to Pain 3 Incomprehensible 2 Moans to Pain 2 None 1 None 1 Total Total
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Pediatric Airway Reviewed 2016
1. Follow initial patient care protocol
Breathing spontaneous on initial assessment with adequate ventilation
BASIC CARE GUIDELINES
a) Maintain oxygenation with cannula, mask, or blow-by if oxygen saturations are below 94%, titrate to 94% - 99%
Breathing without adequate ventilation or not breathing
BASIC CARE GUIDELINES
a) Open the airway
b) Attempt assisted ventilation using an appropriate adjunct with high-flow 100% oxygen. If unable to ventilate, first reposition airway and attempt to ventilate again
c) If ventilation still unsuccessful, check airway for obstruction and attempt to dislodge with age appropriate techniques
ADVANCED CARE GUIDELINES
d) If unsuccessful establish direct view of object and attempt to remove it with Magill forceps
If obstruction cleared
BASIC CARE GUIDELINES
a) Assist with ventilation and provide oxygen.
ADVANCED CARE GUIDELINES
b) If adequate ventilation is NOT maintained proceed to an advanced airway as appropriate for patient size
If obstruction not cleared
ADVANCED CARE GUIDELINES
a) Attempt endotracheal intubation and try to ventilate the patient
b) If endotracheal intubation is not successful, perform needle cricothyrotomy and needle insufflation
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PEDIATRIC ALLERGIC REACTION Reviewed 2012
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
b) Assess airway via Airway Protocol
c) If the patient has a physician prescribed auto-injectable epinephrine assist with administration and monitor for signs of anaphylaxis
ADVANCED CARE GUIDELINES
d) Administer epinephrine 1 mg/ml (1:1,000) concentration 0.01 mg/kg IM, up to a maximum dose of 0.3 - 0.5 mg
e) Establish IV access
f) Administer diphenhydramine at 1.0 mg/kg IV or deep IM, up to a maximum dose of 50 mg
g) Administer epinephrine 1 mg/10 ml (1:10,000) concentration 0.01 mg/kg IV for profound shock, up to a maximum dose of 0.3 - 0.5 mg
h) Administer albuterol 2.5 mg by nebulizer if in respiratory distress
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PEDIATRIC ALTERED MENTAL STATUS Revised 2017
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Obtain blood glucose
b) If conscious & able to swallow, administer glucose 15 gm by mouth for children over 2 years of age.
ADVANCED CARE GUIDELINES
c) If blood sugar less than 60 mg/dL administer Dextrose based on Pediatric Dosing Reference
d) If patient unconscious and no IV access; administer Glucagon 0.025 mg/kg IM up to 1 mg maximum
e) If no improvement in level of consciousness after glucose administration give naloxone 0.1 mg/kg IV up to maximum dose of 2.0 mg per dose
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PEDIATRIC ASTHMA Revised 2016
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Use Airway Protocol to evaluate the airway and adequacy of ventilation
b) If patient has a physician prescribed, hand-held metered dose inhaler, assist with administration
c) Reassess patient and repeat second dose if necessary per medical direction
ADVANCED CARE GUIDELINES
d) Administer albuterol 2.5.mg via Nebulizer. Repeat as necessary.
e) Evaluate the need for epinephrine 1 mg/ 1 ml (1:1,000) concentration according to length/weight based tape (0.01 mg/kg). Dosage may be repeated once after 5 minutes.
f) Evaluate the need for intubation.
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PEDIATRIC BEHAVIORAL EMERGENCIES New 2017
1. Follow initial patient care protocol
2. If there is evidence of immediate danger, protect yourself and others by summoning law enforcement to help ensure safety
BASIC CARE GUIDELINES
a) Consider medical or traumatic causes of behavior problems
b) Keep environment calm
ADVANCED CARE GUIDELINES
c) For severe anxiety, consider a benzodiazepine such as Lorazepam, with dosages based on Pediatric Dosing Reference
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PEDIATRIC BURNS Revised 2016
1. Follow initial patient care protocol
2. Continually monitor the airway for evidence of obstruction
3. Do not use any type of ointment, lotion, or antiseptic
4. Maintain normal patient temperature
5. Transport according to the Out-of-Hospital Trauma Destination Decision Protocol (Appendix B)
Thermal Burns BASIC CARE GUIDELINES
a) Stop the burning process
b) Remove smoldering clothing and jewelry
c) Prevent further contamination of wounds
d) Cover the burned area with a clean, dry dressing or plastic wrap
e) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness
ADVANCED CARE GUIDELINES
f) Establish an IV of LR or NS. For severe burns, consider administration of 20 ml/kg, not to exceed 500 ml.
g) Contact medical control for further fluid administration
h) Treat pain per pain protocol
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Pediatric Burns Continued
Chemical Burns BASIC CARE GUIDELINES
a) Brush off powders prior to flushing. Lint roller may also be used to remove powders prior to flushing
b) Immediately begin to flush with large amounts of water. Continue flushing the contaminated area when en route to the receiving facility
c) Do not contaminate uninjured areas while flushing
d) Attempt to identify contaminant
e) Transport according to the Out-of-Hospital Destination Decision Protocol (Appendix B)
ADVANCED CARE GUIDELINES
f) Treat pain per pain control protocol
Toxin in Eye BASIC CARE GUIDELINES
a) Flood eye(s) with lukewarm water and have patient blink frequently during irrigation. Use caution to not contaminate other body areas
b) Continue irrigation until advanced personnel take over
c) Attempt to identify contaminant
d) Transport to the most appropriate medical facility
ADVANCED CARE GUIDELINES
e) Treat pain per pain control protocol
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Pediatric Burns Continued
Electrical Burns BASIC CARE GUIDELINES
a) Treat soft tissue injuries associated with the burn with dry dressing
b) Treat for shock if indicated
c) Transport according to the Out-of-Hospital Destination Decision Protocol (Appendix B)
d) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness
ADVANCED CARE GUIDELINES
f) Treat pain per pain control protocol
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PEDIATRIC CARDIAC ARRHYTHMIA Updated 2017
1. Follow initial patient care protocol
If no pulse BASIC CARE GUIDELINES
a) Perform high quality CPR immediately, apply AED and follow device prompts
ADVANCED CARE GUIDELINES
b) Perform high quality CPR immediately, apply monitor and check rhythm as soon as possible
Ventricular fibrillation or ventricular tachycardia a) Defibrillate at 2J/kg, immediately resume CPR for two minutes
b) Second defibrillation at 4 J/kg
c) Subsequent defibrillations increasing by 2 J/kg, to a maximum of 10 J/kg, not to exceed
maximum adult dose
d) Evaluate and treat for underlying causes
e) Administer epinephrine 1 mg/ 10 ml (1:10,000) according to Pediatric Dosing Reference every 3-5 minutes
f) Administer anti-arrhythmic
Administer amiodarone according to Pediatric Dosing Reference, may repeat twice
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Pediatric Cardiac Arrhythmia continued
ASYSTOLE/PEA a) Evaluate and treat for underlying causes
b) Administer epinephrine 1 mg/ 10 ml (1:10,000) according to Pediatric Dosing Reference
every 3-5 minutes as needed
Arrhythmias with pulse BASIC CARE GUIDELINES
a) If patient is complaining of shortness of breath, has signs of respiratory distress, or pulse oximetry of less than 94% then titrate oxygen to symptom improvement or to maintain a saturation of 94-99%
b) Evaluate and treat for underlying causes
Bradycardia with signs of poor perfusion BASIC CARE GUIDELINES
a) Start CPR if pulse is less than 60 and altered mental status
ADVANCED CARE GUIDELINES
b) Administer epinephrine 1 mg/ 10 ml (1:10,000) according to Pediatric Dosing Reference every 3-5 minutes
c) Consider administration of atropine according to Pediatric Dosing Reference
Tachycardia (rates greater than 180 in children or 210 in infants) ADVANCED CARE GUIDELINES
a) If patient unstable: a. Perform synchronized cardioversion according to Pediatric Dosing Reference b. Consider sedation according to Pediatric Dosing Reference
b) If patient stable: With wide QRS
• If regular and monomorphic, consider administration of adenosine according to Pediatric Dosing Reference
With narrow QRS • Perform vagal maneuvers • Consider administration of adenosine according to Pediatric Dosing
Reference
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PEDIATRIC DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS Updated 2018
Follow initial patient care protocol
Resuscitation should be started on all patients who are found apneic and pulseless unless the following medical cause, traumatic injury or body condition clearly indicating biological death (irreversible brain death) such as:
• Signs of trauma are conclusively incompatible with life o Decapitation o Transection of the torso o 90% of the body surface area with full thickness burns o Massive crush injury o Apneic, pulseless and without other signs of life (movement, EKG activity,
pupillary response) • Cardiac and respiratory arrest with obvious signs of death including
o Rigor mortis o Dependent lividity
• Physical decomposition of the body
OR A valid DNR order (form, card, bracelet) or other actionable medical order (e.g. I-POST form) that:
• Conforms to the state specifications
If apparent death is confirmed, continue as follows: a) The county Medical Examiner and law enforcement shall be contacted 712-297-7583. b) When possible, contact Iowa Donor Network at 1-800-831-4131.
See Protocol Appendix J c) At least one EMS provider should remain at the scene until the appropriate authority is
present d) Provide psychological support for grieving survivors e) Document the reason(s) no resuscitation was initiated f) Preserve the crime scene if applicable
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PEDIATRIC NAUSEA AND VOMITING Reviewed 2011
1. Follow initial patient care protocol
ADVANCED CARE GUIDELINES
a) Initiate IV access
b) Consider fluid bolus if evidence of hypovolemia
c) If patient nauseated or is vomiting administer anti-emetic medication such as ondansetron (Zofran) 0.1 mg/kg IV up to 4 mg maximum
d) Consider intubating patients with altered mental status who are vomiting and can’t protect their airway
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PEDIATRIC NEAR DROWNING Revised 2012
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Establish patient responsiveness
b) If cervical spine trauma is suspected, manually stabilize the spine
c) Assess airway for patency, protective reflexes and the possible need for advanced airway management. Look for signs of airway obstruction
d) Open the airway using head tilt/chin lift if no spinal trauma is suspected, or modified jaw thrust if spinal trauma is suspected
e) Suction as necessary
f) Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway cannot be maintained with positioning and the patient is unconscious
g) Assess breathing. Obtain pulse oximeter reading
h) If breathing is inadequate, assist ventilation using an appropriate adjunct with high-flow, 100% concentration oxygen
i) Assess circulation and perfusion
j) If breathing is adequate, place the child in a position of comfort and maintain oxygenation with cannula, mask or blow-by if oxygen saturations are below 94% titrate to 94% - 99%
k) Assess mental status
l) Consider CPAP
m) If spinal trauma is suspected, continue manual stabilization, apply a rigid cervical collar, and immobilize the patient on a long backboard or similar device
n) Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature throughout the examination
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Pediatric Near Drowning Continued
o) If the child’s condition is stable, perform focused history and detailed physical examination on the scene, then initiate transport
p) If the child’s condition is stable, perform focused history and detailed physical examination on the scene, then initiate transport
ADVANCED CARE GUIDELINES
q) If abdominal distention arises, consider placing a gastric tube to decompress the stomach if available
r) If the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated
a. Perform RSI to aid with intubation, as permitted by medical direction. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per medical direction
s) Initiate cardiac monitoring and determine rhythm. Consult the appropriate protocol for
treatment of specific dysrhythmias. Refer to AHA guidelines
t) Obtain vascular access. Administer normal saline at a maintenance rate according to weight
If the child’s condition is critical or unstable, initiate transport as quickly as possible. Perform focused history and detailed physical examination enroute to the hospital if patient status and management of resources permit
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PEDIATRIC PAIN CONTROL Reviewed 2011
1. Follow initial patient care protocol
2. First attempt to manage all painful conditions with basic care
BASIC CARE GUIDELINES
a) Splint extremity injuries
b) Place the patient in a position of comfort
ADVANCED CARE GUIDELINES
c) Consider administration of pain medications for patients that have significant pain, do not have a decreased level of consciousness, are hemodynamically stable, and have oxygen saturations above 94% medication
Examples:
Morphine 0.1 mg/kg (maximum individual dose 10 mg) via intravenous or subcutaneous route or
Fentanyl 1.0 mcg/kg (maximum individual dose 100 mcg) via intravenous route or
Ketamine 0.1 mg/kg – 0.3 mg/kg IV/IO or 0.5 mg/kg IM/IN
d) Monitor ECG and O2 saturations
e) The patient must have vital signs taken prior to each dose and be monitored closely. Administration of narcotic medication must stop if at any time there is a decreased level of consciousness, decrease in oxygen saturation below 92% blood pressure drops to 100 mmHg or less
After drug administration, reassess the patient using the appropriate pain scale
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PEDIATRIC POISONING Reviewed 2011
1. Follow initial patient care protocol
2. Identify contaminate and call Poison Control and follow directions given to provide care: 1-800-222-1222
3. Contact Medical Direction as soon as possible with information given by Poison Control and care given
BASIC CARE GUIDELINES
Ingested Poisons
a) Identify and estimate amount of substance ingested
Inhaled Poisons:
a) Remove patient to fresh air
b) Administer high flow oxygen
c) Estimate duration of exposure to inhaled poison
Absorbed Poisons
a) If it will be a hazard to you, use protective clothing and extreme caution
Injected Poisons
a) Be alert for respiratory difficulty. Maintain airway and give high flow oxygen
b) Check patient for marks, rashes, or welts
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PEDIATRIC SEIZURE Revised 2017
1. Follow initial patient care protocol
Active Seizure
BASIC CARE GUIDELINES
a) Protect airway
ADVANCED CARE GUIDELINES
b) Administer Lorazepam or Midazolam, dosage according to Pediatric Dosing Reference to stop seizure. May repeat dose in 5 minutes if still seizing
c) Check blood glucose level, if available, and treat hypoglycemia if present
Post Seizure
BASIC CARE GUIDELINES
a) Protect airway b) Check glucose level
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PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION Revised 2015
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
Patient Presentation:
a) This protocol is intended for patients who present with a traumatic mechanism of injury.
b) Immobilization is contraindicated for patients who have penetrating trauma who do not have a neurological deficit.
Patient Management:
c) Assessment: a) Assess for mental status, neurological deficits, spinal pain, tenderness, any evidence
of intoxication, or other severe injuries.
b) While maintaining spinal alignment, examine the spine for tenderness on palpation or deformities.
c) Treatment and Interventions: i. Apply cervical restriction if there is any of the following:
Patient complains of neck pain.
Any neck tenderness of palpation.
Any abnormal mental status, including extreme agitation, or neurological
deficit.
Any evidence of alcohol or drug intoxication
There are other severe or painful injuries present.
Any communication barrier that prevents accurate assessment.
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PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION CONTINUED
ii. Immobilize Patient with cervical collar and a long spine board, full body vacuum splint, scoop stretcher, or similar devise if:
Patient complains of midline back pain
Any midline back tenderness
Note 1: Distracting injuries or altered mental status does not necessitate long spine board use.
Note 2: Patients should not routinely be transported on long boards, unless the clinical situation warrants long board use. An example of this may be facilitation of multiple extremity injuries or an unstable patient where removal of a board will delay transport and/or other treatment priorities. In these rare situation, long boards should be padded or have a vacuum mattress applied to minimize secondary injury to the patient.
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PEDIATRIC SHOCK Revised 2012
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Assess airway via Airway Protocol
b) Assess circulation and perfusion
c) Control external bleeding
d) Assess mental status
e) Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature throughout the examination
f) Initiate transport. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit
ADVANCED CARE GUIDELINES
g) Initiate cardiac monitoring
h) Establish IV access using an age-appropriate large-bore catheter with large-caliber tubing. If intravenous access cannot be obtained in a child younger than six years, proceed with intraosseous access. Do not delay transport to obtain vascular access
i) Administer a fluid bolus of normal saline at 20 ml/kg over 10 to 15 minutes. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg
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SUSPECTED CHILD ABUSE Reviewed 2011
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Approach child slowly to establish rapport (except in life-threatening situations), then perform exam
b) Treat obvious injuries according to appropriate protocol
c) Genital exam only if indicated in the presence of blood, known or obvious injury and or trauma
d) Interview parents separate from child, if possible
e) Transport if permitted by parents
f) If parents do not allow transport, notify law enforcement for assistance 712-297-7583
g) Communicate vital information only – additional info can be given to attending RN and/or Physician on arrival
h) Record observations and factual information on run report
i) Report all suspected abuse to the National hotline at 1-800-362-2178 within 24 hours of your contact of the patient. This will be an oral report only
j) Within 48 hours of oral reporting, you must submit a written report for all suspected abuse to the Department of Human Services https://dhs.iowa.gov/sites/default/files/470-0665.pdf
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PEDIATRIC TRAUMA Revised 2016
1. Follow initial patient care protocol
2. Follow the Out-of-Hospital Trauma Triage Destination Decision Protocol for the identification of time critical injuries, method of transport and trauma facility resources necessary for treatment of those injuries
3. The goal should be to minimize scene time with time critical injuries, including establishing IVs enroute.
BASIC CARE GUIDELINES
a) Follow Shock Protocol if shock is present
Hemorrhage Control BASIC CARE GUIDELINES
a) Control bleeding with direct pressure. Large gaping wounds may need application of a bulky sterile gauze dressing and direct pressure by hand
b) If direct pressure/pressure dressing is ineffective or impractical, apply a tourniquet to extremity
c) If bleeding site is not amenable to tourniquet placement (i.e. junctional injury), apply a topical hemostatic agent with direct pressure
ADVANCED CARE GUIDELINES
d) Establish large bore IV
e) Cardiac monitor
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Pediatric Trauma continued
Chest Trauma BASIC CARE GUIDELINES
a) Seal open chest wounds immediately. Use occlusive dressing taped down. If the breathing becomes worse, loosen one side of the dressing to release pressure and then reseal
b) Impaled objects must be left in place and should be stabilized by building up around the object with multiple trauma dressings or other cushioning material
c) Take care that the penetrating object is not allowed to do further damage
Abdominal Trauma BASIC CARE GUIDELINES
a) Control external bleeding. Dress open wounds to prevent further contamination
b) Evisceration should be covered with a sterile saline soaked occlusive dressing
c) Impaled objects should be stabilized with bulky dressings for transport
Head, Neck, and Face Trauma BASIC CARE GUIDELINES
a) Place the head in a neutral in-line position unless the patient complains of pain or the head does not easily move into this position
b) Closely monitor the airway. Provide suctioning of secretions or vomit as needed. Be prepared to log roll the patient if they vomit. Maintain manual spinal stabilization if patient is log rolled
c) Reassess vitals, GCS and pupillary response frequently
d) Consider eye shield for any significant eye trauma. If the globe is avulsed, do not put it back into socket; cover with moist saline dressing and then place cup over it
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ENVIRONMENTAL PROTOCOLS
BITES AND ENVENOMATION
FROSTBITE
HYPERTHERMIA
HYPOTHERMIA
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BITES AND ENVENOMATION
HISTORY:
o Type of bite/sting o Description/photo with
patient for identification o Time, locations size of bite /
sting o Previous reaction to bite /
sting o Domestic vs. wild o Tetanus and Rabies risk o Immunocompromised
patient
SIGNS AND SYMPTOMS:
o Rash, skin break, wound o Pain, soft tissue swelling,
redness o Blood oozing from the bite
/ wound o Evidence of infection o Shortness of breath,
wheezing o Allergic reaction, hives,
itching o Hypotension or shock
DIFFERENTIAL:
o Animal bite o Human bite o Snake bite (poisonous) o Spider bite (poisonous) o Insect sting / bite (bee,
wasp, ant, tick) o Infection risk o Rabies risk o Tetanus risk
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Remove any constricting clothing / bands/ jewelery 3. Type of bite
Insect, Ant, Bee/Wasp Sting Cold application
Snake bite Splinting of extremity
Dog/cat/human bite Cold application
4. Consult Medical Control for additional treatment guidelines
ADVANCED CARE GUIDELINES
5. Follow Pain Management Protocol as necessary
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CONSIDERATIONS
o Personal safety is a priority. Do not attempt to capture any snake to transport in with the patient. A photo will do.
o Venomous snakes in the area are generally of the pit viper family: rattlesnake, copperhead and water moccasin.
o Coral snakes are rare in the area: Very little pain but very toxic. “Red on yellow – kill a fellow, red on black – venom lack”
o Even though venomous snakes are rare in Iowa, some individuals keep exotic snakes in their homes.
o Black Widow spider bites have minimal pain initially but may develop muscular pain and severe abdominal pain (spider is black with red hourglass design on underside)
o Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle design on back)
o Mark the margin of the swelling / redness and time o Consider contacting Poison Control for guidance.
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FROSTBITE
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Remove the patient from the cold environment
b) Protect the cold injured extremity from further injury (manual stabilization)
c) Remove wet or restrictive clothing
d) Do not rub or massage
e) Do not re-expose to the cold
f) Remove jewelry
g) Cover with dry clothing or dressings
ADVANCED CARE GUIDELINES
h) Refer to pain control protocol
i) Consider IV access using warm fluid
j) Monitor EKG
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HYPERTHERMIA
HISTORY:
Age Exposure to increased
temperatures and/or humidity Extreme exertion Time and length of exposure Poor oral intake Fatigue and/or muscle cramps SAMPLE Recent illness / infection Psychiatric history
SIGNS AND SYMPTOMS:
o Altered mental status or unconsciousness
o Hot, dry or sweaty skin o Hypotension or shock o Seizures o Nausea
DIFFERENTIAL:
o Dehydration o Medications o Hyperthyroidism (Storm) o Delirium tremens (DT’s) o Heat cramps o Heat exhaustion o Heat stroke o CNS lesions or tumors
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Remove from the hot environment and place in a cool environment (back of air conditioned response vehicle)
3. Loosen or remove clothing 4. Place in recovery position 5. Initially cool patient by fanning and cool mist if available 6. Consider cooling patient with cold packs to neck, groin and axilla 7. If alert, stable, and not nauseated, you may have the patient slowly drink small sips of
water or other fluids e.g. sports drinks ADVANCED CARE GUIDELINES
8. Monitor EKG and treat dysrhythmias following the appropriate protocol(s)
CONSIDERATIONS - Heat stroke consists of high body temperature. A change in mental status is the primary assessment
finding to differentiate heat stroke from heat exhaustion. If you have any doubt as to whether the patient is presenting with heat stroke vs. heat exhaustion, err on the side of aggressive cooling and treatment as though the patient is presenting with heat stroke. Sweating generally disappears as body temperature rises above 104˚F.
- Heat exhaustion consists of dehydration and salt depletion. Patients will often present with elevated body temperature, cool moist skin, weakness, anxious and tachypnea.
- Heat cramps consists of benign muscle cramping due to dehydration and is not associated with an elevated temperature.
- Patients can be predisposed by use of tricyclic antidepressants, phenothiazine’s, anticholinergic medications and alcohol
- Active cooling – Remove the patient’s clothing, wet the patient and increase the air flow over the patient. This promotes evaporative and convective cooling.
- Passive cooling - Limited to removing patient from heat/environmental source and removing clothes - Shivering is a normal part of the cooling process and should NOT be an indication to dc cooling measures.
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HYPOTHERMIA
HISTORY:
o Exposure to environment even in normal temperatures
o Exposure to heat loss conditions (wet, wind, cold)
o Exposure to extreme cold without shelter
o Extremes of age o Drug use: Alcohol, barbiturates o Length of exposure o Trauma, blood loss
SIGNS AND SYMPTOMS:
o Cold victim o Altered mental status,
loss of coordination, slurred speech
o Violent shivering or no shivering in later stages
o Bradycardia o Hypotension or shock o Appearing DOA
DIFFERENTIAL:
o Hypoglycemia o CNS dysfunction
Stroke Head injury Spinal cord injury
o Alcohol, drug, or medication involvement
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Remove wet clothing. 3. If able, check core temperature 4. Handle patient very gently 5. Cover patient with blankets 6. EKG if available
ADVANCED CARE GUIDELINES
7. Administer warm IV fluids if available, do not administer cold fluids 8. Monitor EKG and treat dysrhythmias
• If body temp is confirmed or suspected to be below 86 degrees Fahrenheit i. ONLY give epinephrine every 8 minutes if indicated
ii. Defibrillation is indicated ONLY once iii. Consider spacing other medications used for resuscitation
CONSIDERATIONS
- NO HYPOTHERMIA PATIENT IS DEAD UNTIL WARM AND DEAD - Wet patients lose heat rapidly – Dry patient as soon as wet clothing removed - Active rewarming in the field may not be possible without specialized equipment - Extremes of age are more susceptible (i.e. young and old) due to poor thermoregulatory mechanisms - Skin, oral and axillary temperatures are very unreliable in hypothermia and should not be used. Assess
mental status, shivering activity and breathing rate to estimate core temperature. - Shivering stops as hypothermia progresses and obviously cold victims who are not shivering should be
handled gently to avoid precipitating V-fib - In no detectable pulse, begin CPR. Consult with medical control for ACLS interventions.
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TRAUMA PROTOCOLS
ABDOMINAL / PELVIC TRAUMA
BURNS
ELECTRICAL INJURIES
EXTREMITY TRAUMA
HEAD TRAUMA
MULTI-SYSTEMS TRAUMA
SHOCK – TRAUMA
THORACIC TRAUMA
SELECTIVE SPINAL IMMOBILIZATION
SEXUAL ASSAULT
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ABDOMINAL / PELVIC TRAUMA
HISTORY:
o Time of injury o Type of injury o Other trauma o Loss of consciousness o SAMPLE
SIGNS AND SYMPTOMS:
o Abdominal pain on palpation
o Penetrating wounds o Impaled objects o Abdominal evisceration o Hematuria, bloody stools o Altered bowel sounds o Hemoptysis, hematemesis o Signs/symptoms of shock
DIFFERENTIAL:
o Blunt visceral injury o Open abdominal/pelvic wound o Impaled object o Pelvic fracture o Multiple trauma
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. At any time go to the related protocol: Shock – Trauma or Multiple Trauma 3. Stabilize any impaled object. Do not remove it 4. Cover evisceration(s) with saline soaked trauma dressing. Consider saran wrap to cover. 5. Immobilize any suspected pelvic fracture
ADVANCED CARE GUIDELINES
6. Consider Pain Control Protocol 7. IV/IO 8. Cardiac Monitoring 9. Consider 2nd IV
CONSIDERATIONS
- Be vigilant for internal bleeding and signs of shock and prepare for aggressive management for volume replacement.
- IV fluid administration should be administered in 250 cc increments and should be limited to achieve and maintain a systolic blood pressure of 80 mmHg. Patients with a systolic blood pressure of < 80 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.
- Head injured patients may require more aggressive fluid resuscitation - Fluid resuscitation should occur enroute except in cases of entrapment and other extenuating
circumstances. - Never try to remove an impaled object - Place pregnant patients in the left lateral recumbent position, if possible
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BURNS
HISTORY:
o Type of exposure (heat, gas, chemical)
o Inhalation injury o Time of injury o Other trauma/blast
injury / fall o Loss of consciousness o SAMPLE
SIGNS AND SYMPTOMS:
o Burns, pain, swelling o Dizziness o Loss of consciousness o Hypotension / shock o Airway
compromise/distress o Singed facial or nasal hair o Hoarseness/wheezing
DIFFERENTIAL:
o Superficial (1˚) red & painful o Partial thickness (2˚)
blistering o Full thickness (3˚) painless
and charred or leathery skin o Chemical o Thermal o Electrical o Radiation o C-spine / blunt trauma
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Remove rings, bracelets, and other constricting items Chemical
If eyes involved, irrigate Remove clothing or expose area Brush off any residue and flush area with copious amounts of water or NS
for a minimum of 5 minutes Thermal
Cover burn with a dry burn sheet or plastic wrap
ADVANCED CARE GUIDELINES 3. Consider Pain Control Protocol 4. IV/IO 5. Cardiac Monitoring
CONSIDERATIONS
- Stop the burning process! - Critical Burns: Partial thickness of > 10% body surface area; burns to face, eyes, hands, genitalia, perineum,
or major joints or feet; electrical burns including lightening injury, inhalation burns; deep chemical burns; burns with extremes of age or chronic disease; and burns associated with major traumatic injury. These burns may require hospital admission or transfer to a burn center.
- Early intubation is required in significant inhalation injuries. - Potential carbon monoxide exposure should be treated with 100% oxygen regardless of oxygen saturation. - Circumferential burns to extremities are dangerous due to potential vascular compromise 2˚ to soft tissue
swelling. - Burn patients are prone to hypothermia – Never apply ice or wet dressings to burns. The patient
compartment of the ambulance should be kept warm when caring for burn patients.
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- Early hypovolemia is rare. If hypotensive, it may be associated with other traumas. - Do not overlook the possibility for child abuse with children and burn injuries. - Regardless of the extent of injury, chemical burns should be flushed with copious amounts of water after
disrobing the patient. This should NOT be done in the ambulance to reduce the risk of exposure/combination of the medic.
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ELECTRICAL INJURIES
HISTORY:
o Lightening or electrical exposure
o Single or multiple victims o Trauma secondary to fall
from high wire or MVC into line
o Duration of exposure o Voltage and current (AC /
DC) o SAMPLE
SIGNS AND SYMPTOMS:
o Burns o Pain o Entry and exit wounds o Hypotension or shock o Arrest o Altered level of
consciousness
DIFFERENTIAL:
o Cardiac arrest o Seizure o Burns (see BURNS Protocol) o Multiple trauma
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. At any time go to related protocol: Tachycardia – Wide Complex; Ventricular Fibrillation 3. Obtain 12 Lead ECG and transmit to receiving facility 4. Wound Care
ADVANCED CARE GUIDELINES
5. IV/IO 6. Cardiac monitoring 7. Consider Pain Control Protocol
CONSIDERATIONS
- Scene safety is of utmost importance when entering areas where these type of victims are found. - Exercise additional caution when responding and caring for patients from motor vehicle crashes
involving hybrid vehicles which have high-voltage electrical systems. - Look for entry and/or exit wounds. - Ventricular fibrillation and asystole are the most common dysrhythmias. - Damage is often hidden; the most severe damage will occur in muscle, vessels and nerves. - In a mass casualty lightning incident, attend to victims in full arrest first. If the victim did not
arrest initially, it is likely they will survive. - Do not overlook other trauma (i.e. falls)
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EXTREMITY TRAUMA
HISTORY:
o Type of injury o Mechanism: crush /
penetrating / amputation / blunt
o Time of injury o Open vs. closed wound /
fracture o Wound contamination o SAMPLE
SIGNS AND SYMPTOMS:
o Pain, swelling o Deformity o Altered sensation / motor
function o Diminished pulse / capillary refill o Decreased extremity temperature
DIFFERENTIAL:
o Abrasion o Contusion o Laceration o Sprain o Dislocation o Fracture o Amputation
1. Follow initial patient care protocol 2. Follow Multi System Trauma protocol if indicated
BASIC CARE GUIDELINES
3. At any time go to related protocol: Shock – Trauma 4. Wound care 5. Tourniquet if necessary 6. If bleeding site is not amenable to tourniquet placement (i.e. junctional injury), consider
application of a topical hemostatic agent impregnated gauze with direct pressure 7. If amputation:
Locate amputated part if possible Wrap amputated part in saline moistened gauze Place wrapped amputated part in empty plastic bag Place the plastic bag with the amputated part in a water and ice mixture Do not use ice alone or dry ice Label with patient name, the date, and time Make sure the part is transported with the patient, if possible
8. Splinting
ADVANCED CARE GUIDELINES
9. IV/IO 10. Consider Pain Management Protocol
CONSIDERATIONS
- IV fluid administration should be administered in 250 cc increments and should be limited to achieve and maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood
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pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.
- Head injured patients may require more aggressive fluid resuscitation. - If distal circulation is not present (no distal pulse, no cap refill, cyanosis) make one attempt to
reposition the fracture or dislocation in an effort to restore distal circulation. - Urgently transport any injury with vascular compromise. - Assess color, pulse, motor, sensory function before splinting, after splinting and on arrival to ED. - In amputations, time is critical. Transport and notify Medical Control immediately, so that the
appropriate destination can be determined. - Hip dislocations and knee and elbow fracture/dislocations have a high incidence of vascular
compromise. - Blood loss may be concealed or not apparent with extremity injuries - Immobilize fracture of dislocated joints by securing the bones above and below the injured joint. - Immobilize fracture for bone by securing the joints above and below the injured bone. - The use of tourniquet is appropriate if bleeding is uncontrollable using direct pressure. Document
time of application.
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HEAD TRAUMA
HISTORY:
o Time of injury o Mechanism: blunt /
penetrating o Loss of consciousness o Bleeding o Evidence of multi-trauma o Helmet use or damage to
helmet o Seizure o SAMPLE
SIGNS AND SYMPTOMS:
o Pain, swelling, bleeding o Altered LOC, unconscious o Respiratory destress / failure o Vomiting o Decreased reflexes, paralysis
in extremities o Decorticate / decerebrate
posturing o Pupillary changes
DIFFERENTIAL:
o Skull fracture o Brain injury (concussion,
contusion, hemorrhage or laceration)
o Epidural hematoma o Subdural hematoma o Subarachnoid
hemorrhage o Spinal injury o Abuse
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Assess GCS 3. Utilize Airway protocols to keep SpO2 > 94% 4. Blood glucose 5. If Seizure Activity go to Seizure Protocol
ADVANCED CARE GUIDELINES
6. Consider intubation per RSI protocol 7. Ventilate to CO2 of 35-45 mmHg if airway management necessary 8. Cardiac monitoring
CONSIDERATIONS
- Consider elevating head of stretcher 30˚ if patient has a systolic blood pressure of 90 mmHg or more - Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing’s Response). Do
NOT attempt to lower blood pressure. - Hypotension usually indicated injury or shock unrelated to the head injury and should be aggressively
treated however; limit IV fluids unless patient is hypotensive (systolic BP < 90). - The most important item to monitor and document is a change in the level of consciousness - Concussions are periods of confusion or LOC associated with trauma which may have resolved by the time
EMS arrives. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP.
- Patients with a normal GCS of 15 may have an underlying brain trauma if the following signs or symptoms are seen: vomiting, severe headache, focal temporal blow or restlessness.
- Patients presenting with a GCS < 14 and one or more of the following will require evaluation by a neurosurgeon if possible: penetrating head injury or depressed skull fracture, open head injury with or without CSF leak, deterioration of GCS, lateralizing signs or paralysis ( i.e. one-sided weakness, motor or sensory deficit).
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MULTI-SYSTEMS TRAUMA New 2017
HISTORY:
o Time and mechanism of injury
o Damage to structure or vehicle
o Location in structure or vehicle
o Others injured or dead o Speed and details of
MVC o Restraints / protective
equipment used o SAMPLE
SIGNS AND SYMPTOMS:
o Pain, swelling o Deformity, lesions,
bleeding o Altered LOC, unconscious o Hypotension or shock o Cardiac arrest
DIFFERENTIAL (Life threatening):
o Chest - Tension pneumothorax - Flail chest - Pericardial tamponade - Open chest wound - Hemothorax
o Intra-abdominal bleeding o Pelvis / Femur fracture o Spinal fracture/cord injury o Head injury o Extremity fracture/dislocation o HEENT (Airway obstruction) o Hypothermia
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Appropriate Protocol based on patient condition: Shock-Trauma; Head Trauma; Thoracic Trauma; Seizure
3. Utilize Airway protocol to keep SpO2 > 94%
ADVANCED CARE GUIDELINES
4. Cardiac monitoring 5. IV/IO Consider Fluid Bolus 6. Consider 2nd IV/IO
CONSIDERATIONS - Keys for survival of major trauma includes minimizing scene time and expeditious transport to a trauma
center - IV fluid administration should be administered in 250 cc increments and should be limited to achieve and
maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.
- Head injured patients may require more aggressive fluid resuscitation. - Fluid resuscitation should occur enroute except in cases of entrapment and other extenuating
circumstances. - Consider Mechanism of Injury carefully - A thorough secondary assessment is critical to finding occult injuries - For persistent hypotension, not responsive to 1,500 ml of fluid, consider the possibility of underlying
tension pneumothorax and chest decompression. - Keep the patient warm to prevent hypothermia. Keep the patient compartment warm to prevent heat loss.
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SHOCK - TRAUMA Revised 2017
HISTORY:
o Blood loss (quantify) – vaginal or gastrointestinal bleeding, AAA, ectopic pregnancy
o Pregnancy o SAMPLE
SIGNS AND SYMPTOMS:
o Restlessness, confusion o Weakness, dizziness o Weak, rapid pulse o Pale, cool, clammy skin o Delayed capillary refill o Hypotension – SBP <90
mmHg
DIFFERENTIAL:
o Uncontrolled hemorrhage o Tension pneumothorax o Neurogenic shock
(vasogenic)
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. Assess GCS 3. Utilize Airway protocol to keep SpO2 > 94%
ADVANCED CARE GUIDELINES
4. Cardiac monitoring 5. Administer fluid bolus 20 ml/kg up to 250 ml NS/LR. Repeat as necessary. 6. For Spinal Trauma not responsive to fluid bolus, consider Dopamine infusion
- Don’t delay transport of life or limb threatening injuries to obtain refusals.
CONSIDERATIONS
- Minimize scene time when possible - IV fluid administration should be administered in 250 cc increments and should be limited to
achieve and maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.
- Head injured patients may require more aggressive fluid resuscitation. - Fluid resuscitation should occur enroute except in cases of entrapment and other extenuating
circumstances. - Shock is defined as decreased effective circulation with inadequate delivery of oxygen to tissues
(see Signs and Symptoms section above). - Unlike shock associated with other trauma, spinal trauma resulting in neurogenic shock may not
be associated with tachycardia - Consider a 12 Lead ECG for patients with chest trauma when time permits (enroute).
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THORACIC TRAUMA Revised 2017
HISTORY:
o Time of injury o Type of injury o Other trauma o Loss of consciousness o SAMPLE
SIGNS AND SYMPTOMS:
o Penetrating wounds o Decreased/unilateral breath
sounds o Impaled objects o Tracheal deviation o Respiratory distress o Signs/Symptoms of shock
DIFFERENTIAL:
o Flail chest o Open chest wound o Impaled object o Pulmonary contusion o Cardiac contusion
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
2. At any time go to related protocol: Shock – Trauma; Cardiac; Multi-Systems Trauma 3. Utilize Airway protocols to keep SpO2 94-99% 4. Stabilize impaled object. Do Not Remove
ADVANCED CARE GUIDELINES
5. Open pneumothorax – Chest Seal 6. Tension pneumothorax – Needle Chest Decompression 7. Cardiac monitoring 8. IV/IO
CONSIDERATIONS
- Reassess patient frequently for signs/symptoms of a tension pneumothorax. - Minimize scene time when possible. - IV fluid administration should be administered in 250 cc increments and should be limited to
achieve and maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.
- Head injured patients may require more aggressive fluid resuscitation. - Fluid resuscitation should occur enroute except in cases of entrapment and other extenuating
circumstances - Signs of a tension pneumothorax include hypotension (the most important), jugular venous
distension, diminished breath sounds, hypoxia, tachycardia, and lastly tracheal deviation. - For pediatric patients younger than 13, do not use an IV larger than an 18 gauge - Consider a 12 Lead ECG for patients with chest trauma when time permits (enroute). - If Asherman seal is unavailable , seal the wound with an occlusive dressing.
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SELECTIVE SPINAL IMMOBILIZATION Revised 2018
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
1. Patient Presentation:
a) This protocol is intended for patients who present with a traumatic mechanism of
injury.
b) Spinal motion restriction is contraindicated for patients who have penetrating
trauma who do not have a neurological deficit.
2. Patient Management:
a) Assessment while maintaining spinal alignment:
mental status,
neurological deficits,
spinal pain,
evidence of intoxication,
tenderness on palpation or deformities.
b) Treatment and Interventions:
Apply cervical restriction if there is any of the following:
Patient complains of neck pain.
Any neck tenderness on palpation.
Any abnormal mental status, including extreme agitation, or neurological deficit.
Any evidence of alcohol or drug intoxication
There are other severe or painful injuries present.
Any communication barrier that prevents accurate assessment.
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SPINAL CARE CONTINUED
c) Spinal and cervical motion restriction and a long spine board, full body vacuum splint, scoop stretcher, or similar device if: Patient complains of midline back pain Any midline back tenderness
Note 1: Distracting injuries or altered mental status does not necessitate long spine board use.
Note 2: Patients should not routinely be transported on long boards, unless the clinical situation warrants long board use. An example of this may be facilitation of multiple extremity injuries or an unstable patient where removal of a board will delay transport and/or other treatment priorities. In these rare situation, long boards should be padded or have a vacuum mattress applied to minimize secondary injury to the patient.
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SEXUAL ASSAULT Reviewed 2011
1. Follow initial patient care protocol
BASIC CARE GUIDELINES
a) Identify yourself to the patient, assure patient that they are safe and in no further danger
b) Do not burden patient with questions about the details of the crime; you are there to provide emergency medical care
c) Be alert to immediate scene and document what you see. Touch only what you need to touch at the scene
d) Do not disturb any evidence unless necessary for treatment of patient. (If necessary to disturb evidence, document why and how it was disturbed.)
e) Preserve evidence; such as clothing you may have had to remove for treatment, and make sure that it is never left unattended at any time, to preserve "chain of evidence"
f) Contact local law enforcement if not present
g) Treat other injuries as indicated
h) Treat for shock if indicated
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Iowa EMS Treatment Appendices
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Appendix A - EMS Out-of-Hospital Do-Not-Resuscitate Protocol
Purpose: This protocol is intended to avoid unwarranted resuscitation by emergency care providers in the out-of-hospital setting for a qualified patient. There must be a valid Out-Of-Hospital Do-Not-Resuscitate (OOH DNR) order signed by the qualified patient’s attending physician or the presence of the OOH DNR identifier indicating the existence of a valid OOH DNR order.
No resuscitation: Means withholding any medical intervention that utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function, including but not limited to:
1. Chest compressions 2. Defibrillation, 3. Esophageal/tracheal/double-lumen airway; endotracheal intubation, or 4. Emergency drugs to alter cardiac or respiratory function or otherwise sustain life.
Patient criteria: The following patients are recognized as qualified patients to receive no resuscitation:
1. The presence of the uniform OOH DNR order or uniform OOH DNR identifier, or 2. The presence of the attending physician to provide direct verbal orders for care of the patient.
The presence of a signed physician order on a form other than the uniform OOH DNR order form approved by the department may be honored if approved by the service program EMS medical director. However, the immunities provided by law apply only in the presence of the uniform OOH DNR order or uniform OOH DNR identifier. When the uniform OOH DNR order or uniform OOH DNR identifier is not present contact must be made with on-line medical control and on-line medical control must concur that no resuscitation is appropriate.
Revocation: An OOH DNR order is deemed revoked at any time that a patient, or an individual authorized to act on the patient’s behalf as listed on the OOH DNR order, is able to communicate in any manner the intent that the order be revoked. The personal wishes of family members or other individuals who are not authorized in the order to act on the patient’s behalf shall not supersede a valid OOH DNR order.
Comfort Care (♥): When a patient has met the criteria for no resuscitation under the foregoing information, the emergency care provider should continue to provide that care which is intended to make the patient comfortable (a.k.a. ♥ Comfort Care). Whether other types of care are indicated will depend upon individual circumstances for which medical control may be contacted by or through the responding ambulance service personnel.
♥ Comfort Care may include, but is not limited to: 1. Pain medication. 2. Fluid therapy. 3. Respiratory assistance (oxygen and suctioning).
Qualified Patient means an adult patient determined by an attending physician to be in a terminal condition for which the attending physician has issued an Out of Hospital DNR order in accordance with the law. Iowa Administrative Code 641-142.1 (144A) Definitions.
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Appendix B: Adult Out-Of-Hospital Trauma Triage Destination Decision Protocol The following criteria shall be utilized to assist the EMS provider in the identification of time critical injuries, method of transport and trauma care facility resources necessary for treatment of those injuries Step 1 - Assess for Time Critical Injuries: Level of Consciousness & Vital Signs Glasgow Coma Score ≤13 Respiratory rate <10 or >29 breaths per minute, or need for ventilatory support. Systolic B/P (mmHg) less than <90 mmHg If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes, ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 1 does not apply, move on to step 2 Step 2 - Assess for Anatomy of an Injury All penetrating injuries to head, neck, torso and extremities
proximal to elbow or knee Chest wall instability or deformity (e.g., flail chest) Suspected two or more proximal long-bone fractures Suspected pelvic fractures Crushed, degloved, mangled, or pulseless extremity
Open or depressed skull fracture Amputation proximal to wrist or ankle Paralysis or Paresthesia Partial or full thickness burns > 10% TBSA or involving
face/airway
If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 2 does not apply, move on to step 3 Step 3 - Consider Mechanism of Injury & High Energy Transfer Falls
o Adult: > 20 ft. (one story is equal to 10 feet) High-risk auto crash:
o Interior compartment intrusion, including roof: >12 inches’ occupant site; >18 inches any site
o Ejection (partial or complete) from automobile
o Death in same passenger compartment o Vehicle telemetry data consistent with high risk of injury
Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact
Motorcycle crash >20 mph
Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If step 3 does not apply, move on to step 4 Step 4 - Consider risk factors: Older adults
o Risk of injury/death increases after age 55 years o SBP<110 might represent shock after age 65 years
EMS provider judgment Low impact mechanisms (e.g. ground level falls) might result in
severe injury
ETOH/Drug use Pregnancy > 20 weeks Anticoagulants and bleeding disorders Patients with head injury are at high risk for rapid deterioration
Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If none of the criteria in the above 4 steps are met, follow local protocol for patient disposition. When in doubt, transport to nearest trauma care facility for evaluation. For all Transported Trauma Patients: 1. Patient report to include: MOI, Injuries, Vital Signs & GCS, Treatment, Age, Gender and ETA 2. Obtain further orders from medical control as needed.
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Pediatric Out-Of-Hospital Trauma Triage Destination Decision Protocol The following criteria shall be utilized to assist the EMS provider in the identification of time critical injuries, method of transport and trauma care facility resources necessary for treatment of those injuries Step 1 - Assess for Time Critical Injuries: Level of Consciousness & Vital Signs Abnormal Responsiveness: abnormal or absent cry or speech. Decreased response to parents or environmental stimuli. Floppy or rigid muscle
tone or not moving. Verbal, Pain, or Unresponsive on AVPU scale. OR Airway/Breathing Compromise: obstruction to airflow, gurgling, stridor or noisy breathing. Increased/excessive retractions or abdominal
muscle use, nasal flaring, stridor, wheezes, grunting, gasping, or gurgling. Decreased/absent respiratory effort or noisy breathing. Respiratory rate outside normal range.
OR Circulatory Compromise: cyanosis, mottling, paleness/pallor or obvious significant bleeding. Absent or weak peripheral or central pulses;
pulse or systolic BP outside normal range. Capillary refill > 2 seconds with other abnormal findings. Glasgow Coma Score ≤13 If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes, ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 1 does not apply, move on to step 2 Step 2 - Assess for Anatomy of an Injury All penetrating injuries to head, neck, torso and extremities
proximal to elbow or knee Chest wall instability or deformity (e.g., flail chest) Suspected two or more proximal long-bone fractures Suspected pelvic fractures Crushed, degloved, mangled, or pulseless extremity
Open or depressed skull fracture Amputation proximal to wrist or ankle Paralysis or Paresthesia Partial or full thickness burns > 10% TBSA or involving
face/airway
If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 2 does not apply, move on to step 3 Step 3 - Consider Mechanism of Injury & High Energy Transfer Falls >10 feet or two times the height of the child High-risk auto crash:
o Interior compartment intrusion, including roof: >12 inches occupant site; >18 inches any site
o Ejection (partial or complete) from automobile
o Death in same passenger compartment o Vehicle telemetry data consistent with high risk of injury
Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact
Motorcycle crash >20 mph
Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If step 3 does not apply, move on to step 4 Step 4 - Consider risk factors: Pregnancy > 20 weeks Anticoagulants and bleeding disorders Patients with head injury are at high risk for rapid deterioration
EMS provider Judgment ETOH/Drug use
Transport to the nearest (Any Level) Trauma Care Facility. If none of the criteria in the above 4 steps are met, follow local protocol for patient disposition. When in doubt, transport to nearest trauma care facility for evaluation. For all Transported Trauma Patients: 1. Patient report to include: MOI, Injuries, Vital Signs & GCS, Treatment, Age, Gender and ETA 2. Obtain further orders from medical control as needed
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Appendix C: Physician on Scene Your offer of assistance is appreciated. However, this EMS service, under law and in accordance with nationally recognized standards of care in Emergency Medicine, operates under the direct authority of a Physician Medical Director. Our Medical Director and physician designees have already established a physician-patient relationship with this patient. To ensure the best possible patient care, and to prevent inadvertent patient abandonment or interference with an established physician-patient relationship, please comply with our established protocols.
Please review the following if you wish to assume responsibility for this patient:
1. You must be recognized or identify yourself as a qualified physician.
2. You must be able to provide proof of licensure and identify your specialty.
3. If requested, you must speak directly with the on-line medical control physician to verify transfer of responsibility for the patient from that physician to you.
4. EMS personnel, in accordance with state law, can only follow orders that are consistent with the approved protocols.
5. You must accompany this patient to the hospital, unless the on-line medical control physician agrees to re-assume responsibility for this patient prior to transport.
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Appendix D: Air Medical Transport - Utilization Guidelines for Scene Response These guidelines have been developed to assist with the decision making for use of air medical transport by the emergency medical services community. The goal is to match the patient’s needs to the timely availability of resources in order to improve the care and outcome of the patient from injury or illness. Clinical indicators:
1. Advanced level of care need (skills or medications) exists that could be made available more promptly with an air medical tier versus tiering with ground ALS service, and further delay would likely jeopardize the outcome of the patient
2. Transport time to definitive care hospital can be significantly reduced for a critically ill or
injured patient where saving time is in the best interest of the patient
3. Multiple critically ill or injured patients at the scene where the needs exceed the means available
4. EMS Provider ‘index of suspicion’ based upon mechanism of injury and patient
assessment
Difficult access situations:
1. Wilderness or water rescue assistance needed
2. Road conditions impaired due to weather, traffic, or road construction / repair
3. Other locations difficult to access The local EMS provider must have a good understanding of regional EMS resources and strive to integrate resources to assure that ground and air services cooperate as efficiently and effectively as possible in the best interest of the patient. Medical directors for ambulance services should assure that EMS providers are aware of their own service’s abilities and limitations given the level of care and geographic response area being served. Audits should be conducted on an ongoing basis to assure that utilization of regional resources (ground and air) is appropriate in order to provide the level of care needed on a timely basis.
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Appendix E: Intentionally Left Blank
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Appendix F: Reperfusion Therapy Screening Not Limited to Paramedic Level
This form should be completed for patients suffering from Acute Coronary Syndromes. This tool will be used to triage patients to the appropriate receiving facility, and provide a template for passing information on to the receiving facility. Fibrinolytic screening may be done at the EMT level; however, the decision to bypass a local hospital to transport to a Percutaneous Coronary Intervention (PCI) capable facility is reserved for the PS and Paramedic levels.
1. If available, obtain 12-Lead EKG and transmit to receiving facility
2. EMT level – Transport patient to closest appropriate facility. Contact medical control for decision on completing thrombolytic checklist.
3. Paramedic Level – Evaluate 12-Lead for evidence of STEMI.
If STEMI is present, determine appropriate destination. If transport time to a facility capable of providing emergency PCI care is 60 minutes or less, it is
recommended that all of these patients be transported directly to the emergency PCI capable facility. If transport time to a facility capable of providing emergency PCI care is between 60 - 90 minutes,
transport to the PCI capable facility should be considered. If transport is initiated to a non-PCI facility:
Complete fibrinolytic therapy checklist on next page.
If a local protocol for fibrinolytic therapy in the field has been established, then proceed with fibrinolytic protocol if:
o Authorized by voice contact with medical control, and o The Paramedic has received training and has the approval of their physician medical director
In all instances those patients requiring immediate hemodynamic or airway stabilization should be transported to the closest appropriate facility. If STEMI is not present, transport patient to closest appropriate facility. Note: See Fibrinolytic Checklist on the following page
If directed by medical control, complete fibrinolytic checklist below
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Fibrinolytic Checklist
Any YES findings will be relayed to medical control. Absolute Contraindications preclude the use of fibrinolytics. Relative Contraindications require consultation with medical control.
DATE: PATIENT AGE: MALE FEMALE INCIDENT/RECORD #: YES NO
ABSOLUTE CONTRAINDICATIONS
Any known intracranial hemorrhage?
Known structural cerebral vascular lesion?
Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours?
Suspected aortic dissection?
Active bleeding or bleeding diathesis (excluding menses)?
Significant closed head trauma or facial trauma within 3 months?
RELATIVE CONTRAINDICATIONS
History of chronic, severe, poorly controlled hypertension?
Severe, uncontrolled hypertension on presentation (S >180mmHg or D>110mmHg)
History of prior ischemic stroke >3 months, dementia, or known intracranial pathology?
Traumatic or prolonged (>10 min) CPR or major surgery (<3 weeks)
Non-compressible vascular punctures?
Pregnancy?
Active peptic ulcer?
Current use of anticoagulants?
EMS Provider Print Name: Signature:
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Appendix G: Strategies for Reperfusion Therapy: Acute Stroke Revised 2017
Reperfusion Therapy Screening Not Limited to Paramedic Level
This appendix should be used for suspected acute stroke. This tool will be used to triage patients to the appropriate receiving facility, and provide a template for passing information to the receiving facility.
1. Perform a validated stroke assessment such as the MEND exam.
2. If assessment is positive for stroke, and onset of symptoms can be established within the past 4.5 hours, then determine the appropriate destination:
a. If transport time to a Primary Stroke Center is less than 30 minutes, it is recommended that all of these patients be transported directly to the Primary Stroke Center
b. If transport time to a Primary Stroke Center is greater than 30 minutes, then transport to the nearest stroke capable hospital.
3. Consider the use of air transport if it will facilitate the arrival of the acute stroke patient for treatment within 4.5 hours to a Primary Stroke Center or stroke capable hospital.
4. If transport to a Primary Stroke Center or stroke capable hospital cannot be achieved to arrive within 4.5 hours, then transport to the closest appropriate facility.
5. In all instances, those patients requiring immediate hemodynamic or airway stabilization should be transported to the closest appropriate facility.
6. Complete the fibrinolytic checklist on next page.
Levels of Stroke Care Capacity:
Comprehensive Stroke Center: Hospitals that have been certified by the Joint Commission-accredited acute care hospitals and must meet all the criteria for Primary Stroke Certification
Primary Stroke Center: Hospitals that have been certified by the Joint Commission on Hospital Accreditation or an equivalent agency to meet Brain Attack Coalition and American Stroke Association guidelines for stroke care
Stroke capable hospital: Hospitals that have the following:
• rt-PA readily available for administration • Head CT, laboratory and EKG capabilities 24/7 • Process in place for transporting appropriate patients to a Primary Stroke Center • Stroke protocol in place that follows American Stroke Association guidelines • Emergency department coverage by physician, or advanced practitioner
The list of Iowa Hospital Triage Designations is available on the Iowa Healthcare Collaborative web site at:
https://www.ihconline.org/additional-tools/initiatives/coverdell-stroke-project/
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If directed by medical control, complete fibrinolytic checklist below
Fibrinolytic Checklist
Any YES findings will be relayed to medical control. Absolute Contraindications preclude the use of fibrinolytics. Relative Contraindications require consultation with medical control.
DATE: PATIENT AGE: MALE FEMALE INCIDENT/RECORD #: YES NO
ABSOLUTE CONTRAINDICATIONS
Any known intracranial hemorrhage?
Known structural cerebral vascular lesion?
Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours?
Suspected aortic dissection?
Active bleeding or bleeding diathesis (excluding menses)?
Significant closed head trauma or facial trauma within 3 months?
RELATIVE CONTRAINDICATIONS
History of chronic, severe, poorly controlled hypertension?
Severe, uncontrolled hypertension on presentation (S >180mmHg or D>110mmHg)
History of prior ischemic stroke >3 months, dementia, or known intracranial pathology?
Traumatic or prolonged (>10 min) CPR or major surgery (<3 weeks)
Non-compressible vascular punctures?
Pregnancy?
Active peptic ulcer?
Current use of anticoagulants?
EMS Provider Print Name: Signature:
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Appendix H: Simple Triage and Rapid Treatment (START)
S T A R T
The following are guidelines for initial tactical triage using the START method. START is most useful in initially clearing the disaster zone where there are numerous casualties. It focuses on respiration rate, perfusion, and mental status and takes under one minute to complete. Once the patient moves toward a higher level of care (evacuation), a more detailed approach to triage may be needed.
Respirations Perfusion Mental Status
Green = Minor/Ambulatory Yellow = Delayed Red = Immediate Black = Deceased/Expectant
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Simple Triage and Rapid Treatment – Pediatric JumpSTART
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Appendix I: Suspected Abuse/Assault/Neglect/Maltreatment
k) Provide reassurance l) Contact local law enforcement if not present m) Provide appropriate medical care per protocol n) Do not burden patient with questions about the details of the assault o) Be alert to immediate scene and document what you see. p) Touch only what you need to touch at the scene q) Do not disturb any evidence unless necessary for treatment of patient. (If necessary to disturb
evidence, document why and how it was disturbed.) r) Preserve evidence; such as clothing you may have had to remove for treatment, and make sure that it
is never left unattended at any time, to preserve "chain of evidence" s) Provide local referrals as available t) Communicate vital information only – additional info can be given to receiving RN and/or Physician on
arrival u) Record observations and factual information on run report
Pediatric Considerations:
a) Approach child slowly in order to establish rapport (except in life-threatening situations), then perform exam
b) Provide appropriate medical care per protocol c) Genital exam only if indicated in the presence of blood, known or obvious injury and or trauma d) Interview parents separate from child, if possible e) Transport if permitted by parents f) If parents do not allow transport, notify law enforcement for assistance
Report all suspected abuse to the pediatric and dependent adult hotline at 1-800-362-2178 within 24 hours of your contact of the patient. This will be an oral report only. Within 48 hours of oral reporting, you must submit a written report for all suspected abuse to the Iowa Department of Human Services
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Appendix J: Guidelines for EMS Provider Initiating Organ and Tissue Donation at the Scene of the Deceased
1. All appropriate patient care protocols will be enacted to assure patient care is provided according to
prevailing standards.
2. If resuscitation efforts are unsuccessful or if upon arrival the patient is deceased and without indications to initiate resuscitation, then on-line medical direction will be contacted to confirm that no further medical care is to be given.
3. As per Iowa Code 142C.7 a medical examiner or a medical examiner’s designee, peace officer, fire
fighter, or emergency medical care provider may release an individual’s information to an organ procurement organization, donor registry, or bank or storage organization to determine if the individual is a donor.
4. As per Iowa Code 142C.7 any information regarding a patient, including the patient’s identity,
however, constitutes confidential medical information and under any other circumstances is prohibited from disclosure without the written consent of the patient or the patient’s legal representative.
5. At least one EMS provider should remain at the scene until the appropriate authority (medical
examiner, funeral home, public safety, etc.) is present.
6. Contact Iowa Donor Network at 800-831-4131
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Appendix K: Guidelines for EMS Providers Responding to a patient with special needs This protocol is not intended for interfacility transfers These guidelines should be used when an EMS provider, responding to a call, is confronted with a patient using specialized medical equipment that the EMS provider has not been trained to use, and the operation of that equipment is outside of the EMS provider’s scope of practice. The EMS provider may treat and transport the patient, as long as the EMS provider doesn’t monitor or operate the equipment in any way while providing care. When providing care to patients with special needs, EMS personnel should provide the level of care necessary, within their level of training and certification. When possible, the EMS provider should consider utilizing a family member or caregiver who has been using this equipment to help with monitoring and operating the special medical equipment if necessary during transport. Some examples of special medical devices:
• PCA (patient controlled analgesic) • Chest Tube
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Appendix L: EMS Approved Abbreviationsā before ABC airway, breathing,
circulation ALS advanced life support AMI acute myocardial
infarction amps ampules ASA aspirin AT atrial tachycardia AV atrioventricular bicarb sodium bicarbonate BID twice a day BLS basic life support BP blood pressure BS blood sugar c ̅ with CAD coronary artery
disease CC chief complaint cc cubic centimeter CCU coronary care unit CHB complete heart block CHF congestive heart
failure cm centimeter CNS central nervous system c/o complains of CO carbon monoxide C02 carbon dioxide COPD chronic obstructive
pulmonary disease CPR cardiopulmonary
resuscitation CSF cerebral spinal fluid CVA cerebral vascular
accident D/C discontinue DOA dead on arrival D5W 5% dextrose in water Dx diagnoses ED emergency
department EKG/ECG electrocardiogram Epi epinephrine ER emergency room
ET endotracheal ETOH alcohol fib fibrillation fl fluid fx fracture GI gastrointestinal gm gram gr grain gt(t) drop(s) h, hr hour hx history ICU intensive care unit IM intramuscular IV intravenous Kg kilogram KVO keep vein open L liter LOC level of
consciousness LR lactated ringers Mgtt microdrip MD medical doctor mEq milliequivalents mg milligram MI myocardial
infarction min minute ml milliliter mm millimeter MS morphine sulfate NaCI sodium chloride NaHCO3 sodium bicarbonate NG,N/G nasogastric nitro nitroglycerine NPO nothing by mouth NS normal saline NSR normal sinus rhythm NTG nitroglycerine 02 oxygen OB obstetrics OD overdose OR operating room P pulse p after PAC premature atrial
contraction
PAT paroxysmal atrial tachycardia
PCR patient care record PE physical exam,
pulmonary edema pedi pediatric PERL pupils equal, reactive to
light PJC premature junctional po by mouth pr per rectum prn whenever necessary,
as needed PVC premature ventricular
contraction q every QID four times a day R respirations R/O rule out RN registered nurse Rx treatment s without SC subcutaneous Sec second SL sublingual SOB shortness of breath SQ subcutaneous STAT immediately s/s sign, symptoms SVT supraventricular
tachycardia Sx symptoms TIA transient ischemic
attack TID three times a day TKO to keep open VF ventricular fibrillation w/s watt second setting x times y/o years old
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Appendix M: Guidelines for New Protocol Development
Making a decision to develop a new protocol or evaluate an existing one should be based on a rational process. Questions that should be asked and answered when considering a new drug therapy or procedure are as follows:
Key Questions for any New Protocol
1. Is the drug therapy or procedure medically indicated and safe? 2. Is it within the scope of practice for the provider? 3. How specifically will this protocol benefit patient care? 4. What specifically is needed to implement this protocol (education/training, medical director protocol
development/authorization, equipment needs, etc.)? 5. How will this protocol impact operation? 6. What is the opinion of providers concerning this protocol? 7. Does the medical community support this protocol change? 8. What are all the costs versus benefits associated with implementation and maintenance? 9. What are the medical-legal implications? 10. What ongoing provider involvement such as skills maintenance and continuous quality improvement is
necessary? 11. How will success be measured?
Rational Protocol Development Process to Make the Right Protocol Decision
1. Study the issue thoroughly 2. Identify key questions 3. Compare with goals 4. Assess fit with system 5. Cost benefit analysis 6. Identify measuring tools
Stakeholders in this process are recognized to include, but not be limited to:
1. Medical direction (on-line and off-line) 2. Educators/training programs 3. Regulators of policy and rules 4. Service directors 5. Service providers 6. Consumers 7. Third party payers
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Appendix N: Rapid Sequence Induction
This skill is to be performed only by Paramedics who have demonstrated competencies in medication administration and airway management as determined by the service Medical Director.
INDICATIONS
1. Decreased level of consciousness, combativeness or severe agitation secondary to trauma.
2. Suspected CVA with GCS of 8 or less with a gag reflex where loss of airway is presumed inevitable.
3. Acute respiratory distress requiring ventilatory assistance or control. 4. Burn patient with potential or existing respiratory or airway compromise. 5. Prolonged seizure activity 6. CHF, COPD, or Asthma patients with hypoxia and/or respiratory crisis who cannot be
intubated nasally CONTRAINDICATIONS
1. Contraindications to the medications being used in the RSI procedure. 2. Patient has known valid DNR or DNI
PROCEDURE
1. Determine need for intubation 2. Ensure IV access 3. Monitor cardiac rhythm and vital signs including oxygen saturation 4. Provide oxygen as necessary to preoxygenate and maintain > 93% SPO2 5. Determine that all necessary equipment is available and in working order including
alternative airway 6. Follow Cardiac Arrhythmia Protocol for presence of arrhythmia 7. Follow Seizure protocol for presence of seizure 8. Sedate patient: Administer 1-2 mg/kg ketamine IV/IO. 9. Paralyze patient: Administer 1-1.5 mg/kg rocuronium. 10. Once induced, intubate patient and verify tube placement by auscultation and CO2
monitoring i. If further sedation is needed after intubation:
Administer 1-2 mg/kg ketamine q15 min or Administer 2-4 mg Midazolam IV/IO every 15 minutes (0.1 mg/kg pediatric) if systolic blood pressure greater than 90.
11. If further paralytic is needed after intubation: Administer 1-1.5 mg/kg rocuronium
IF Intubation is unsuccessful (no more than 2 attempts), manage airway with supraglottic airway, IF supraglottic airway is unsuccessful manage airway using percutaneous cricothyrotomy
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LBS KGS LBS KGS100 - 150 45 - 68 90 mg 0.9 cc 70 mg 7 cc 100 - 150 45 - 68150 - 200 68 - 91 120 mg 1.2 cc 100 mg 10 cc 150 - 200 68 - 91200 - 250 91 - 113 170 mg 1.7 cc 130 mg 13 cc 200 - 250 91 - 113250 - 293 113 - 133 220 mg 2.2 cc 170 mg 17 cc 250 - 293 113 - 133
ConcentrationOnset/duration 9/27/18
Sedate > Paralyze >
RSI Dosage ChartRepeat q15min
Ketalar ZemuronRepeat q15 PRN
(ketamine) (rocuronium)
olor coded length based dosage advised for pediatric
mgcc/mlmg
1 - 2 mg/kg 1 - 1.5 mg/kg
100mg per 1ml 10mg per 1ml
cc/ml
30 sec / 20 min 45 sec / 25 min
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Appendix O: Continuous Positive Airway Pressure (CPAP) Indications:
Any patient presenting in respiratory distress who is aged 12 years or older, able to follow commands, with the ability to maintain a patent airway and adequate mask seal displaying findings in the medical history or assessment suggestive of any of the following conditions: 1. Asthma 2. COPD 3. CHF 4. Pulmonary edema
AND meets two or more of the following criteria: 1. Respiratory rate of 25 / minute or greater 2. Initial or subsequent SpO2 of less than 95% 3. Skin signs suggestive of hypoxia such as pallor, mottling or cyanosis 4. Presence of abnormal breath sounds or frothy sputum 5. Notable increased work of breathing
Contraindications:
1. Insufficient spontaneous ventilatory effort 2. Systolic blood pressure less than 90 mmHg 3. Suspected pneumothorax or has suffered trauma to the chest 4. Tracheostomy 5. Active vomiting 6. Upper GI or upper airway bleeding
Special Considerations:
1. CPAP is designed to be a continuous therapy and should only be discontinued in the case of the patient being unable to tolerate the mask or in case of progression to spontaneous ventilatory failure
2. Advise the receiving facility of your patient’s CPAP therapy as soon as practical so they may prepare for continuation of therapy
3. Observe patients for signs of gastric distention 4. Monitor patients closely for changes in hemodynamic or respiratory status 5. Procedure may be performed on patient with Do Not Resuscitate Order.
Procedure:
1. Explain the procedure to the patient. 2. Ensure adequate oxygen supply to ventilation device 3. Place the patient on continuous pulse oximetry 4. Place the patient on cardiac monitor and record rhythm strips 5. Place the delivery device over the mouth and nose and secure the mask with provided straps 6. Use 10 cm of H2O of PEEP valve initially
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7. Check for air leaks 8. Monitor and document the patient’s respiratory response to treatment 9. Due to changes in preload and afterload of the heart during CPAP therapy, a complete set of vital sings must be obtained and documented every 5 minutes 10. Administer appropriate medication as certified (continuous nebulized Albuterol for COPD/Asthma and repeated administration of nitroglycerin for CHF)
Removal Procedure:
1. Do not remove CPAP until hospital therapy is ready to be placed on the patient. 2. CPAP therapy needs to be continuous and should not be removed unless the patient cannot tolerate the mask or experiences respiratory arrest or begins to vomit. 3. Intermittent positive pressure ventilation with a Bag-Valve-Mask, placement of a non-visualized airway and/or endotracheal intubation should be considered if the patient is removed from CPAP therapy.
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Appendix P: PEEP Valve Guidelines
Indications:
PEEP should be considered if equipment is available in pulsatile intubated patients of all age groups to increase alveolar recruitment, reduce risk of repetitive alveolar collapse injury, and increase oxygenation.
Patients presenting with the following history or signs may benefit from PEEP:
• Conditions prior to respiratory arrest would indicate CPAP. • Hypoxia • Lung disease prior to intubation such as ARDS, Asthma or COPD • Atelectasis (alveoli collapse) • Extended duration of artificial respiration such as interfacility transfer (Greater than 30 minutes) • Pulmonary contusion or flail chest
Contraindications:
• Hypotension (Systolic BP less than 90) • Cardiac Arrest (reduces effectiveness of CPR) • Pneumothorax
Special Considerations:
• Patients should be monitored closely for pneumothorax. • The airway should be monitored closely for the need to suction. • Higher levels of PEEP can decrease ETCO2. • Monitor for stacked breaths (Auto-PEEP) due to incomplete exhalation. • If at any time ventilation becomes difficult, or hypotension occurs, the PEEP valve should be removed. • Decreased tidal volumes are often required to achieve adequate chest rise with PEEP. • Nebulized medications can be administered during PEEP use.
Procedure:
• Connect PEEP valve to exhalation port of BVM or ventilator circuit. • If CPAP was used prior to intubation, set PEEP valve to last CPAP level. • If no previous CPAP, initially set PEEP valve at 5 cmH2O (physiologic PEEP) • Titrate PEEP in 5 cmH2O increments as needed to achieve SPO2 >93% and reduce adventitious lung
sounds. • Medical direction should be sought when PEEP greater than 15 cmH2O is indicated.
If abrupt decrease in O2 saturation, evaluate for potential causes DOPES: Tube Displacement, Obstruction, Pneumothorax, Equipment, Stacked Breaths
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Appendix Q: Special Events The Special Events Protocol is for occasions that the service may be called to stand-by or perform First Aid. This protocol is for those patients seeking minor first aid. If a medical emergency exists, follow the appropriate protocol for that condition. If no medical emergency exists, but the person wants further care, continue with:
MINOR ACHES AND PAINS
Provide Acetaminophen 500mg -1000mg following directions on label.
TREATMENT OF MINOR SUNBURN
Apply over counter First Aid Burn Cream to burned area following instructions on label.
MINOR ABRASIONS
Clean area with sterile water or saline, stop bleeding and apply a thin layer of antibiotic ointment. Cover the wound to control bleeding and prevent infection.
All individuals seeking first aid shall have documentation on appropriate forms of treatments given.
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Appendix R: Swiss Mountain Society Stages of Hypothermia
Stage Mental Status Shivering Breathing Est. Core Temperature
0 Alert, Oriented Yes Yes >95°F (37°C)
I Responsive to voice -confused, slurred speech, may appear disoriented or agitated
Yes Yes 95-89.6 (35-32)
II Drowsy -inappropriately responsive to pain or voice No Yes 89.5-82.4 (31.9- 32)
III Unresponsive to most stimuli – may respond slowly to deep pain
No Yes 82.3-75.2 (27.9- 24)
IV Unresponsive No No <75.2 (<24)
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APGAR Score The Apgar score should be obtained and recorded 1 minute and again at 5 minutes after the birth or delivery of any infant.
Sign 0 1 2 Heart Rate Absent <100 min. >100 min.
Respiratory Effort Absent Weak Cry Strong Cry
Muscle Tone Limp Some Flexion Good Flexion
Reflex Irritability (when feet stimulated)
No Response Some Motion Cry
Color Blue; Pale Body Pink Extremities Blue
Pink
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Cincinnati Stroke Scale
FACIAL DROOP (have patient show teeth or smile)
-Normal – both sides of face move equally -Abnormal – one side of face does not move as well as the other side
ARM DRIFT (patient closes eyes and hold both arms straight out for 10 seconds)
-Normal – both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful)
-Abnormal – one arm does not move or one arm drifts down compared with the other
ABNORMAL SPEECH (have the patient say “you can’t teach an old dog new tricks”
-Normal – patient uses correct words with no slurring
-Abnormal – patient slurs words, uses the wrong words, or is unable to speak
Considerations: o If any one of the 3 signs is abnormal, the probability of a stroke is approximately 72%.
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Pediatric Glasgow Coma Scale
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Wong-Baker Faces Pain Rating Scale
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Pediatric Assessment Triangle
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Rule of Nines
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Dopamine Chart
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Medication References
ADENOSINE (Adenocard)
1. Classification: antiarrhythmic 2. Physiologic Effect: depresses the activity of the SA and AV nodes; interrupts re-entry; immediate
onset, duration <10 seconds. 3. Major Indications: SVT refractory to common vagal maneuvers 4. Primary Contraindications:
4.1. second or third-degree AV block 4.2. sick sinus syndrome (except in patients with functioning pacemakers) 4.3. hypersensitivity 4.4. symptomatic bradycardia
5. Relative Contraindications: 5.1. pregnancy 5.2. pts taking theophylline, dipyridamole or carbamazepine
6. Side Effects: 6.1. flushing 6.2. dyspnea 6.3. chest pain 6.4. transient periods of asystole, sinus bradycardia, or ventricular ectopy 6.5. hypotension 6.6. palpitations
7. Additional Information: 7.1. large (14-18 gauge) IV access 7.2. administer through injection port closest to patient. 7.3. follow with rapid saline flush
ALBUTEROL (PROVENTIL, VENTOLIN) 1. Classification: bronchodilator (sympathomimetic) 2. Physiologic Effect: stimulates the sympathetic beta-2 adrenergic receptors in the bronchial tree
causing bronchial smooth muscle relaxation; stimulates heart 3. Major Indications: relieve bronchospasms in patients with asthma, chronic bronchitis, emphysema,
and acute attacks of bronchospasm 4. Primary Contraindication: hypersensitivity 5. Relative Contraindications:
5.1. cardiovascular disease 5.2. diabetes mellitus 5.3. convulsive disorders 5.4. cerebrovascular disease 5.5. beta blocker medications
6. Side Effects: 5.6. nervousness, tremors 5.7. dizziness, seizures, headache 5.8. tachycardia, palpitations 5.9. hypertension
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AMIODARONE 1. Classification: Anti-dysrhythmic 2. Physiologic Effects: It acts on all cardiac tissues. It is thought to prolong the duration of the action
potential and refractory period without significantly affecting the resting membrane potential. The IV formulation relaxes vascular smooth muscle, decreases peripheral vascular resistance, and increases coronary blood flow.
3. Major Indications: 3.1. wide complex tachycardia 3.2. ventricular fibrillation
4. Primary Contraindications: 4.1. cardiogenic shock 4.2. severe sinus bradycardia
5. Side Effects: 5.1. fatigue 5.2. dizziness 5.3. bradycardia 5.4. sinus arrest 5.5. cardiogenic shock 5.6. CHF
6. Additional Information: Use with caution in patients with severe liver damage
ASPIRIN 1. Classification: non-steroidal anti-inflammatory, analgesic and antipyretic agent 2. Physiologic Effects: inhibits platelet aggregation 3. Major Indications: to inhibit clot formation in acute MI patients 4. Primary Contraindications:
4.1. gastrointestinal disease (hemorrhagic or non-hemorrhagic) 4.2. bleeding disorders 4.3. hypersensitivity
5. Relative Contraindications: asthma 6. Side Effects:
6.1. nausea/vomiting 6.2. stomach pain 6.3. tinnitis or decreased auditory acuity 6.4. hyperventilation
7. Additional Information: 7.1. children and teenagers should not use this medication without consulting a physician; this
drug may precipitate Reye’s Syndrome 7.2. use caution in patients with allergies to other NSAIDS and other bleeding disorders
ATROPINE 1. Classification: anticholinergic (Parasympatholytic) 2. Physiologic Effects: blocks the parasympathetic nervous system's action on the heart, resulting in
increased heart rate 3. Major Indications:
3.1. symptomatic bradycardia 3.2. organophosphate poisoning
4. Relative Contraindications: 4.1. glaucoma 4.2. mitral valve stenosis 4.3. bronchial asthma
5. Side Effects: 5.1. blurred vision, headache, and pupillary dilation
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5.2. dry mouth and thirst 5.3. flushing 5.4. seizures 5.5. if given too slowly, a transient slowing of the heart rate may result 5.6. hypertension 5.7. dysrhythmias
CALCIUM CHLORIDE 1. Classification: electrolyte 2. Physiologic Effect: increases the cardiac contractile state and enhances ventricular automaticity 3. Major Indications:
3.1. hyperkalemia 3.2. calcium channel blocker toxicity
4. Primary Contraindications: 4.1. hypercalcemia 4.2. hypersensitivity
5. Relative Contraindication: patients taking digitalis 6. Side Effect: may slow the heart rate 7. Additional Information: calcium chloride is incompatible with all other drugs; be sure to
adequately flush the IV line before and after administration
DEXTROSE (D50W, D25W, D10W) 1. Classification: Carbohydrate-hypertonic dextrose solution 2. Physiologic Effect: elevates blood glucose 3. Major Indication: hypoglycemia-blood glucose < 60 4. Primary Contraindication: intracranial hemorrhage 5. Relative Contraindications:
5.1. acute alcohol related emergencies (should be used in conjunction with thiamine) 5.2. hyperglycemia
6. Side Effect: extravasation causes tissue necrosis 7. Additional Information:
7.1. do not occlude the IV line while giving IV D50W DILTIAZEM (CARDIZEM)
1. Classification: antihypertensive, calcium channel blocker 2. Physiologic Effect: inhibits calcium influx into myocardial cells and arterial smooth muscle 3. Major Indications:
3.1. acute hypertension 3.2. angina 3.3. rapid atrial fibrillation or atrial flutter
4. Primary Contraindications: 4.1. hypersensitivity 4.2. heart blocks 4.3. hypotension
5. Side Effects: 5.1. hypotension 5.2. bradycardia 5.3. headache 5.4. dizziness 5.5. arrhythmias 5.6. nausea/vomiting
6. Additional information:
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6.1. monitor heart rate and blood pressure closely
DIPHENHYDRAMINE (BENADRYL) 1. Classification: antihistamine 2. Physiologic Effect: blocks the cellular histamine receptors resulting in decreased capillary
permeability; decreases itching, edema, bronchoconstriction, and vasodilation. 3. Major Indication: allergic reaction 4. Primary Contraindications:
4.1. pregnancy 4.2. nursing mothers 4.3. newborns 4.4. hypersensitivity
5. Relative Contraindications: 5.1. bronchial asthma 5.2. hyperthyroidism
6. Side Effects: drowsiness
DOPAMINE (INTROPIN) CHART
1. Classification: sympathomimetic agent 2. Physiologic Effects: varies according to dosage
2.1. low doses, (1-2 mcg/kg/min) dopaminergic effects dilate renal and mesenteric blood vessels and increase renal perfusion
2.2. intermediate doses (2-10 mcg/kg/min) beta-adrenergic effects increase heart’s force of contraction and rate
2.3. high doses (>10 mcg/kg/min) alpha-adrenergic effects cause peripheral vasoconstriction and elevation of blood pressure
3. Major Indications: 3.1. cardiogenic shock 3.2. hemodynamically significant hypotension not resulting from hypovolemia
4. Primary Contraindications: 4.1. pheochromocytoma (adrenal gland tumor) 4.2. hypersensitivity
5. Relative Contraindications: 5.1. hypovolemia 5.2. uncorrected tachyarrhythmias and v-fib
6. Side Effects: 6.1. cardiac dysrhythmias 6.2. nausea and vomiting 6.3. dyspnea 6.4. extravasation causes tissue necrosis
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EPINEPHRINE (ADRENALIN) 1. Classification: sympathomimetic agent 2. Physiologic Effects: increases myocardial contractility, decreases the threshold for defibrillation,
elevates perfusion pressure, and may restore electrical activity in asystole; acts as a potent bronchodilator
3. Major Indications: 3.1. cardiac arrest 3.2. severe allergic reactions and anaphylaxis 3.3. status asthmaticus 3.4. bradycardia refractory to pacing or atropine
4. Primary Contraindications: 4.1. hypertension 4.2. hypothermia 4.3. hypersensitivity
5. Side Effects: 5.1. hypertension 5.2. palpitations 5.3. anxiety 5.4. cardiac dysrhythmias 5.5. tremors
FENTANYL CITRATE (SUBLIMAZE) 1. Classification: narcotic analgesic 2. Physiologic Effect: binds to receptors in the brain to change or alter the perception of pain 3. Major Indications: for analgesic purposes 4. Primary Contraindications:
4.1. hypersensitivity to fentanyl 4.2. head injuries
5. Side Effects: 5.1. respiratory depression 5.2. hypotension 5.3. nausea and vomiting
6. Additional information: 6.1. use with caution in patients who are debilitated or have COPD 6.2. fentanyl can be administered in various ways including through a patch or a lollipop for
pediatric cases 6.3. be prepared to assist ventilation if needed
7. Additional Information: 7.1. For IV Administration Only: Dilute Fentanyl 100 mcg / 2 ml in 8 ml of normal saline to yield a
concentration of 10 mcg / ml. 7.2. Do not dilute Fentanyl for intranasal (IN) or intramuscular (IM) administration.
GLUCAGON 1. Classification: hormone-hyperglycemic agent 2. Physiologic Effect: increases blood glucose levels through the release of glycogen stores from
the liver 3. Major Indications:
3.1. blood glucose determination <60 3.2. beta blocker overdose
4. Primary Contraindications: 4.1. pheochromocytoma (adrenal gland tumor)
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4.2. hypersensitivity 5. Side Effects:
5.1. nausea and vomiting 5.2. hypotension
6. Additional Information: 6.1. should always be followed by administration of dextrose 50% or glucose. 6.2. use with caution in patients with a history suggestive of insulinoma (tumor of Islets
of Langerhans) and/or pheochromocytoma
GLUCOSE (ORAL) 1. Classification: monosaccharide 2. Physiologic Effect: increases blood serum glucose level by absorption through mucous membranes 3. Major Indication: hypoglycemia 4. Primary Contraindication: none
Haloperidol (Haldol) 1. Classification: Butyrophenone antipsychotic 2. Physiologic Effect: blocks the effects of dopamine and increases its turnover rate 3. Major Indications:
3.1. Schizophrenia 3.2. Manic episodes
4. Primary Contraindications: 4.1. Use in patient with history of Parkinson’s 4.2. Use during pregnancy
5. Side Effects: 5.1. Tachycardia 5.2. Hypotension 5.3. Hypertension
6. Additional Information: 6.1. Risk of Tardive Dyskinesia 6.2. Risk of Q-T prolongation
KETAMINE (KETALAR) 1. Classification: NMDA receptor antagonist, 2. Physiologic Effect: primarily used for the induction and maintenance of general anethesia usually
in combination with a sedative and can be used in the treatment of bronchospasms. 3. Major Indications:
3.1. Sedation prior to intubation in RSI procedure 3.2. Chemical extrication (Air Med) 3.3. Anxiety and agitation associated with behavioral emergencies and excited delirium 3.4. Refractory pain
4. Primary Contraindications: 4.1. Hypersensitivity 4.2. Hypertension
5. Relative Contraindications: 5.1. Caution if CAD 5.2. Caution if CHF 5.3. Caution if chronic alcohol/substance abuse
6. Side Effects: 6.1. Respiratory depression 6.2. Hypotension 6.3. Bradycardia 6.4. Arrhythmias
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6.5. Hallucinations 6.6. Tonic-Clonic movements
7. Additional Information: 7.1. Closely monitor the patients level of consciousness and respiratory rate
LIDOCAINE 1. Classification: Anti-dysrhythmic 2. Physiologic Effect: increases fibrillatory threshold thereby decreasing ventricular ectopy and
increasing the likelihood of successful electrical cardioversion of ventricular dysrhythmias 3. Major Indication:
3.1. To minimize discomfort associated with EZ-IO infusion/administration 4. Primary Contraindication:
4.1. allergy to related local anesthetics of the amide type 4.2. WPW syndrome 4.3. Stokes-Adam syndrome
5. Side Effects: 5.1. CNS disturbances; convulsions 5.2. tinnitus 5.3. blurred or double vision 5.4. bradycardia 5.5. hypotension 5.6. anaphylaxis 5.7. respiratory depression
6. Additional Information: 6.1. halve the dose for the elderly, individuals with liver dysfunction, and patients weighing less
than 25 kg 6.2. use with extreme caution in patients with second or third degree heart blocks 6.3. do not use to treat ectopic beats if heart rate is less than 60; increase the heart rate instead
Lorazepam (Ativan) 1. Classification: benzodiazepine-sedative 2. Physiologic Effects: Depresses subcortical levels of CNS (e.g., limbic and reticular formation),
possibly by increasing activity of GABA. 3. Major Indication: Severe pain, Seizure activity 4. Primary Contraindication: hypersensitivity 5. Relative Contraindications:
5.1. shock 5.2. hypotension, especially in the head injured patient 5.3. coma 5.4. alcohol intoxication, use of barbiturates, narcotics or CNS depressants 5.5. pregnancy 5.6. chronic renal failure 5.7. congestive heart failure 5.8. chronic obstructive pulmonary disease 5.9. hepatic function impairment
6. Side Effects: 6.1. respiratory depression 6.2. respiratory arrest 6.3. hypotension 6.4. cardiac arrhythmias 6.5. headache 6.6. blurred vision
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MAGNESIUM SULFATE 1. Classification: anticonvulsant; electrolyte 2. Physiologic Effects:
2.1. depresses the CNS and blocks peripheral neuromuscular transmission by decreasing the amount of acetylcholine released by the motor nerve impulse
2.2. slows formation of SA impulses and prolongs conduction time 2.3. in severe asthma: Antagonizes translocation of Ca across cell membrane, leads to smooth
muscle relaxation & bronchodilation 2.3.1. Inhibits degranulation of mast cells (that release histamine) 2.3.2. Decreases release of acetylcholine (decreases excitability of muscle fiber membranes)
3. Major Indications: 3.1. seizure activity due to eclampsia 3.2. refractory ventricular fibrillation and pulseless v-tach 3.3. ventricular tachycardia (often torsades de pointes) due to hypomagnesemia 3.4. hypomagnesemia associated with AMI 3.5. severe asthma
4. Primary Contraindications: 4.1. severe renal impairment 4.2. heart blocks 4.3. hypersensitivity
5. Side Effects: 5.1. hypotension 5.2. respiratory paralysis 5.3. cardiac depression or asystole 5.4. CNS depression and paralysis 5.5. flushing and sweating
6. Additional Information: 6.1. toxic accumulation may occur in renal failure 6.2. check patellar reflex to avoid intoxication 6.3. calcium salts used as the antidote for intoxication
METHYLPREDNISOLONE (SOLU-MEDROL) 1. Classification: steroid-glucocorticoid; a potent anti-inflammatory 2. Physiologic Effect: suppression of acute and chronic inflammation of the immune system 3. Major Indications:
3.1. bronchodilation 3.2. asthma & COPD 3.3. allergic reactions 3.4. anaphylaxis
4. Relative Contraindications: 4.1. immune suppressing drugs 4.2. active infectious processes 4.3. peptic ulcer disease or gastrointestinal bleeding 4.4. pregnant or nursing mothers 4.5. sepsis
5. Side Effects: 5.1. headache 5.2. hypertension 5.3. CHF 5.4. hypokalemia 5.5. GI bleed
6. Additional Information: 6.1. reconstituted medication must be used within 48 hours. 6.2. methylprednisolone may interfere with the performance of hypoglycemic agents 6.3. use with caution in patients receiving potassium-depleting agents
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MIDAZOLAM (VERSED) 1. Classification: Short acting benzodiazepine-sedative 2. Physiologic Effects: Depresses subcortical levels of CNS (e.g., limbic and reticular formation),
possibly by increasing activity of GABA. Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Also useful for its amnestic effects.
3. Major Indications: 3.1. status epilepticus 3.2. premedication before transcutaneous pacing 3.3. anxiety and agitation 3.4. facilitated intubation
4. Absolute Contraindications: 4.1. hypersensitivity
5. Relative Contraindications: 5.1. shock 5.2. hypotension, especially in the head injured patient 5.3. coma 5.4. alcohol intoxication, use of barbiturates, narcotics or CNS depressants 5.5. pregnancy 5.6. chronic renal failure 5.7. congestive heart failure 5.8. chronic obstructive pulmonary disease 5.9. hepatic function impairment
6. Side Effects: 6.1. respiratory depression 6.2. respiratory arrest 6.3. hypotension 6.4. cardiac arrhythmias 6.5. headache 6.6. blurred vision 6.7. nausea and vomiting
7. Additional Information 7.1. Dilute for IV administration: Draw 10 mg (2 ml) in 10 ml syringe and dilute with 8 ml of saline for
1.0 mg/ml
7.2. Do not dilute for intramuscular administration: Draw 10 mg (2 ml) in 5-10 ml syringe give deep intramuscular injection
7.3. Do not dilute for intranasal administration: draw in 1 ml syringe and administer via the M.A.D.
Morphine Sulfate 7. Classification: Opioid agonist 8. Physiologic Effects: Provides analgesia by potentiating opioid receptors 9. Major Indication: Pain control 10. Primary Contraindications: Hypersensitivity, hypotension, respiratory depression 11. Side Effects:
11.1. Antihistamine mediated vasodilation 11.2. Respiratory depression 11.3. Nausea
NALOXONE (NARCAN) 1. Classification: narcotic antagonist 2. Physiologic Effects: causes reversal of narcotic depression induced by opioids by acting as an
antagonist in the opioid receptor sites 3. Major Indication: narcotic induced respiratory depression 4. Primary Contraindication: hypersensitivity
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5. Side Effects: 5.1. withdrawal symptoms (especially in neonates) 5.2. combativeness 5.3. hyperventilation
6. Additional Information: 6.1. Naloxone is sensitive to light, steps should be taken to shield the vial from UV light until ready
for usage 6.2. The smallest dose should be used to reverse respiratory depression, not to fully awake patient. 6.3. Common opioids include; morphine, methadone, codeine, Demerol, dilaudid, fentanyl,
and hydrocodone
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NITROGLYCERIN (NTG) 1. Classification: vasodilator 2. Physiologic Effects: relaxes smooth muscle producing vasodilator effects on
arteries and veins in the peripheral and core circulation thus reducing preload and afterload; causes coronary artery dilation
3. Major Indications: 3.1. To increase coronary perfusion in angina and acute myocardial infarction 3.2. To reduce preload in acute pulmonary edema 3.3. hypertensive crisis
4. Primary Contraindications: 4.1. patients having taken Viagra, Levitra, or Cialis or other erectile dysfunction
medications in the past 24-36 hours 4.2. hypovolemia 4.3. hypersensitivity
5. Side Effects: 5.1. headache 5.2. hypotension 5.3. palpitations 5.4. SL burning
6. Additional Information: 6.1. monitor blood pressure after each dose 6.2. use gloves for application 6.3. do not allow medication to come in contact with your skin or mucous membrane
ONDANSETRON HCL (ZOFRAN) 1. Classification: antiemetic 2. Physiologic Effects: blocks the release of chemicals in the brain that stimulate
the impulse to vomit. 3. Major Indications: prevent nausea and vomiting 4. Primary Contraindications: known hypersensitivity to ondansetron 5. Side Effects:
5.1. constipation 5.2. drowsiness 5.3. dry mouth
6. Additional Information: 6.1. No adequate and well-controlled studies in pregnant patients. 6.2. It is unknown if ondansetron is excreted in breast milk. Because many drugs
are excreted in human milk, extreme caution should be exercised before administering to a nursing mother.
OXYGEN 1. Classification: gas 2. Physiologic Effects: increases arterial oxygen tension and hemoglobin saturation to
improve tissue oxygenation 3. Major Indications:
3.1. hypoxia 3.2. cardiopulmonary or respiratory arrest 3.3. shock 3.4. CNS injuries 3.5. decreased level of consciousness 3.6. acute chest pain which may be due to cardiac ischemia
4. Primary Contraindications: none 5. Relative Contraindications:
5.1. chronic obstructive pulmonary disease
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5.2. hyperventilation syndrome 6. Administration and Dosage:
6.1. adult and pediatric patients without COPD 24% - 100% based on patient’s condition
6.2. COPD patients: 2-6 lpm via nasal cannula to SPO2 level of 92-93% 7. Side Effects:
7.1. respiratory arrest in patients with hypoxic drive 7.2. drying of respiratory mucosa 7.3. possible bronchospasm if the gas is extremely cold and dry
8. Additional Information: use unhumidified oxygen unless: 8.1. administration time > 20 min 8.2. patient is on humidified oxygen at home 8.3. medical control orders humidified oxygen
9. Device Information:
Device Concentration Flow Rate in liters per minute nasal cannula 24-44% 1-6 simple face mask 40-60% 6-10 non-rebreather mask 90-100% 10-15 BVM (no reservoir) 40-60% 12-15 BVM (with reservoir) 90-100% 12-15
O2 Saturation Reading
Range Recommended O2 Flows
95-100% Normal O2 PRN for Comfort 91-94% Mild Hypoxia O2 to improve to Normal 86-90% Moderate
Hypoxia 100% FiO2, evaluate respiratory rate and consider assist BVM/ intubation if outside normal range
<85% Severe Hypoxia
100% FiO2 Assist Ventilation and Intubate if improvement is not rapid or LOC is decreased
ROCURONIUM BROMIDE (ZEMURON) 1. Classification: non-depolarizing neuromuscular blocking agent 2. Physiologic Effect: competitively blocks acetylcholine from binding to post
synaptic sites and prevents muscle depolarization 3. Major Indications: to facilitate rapid sequence intubation 4. Primary Contraindications: hypersensitivity to rocuronium 5. Side Effects: malignant hypertension 6. Additional information:
6.1. must be accompanied with a sedating agent such as Versed or Etomidate 6.2. eye lubrication is required for prolonged paralysis
SODIUM BICARBONATE (BICARB) 1. Classification: systemic alkalizer, electrolyte buffer 2. Physiologic Effect: buffers H+ ions in metabolic acidosis 3. Major Indications:
3.1. preexisting metabolic acidosis (perfusing patient) 3.2. hyperkalemia 3.3. tricyclic, phenobarbital, or aspirin overdoses 3.4. during cardiac arrest, after prolonged resuscitative efforts
4. Primary Contraindications: 4.1. metabolic alkalosis 4.2. hypokalemia
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4.3. simultaneously with calcium chloride 4.4. simultaneously with catecholamines
5. Side Effects: 5.1. metabolic alkalosis 5.2. CHF (edema secondary to sodium overload) 5.3. hypernatremia
6. Additional Information: administration should be guided by arterial blood gas analysis in a perfusing patient
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