prince william county fire and rescue association box/2018 ems... · protocol), exercise their own...

Prince William CountyFire and Rescue Association

Patient Care Manual Effective Date: January 1, 2017

Revision Date: January 15, 2018

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Preliminary Information

Preliminary Information Overview ................................................................................................................ I Acknowledgements .............................................................................................. II Authorization ....................................................................................................... III General Principles for Medical Care ................................................................... IV ALS Intercept Guidelines .................................................................................... VIII Medical Transport Destination ............................................................................ IX Patient Care During Transport .............................................................................. X Medical Control Contact ..................................................................................... XI Automatic Notification of the Medical Director ................................................ XII Transfer of Care at Hospitals ............................................................................. XIII Document Guide for Written Format ................................................................ XIV

Adult Protocols

General Patient Care Protocol – Adult ................................................................. 1 Respiratory Emergencies:

Dyspnea ................................................................................................................. 5 Acute Bronchospasm ............................................................................................. 7 Pulmonary Edema ................................................................................................. 8 Submersion Injury ............................................................................................... 10 Respiratory Failure .............................................................................................. 11 Failed Airway ....................................................................................................... 13

Cardiac Arrest: General Approach ............................................................................................... 15 Asystole/PEA ....................................................................................................... 17 V‐Fib/Pulseless V‐Tach ........................................................................................ 19 Post Resuscitation Care ....................................................................................... 21 Cardiac Emergencies:

Acute Coronary Syndrome .................................................................................. 22 Bradycardia ......................................................................................................... 24 Regular Narrow Complex Tachycardia (SVT) ..................................................... 25 Irregular Narrow Complex Tachycardia (A‐Fib) ................................................. 26

Wide Complex Tachycardia ................................................................................. 27 Polymorphus V‐Tach (Torsades de Pointes) ...................................................... 29 Environmental Emergencies: Bites and Envenomation ..................................................................................... 30 Hyperthermia ...................................................................................................... 31 Hypothermia ........................................................................................................ 32

Hazardous Materials Exposure: General Approach ............................................................................................... 33 Cyanide Toxicity and Smoke Inhalation ............................................................. 35

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Nerve Agent WMD .............................................................................................. 37 Medical: Abdominal Pain ................................................................................................... 39 Allergic Reaction ................................................................................................. 40 Altered Mental Status/Syncope .......................................................................... 42 Behavioral Emergencies/Excited Delirium ......................................................... 43 Diabetic Emergencies .......................................................................................... 45 Seizure ................................................................................................................. 46 Sepsis ................................................................................................................... 47 Stroke Suspected ................................................................................................. 48 OB/GYN: Childbirth ............................................................................................................. 49

Pre‐Eclampsia/Eclampsia .................................................................................... 52 Vaginal Bleeding ................................................................................................. 53 Overdose and Poisoning: General Approach ............................................................................................... 54 Antidepressants ................................................................................................... 55 Antipsychotics/Acute Dystonic Reaction ............................................................ 57 Beta Blocker Toxicity ........................................................................................... 58 Calcium Channel Blocker ..................................................................................... 59 Carbon Monoxide ................................................................................................ 60 Cholinergic Organophosphate ........................................................................... 61 Pain Management: Medical/Trauma ................................................................................................. 62

Trauma: General Patient Care Protocol – Adult Trauma .................................................. 63 Abdominal Injuries .............................................................................................. 65

Burns .................................................................................................................... 66 Chest Injuries ....................................................................................................... 68 Extremity Injuries ................................................................................................ 70

Eye Injuries .......................................................................................................... 71 Head Injuries........................................................................................................ 72 Sexual Assault ..................................................................................................... 74 Traumatic Amputations ...................................................................................... 75

Pediatric Protocols

General Patient Care Protocol – Pediatric .......................................................... 76 Pediatric Respiratory Emergencies: Dyspnea ............................................................................................................... 80 Acute Bronchospasm ........................................................................................... 81 Stridor .................................................................................................................. 82

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Submersion Injury ............................................................................................... 84 Respiratory Failure .............................................................................................. 85 Pediatric Cardiac Arrest: General Approach .............................................................................................. 87

Asystole/PEA ....................................................................................................... 89 V‐Fib/Pulseless V‐Tach ........................................................................................ 91 Neonatal Resuscitation ....................................................................................... 92

Post Resuscitation Care ....................................................................................... 95 Pediatric Cardiac Emergencies: Bradycardia ......................................................................................................... 96 Tachycardia ......................................................................................................... 98

Hazardous Materials Exposure: Cyanide Toxicity and Smoke Inhalation ........................................................... 100

Pediatric Medical: Allergic Reaction ............................................................................................... 101 Altered Mental Status/Syncope ........................................................................ 102 Apparent Life‐Threatening Event ..................................................................... 103 Diabetic Emergencies ........................................................................................ 105

Seizure ............................................................................................................... 107 Sepsis ................................................................................................................. 108

Pediatric Overdose and Poisoning: Pediatric Overdose and Poisoning .................................................................... 110 Pediatric Pain Management:

Medical/Trauma ............................................................................................... 111 Trauma: General Patient Care Protocol – Pediatric Trauma .......................................... 113

Abdominal Injuries .......................................................................................... 115 Burns .................................................................................................................. 116 Chest Injuries .................................................................................................... 118 Extremity Injuries ............................................................................................. 120 Eye Injuries ........................................................................................................ 121

Head Injuries ..................................................................................................... 122 Sexual Assault .................................................................................................. 124

Traumatic Amputations ................................................................................... 125

Procedures

Administrative Procedures: Abuse and Neglect ............................................................................................ 126 Americans with Disabilities Act ........................................................................ 129

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Burn Center Criteria........................................................................................... 132 Code Sepsis ........................................................................................................ 134 Code STEMI ....................................................................................................... 135 Code Stroke ........................................................................................................ 136 Do Not Resuscitate ............................................................................................ 137 Emergency Department Notification ................................................................ 138 Extraordinary Care ............................................................................................ 139 Lights and Siren Use During Transport ............................................................ 141 Medication Administration Cross Check (MACC) ............................................ 143 Patient Care During Interfacility Transport ..................................................... 145 Physician on Scene ........................................................................................... 146 Police Custody Patient Care Standards ............................................................ 148 Refusal of Medical Care .................................................................................... 150 Refusal of Transport After Treatment .............................................................. 155 Restraints ........................................................................................................... 157 Trauma Triage Criteria ...................................................................................... 158 Withholding Resuscitation ................................................................................ 160

Clinical Procedures (Airway/Respiratory):

Advanced Suctioning ......................................................................................... 162 Basic Suctioning ................................................................................................. 163 Carboxyhemoglobin Monitoring ...................................................................... 164 Chest Decompression ........................................................................................ 167 Confirmation of Placement/Effectiveness of Ventilation ............................... 169 Continuous Positive Airway Pressure (CPAP) ................................................... 170 Cricothyrotomy ................................................................................................. 172 End Tidal CO2 Monitoring .................................................................................. 175 General Airway Management ......................................................................... 176 Laryngeal Tube Airway (KING LTS‐D) ............................................................... 178 Obstructed Airway ............................................................................................ 180 Orotracheal Intubation/Bougie ........................................................................ 182 Pulse Oximetry ................................................................................................. 187

Clinical Procedures (Cardiac):

12‐Lead ECG ....................................................................................................... 188 Cardiopulmonary Resuscitation ........................................................................ 190 Cardioversion ..................................................................................................... 191 Defibrillation Automated .................................................................................. 192 Defibrillation Manual ........................................................................................ 194 External Cardiac Pacing .................................................................................... 195 High Performance CPR ...................................................................................... 197 Implanted Cardiac Device ................................................................................. 204 Posterior ECG ..................................................................................................... 209 Right Sided ECG ................................................................................................. 211 Termination of Resuscitation ............................................................................ 213

Clinical Procedures (Other): Blood Glucose Analysis ..................................................................................... 216

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Electronic Control Device (Taser) ...................................................................... 217 Eye Irrigation ..................................................................................................... 218 Medication Administration ............................................................................... 219 Selective Spinal Motion Restriction (SSMR) ..................................................... 223 Splinting ............................................................................................................. 227 Tactical Emergency Casualty Care (TECC) ........................................................ 228 Temperature Measurements ............................................................................ 232 Venous Access Indwelling Catheters ................................................................ 233 Venous Access Intraosseous ............................................................................. 234 Venous Access Peripheral ................................................................................. 237 Wound Care/Hemorrhage Control ................................................................... 239

Pharmacology

Authorized Pharmaceuticals ............................................................................. 242 Adenosine .......................................................................................................... 243 Albuterol Sulfate ............................................................................................... 244 Amiodarone ....................................................................................................... 246 Aspirin ................................................................................................................ 248 Atropine Sulfate (cardiac indications) .............................................................. 249 Atropine Sulfate (antidote for poisoning) ........................................................ 250 Calcium Chloride ................................................................................................ 252 Dextrose ............................................................................................................. 254 Diphenhydramine Hydrochloride ...................................................................... 256 Dopamine Hydrochloride .................................................................................. 258 Epinephrine Hydrochloride (1mg/ml) ............................................................... 260 Epinephrine Hydrochloride (0.1mg/ml) ............................................................ 262 Fentanyl ............................................................................................................. 264 Glucagon ............................................................................................................ 266 Hydroxocobalamin ............................................................................................ 267 Ipratropium Bromide ........................................................................................ 268 Ketamine Hydrochloride ................................................................................... 270 Lidocaine ............................................................................................................ 271 Magnesium Sulfate ........................................................................................... 272 Methylprednisolone .......................................................................................... 274 Metoprolol ......................................................................................................... 275 Morphine Sulfate ............................................................................................... 276 Midazolam ......................................................................................................... 278 Naloxone............................................................................................................ 281 Nitroglycerin ...................................................................................................... 283 Ondansetron Hydrochloride .............................................................................. 285 Promethazine .................................................................................................... 286 Racemic Epinephrine ........................................................................................ 287 Sodium Bicarbonate .......................................................................................... 288 Tranexamic Acid ................................................................................................ 290

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Reference Documents

Pediatric Quick Reference ................................................................................. 291 Triage Quick Reference ..................................................................................... 293 SAMPLE Durable Do Not Resuscitate Order (DDNR) SAMPLE Physician Orders for Scope of Treatment (POST) Virginia Scope of Practice – Procedures for EMS Personnel Virginia Scope of Practice – Formulary for EMS Personnel EMS Field Guide for Ventricular Assist Devices Medication Administration Cross Check (MACC) Quick Reference HPCPR Triangles Airtraq – Video Downloading Instructions

Prince William County Fire and Rescue Association

Preliminary Information

Preliminary Information: Overview


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ThePrinceWilliamCountyFireandRescueAssociation(FRA)PatientCareManualisintendedto

provideandensureuniformtreatmentforallpatientswhoreceivecarefromagencies

participatinginthePrinceWilliamCountyEMSSystem.Theprotocolswithinapplyexclusivelyto

agenciesrespondingtoactivationofthe911systemwithinPrinceWilliamCounty.Anyotheruse

mustreceivepriorapprovalfromtheOperationalMedicalDirector(OMD)ofPrinceWilliam

County,Virginia.

Whileattemptshavebeenmadetoaddressallpatientcarescenarios,unforeseencircumstances

andpatientcareneedswillarise.Fortheseinstances,medicalpersonnelshouldfollowthe

GeneralPrinciplesforMedicalCareandGeneralPatientCareProtocol(orotherappropriate

protocol),exercisetheirownbestjudgment,andcontactOnlineMedicalControl(OLMC)for

additionalphysicianordersasneeded.Thepatient’sbestinterestshouldbethefinaldeterminant

foralldecisions.

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Preliminary Information: Acknowledgements


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TheOMDwishestothankthefollowingagenciesandindividualsfortheirhardworkand

commitmentduringthedevelopmentoftheseprotocols.

ContributingAgenciesandIndividuals

PrinceWilliamCountyDepartmentFireRescueBattalionChiefMichaelLaSalleCaptainCraigBeaversCaptainRobertMontminyCaptainBrettHambyCaptainMarcusSaagerCaptainJasonReeseLieutenantRandyCogginLieutenantSamKayeLieutenantRyanKirkLieutenantRobertMoreauLieutenantDavidSeifertLieutenantRobertWienckoTechnicianIIYasminAhmadyTechnicianIIAmandaGottTechnicianIIWerterWillisWilliamFritz,ALSTrainingSpecialistChristineGallagher,TechnicalServicesAnalyst

OtherContributingAgenciesandIndividualsEMSAdvisoryCommitteeDebbieEaton,FRAAdministrativeCoordinatorMarySmith,AdministrativeSupportAssistantIIIDynetteRombough,SentaraEmergencyServiceNurseManagerTheHonorableDevanLeeKirk,31stJudicialDistrictTiffanyFischer,Novant/UVAPrinceWilliamEmergencyServicesNurseManagerJessicaSilcox,SentaraStrokeCoordinator

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Preliminary Information: Authorization


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Inaccordancewith12VAC5‐31‐1040,effective1January2017thefollowingPatientCareManual

isauthorizedbytheOMDforuseinthePrinceWilliamCountyEMSSystem.Changestothis

manualmayonlybemadewithwrittenauthorizationoftheOMD.

ChristianC.Zuver,MD,FACEP,FAAEM

OperationalMedicalDirector

PrinceWilliamCounty

Preliminary Information: General Principles for Medical Care


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Thefollowingmeasuresshallbeappliedtohelppromotepromptandefficientemergencymedical

caretothesick,ill,injured,orinfirmed.TheyshallbeutilizedbyEMSpersonnelinthefield,inthe

EmergencyDepartment,andwhendealingwithOLMCPhysicians.

1. Thisdocumentmakesreferencesto“provider”.Providerislimitedtomeanthose

individualswhomaintainactiveendorsementbytheOMDateithertheBasicLifeSupport

(BLS)orAdvancedLifeSupport(ALS)level.

2. ApatientisdefinedbyTheVirginiaDepartmentofHealthOfficeofEMSas:

“apersonwhoneedsimmediatemedicalattentionortransport,orboth,whosephysicalormentalconditionissuchthatheisindangeroflossoflifeorhealthimpairment,orwhomaybeincapacitatedorhelplessasaresultofphysicalormentalconditionorapersonwhorequiresmedicalattentionduringtransportfromonemedicalcarefacilitytoanother.”‐12VAC5‐31‐10.

3. Apatientcareencounterandaprovider‐patientrelationshipisestablishedwheneverthe

EMSproviderhasdeterminedthatassessmentoftheindividualisnecessarytoensureno

illnessorinjuryexistsandtoensuretheindividual’scapacitytodeclineassessmentorcare

isnotimpairedbyillness,injury,orintoxication.

4. ThesafetyofEMSpersonnelisparamount.Eachscenemustbeproperlyevaluatedfor

crewsafetyandhazardsuponarrivalandthroughoutpatientcare.Assesstheneedfor

additionalpublicsafetyresourcesassoonaspossibleafterarrival.

5. ProperPersonalProtectiveEquipment(PPE)andBodySubstanceIsolation(BSI)mustbe

utilizedaccordingtotheExposureControlPlan,FireRescueAssociationPolicy4.8.1.

6. AllpatientsinthecareofEMSshallbeofferedtransportbyambulancetothenearest

appropriatehospitalorprotocol‐baseddestination.IntheeventapatientforwhomEMS

hasrespondedrefusestransporttothehospital,aproperlyexecutedrefusalprocessmust

becompleted.

7. TheonlyappropriatedestinationforEMSpatientstransportedbyambulanceisan

EmergencyDepartment.Exceptionsanddetailsconcerninghospitaldestinationbasedon

clinicalcriteriaareoutlinedinspecificprotocols.

Prince William County Fire and Rescue Association V

8. Forall911calls,uponinitialpatientcontact,bepreparedforimmediatemedicalinterventionappropriateforthecalllevel(defibrillation,airwaymanagement,drugtherapy,etc.).

9. UponarrivalatascenewhereaninitialEMScrewisrenderingpatientcare,allsubsequentarrivingEMScrewsshouldimmediatelyengagetheon‐scenecrew.Thegoalistodeterminethestatusofthepatientassessmentandseamlesslyassistwith,ortransfer,patientcare.

10. Priortothetransferofcarebetweencrews,theproviderrenderinginitialcareshoulddirectlyinterfacewiththeproviderassumingcare,toensureallpertinentinformationisconveyed.

11. Verbalconsentpriortotreatmentshouldbeobtainedwheneverpossible.Thepatient’srightstoprivacyanddignitymustberespected.Courtesy,concern,andcommonsensewillensurethepatientreceivesthebestpossiblecare.

12. Theprovidershouldgenerallybeabletodecidewithin3minutesafterpatientcontactif ALSmeasureswillbeneeded.Ifidentified,theyshouldberequestedand/orinstitutedsimultaneouslywiththeinitialassessment.Asecondary,comprehensiveexamisappropriateafterthepatienthasbeenstabilized.

13. Generally,initialassessmentandtherapyshouldbecompletedwithin10minutesafterpatientcontact.Exceptforextensiveextricationoratypicalsituations,traumapatientsshouldbeenroutetothereceivingfacilitywithin10minutes.Medicalpatients(excludingcardiacarrests)shouldbeenroutetothereceivingfacilitywithin20minutes.Additionaltherapy,ifindicated,shouldbecontinuedduringtransport.

14.Highacuitypatients(thosewithunstablevitalsignsorwhorequireassistancewithairway,breathing,orcirculation)requireaninitialassessmentandinterventionbytherespondingcrew.PromptpatientcareshalltakepriorityoverobtainingdemographicinformationorPatientCareReport(PCR)data.

15. Forall911callswhereBLSandALSprovidersareinattendance,theALSprovidershallmakefinalpatientcaredecisions.TheALSproviderwilltransportifthereisadifferenceofopinionregardingappropriatelevelofcare.

16.WhenbothBLSandALStransportunitshavemadepatientcontactandthepatientisdeemedtonotneedALStransport,theALSprovidermustperformanddocumentanassessmentandrationaleinthePCR.

17.Whenpossible,priortoadministrationofanymedication,medicationallergiesmustbeassessed.Ifanyquestionsariseinreferencetomedicationallergies,contactOLMCpriortoadministration.

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18.Whencaringforpediatricpatients,useaweight/lengthbasedsystemtodeterminemedicationdosagesandequipmentsizes.

19. Forcasesthatdonotexactlyfitintoatreatmentprotocol,refertotheGeneralPatientCareProtocol(AdultorPediatric),andcontactOLMCasneeded.

20. Followingtraining,OMDauthorization,andwhenauthorizedbyprotocol,allprovidersinthissystemareauthorizedto:

Administeroxygen. Administeroralaspirin. Administeroralglucose. Administernebulizedalbuterol. Administerintranasalnaloxone. Administerondansetronviaoraldisintegratingtablet(ODT). Administersublingualnitroglycerin. Administercontinuouspositiveairwaypressure(CPAP). Applypulseoximetryandcapnographymonitoringdevices. Performbloodglucoseevaluations. Performlaryngealtubeairway(LTA)insertionandventilation. Obtainandtransmit12‐leadECGs.

21. PerformallproceduresasperthePrinceWilliamCountyFRAPCM.Ifaprocedureisnotaddressedinthismanualandisdeemednecessary,contactOLMCorthereceivinghospitalphysicianfororderspriortoproceeding.

22. Inthesettingofconcernforimmediatelossoflifeorlimb,OLMCmayapproveordersforaprocedurethatisnotcoveredinthePrinceWilliamCountyFRAPCM,butiswithinthescopeofpracticeofanendorsedprovider.Ifaprovideristrainedintheprocedureandisproficientinperformingtheprocedure,theymayfollowtheordersofOLMC(12VAC5‐31‐1070).

23.EMSprovidershavetherighttorefusetoperformspecificproceduresortreatmentsorderedbyOLMCinthefollowingcircumstances(12VAC5‐31‐1080):

Ifnotadequatelytrainedandproficienttoperformtheprocedure; Iftheprocedureisnotfullyunderstood;or Iftheprocedureisjudgednottobeinthebestinterestsofthepatient.

24. Forallcaseswherepatientsrequireadministrationofopiatesorsedativeagents(midazolam/ketamine/diphenhydramine),endorsedprovidersshallperformcontinuousECGmonitoring,oxygensaturationmonitoring(SpO2),andend‐tidalcarbondioxidemonitoring(ETCO2)untilformaltransferofcarehasoccurred.


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25. TheRegionalPoisonControlCenter(RPCC)shouldbecontactedwhenhandlingcallsinvolvingpoisonous/hazardousmaterialexposures,overdoses,orsuspectedenvenomation.IntheeventthattheRPCCgivesrecommendationsthatarenotcoveredinthePrinceWilliamCountyFRAPCM,butiswithinthescopeofpracticeofanendorsedproviderandtheindividualhasbeentrainedintheprocedure,EMSprovidersshouldconfirmwithOLMCbeforecarryingouttheRPCCsrecommendations.TheRPCCcanbereachedat1.800.222.1222.

26. AllmedicalequipmentusedinPrinceWilliamCountymustbeauthorizedbytheOMD.


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Preliminary Information: ALS Intercept Guidelines


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ThefollowingsituationsdefinewhenanALSunitshouldberequestedtointerceptwithan

ambulancestaffedattheBLSlevel.

IfanALSintercepthasbeenrequestedbuttheestimatedtimeofALSarrivalislongerthanthe

timeitwouldtaketotransportthepatienttothehospitalviaBLSambulance,thepatientshouldbe

transportedwithoutdelay.Ingeneral,BLStransportunitsshouldnotwaitonsceneforALS.

IndicationsforALSIntercept:

Cardiacarrest(duringtransport).

Unconsciousness.

Difficultybreathing/compromisedairway/respiratoryarrest.

Multi‐systemtrauma.

Chestpain–suspectedcardiac.

Diabeticwithpersistentalteredlevelofconsciousness.

Patientswithunstableordeterioratingvitalsigns.

Firstseizure,seizurefollowingheadtrauma,oractivepersistentseizures.

llergicreaction. Anyothersituation,intheopinionoftheBLSproviderorOLMC,thatmaybenefit

fromadvancedlevelcare.

Preliminary Information: Medical Transport Destination


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Allpatientsshouldbetransportedtothenearestappropriatehospital.Ifseveralhospitalsare

withinthesameapproximatedistance/timefromthescene,allowthepatient,and/orpatient’s

familytoselectthereceivingfacilityoftheirchoice.

Allpatientswhoseconditionisjudgedtobeunstablewillbetransportedtotheclosestappropriate

receivingfacility.

ThedutyBattalionChiefshouldbenotifiedfortransportsoutsideofcountyboundaries.

FortransportdestinationofSEPSIS,STROKE,STEMI,TRAUMA,orBURNpatients,refertothe

appropriateprotocol.

Preliminary Information: Patient Care During Transport


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Inthefollowingsituationsmorethan1attendantinthebackofatransportunitisrequired,unless

operationallynotfeasible:

Medicalortraumaticcardiacarrestorpost‐resuscitationcare.

STEMIorunstablecardiacpatients.

Patientswithunstablevitalsignsrequiringactiveinterventionorassistance.

Patientconditionsrequiringemergenttransporttothehospital.

Patientsrequiringactiveairwayassistance(CPAP,BVM,LTA,ETT).

Imminentdelivery.

Providerrequest.

Preliminary Information: Medical Control Contact


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ContactOLMCforanyadditionalordersorwithquestionsneededtomeetthepatient’sneeds

duringon‐scenecareortransport.

Novant/UVAHaymarketMedicalCenter

571‐261‐3413

RadioChannel59Charlie

Novant/UVAPrinceWilliamMedicalCenter

703‐396‐5260

RadioChannel59Bravo

SentaraNorthernVirginiaMedicalCenter

703‐670‐0129

RadioChannel59Alpha

INOVAFairfaxHospital

703‐876‐0522

RadioChannel59Delta

INOVAFairOaksHospital

703‐391‐0767

RadioChannel49Delta

FauquierHospital

540‐316‐4911or540‐316‐4900

RadioChannel59Lima

MaryWashingtonHospital

540‐373‐0348or540‐741‐2124

RadioChannel59November

StaffordHospital

540‐741‐9102

RadioChannel59Mike

AnyqualityconcernsinvolvingOLMCshouldbeforwardedtotheOfficeoftheMedicalDirectorfor

reviewassoonaspossible.

Preliminary Information: Automatic Notification of the Medical Director


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Asweworktogethertoprovidethehighestqualitypatientcare,anyincidentwhichpotentiallyhas

anadverseornegativeimpactonthepatientorthesystem,shallbeimmediatelyreportedtoEMS

OperationsQualityAssuranceLieutenantbyphoneoremail.

Eventsthatrequirethisnotificationinclude:

Cardiacand/orrespiratoryarrestoccurringafteradministrationofketamine,

midazolam,morphine,orfentanyl.

Cardiacarrestafteradministrationofanantiarrhythmicagentinapreviouslystable

patient.

Anyattempt(successfulorunsuccessful)atcricothyrotomy.

Incorrectmedicationadministrationwithpatientcomplication(wrongdose,etc.).

Anycardiacand/orrespiratoryarrestorpatientinjuryrelatedtotheuseofphysical

restraints.

Aprovideroperatingoutsideoftheirscopeofpractice.Thescopeofpracticeis

definedbytheprovider’sstatecertificationandtheprovider’slevelofOMD

endorsement.

Failuretorecognizeamisplacedadvancedairwaydeviceorothercomplication

relatedtoadvancedairwaymanagement.

Iftheproviderhasotherpatientcareconcerns(potentialadverseevents,follow‐upquestions,or

clinicalissues)thatarenotnotedabove,theprovidershouldcontacttheQualityAssurance

LieutenantinEMSOperationsduringregularbusinesshours.

Preliminary Information: Transfer of Care at Hospitals


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Onceonhospitalproperty,thereceivingfacilityassumesresponsibilityforallfurthermedicalcare

deliveredtopatientstransportedbyEMS.Patientmonitoringtoincludevitalsigns,SpO2,ETCO2

andcardiacmonitoringshouldcontinueuntilpatientcarehasbeentransferred.EMSpersonnel

arenotauthorizedtofollowpre‐hospitalprotocolsafterarrivalatanEmergencyDepartmentand

OLMCshouldnotbecontactedfororders.

Exceptionstothisshouldoccuronlyinthefollowingcircumstances:

Life‐threateningsituations(e.g.,cardiacarrest,airwayemergencies,orimminent

deliveryofanewborn).

Continuationoftreatmentstartedpriortoarrival(e.g.,nebulizers,CPAP,IVfluids).

WhenspecificallyinstructedtocontinuecarebytheEDphysician(documentthe

physician’snameandthetimetheverbalorderwasgiven).

Toensureallknownpertinentinformationisconveyedtothehospitalstaff,crewsshouldinterface

withnursingstaffwithin5minutesofarrivaltogiveaverbalreport.Crewsshouldprovidethe

receivingfacilitywithallknownpertinentpatientinformation.Inaddition,providethereceiving

facilitywithacopyofpre‐hospital12‐leadECGs.

PCRsshouldbetransmittedinaccordancewithVAOEMSregulations:

“ShouldEMSpersonnelbeunabletoprovidethefullprehospitalpatientcarereportatthetimeofpatienttransfer,EMSpersonnelshallprovideanabbreviateddocumentedreportwiththecriticalEMSfindingsandactionsatthetimeofpatienttransferandthefullprehospitalpatientcarereportshallbeprovidedtotheacceptingfacilitywithin12hours.”‐12VAC5‐31‐1140.

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AllpatientsshallbeassessedandtreatedbasedontheappropriateGeneralPatientCareProtocol.

GeneralPatientCareProtocol‐Adult.

GeneralPatientCareProtocol‐AdultTrauma.

GeneralPatientCareProtocol‐Pediatric.

GeneralPatientCareProtocol‐PediatricTrauma.

GeneralPatientCareProtocolsshallbeusedinconjunctionwithotherspecificprotocolsand

proceduresasindicated.

ItemsindicatedinBoldItalicFontarereferencestootherprotocolsorprocedures.

ItemsindicatedinBoldFontindicatesamedicationadministration.

Protocolswillbeformattedasfollows:

All Providers

Medical Control

Advanced Life Support

TreatmentsunderthissectionareauthorizedforallendorsedBLSandALSproviders.

TreatmentsunderthissectionareauthorizedforallendorsedALSproviders.

Paramedic Only

TreatmentsunderthissectionareauthorizedbyOLMC.

TreatmentsunderthissectionareauthorizedforallendorsedParamedics.

Preliminary Information: Document Guide for Written Format


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AbbreviationsFoundinthisDocument

ALS AdvancedLifeSupportBGL BloodGlucoseLevelBLS BasicLifeSupportBSI BodySubstanceIsolationBVM BagValveMaskCHF CongestiveHeartFailureCO CarbonMonoxideCPAP ContinuousPositiveAirwayPressureECG ElectrocardiogramESRD End‐StageRenalDiseaseETCO2 End‐TidalCarbonMonoxideETT EndotrachealTubeFiO2 FractionofInspiredOxygenFRA FireRescueAssociationGCS GlasgowComaScoreHR HearRateIV IntravenousIO IntraosseousIVP IntravenousPushLOC LevelOfConsciousnessLPM LittersPerMinuteLTA LaryngealTubeAirwayMAP MeanArterialPressureMI MyocardialInfarctionNPA NasalPharyngealAirwayNRB Non‐RebreatherNS NormalSalineO2 OxygenODT OralDissolvingTabletOLMC On‐LineMedicalControlOMD OperationalMedicalDirectorOPA OralPharyngealAirwayPCR PatientCareReportPEA PulselessElectricalActivityPO “PerOs”orallyPPE PersonalProtectiveEquipmentROSC ReturnOfSpontaneousCirculationSBP SystolicBloodPressureSL SublingualSpO2 PeripheralCapillaryOxygenSaturationTBSA TotalBurnSurfaceAreaV‐Fib VentricularFibrillationV‐Tach VentricularTachycardia


Adult Protocols

General Patient Care Protocol - Adult


Thefollowingmeasureswillserveasthe“GeneralPatientCareProtocol‐Adult”andapply tothe

managementofalladultpatients.

All Providers

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Assessthepatient’smentalstatusandnatureofillness.

o Formentalstatus,usetheAVPUscale:

A–ThepatientisAlertandoriented.

V–ThepatientisresponsivetoVerbalstimulus.

P–ThepatientisresponsivetoPainfulstimulus.

U–ThepatientisUnresponsivetoanystimulus.

Assessthepatient’scirculationforpresenceofpulse,rateandquality.IfnocentralpulseispalpableinitiateCPR.RefertoCardiacArrest:GeneralApproach.

Incasesofcardiacarrest,initiatecontinuouschestcompressions,placeanOPAandNRBmaskonthepatientat15LPMandwithholdpositivepressureventilationperprotocoluntilresourcesallow.

Ifcardiacarrestisnotevident,ensureapatentairwayutilizingBLSstandards.

Assessthepatient’srespiratorystatustoincludelungsounds,respiratoryrateandworkofbreathing.UtilizepulseoximetrytoobtainSpO2.

ProvidesupplementaloxygentomaintainSpO2≥92%orifanyrespiratorysignsorsymptomspresent.Useadjunctsasnecessary.

Note:FalseSpO2readingsmayoccurinthefollowingsituations:hypothermia,hypoperfusion

(shock),carbonmonoxidepoisoning,andperipheralvasoconstriction.

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Ifsuspicionofacuteallergicreaction:

o RefertoMedical:AllergicReaction.

Ifsuspicionoftrauma:

o RefertoClinicalProcedure:SelectiveSpinalMotionRestriction(SSMR).

OxygenSaturation Range PatientCareGuidelines

92%‐100% Normal Ifsymptomatic,O2 byNC.

90%‐91% MildHypoxia O2 byNC asnecessary.

86%‐89% ModerateHypoxia O2 byNRB.

<86% SevereHypoxia O2 byNRB,considerCPAP/BVMorairway

adjunctasnecessary.



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Manageanyprofusebleedingandexamineforsignsofpoorperfusion.Ifevidenceoftrauma,refertoGeneralPatientCareProtocol‐AdultTrauma.

Attempttoobtainthepatient’scurrentmedicalcomplaintandpertinentmedicalhistory.UtilizeSAMPLEhistoryandOPQRST.Ifnecessary,utilizefamilyorbystanders.

Evaluatepupillaryreaction,motorfunction,sensationandGCS.

Ifappropriate,performanddocumentacompleteneurologicalassessmentandCincinnatiPrehospitalStrokeScale,includingtimethepatientwaslastseennormal.

Recordandmonitorvitalsignsincludinglevelofconsciousness,pulse,respiratoryrate,skin(color,condition,andtemperature),bloodpressure,bloodglucose,continuousSpO2,andETCO2(whenappropriate).

o Reassessanddocumentevery5minutesforcriticalpatientsor15minutesfornon‐criticalpatients.

Performa12‐leadECGifchestpain/ischemicequivalentsymptomsorabdominalpainabovetheumbilicus.IfALSisnotonscene,thecrewshouldtransmitandconfirmthattheEmergencyDepartmentreceivedthetransmission.IfALSisonscene,documentthenameofthereviewingprovider.

RecordBGLforanypatientexperiencingweakness,alteredmentalstatus,orhistoryofdiabetesperClinicalProcedure:BloodGlucoseAnalysis.

o Hypoglycemia<60mg/dL:

RefertoMedical:DiabeticEmergenciesifindicated.

o Hyperglycemia>250mg/dL:


Forseverenauseaandvomiting:

o ConsiderOndansetron4mgODT(contraindicatedinthesettingofpregnancyorsuspectedpregnancy).

Forpatientswithsuspectedopiateoverdosewithrespiratorydepression:

o AdministerNaloxone2mgIN.

Unlessauthorizedbyprotocol,nothingbymouth.

Refertoappropriateprotocolforspecifictreatmentsandinterventions.

TransportpatienttonearestappropriateEmergencyDepartment.

Minimizeon‐scenetimewhenpossible.

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Whenconditionwarrants(specifiedas“FullALSAssessmentandTreatment”inindividualprotocols).

Advancedairway/ventilatorymanagementifindicated.

Performcardiacmonitoring.

ContinuouslymonitorSpO2andETCO2.




Ifnotalreadydone,performa12‐leadECGifchestpainorabdominalpainisabovetheumbilicusorischemicequivalentsymptoms.

o IfSTEMIcriteriapresenton12‐LeadECG,transmitECGtoaPercutaneousCoronaryIntervention(PCI)EmergencyDepartmentandexpeditetransport.RefertoChestPain:AcuteCoronarySyndrome.

EstablishIVaccessNSKVOorIVlockifindicated(severesymptomsorformedicationaccess).

o RefertoClinicalProcedure:VenousAccessPeripheral.

Ifpatientisunstableandtimepermits,establishasecondIV.

AdministerNS:

o Ifevidenceofdehydration(tachycardia,drymucousmembranes,poorskinturgor)orhypovolemia,administerNS250ml,repeatonceifindicated.

o Consider250mlIVNSbolusatwideopenrateuntilSBP≥90mmHgorMAP≥65(maxcumulativedose2L).

Contraindicatedifevidenceofdecompensatedcongestiveheartfailure(e.g.,rales).

Ifpatientexhibitssignsofseverecardiopulmonarycompromise(poorsystemicperfusion,hypotension,alteredconsciousnessand/orrespiratorydistress/failure)andIVattemptsunsuccessful:

o EstablishIO,refertoClinicalProcedure:VenousAccessIntraosseous.

Forpatientswithseverenauseaorvomiting:

o AdministerOndansetron4mgODT/IV/IM/IO(contraindicatedinpregnantorsuspectedpregnantpatients)repeatoncein10minutesifindicated(maxcumulativedose8mg).

o AdministerPromethazine12.5mgdilutedin100mlNSIVatawideopenrateinapatent20gorlargerIV.IVmustbelocatedintheantecubital(foruseinpregnantorsuspectedpregnantpatientsONLY).

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Administration of Promethazine can cause akathisia (restlessness, anxiety and involuntary movements [dystonia]). If any of these are noted after administration of Promethazine, refer to Overdose and Poisoning: Antipsychotic/Acute Dystonic Reaction.

ForpatientswithsuspectedopioidoverdoseconsiderNaloxone2mgIN/IMorifvascularaccessestablishedconsiderNaloxone0.4mgIV/IOtitratedtomaintainadequaterespiratoryrate(maxcumulativedose4mg).

ForpatientswithmoderateorseverepainrefertoPainManagement:Medical/Trauma.


o UsecautionwithNaloxoneadministrationinchronicallydependentpatients(e.g.,cancerpatients)asitmayprecipitateacutewithdrawal.

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ContactOLMCforanyadditionalordersorquestions.

Respiratory Emergencies: Dyspnea


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GeneralPatientCareProtocol–Adult.

Sitpatientuprightorinpositionofcomfortunlesscontraindicated.

Observeforsignsofimpendingrespiratoryfailure,refertoRespiratoryEmergencies:RespiratoryFailureifindicated.

o Decreasedlevelofconsciousnesswithhypoxia(SpO2<90%)despite100%O2therapy,apnea,and/orrespiratoryrate<8.

o Poorventilatoryeffort(withhypoxiadespite100%O2therapy).

o Patientsrequiringactiveventilatoryassistance.

o Inabilitytomaintainpatentairway.

o Symptomaticairwayobstruction.

Ifsymptomsaresevere,initiateCPAPperClinicalProcedure:ContinuousPositiveAirwayPressure(CPAP).

o OnlyALSProvidersmaytitrateCPAPpressures.

o IfhypoxiapersistswhileonCPAP,O2viacapnography‐capableNCshouldbeusedinadditiontoCPAPtoincreasetheamountofO2delivered.ExpectFiO2toincreaseapproximately4%witheachadditionalLPMofO2.

Ifwheezing:

o AdministerAlbuterol2.5mgvianebulizerrepeatoncein5minutesifindicated.

o MaybeusedinconjunctionwithCPAP.

Ifsuspectedcardiacorigin:

o Perform12‐leadECG.

o AdministerAspirin324mgPO.

RefertoappropriateRespiratoryEmergenciesprotocol:

o RespiratoryEmergencies:AcuteBronchospasm.

o RespiratoryEmergencies:AcutePulmonaryEdemaSuspected.

o RespiratoryEmergencies:SubmersionInjury.

o RespiratoryEmergencies:FailedAirway.

IfconcernforforeignbodyobstructionrefertoClinicalProcedure:ObstructedAirway.

FullALSAssessmentandTreatment.

o TitratethepressureofCPAPpertheClinicalProcedure:ContinuousPositiveAirwayPresure(CPAP)ifindicated.

Respiratory Emergencies: Dyspnea


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Respiratory Emergencies: Acute Bronchospasm


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Medical Control


RefertoRespiratoryEmergencies:Dyspnea.

RefertoMedical:AllergicReaction.

Ifwheezing/dyspnea:

o AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated.

AtroventisonlycontraindicatedinthesettingofknownallergytoAtroventorAtropine.

Ifwheezingpersists:

o AdministerAlbuterol2.5mgvianebulizer,repeatevery5minutesifindicated(maxcumulativedose15mg).

Ifwheezing/dyspneapersistsafterfirstnebulizertreatment:

o AdministerMethylprednisolone125mgIV/IM/IO.

o ConsiderCPAPifsymptomsaremoderatetosevere.

RefertoClinicalProcedure:ContinuousPositiveAirwayPressure(CPAP).

Ifwheezing/dyspneaisnotimproving:

o AdministerMagnesiumSulfate2gdilutedin100mlNSIV/IOover10minutes.

Contraindicatedifhistoryofrenalfailure(e.g.,dialysispatient).

DonotuseifCHFsuspected.

Severesymptoms(notspeaking,littleornoairmovementornotimproving):

o ConsiderEpinephrine(1mg/ml)0.3mgIM*.


*Ifage>50,HR>150,orhistoryofCoronaryArteryDisease,contactOLMCpriortoadministeringEpinephrine(1mg/ml)0.3mgIM.


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Respiratory Emergencies: Pulmonary Edema


(HistoryofCHF,PeripheralEdema,ElevatedSBP,Rales,DecreasedBreathSounds)

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o Ifsymptomsaremoderate/severe,initiateCPAPperClinicalProcedure:ContinuousPositiveAirwayPressure(CPAP).

ConsiderNitroglycerin0.4mgSL,repeatin5minutesifindicated(maxcumulativedoseof1.2mgadministeredbypatientorprovider).

o Assessbloodpressurebeforeeachdose.

o ContraindicatedifSBP<100mmHgorMAP<65.

o ContraindicatedifuseofaPhosphodiesterase‐5(PDE5)inhibitorwithinlast48hours.


Ifnotalreadyinitiated,initiateCPAPifsymptomsaremoderate/severe:

o Moderate:

Moderatedyspnea,SpO2<92%onoxygen.SBPusuallygreaterthan150.Unabletospeakinfullsentences.Normalmentalstatus.

o Severe:

Severedyspnea,respiratoryfailure,hypoxia(SpO2<90%O2),diaphoresis,SBPcommonly>180mmHg.Onewordsentences,alteredlevelofconsciousness.

o RefertoClinicalProcedure:ContinuousPositiveAirwayPressure(CPAP).

Forpatientswithhypertensionandseveresymptoms:

o AdministerNitroglycerin0.4mgSL,reassessbloodpressurein5minutes.

Ifpatientremainshypertensivewithmoderate/severesymptoms,administerNitroglycerin0.8mgSL.

o ContinuewithNitroglycerin0.8mgSLevery5minutes.Reassessbloodpressurebeforeeachadministration.Thegoalistoachievea20%reductioninSBP.

ContraindicatedifSBP<100mmHgorMAP<65.

ContraindicatedifuseofaPhosphodiesterase‐5(PDE5)inhibitorwithinlast48hours.

Inthesettingofseverepulmonaryedema,CPAPisthepreferredtreatment.

Itisnotrequiredtogiveadditionalnitroglycerinoraspirin.


Respiratory Emergencies: Pulmonary Edema


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AdministerAspirin324mgPOifnotalreadyadministered.

Ifhypertensive(SBP>150mmHg)afterCPAPand/ornitrates:

o ConsiderMorphineSulfate.05‐0.1mg/kgIV(maxdose5mg),repeatevery5minutesforpersistentseverehypertension(maxcumulativedose15mg).

UsecautionandtitratewhenusedinconjunctionwithCPAPandnitroglycerin.

Ifhypotensive(SBP<90mmHgorMAP<65):

o Consider250mlIVNSbolusatawideopenrateuntilSBP≥90mmHgorMAP≥65,repeatonceifindicated.

ReassessbreathsoundspriortosecondNSbolusadministration.Donotadministeradditionalfluidsifprogressivedeterioration.

o ConsiderDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

ForwheezingassociatedwithAcutePulmonaryEdema:

o AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated(maxcumulativeAlbuteroldose15mg).

AtroventisonlycontraindicatedinthesettingofknownallergytoAtroventorAtropine

RefertoRespiratoryEmergencies:RespiratoryFailureifindicated.

ContactOLMCforanyadditionalordersorquestions.Medical Control

Respiratory Emergencies: Submersion Injury


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Protectfromheatloss.

Patientsmaydevelopdelayedonsetrespiratorysymptoms:

o Encouragetransportforevaluation.

o ConsiderCPAPforpatientswithsignificantdyspneaorhypoxia.

RefertoClinicalProcedure:ContinuousPositiveAirwayPressure(CPAP)ifindicated.


Respiratory Emergencies: Respiratory Failure


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Ifsignsofairwayobstruction,refertoClinicalProcedure:ObstructedAirway.

RefertoClinicalProcedure:ContinuousPositiveAirwayPressure(CPAP)ifindicated.


Observeforsignsofimpendingrespiratoryfailure:






Suctionalldebris/secretionsandremoveanyvisibleforeignbodyfromairway.

Performbasicairwaymaneuvers:

o Openairway,insertNPA/OPAanduseBVMifneeded.

Ventilateonceevery6seconds(10times/minute).

IfpatientdoesnotrespondtoabovemeasuresordeterioratesconsiderventilationsviaLTA.

o RefertoClinicalProcedureLaryngealTubeAirway(KINGLTS‐D).

FollowingplacementofLTAconfirmproperplacement.

o RefertoClinicalProcedure:ConfirmationofPlacement/EffectivenessofVentilation.

Asconditionallows,obtain12‐leadECG.


IfLTAalreadyinplace,confirmproperplacement.

o RefertoClinicalProcedure:ConfirmationofPlacementandEffectivenessofVentilation.

FollowAirwayEmergenciesAlgorithmonnextpageifinvasiveairwayinterventionisneededLTA/ETTinthesettingofanabsentgagreflex.

RefertoClinicalProcedure:OrotrachealIntubationifindicated.

o RefertoClinicalProcedure:ConfirmationofPlacementandEffectivenessofVentilation.



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AssessABCs,RR,effort,andadequacy

Adequate Inadequate

Administersupplemental100%

O2.

(+)GagReflex?

CPAP/BVM

OpenairwayandinsertNPA/OPA,BVM,withgoaltokeepO2saturations>92%ifpossible1.

(–)GagReflex?

LaryngealTubeAirway2(KINGLT‐SD)

Only2attempts**formedical.Only1attempt**fortrauma.

EndotrachealIntubationOnly2attempts**formedical.Only1attempt**fortrauma.

ConfirmwithETCO2

andexam

Successful Unsuccessful

Continueventilation2andmonitoring.

ResumeBVM1withadjunctsasneeded4.

Asalastresort,ifunabletoventilatebyanyothermeans,consider

cricothyrotomy3.

1. At any step of the airway algorithm, effective BVM venitlation is an acceptable level of airway management.2. Components of effective ventilation include oxygenation, chest rise and fall, adequate lung sounds and the presence of an alveolar waveform on capnograophy. 3. Attempt cricothyrotomy only after all other ventilation method have failed.4. If patient condition allows, another ALS provider may attempt a non‐visualized airway prior to performing a surgical airway.

**Attempt DefinedAn attempt is the

introduction of the tip of the laryngoscope blade or LTA past the

teeth.

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Respiratory Emergencies: Failed Airway


Apatientwithafailedairwayisonewhoisneardeathordying,notstable,ornotimproving.Afailed

airwayoccurswhenaproviderbeginsacourseofairwaymanagementandidentifiesthatitwillnot

besuccessful.

Conditionswhichdefineafailedairway:

FailuretomaintainadequateSpO2after2ormorefailedintubationattempts.

AND

Inabilitytosuccessfullyoxygenate/ventilateviaLTA,inapatientwhorequiresan

advancedairwaytopreventdeath.

AND

UnabletomaintainadequateSpO2(>90%)withBVMtechniquesbymostexperienced

provideronsceneandinsufficienttimetoattemptalternativemaneuvers.

ManagingairwaywithBLStechniques:

Patientswhocannotbeintubated,orwhodonothaveanSpO2>90%,donot

necessarilyhaveafailedairway.

o PatientsmaybesustainedbyBVMand/orbasicairwayadjuncts(e.g.,OPA,NPA,

LTA).Ifeffective,itisacceptabletocontinuewithbasicairwaymeasuresand

continuousmonitoringofSpO2andETCO2.

o Basedonpathophysiologicconditionwithotherwisereassuringvitalsigns,itis

acceptabletocontinuewithbasicairwaymeasures.

Wheninafailedairwayscenario,immediatetransporttothenearestemergencydepartmentand

notificationofOLMCisrequired.

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GeneralPatientCareProtocol—Adult.

IfventilationisineffectivewithsinglepersonBVM,placeanOPAand/orNPAandbegintwo‐personBVM.

Ifventilationisineffectivewithtwo‐personBVMandpatienthasnogagreflex,attempttoplaceLTA.

o RefertoClinicalProcedure:LaryngealTubeAirway(KINGLTS‐D).

Respiratory Emergencies: Failed Airway


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FailedIntubation:

o AttemptventilationwithBVMandOPAand/orNPA.

Ventilationacceptable:

ContinuewithBVMandinitiaterapidtransport.

ContinuouslymonitorSpO2,ETCO2,andECG.

ConsidersecuringairwaywithanLTA.RefertoClinicalProcedure:LaryngealTubeAirway(KING

LTS‐D).

Iftimepermits,contactOLMCforcricothyrotomy. ContactOLMCforanyadditionalordersorquestions.

Paramedic Only

Cannotintubateoroxygenate/ventilatebyanyothermeans:

o PerformCricothyrotomy.

RefertoClinicalProcedure:Cricothyrotomy.

Ifintheparamedics’judgement,thetimenecessarytocontactOLMCwillcompromisethepatient’schanceofsurvivalanditisnotpossibletoventilatethepatientbyANYOTHERMEANSduringtransport,cricothyrotomymaybeperformedwithoutOLMC.

Cardiac Arrest: General Approach


Successfulresuscitationrequiresplanningandclearroledefinition.

Good,fast(100‐120),hardanddeep(2‐2.4”)compressionswithadequaterecoilandminimalinterruptionsareessentialtoasuccessfulresuscitation.Ametronomeshallbeutilizedtoaidinmaintainingacorrectcompressionrate.

Compressorsshouldberotatedevery2minutes.

ApplytheAED/Monitorasquicklyaspossibletodefibrillateshockablerhythms.

Alldefibrillationswillbeat360J.

IntheeventapatientsufferscardiacarrestinthepresenceofEMS(EMSwitnessedCardiacArrest),theabsolutehighestpriorityistoapplytheAED/Defibrillatorwhilecompressionsareongoinganddeliverashockimmediatelyifindicated.

Managementofairwayandbreathingisimportantbutsecondarytocompressionsanddefibrillation.

Reassessairwaypatencyfrequentlyandwitheverypatientmove.

DONOTINTERRUPTCHESTCOMPRESSIONS!

Designatea“CodeManager”tocoordinatetransitions,defibrillationandpharmacologicalinterventions.The“CodeManager”shouldtypicallynothaveanyproceduraltasks.Ifthe“CodeManager”isneededforaspecifictask,anewleadermustbedesignated.

Typicallycardiacarrestshouldbeworkedinthefielduntil:

o ROSCisobtained.

o CriteriaforTerminationofResuscitationaremet,refertoClinicalProcedure:TerminationofResuscitation.

o ExclusioncriteriaforTerminationofResuscitationaremet,refertoClinicalProcedure:TerminationofResuscitation.

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RefertoClinicalProcedure:HighPerformanceCPR.

Checkresponsiveness,breathing,andforacarotidpulse.

Announce“CPRinprogress”toincomingunitsandcommunications.

Considerneedforresuscitation:

o PresenceofDNR/POST.

o DOA/WithholdingResuscitationcriteria.

Ifadequatebystandercompressionsongoing,havebystandercontinuecompressionsuntilmonitorpadsareinplaceandthemonitorischarged.Stopcompressionsforrhythmanalysisfornomorethan10seconds.

Ifcompressionsarenotbeingperformeduponarrivalorifcompressionsarenotdeemedadequate,immediatelyperformcompressionsatarateof100‐120compressionsperminutewhileapplyingdefibrillator.

Cardiac Arrest: General Approach


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Afteranalysisand(possible)defibrillation,immediatelyresumechestcompressionswithadifferentcompressor.Donotpauseforpost‐shockrhythmanalysis.Stopcompressionsonlyforsignsoflife(patientmovement)orpre‐defibrillationrhythmanalysisevery2minutes.AgonalrespirationsareabrainstemreflexandNOTanindicationtostopcompressions.

Asresourcesallowmaintainadequateairwayandventilations.

o UseBLSadjunctsandsuctionasnecessary.

o Inatworespondersituation,insertanOPAandadministerpassiveoxygenationviaNRB.

o Onceadequateresourcesareavailable,initiate10:1BVMventilation.

o Establishadvancedairwayifindicated.

Donotpausecompressionstoinsertadvancedairway.

Donotpausecompressionstoventilate.



Refertorhythmappropriateprotocol.

Establishvascularaccess.

Ifpatientregainsapulse,reassessvitalsigns,maintainpatientairway,supportrespirationsandrefertoCardiacArrest:PostResuscitationCare.

RefertoClinicalProcedure:TerminationofResuscitationifindicated.


Cardiac Arrest: Asystole/PEA


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CardiacArrest:GeneralApproach.

ClinicalProcedure:HighPerformanceCPR.

WhenAsystoleisseenonthecardiacmonitor,confirmationoftherhythmshallincludeaprinted

rhythmstrip.LowamplitudeV‐FiborPEAmaybedifficulttodistinguishfromasystolewhenusing

onlythecardiacmonitorforinterpretation.


Considerandtreatpossiblecauses.

AdministerEpinephrine(0.1mg/ml)1mgIV/IOevery3‐5minutesduringarrest.

Donotdiscontinuecompressionsunlessthereisadefinitivepulse.

Suspectedhyperkalemia(dialysispatient):

o AdministerCalciumChloride1gIV/IO.

ContraindicatedinpatientsonDigoxin/Lanoxin.

o AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq),mayrepeatoncein10minutes.

SodiumBicarbonateandCalciumChlorideshallnotbeadministeredinthesameline.Ifsecondlineunavailable,ensurelineisadequatelyflushed.

PotentialCausesofPEA Treatment

Hypovolemia NormalSaline1‐2litersIV/IO

Hypoxia Secureairwayandventilate

HydrogenIon(acidosis) SodiumBicarbonate1mEq/kgIV/IO

Hyperkalemia(endstagerenaldisease) SodiumBicarbonate1mEq/kgIV/IO

CalciumChloride1gIV/IO

Hypothermia Activerewarming

Tablets(drugoverdose) Seebelow

Tamponade,Cardiac NormalSaline1‐2litersIV/IO

Expeditetransport

Tensionpneumothorax Needlethoracostomy

Cardiac Arrest: Asystole/PEA


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Suspectedoverdose:

o BetaBlockerOD:

AdministerGlucagon3mgIV/IOslowpush.

o CalciumChannelBlockerOD:

AdministerCalciumChloride1gIV/IO.

o TricyclicantidepressantOD:

AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq),mayrepeatoncein10minutes.

Ifnoresponsetoresuscitativeeffortsafteratleast30minutes(includingatleast3roundsofmedications)considerdiscontinuationofeffortsperClinicalProcedure:TerminationofResuscitation.


Cardiac Arrest: V-Fib/Pulseless V-Tach


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RefertoCardiacArrest:GeneralApproach.

RefertoAdministrativeProcedure:HighPerformanceCPR.


Applytherapypads,printstrip,andpre‐chargeto360J.

ConfirmthepresenceofV‐Fib/PulselessV‐Tach.

Initiate/continuecompressionswhiledefibrillatorcharges.

DefibrillateV‐Fib/PulselessV‐Tachat360J.

o ImmediatelyresumeCPRaftershock(donotstoptocheckpulse).

Usingthemostreadilyavailableroute:

o Administer(duringCPR)Epinephrine(0.1mg/ml)1mgIV/IOevery3‐5minutesduringarrest.

Analyzerhythmafter2minutesofhighqualityCPR:

o IfV‐Fib/PulselessV‐Tachpersistsdefibrillateat360J.

Continuecompressionswhiledefibrillatorcharges.

ImmediatelyresumeCPRaftershock.


o Administer(duringCPR)Amiodarone300mgbolusIV/IO.

ForpersistentV‐Fib/PulselessV‐Tach,mayrepeatoncein3‐5minutes,Amiodarone150mgIV/IO(maxcumulativedose450mg).

o Suspectedtorsadesdepointesorhypomagnesemicstate(chronicalcoholuseordiureticuse).

AdministerMagnesiumSulfate2gIV/IO.


o IfV‐Fib/PulselessV‐Tachpersistsdefibrillateat360J.



Continuecycle(Defibrillate→CPR→Medication→Analyzeevery2min).

Hyperkalemiasuspected(dialysispatient):


ContraindicatedinpatientonDigoxin/Lanoxin.

o AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq),mayrepeatoncein10minutes.

Cardiac Arrest: V-Fib/Pulseless V-Tach


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Suspectedoverdose:

o TricyclicantidepressantOD:

AdministerSodiumBicarbonate1mEq/kgIV/IO,(maxdose50mEq),may

repeatoncein10minutes.

Cardiac Arrest: Post Resuscitation Care


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Maintainassistedventilationasneeded.

o MonitorETCO2,goalis40,DONOTHYPERVENTILATE!

TitrateO2tomaintainSpO2of92%‐99%.

Obtainandtransmit12‐leadECGwithin5minutesofROSC.



MonitorETCO2,goalis40mmHg,DONOTHYPERVENTILATE!

Forhypotension(SBP<90mmHgorMAP<65)notimprovedbyfluidboluses,orwhenfluidadministrationiscontraindicated:

o AdministerDopamineinfusionat5mcg/kg/mintitrateupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

IfV‐Fib/V‐TachoccurredduringarrestandAmiodaronewasadministered:

o Noadditionalanti‐arrhythmicisrequiredunlessarrhythmiareoccurs.

IfV‐Fib/V‐TachoccurredduringarrestandnoAmiodaronewasadministered:

o AdministerAmiodarone150mgdilutedin100mlNSIV/IOpiggybackover10minutes.

Ifarrestisthoughttobesecondarytoopiateoverdoseconsider:

o Naloxone0.4mgIV/IOtitratedtorespiratoryrateupto4mgIV/IO.

Considersedationifpatientbecomescombative:

o AdministerFentanyl1mcg/kgIV/IO(maxdose50mcg),repeatevery5minutesifindicated(maxcumulativedose200mcg).

o AdministerMidazolam2.5mgIV/IO,repeatin5minutesifindicatedandmonitorforhypotension(maxcumulativedose5mg).

Suspectedhyperkalemia(dialysispatient):



o AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq).


o AdministerAlbuterol5mgviaNeb.

ContactOLMCforadditionalsedation. ContactOLMCforanyadditionalordersorquestions.

Cardiac Emergencies: Acute Coronary Syndrome


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All Providers GeneralPatientCareProtocol–Adult.

Obtainandtransmit12‐leadECGwithin5minutesofarrivalatpatient.

Theroutineuseofoxygenisnotindicated.OxygenisindicatedifSp02is≤92%orifthereisevidenceofrespiratorydistress.

AdministerAspirin324mgPOchewedifpatientisabletoswallow.

ConsiderNitroglycerin0.4mgSL,repeatevery5minutesforcontinuedchestpain(maxcumulativedose1.2mgprovidedbyeitherpatientorprovider).


o ContraindicatedifSBP<100mmHgorMAP<65orifaSBPdrop≥30mmHg.



Patient Care Goals: 5/5/10/2

At patient to 12‐Lead ECG < 5 minutes

STEMI identification to Emergency Department notification < 5 minutes

STEMI identification to transport < 10 minutes

Providers during transport ‐ 2


Obtain12‐leadECGwithin5minutesofarrivalatpatient.

IdentifythepresenceofECGchangessuggestiveofAcuteMyocardialInfarct(AMI).

o Pre‐alertreceivinghospitalasperAdministrativeProcedure:CodeSTEMI.

o InferiorwallMI’smaybeassociatedwithrightventricularinvolvement.ConsiderrightsidedtracingperClinicalProcedure:RightSidedECG.

o IfconcernforPosteriorMIandpatientcondition/timepermits,consider15‐leadECGpriortotransportperClinicalProcedure:15‐LeadECG.

ConsiderNitroglycerin0.4mgSLrepeatevery5minutesforcontinuedchestpain.


o ContraindicatedifSBP<100mmHgorMAP<65.


o UsewithcautioninAcuteInferiorWallMI,orRightVentricularinfarct(STelevationinrightsidedtracing).

IVaccessisrecommendedpriortoadministrationofnitroglycerinininferiororrightventricularinfarctsasthepatientispreloaddependent.

Cardiac Emergencies: Acute Coronary Syndrome


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Medical Control


23

Usecautionwithadditionaladministrationifsignificantdropinbloodpressureafteradministration(≥30mmHgSBP).

Ifhypotensiondevelops,administer250mlIVNSbolusatwideopenrateuntiluntilSBP≥90mmHgorMAP≥65(maxcumulativedose2L).Contraindicatedifevidenceofdecompensatedcongestiveheartfailure

(e.g.,rales). AdministerFentanyl1mcg/kgslowIV(maxdose50mcg),repeatevery5minutesif

indicated(maxcumulativedose200mcg).

o IfFentanylallergy:

AdministerMorphineSulfate0.1mg/kgslowIV(maxdose5mg),repeatevery5minutesifindicated(maxcumulativedose15mg).

OpiatesarecontraindicatedifSBP<90mmHgorMAP<65.

UsewithcautioninrightventricularorposteriorwallMI(STelevationinposteriorleadswithmarkeddepressioninV1‐V3).

RunsofVentricularTachycardia(≥6consecutivebeats):

o RefertoCardiacEmergencies:Wide‐ComplexTachycardia.

Cardiac Emergencies: Bradycardia


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Medical Control




Donotdelaytreatmentifpatientisunstable,byobtaininga12‐leadECG,unlessdiagnosisisinquestion.

Stablewithmildsymptoms:

o Providesupportivecareandexpeditetransport(PatientscanoftentolerateHRmuchlessthanthetextbookrateof60BPM).

UnstablewithseveresymptomsandSBP<90mmHgorMAP<65:

o AdministerAtropine0.5mgIV,repeatevery3‐5minutesifindicated(maxcumulativedose3mg).

UsecautioninthesettingofseconddegreeTypeII/3rddegreeblocks.

o IfsymptomspersistafterAtropineoranydelayinestablishingIV:

Considersedationifpatientconditionandtimeallows.

AdministerFentanyl1mcg/kgIV/IO(maxdose50mcg),repeatevery5minutesifindicated(maxcumulativedose200mcg).

AdministerMidazolam2.5mgIV/IO,repeatin5minutesifindicatedandmonitorforhypotension(maxcumulativedose5mg).

InitiatetranscutaneouspacingperClinicalProcedure:ExternalCardiacPacing.

o Forhypotension(SBP<90mmHgorMAP<65)notimprovedbyabove:

ConsiderDopamineinfusionat5mcg/kg/mintitratedto20mcg/kg/mininordertomaintainSBP≥90mmHg,MAP≥65.

o Ifdruginduced,treatforperapplicabledrugoverdoseprotocol.

Mild Symptoms: Chest Pain, Shortness of Breath, or Lightheadedness.

Severe Symptoms: Acute Altered Mental Status, Hypotension (SBP < 90 mmHg or MAP < 65), Ischemic Chest Discomfort, Acute Heart Failure, or Other Signs of Shock.

ContactOLMCforEpinephrineinfusionat2mcg/mintitratedupto10mcg/mintomaintainSBP≥90mmHgorMAP≥65.

o Mix2mg(1mg/ml)in500mlNS.


Cardiac Emergencies: Regular Narrow Complex Tachycardia (SVT)


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eg

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r Na

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Co

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lex T

ac

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ia (S

VT

)

All Providers

Medical Control




Severe Symptoms: Acute Altered Mental Status, Hypotension (SBP < 90 mmHg or MAP < 65), Ischemic Chest Discomfort, Acute Heart Failure, or Other Signs of Shock.


Stablewithmildsymptomsandventricularrate>150:

o Vagalmaneuvers(e.g.,valsalva,cough).

o AdministerAdenosine6mgrapidIVPover1‐3secondswith20mlNSflush.

Ifnoresponsein2minutes:

AdministerAdenosine12mgrapidIVPover1‐3secondswith20mlNSflush.

RecordtheECGduringAdenosineadministrationandassessunderlyingrhythm.

o Ifatrialfibrillationsuspected,refertoCardiacEmergencies:IrregularNarrowComplexTachycardia(A‐Fib).

Unstablewithseveresymptomsandventricularrate>150:

o ConsiderAdenosine6mgrapidIVP(ifnotalreadygiven)over1‐3secondswith20mlNSflush,whilesettingupforcardioversion.

o Considersedationifpatientconditionandtimeallows.



o RefertoClinicalProcedure:SynchronizedCardioversion.

SynchronizedCardioversionEnergySettings

Firstenergylevel: 200Joules

Ifnoresponse: 300Joules


ContactOLMCforAmiodarone150mgdilutedin100mlNSIVPiggybackover10minutes.


25

Cardiac Emergencies: Irregular Narrow Complex Tachycardia (A-Fib)


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gu

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om

ple

x Ta

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yca

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(A-F

ib)

All Providers

Medical Control




Severe Symptoms: Acute Altered Mental Status, Hypotension (SBP < 90mmHg or MAP < 65), Ischemic Chest Discomfort, Acute Heart Failure, or Other Signs of Shock.


Stablewithmildsymptomsandnoevidenceofrapidventricularrate(typicallysustainedHR<150):

o Providesupportivecareandexpeditetransport.

Stablewithmildsymptoms,SBP≥90mmHgorMAP≥65,andrapidventricularrate(typicallysustainedHR>150).

o NohistoryofWolff‐Parkinson‐White(WPW):

ConsiderMetoprolol5mgIV/IOover1‐2minutes,repeatevery5minutesifindicated(maxcumulativedose15mg).

o HistoryofWPW:

BetablockersandAmiodaronearecontraindicated.ContactOLMCandexpeditetransport.

UnstablewithseveresymptomsandSBP<90mmHgorMAP<65:

o Atrialfibrillationorflutterwitharapidventricularrate(typicallysustainedHR>150beats)andseveresymptomsattributedtothetachycardia.










Cardiac Emergencies: Wide Complex Tachycardia


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Advanced Life Support FullALSAssessmentandTreatment.


Ingeneral,assumeunknownwidecomplextachycardia(QRS≥0.12),atratesover150representventriculartachycardia.

V‐Tachisdefinedas6consecutivePVC’s.

Stablewithmildsymptoms,SBP≥90mmHgorMAP≥65,andunknownwidecomplexorventriculartachycardialikely(typicallysustainedHR>150BPM):

o AdministerAmiodarone150mgdilutedin100mlNSIVPiggybackover10minutes.

UnstablewithseveresymptomsandunknownwidecomplexorV‐Tachlikely(typicallysustainedHR>150BPM):









o Ifdelaysinsynchronizationoccurandconditioniscritical,goimmediatelytounsynchronizedshocks.

o Ifwidecomplextachycardiareoccursfollowingelectricalcardioversion:

AdministerAmiodarone150mgdilutedin100mlNSIVPiggybackover10minutes,mayrepeatonce.

o Suspectedhyperkalemia(dialysispatient):




Severe Symptoms: Acute Altered Mental Status, Hypotension (SBP <90 mmHg or MAP <65), Ischemic Chest Discomfort, Acute Heart Failure, or Other Signs of Shock.

Cardiac Emergencies: Wide Complex Tachycardia


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Medical Control

AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq).

SodiumBicarbonateandCalciumChlorideshallnotbeadministeredinthesameline.Ifsecondlineunavailable,ensurelineisflushedadequately.

AdministerAlbuterol5mgviaNeb.


Cardiac Emergencies: Polymorphous V-Tach (Torsades de Pointes)


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(To

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All Providers

Medical Control





Stablewithmildsymptoms,SBP≥90mmHgorMAP≥65,andunknownwidecomplexorV‐Tachlikely(typicallysustainedHR>150BPM):

o AdministerMagnesiumSulfate2gdilutedin10mlNS,IVover2minutes.

Ifnoresponse:

AdministerAmiodarone150mgdilutedin100mlNSIVPiggybackover10minutes.

UnstablewithseveresymptomsandunknownwidecomplexorV‐Tachlikely(typicallysustainedHR>150BPM):




o Defibrillateat360J.



Severe Symptoms: Acute Altered Mental Status, Hypotension (SBP <90 mmHg or MAP <65), Ischemic Chest Discomfort, Acute Heart Failure, or Other Signs of Shock.

Environmental Emergencies: Bites and Envenomation


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nve

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tion

All Providers

Medical Control


Irrigate/cleansewoundwithNS(removeanylargedebris).

Removestingerifappropriateandeasilyremovable.

Markedematousareawithpenandnotetime.

Immobilizeaffectedpartandremovedistaljewelry.

Donotinciseandsuctionbitesite.

Donotapplytourniquet.

AttempttoidentifywhatcausedbiteandbringtoEmergencyDepartmentifdead(usecautionwhenhandlingdeadsnakesasenvenomationhasoccurredsecondarytoreflexmotormovement).




Forhypotension(SBP<90mmHgorMAP<65),thoughttobesecondarytoenvenomationandnotimprovedwithfluidbolusesupto2L,NSorwhenfluidbolusesarecontraindicatedduetoevidenceofdecompensatedcongestiveheartfailure(e.g.,rales).

o AdministerDopamineinfusionat5mcg/kg/mintitratedto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

RefertoMedical:AllergicReactionifindicated.

Transporttoclosestappropriatefacility.

Environmental Emergencies: Hyperthermia


En

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s: Hyp

erth

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ia

All Providers

Medical Control




Movepatienttocoolerenvironment.

HeatCramps(Painfulspasmsoftheextremitiesorabdominalmuscles,normalmentalstatusandvitalsigns):

o Oralfluidsiftolerated.

o Spritzwithcoolwater.

HeatExhaustion(Dizziness,light‐headedness,headache,irritability,normalorslightlydecreasedLOC,normalordecreasedbloodpressure[hypovolemia],tachycardia,normalorslightlyelevatedtemperature):

o Removeclothing.

o Spritzwithcoolwaterandfan.

HeatStroke(MarkedalterationinLOC,extremelyhightemperature[often>104°F]maybesweatingorhavered/hot/dryskin):

o Semi‐recliningwithheadelevated15°‐30°.

o Rapidcooling(preventshiveringasitincreasesbodytemperature).

o Coldpacks(backofneck,groin,axillary),spritzwithcoolwater,fan.

Ifthereisconcernforheatexhaustionorheatstroke,performFullALSAssessmentandTreatment.

ConsiderNS:

o Ifevidenceofdehydration(tachycardia,drymucousmembranes,poorskinturgor)orhypovolemia,administerNSat250ml,repeatonceifindicated.

Consider250mlIVNSbolusatawideopenrateuntilSBP≥90mmHgorMAP≥65(maxcumulativedose2L).


Hyperthermiamayresultinmultipleetiologiesincludingcocaine,exciteddelirium,orsympathomimetictoxicity.

Environmental Emergencies: Hypothermia


En

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oth

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All Providers

Medical Control


Removewetclothing.

Measuretemperature.If<90°F,handlegently.

Movepatienttoawarmenvironmentandprovidewarmblankets.

Checkpulsefor30‐45secondstodifferentiatecardiacarrestfromprofoundbradycardia.




Ifavailable,administerwarmedNS.

o Contraindicatedifevidenceofdecompensatedcongestiveheartfailure(e.g.,rales).

Ifcardiacarrestoccurswithatemp≤90°F:

o RefertoCardiacArrest:GeneralApproach.

o AdministeroneroundofEpinephrine(0.1mg/ml)1mgIV/IO.

o Ifdefibrillationisnecessary,limittooneshock.

o ContinueCPR.

Hazardous Materials Exposures: General Approach


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ConsultOn‐DutyHAZMATTECHbeforeattemptingtohandleanytoxicchemicalexposurepatient.

ContacttheRegionalPoisonControlCenter(1‐800‐222‐1222)uponidentifyingapossibletoxic

exposureoroverdose.ConsidercontactingCHEMTREC(1‐800‐424‐9300)forassistance.


Stoptheburningprocess.

Removeallclothingpriortoirrigation.

Ifacausticliquidisinvolved,flushwithcopiousamountsofwater.

Forchemicalburnswitheyeinvolvement:

o RefertoTrauma:EyeInjuries.

Ifadrychemicalisinvolved,brushitoff,thenflushwithcopiousamountofwater.

Elementalmetals(sodium,potassium,lithium):

o Removeobviousmetallicfragmentsfromtheskin.

o Covertheburnwithmineraloilorcookingoil.

Ifneitherareavailable,flushthematerialwithcopiousamountsofwater.

Phenols(carbolicacid,hydroxybenzene,phenylalcohol)penetratetheskinmorereadilywhendilutedwithwater.

o Ifavailable,dilutewiththefollowing(listedinorderofefficacy):

Polyethyleneglycol(PEG).

Glycerol.

VegetableOil.

Asalastresortuseextremelylargeamountsofsoapandwaterwithcontinuousirrigationuntilallphenolsareremoved.

Applyaburnsheetordrysteriledressingtoburnareas.

Forinhaledtoxinwithacutebronchospasm:

o AdministerAlbuterol2.5mgvianebulizer.


Forinhaledtoxinwithacutebronchospasm:

o AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgmlvianebulizer,repeatoncein5minutesifindicated.

AtroventisonlycontraindicatedinthesettingofknownallergytoAtroventorAtropine

Hazardous Materials Exposures: General Approach


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Medical Control

Forpersistentburningsensationoftheairways(afterAlbuterol/Atroventadministration)inthesettingofChlorine/Chloramineexposure:

o Administer4.2%SodiumBicarbonate5mlviaNebulizer.

Mix2.5mlof8.4%SodiumBicarbonatewith2.5mlofNS.


o Ifwheezingpersists:

AdministerAlbuterol2.5mgvianebulizer,repeatevery5minutesifindicated(maxcumulativedose15mg).

Observeforsignsofimpendingrespiratoryfailure.RefertoRespiratoryEmergencies:RespiratoryFailureifindicated.

RefertoPainManagement:Medcial/TraumaProtocolifindicated.

34

Hazardous Materials Exposure: Cyanide Toxicity and Smoke Inhalation


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To

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Sm

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Inh

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All Providers


Supplemental100%O2.

Considerpatientdecontamination.

Cyanidepoisoningmayresultfrominhalation,ingestionordermalexposuretocyanidecontaining

compounds,includingsmokefromclosed‐spacefires.Thepresenceandextentofthepoisoningare

oftenunknowninitially.Treatmentdecisionsmustbemadeonthebasisofclinicalhistoryandsigns

andsymptomsofcyanideintoxication.

Notallpatientswhohavesufferedsmokeinhalationfromaclosed‐spacefirewillhavecyanide

poisoning.Otherconditionssuchasburns,trauma,orothertoxicinhalations(e.g.,carbonmonoxide)

maybethecauseofsymptoms.Whensmokeinhalationisthesuspectedsourceofcyanideexposure

assessthepatientforthefollowing:

Exposuretofireorsmokeinanenclosedspace.

Presenceofsootaroundthemouth,noseororopharynx.

Alteredmentalstatus.

CommonSignsandSymptomsofCyanideToxicity


EvaluatethepatientfortheclinicalsuspicionofCyanidepoisoning:

o Known/suspectedingestion,inhalation,orexposuretocyanideproduct.

OR

o Historyofbeingexposedtodensesmokeinaconfinedspaceorthepresenceoforopharyngealsootorcarbonaceousexpectorations.

Symptoms Signs

Headache Alteredmentalstatus

Confusion Seizuresorcoma

Shortnessofbreath Dyspnea/Tachypnea

ChestPainortightness Respiratorydistress/Apnea

Nausea/Vomiting Hypertension(early)

Hypotension(late)

Cardiovascularcollapse/Cardiacarrest

Hazardous Materials Exposure: Cyanide Toxicity and Smoke Inhalation


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Medical Control


IfclinicalsuspicionofCyanidepoisoningishighANDthepatientpresentswithalteredmentalstatus,seizures,moderate/severerespiratorydistress,unexplainedhypotension,orcardiacarrest,administer:

o Hydroxocobalamin(Cyanokit®)5gIV/IOover15minutes.

UseNSasthediluentforCyanokit®aspermanufacturerinstructions.

Requiresdedicatedvenousaccessasitisincompatiblewithnumerousmedications.

Contraindicatedinpatientswithknownanaphylacticreactionstohydroxocobalaminorcyanocobalamin.

Mayrepeatonceifpatientisnotresponsivetotreatment.

o Expeditetransportandtreatotherconditionsasperappropriateprotocol.

o RefertoRespiratoryEmergencies:RespiratoryFailureifindicated.

Hazardous Materials Exposure: Nerve Agent/WMD


Ha

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erve

Ag

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D

All Providers


EnsurescenesafetyandproperPPE.

Considerneedforadditionalresources.

Obtainhistoryofexposure,observefortoxidromes.

Initiatetriage/decontamination.


REQUESTHAZMATRESPONSEANDALERTONLINEMEDICALCONTROL


Assessformildorseveresymptoms.

DuoDote™

DuoDote™KitscarriedonresponsevehiclesareprimarilyforRespondersONLY.Theusereferenced

belowimpliesthattheWMDstockpilehasbeenreleasedanddeliveredtothescene.

Ifpatientdevelops2ormoremildsymptoms,immediatelyadminister1DuoDote™IM.

o Ifin15minutesthepatientdevelopsANYseveresymptomsimmediatelyadminister2additionalDuoDote™IM.

Ifpatientdevelopsanyseveresymptoms,immediatelyadminister3DuoDote™IM.

o ConsiderAtropine2mgIV/IM/IOevery5minutesuntilsymptomsresolve.

o Ifthepatientdevelopsseizures,refertoMedical:Seizure.

MildSymptoms SevereSymptoms

Blurredvision Strangeorconfusedbehavior

Excessivetearyeyes/Runnynose Severedifficultybreathing

Increasedsalivation Copioussecretionsintheairway

Chesttightness Severemuscletwitching

Difficultybreathing Involuntaryurination/Defecation

Muscletremors Convulsions

Nausea/Vomiting Unconsciousness

Unexplainedwheezing/Coughing

Acuteonsetstomachcramps

Hazardous Materials Exposure: Nerve Agent/WMD


Ha

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Ag

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D

Medical Control


Medical: Abdominal Pain


Me

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All Providers

Medical Control


o Ifpainisabovetheumbilicus,perform12‐LeadECG.

o RefertoCardiacEmergencies:AcuteCoronarySyndromeifindicated.

Administernothingbymouthunlessindicatedbyprotocol.

Assessanddocumentpresenceofdistallowerextremitypulsesinpatients≥50yearsofage.




Performcontinuouscardiacmonitoring.

ConsiderPainManagement:Medical/Traumaifindicated.

Suspectedkidneystone:

o Administer250mlIVNSatawideopenrate.

Medical: Allergic Reaction


Me

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All Providers


Assistpatientinself‐administrationofpreviouslyprescribedepinephrineauto‐injector(e.g.,Epi‐Pen).

Ifwheezingpresent:

o AdministerAlbuterol2.5mgvianebulizer,repeatoncein5minutesifindicated.


Mild Reaction: Itching/Hives.

Moderate Reaction: Dyspnea, Wheezing, Chest Tightness.

Severe Systemic Reaction (Anaphylaxis): SBP < 90 mmHg, MAP < 65, Throat Complaints, Stridor, Severe Respiratory Distress, Gastrointestinal Symptoms (vomiting and abdominal pain)


MildReaction:

o AdministerDiphenhydramine1mg/kgIV/IM/IO(maxdose50mg).

ModerateorSevereSystemicReaction:

o AdministerEpinephrine(1mg/ml)0.3mgIMforrapidlyprogressiveworseningsymptoms.Repeatoncein5minutesifindicated.



o AdministerMethylprednisolone125mgIV/IM/IO.

o Consider250mlIVNSbolusatawideopenrateuntilSBP≥90mmHgorMAP≥65(maxcumulativedose2L).

Contraindicatedifevidenceofdecomensatedcongestiveheartfailure(e.g.,rales).

ImminentCardiopulmonaryArrest(e.g.,profoundbradycardiaorhypotensionwithsignsandsymptomsofsevereshockwithalteredmentalstatus):

o ConsiderEpinephrine(0.1mg/ml)0.5mgIV/IO.

o TreatperModerateorSevereSystemicReaction.

CardiacArrest:

o Refertotheappropriatecardiacarrestprotocol.

o Inthesettingofcardiacarrest,thefollowingitemsshouldbeperformedinthepost‐resuscitativephase,ifnotalreadycompleted,whentimeallows:

AdministerAlbuterol2.5mgvianebulizer,repeatevery5minutesifindicated(maxcumulativedose15mg).

AdministerDiphenhydramine1mg/kgIV/IM/IO(maxdose50mg).

AdministerMethylprednisolone125mgIV/IO.

Medical: Allergic Reaction


Me

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n

Medical Control

ContactOLMCforadditionalEpinephrine(1mg/ml)0.3mgIM.

ContactOLMCforEpinephrineinfusion2mcg/mintitratedupto10mcg/mintomaintainSBP≥90mmHgorMAP≥65.



Medical: Altered Mental Status/Syncope


Me

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All Providers

Medical Control


ObtainBGLandrefertoMedical:DiabeticEmergencies.

Obtain12‐LeadECG.

IfstrokesuspectedrefertoMedical:StrokeSuspected.

IfheadinjurysuspectedrefertoTrauma:HeadInjuries.

Ifseverelyagitatedand/orviolentrefertoMedical:BehavioralEmergencies/ExcitedDelirium.

Ifsepsissuspected(advancedage,highriskforinfection,febrile)refertoMedical:Sepsis.

Ifsuspectedpoisoning:

o RefertoOverdoseandPoisoning:GeneralApproach.




Ifcardiacarrhythmiapresent,refertotheappropriatecardiacemergenciesprotocol.

Medical: Behavioral Emergencies/Excited Delirium


Me

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eh

avio

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Ifneeded,applyphysicalrestraintstoensurepatient/crewsafety.ReferandadheretoAdministrativeProcedure:Restraintswhenthisprocessisdeemednecessary.

RefertoMedical:AlteredMentalStatus/Syncopeifindicated.

RefertoOverdoseandPoisoning:GeneralApproachifindicated.

Assessandtreatforhyperthermia,refertoEnvironmentalEmergency:Hyperthermia.


NEVERRESTRAINORTRANSPORTINPRONEPOSITION


Forpatientswithsevereagitationcompromisingpatient/crewsafety,orforpatientswhocontinuetostruggleagainstphysicalrestraints:

o Age≤65:

AdministerMidazolam5mgIV/IM/IN/IO,repeatin5minutesifindicated(maxcumulativedose10mg).

o Age>65:

AdministerMidazolam2.5mgIV/IM/IN/IO,mayrepeatin5minutesifindicated(maxcumulativedose5mg).

Ifevidenceoftachycardia,tachypnea,orhyperthermia:

o Consider250mlIVNSbolusatwideopenrate(maxcumulativedose2L).

Contraindicatedifevidenceofdecompensatedcongestedhearfailure(e.g.,rales).

Paramedic Only

IfconcernsforExcitedDeliriumarenotcontrolledwithMidazolamafter10minutes:

SignsandSymptomsofExcitedDelirium

Extremelyaggressiveorviolentbehavior Hottotouch

Doesnotrespondtopolicepresence Rapidbreathing

Naked/Inadequatelyclothed Profusesweating

Excessivestrength Seeminglyinsensitivetopain

Doesnotfatigue

Medical: Behavioral Emergencies/Excited Delirium


Medical Control

ContactOLMCforSodiumBicarbonate50mEqin1,000mlNSIVwideopen.

ContactOLMCforallrefusalsornon‐transports.


o ConsiderKetamine:

Ketamine3mg/kgIM.

OR

Ketamine1mg/kgIV.

Me

dic

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eh

avio

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xcite

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m

Medical: Diabetic Emergencies


Me

dic

al: D

iab

etic

Em

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en

cie

s

All Providers

Medical Control


Hypoglycemia(BGL<60mg/dL):

o ConsiderOralGlucoseGel15gorGlucosecontainingbeverage(e.g.,orangejuice).

Patientmustbealertandabletoself‐administer.




Determinebloodglucoseandtreat:

o Hypoglycemia(BGL<60mg/dL):

Administer100mlof10%Dextrose,titratetoimprovedmentalstatusandBGL,mayrepeatevery5minutes(maxcumulativedose250ml).

Ifhypoglycemiapersists,repeatbloodglucosecheckwithadifferentglucometer.

IfunabletoobtainIV/IOaccess:

AdministerOralGlucoseGel15gorglucosecontainingbeverage(e.g.,orangejuice).


Ifunabletoadministerglucosebymouth:

AdministerGlucagon1mgIM.

o Hyperglycemia(BGL>250mg/dL):

Ifevidenceofdehydration(tachycardia,drymucousmembranes,poorskinturgor)orhypovolemia,administerNSat250ml,repeatonceifindicated.

Consider250mlIVNSbolusatawideopenrateuntilSBP≥90mmHgorMAP≥65(maxcumulativedose2L).


RefertoAdministrativeProcedure:RefusalofTransportAfterTreatmentifindicated.

45

Medical: Seizure


Me

dic

al: S

eizu

re

All Providers

Medical Control


Protectpatientfrominjury.





Foractiveseizures:

o Age≤65:


o Age>65:

AdministerMidazolam2.5mgIV/IM/IN/IO,repeatin5minutesifindicated(maxcumulativedose5mg).

Forsuspectedhypoxicseizures,druginducedseizures,seizuresfromheadtrauma,stroke,oreclampsiasuspected:

o Treatasaboveandrefertoappropriateprotocol.

Medical: Sepsis


Me

dic

al: S

ep

sis

All Providers

Medical Control



Sepsisisarapidlyprogressinglife‐threateningcomplicationofsystemicinfection.Itoccurswhenan

inflammatoryresponsecalledSystemicInflammatoryResponseSyndrome(SIRS)istriggeredin

responsetoinfection.Sepsismustberecognizedandtreatedaggressivelytopreventprogressionto

shockanddeath.SepsiscanbeidentifiedwhenthefollowingSIRSmarkersarepresentinapatient

withsuspectedinfection.

Feverorhypothermia(>100.4For<96.8F).

Tachypnea(respiratoryrate>20).

Tachycardia(heartrate>90).

InadditiontophysiologicsignsofSIRS,severesepsismaycausehypoxiaandinadequateorgan

perfusion,resultinginmetabolicacidosismarkedbyelevatedserumlactatelevelsanddecreased

ETCO2(measuredbycapnography).



Notifyhospitalofa“CODESepsis”priortoarrivalperAdministrativeProcedure:CodeSepsis.

Administer1LNS:

o Reassessvitalsignsandrespiratorystatusaftereach500ml.

o Ifafter1LNS,SBP<90mmHgorMAP<65:

Administer2ndLNS.

Usecautioninpatientswith:CHFandESRD/Dialysis.

o TotalamountofNSshallnotexceed30ml/kg(maxcumulativedose2L).

IfSBP<90mmHgorMAP<65after2LNS:

o ConsiderDopamine5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

Medical: Stroke Suspected


Me

dic

al: S

troke

Su

spe

cte

d

All Providers

Medical Control


Identifyanddocumenttimethepatientwaslastseennormal.

o Utilizebystandersandfamilyifavailable.

Keepheadofstretcherat30°‐45°elevation(unlessclinicalconditionwillnotallow).

Ifspinalimmobilizationisindicated;elevateheadofbackboard15°‐30°.

CheckBGLperClinicalProcedure:BloodGlucoseAnalysis.

o RefertoMedical:DiabeticEmergenciesifindicated.

Givenothingbymouth.

PerformanddocumenttheCincinnatiPre‐HospitalStrokeScore.


Earlyrecognitionandtransportofstrokeisessentialtogoodpatientoutcomes.Anypatient

presentingwithanormalbloodglucose(>60mg/dL),apositiveCincinnatiPre‐HospitalStroke

Screen,andonsetofsymptoms(whenlastseennormal)lessthan8hoursshouldhaveearly

notificationofthestrokecenter(CodeStroke)andrapidtransport.


Patient Care Goals: 5/5/10/2

At patient to stroke assessment < 5 min

Positive stroke assessment to Emergency Department notification < 5 min

Positive stroke assessment to transport < 10 min

Providers during transport ‐ 2


DonotdelaytransporttoobtainIVaccess.

OB/GYN: Childbirth


OB

/GY

N: C

hild

birth

All Providers


Duringassessment,donotplaceanythinginsideofthebirthcanal.

Ifpresentingpartisnotthehead(e.g.,foot,arm,orbuttocks),immediatelybegintransportwhilefurthercarecontinues.

Non‐ComplicatedDelivery:

o Slow,controlleddeliveryofhead;applygentleperinealpressure.

o Observeformeconiumstaining.

Ifpresent,suctionoralpharynxandnoseassoonasheadisdelivered.

o Followingdelivery,refertoPediatricCardiacArrest:NeonatalResuscitationifindicated.

o Recorddeliverytime.

o Keepinfantatlevelofperineumuntilyouhavedoubleclampedthecord8‐10inchesfromthenewborn’sabdomen.

o Cutcordbetweenclamps.

o PerformAPGARassessmentat1and5minutespostdelivery.

APGARSCORINGCHART

Conditionsthatrequireimmediatetransporteveninthesettingofimminentdeliveryinclude:

prolongedruptureofmembranes,preeclampsia/eclampsia,breechpresentation,cordpresentation,

extremitypresentation,nuchalcord,andmeconiumstaining.

o Maintainbodytemperatureofthenewbornandthemother.

o Allowspontaneousdeliveryofplacenta;donotapplytractiontoumbilicalcordforplacentaldelivery.

Ifplacentaldeliveryoccurs,packageinbiohazardouswastebagandhandovertohospitalstaffuponarrival.

Sign Score0 Score 1 Score2

Appearance Pale/Blue Blueextremities Pink

Pulse Absent <100perminute >100perminute

Grimace Noresponse Grimace CoughorSneeze

Activity Flaccid Someflexion Wellflexed

Respiration Absent Weak Goodcry

OB/GYN: Childbirth


OB

/GY

N: C

hild

birth

SpecificDeliveryEmergencies:

o SeverePostpartumHemorrhage:

Controlexternalperinealbleedingbyapplyingdirectpressuretoanylacerations.

Performfundalmassage(ifplacentahasdelivered).

Encouragethemothertonursethenewborn(ifpossible).

o Breech/LimborAbnormalPresentation:

Transportinkneetochestposition,unlessdeliveryimminent.

Encouragemothertorefrainfrompushing.

Supportpresentingparts,donotpull.

Insertglovedfingersintovagina,elevatepressureoffofcordandtoassistinmaintainingairway.Maintainthisposition.

o ProlapsedCord:

Elevatemother’shipsandplaceinthekneetochestposition.

Encouragemothernottopush.

Evaluatefetalheartrate/cordpulsation.

Covercordwithmoiststeriledressing.

Donotattempttopushcordbackintovagina.

Emergenttransport.

o ShoulderDystocia:

Placemotherinknee‐chestpositionandreattemptdelivery.

Ifdeliveryfails,supportchild’sairway,providesupplementaloxygen.

Postpartum:

o Forneonate,refertoPediatricCardiacArrest:NeonatalResuscitationifindicated.

o Assessforpostpartumhemorrhage.

o Afterplacentadelivers,considergentleabdominalmassageoverlyingtheuterinefundusuntilfirm.


ConsiderIVaccess.

ConsiderPainManagement:Medical/Trauma.

Transporttonearestobstetricsreceivingfacility.

OB/GYN: Childbirth


OB

/GY

N: C

hild

birth

Medical Control


OB/GYN: Pre-Eclampsia/Eclampsia


OB

/GY

N: P

re-E

cla

mp

sia/E

cla

mp

sia

All Providers

Medical Control



Pregnancy‐inducedhypertension,pre‐eclampsia,andeclampsiaareconditionstypicallyencountered

inlate2ndor3rdtrimesterofpregnancy,andmayoccurupto6weekspostpartum.Clinical

manifestationsmayincludeelevatedbloodpressure(SBP>160mmHgorDiastolic>120mmHg),

headache,confusion,oragitation.

ContactOLMCforpatients<20weeksgestation.



<20weeksgestation:

o Donotinitiatepharmacologicalintervention.ContactOLMC.

≥20weeksgestation:

o Pre‐Eclampsia(SystolicBP>160mmHgorDiastolic>120mmHgontwoconsecutivereadings):

AdministerMagnesiumSulfate4gdilutedin100mlNSIVover10minutes.

o Eclampsia:



**DONOTDELAYMIDAZOLAMADMINISTRATIONTOESTABLISHIVACCESS**

UnlessIValreadyestablished,administerIM/INandthenobtainIVaccess.

OB/GYN: Vaginal Bleeding


OB

/GY

N: V

ag

ina

l Ble

ed

in

All Providers

Medical Control


1stor2ndtrimesterbleedingorunknownpregnancystatus:

o Placethepatientinapositionofcomfort,considerlateralrecumbentposition.

3rdtrimesterbleeding(>26weeks):

o Iftolerated,placepatientinleftlateralrecumbentposition.

o Duringassessment,donotplaceanythinginsidethebirthcanal.




Ifgestationalageknowntobe<20weeks:

o TransporttoclosestEmergencyDepartment.

Ifgestationalageknownorpossibly≥20weeks:

o ContactEmergencyDepartmentforconsiderationoftransportdirectlytoLaborandDeliveryDepartment.

Wheneverpossible,transporttopatient’srequestedobstetricreceivingfacility

(withincountyboundaries)ifpatientnothavingimminentdelivery.

Overdose and Poisoning: General Approach


Ove

rdo

se a

nd

Po

ison

ing

: Ge

ne

ral A

pp

roa

ch

All Providers

Medical Control


Nothingbymouth,unlessadvisedbyRegionalPoisonControlCenter.

Forpatientswithsuspectedopiateoverdosewithrespiratorydepression:

o AdministerNaloxone2mgIN.

RefertoappropriateOverdoseandPoisoningprotocol:

o OverdoseandPoisoning:Antidepressants.

o OverdoseandPoisoning:AntipsychoticsandDystonicReaction.

o OverdoseandPoisoning:BetaBlockerToxicity.

o OverdoseandPoisoning:CalciumChannelBlocker.

o OverdoseandPoisoning:CarbonMonoxide.

o OverdoseandPoisoning:Organophosphate.


Foranyoverdoseorpoisoning,contactshouldbemadewiththeRegionalPoisonControlCenter

1‐800‐222‐1222.Wheneverpossible,determinetheagent(s)involved,thetimeoftheingestion/

exposure,andtheamountingested.Bringemptypillbottles,etc.tothereceivingfacility.

Treatmentforspecifictoxicexposuresisindicatedonlywhenpatientsareclearlysymptomatic.Inthe

absenceofsignificantsymptoms,monitorcloselyandexpeditetransport.



Forpatientswithsuspectedopioidoverdose:

o ConsiderNaloxone2mgIN/IM

OR

o ConsiderNaloxone0.4mgIV/IO,titratedtomaintainadequaterespiratoryrate(maxcumulativedose4mg).

Overdose and Poisoning: Antidepressants


Ove

rdo

se a

nd

Po

ison

ing

: An

tide

pre

ssan

ts

All Providers



CommonAntidepressantsandOverdoseEffects


Forhypotension(SBP<90mmHgorMAP<65)notimprovedbyfluidboluses,orwhenfluidresuscitationiscontraindicated:

o ConsiderDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

Category Drugs OverdoseEffects

Tricyclic

Antidepressants

Amitriptyline(Elavil,Endep,Vanatrip,

Levate)

Clomipramine(Anafranil)

Doxepin(Sinequan,Zonalon,Tridapin)

Imipramine(Tofranil,Impril)

Nortryptyline(Aventyl,Pamelor,

Norventyl)

Desipramine(Norpramin)

Protriptyline(Vivactil)

Triimipramine(Surmontil)

Amitriptyline+Chlordiazepoxide

(Limbitrol)

Hypotension

Anti‐cholinergiceffects

(tachycardia,seizures,

alteredmentalstatus,

mydriasis)

AVconductionblocks

(prolongedQTinterval,wide

QRS)

VTandVF

OtherCyclic

Antidepressants

Maprotiline(ludiomil)

Amoxapine(Asendin)

Buproprion(Wellbutrin)

Trazodone(Desyrel,Trazorel)

Similartotricyclics

Seizures

Seizures

Similartotricyclics

SelectiveSerotonin

ReuptakeInhibitors

(SSRIs)

Citalopram(Celexa)

Fluoexitine(Prozac)

Fluvoxamine(Luvox)

Paroxetine(Paxil)

Sertraline(Zoloft)

Hypertension,tachycardia,

agitation,diaphoresis,

shivering,tremor,muscle

rigidity

MalignantHyperthermia

Overdose and Poisoning: Antidepressants


Ove

rdo

se a

nd

Po

ison

ing

: An

tide

pre

ssan

ts

Medical Control


IfsustainedwideQRScomplex(≥0.12sec)withtachycardia(>120bpm),hypotension,anyarrhythmia,orseizure:

o AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq),mayrepeatoncein10minutesifindicated.

RefertoCardiacArrest:V‐Fib/PulselessV‐Tachifindicated.

RefertoMedical:AlteredMentalStatus/Syncopeifindicated.

RefertoMedical:Seizureifindicated.

Overdose and Poisoning: Antipsychotics/Acute Dystonic Reaction


Ove

rdo

se a

nd

Po

ison

ing

: An

tipsyc

ho

tics/A

cu

te D

yston

ic R

ea

ctio

n

All Providers

Medical Control



CommonAntipsychoticMedications



ForDystonicreactions:

o ConsiderDiphenhydramine25mgIV/IM,repeatoncein10minutesifindicated.

Medication MedicationEffects

Haloperidol

Prolixin

Thorazine

Prochloperazine(Compazine)

Promethazine(Phenergan)

Administrationoftheseagentsmaycause

akathisia(restlessness,anxiety,and

involuntarymovements[dystonia])

Overdose and Poisoning: Beta Blocker Toxicity


Ove

rdo

se a

nd

Po

ison

ing

: Be

ta B

loc

ker T

oxic

ity

All Providers

Medical Control



CommonBetaBlockerMedications



ForallpatientswithcardiovasculartoxicityinthesettingofsuspectedacuteBetaBlockertoxicity,definedby:

o ChestPain,SBP<90mmHgorMAP<65,acutelyalteredmentalstatus.

AND

o HeartRate<60or2ndor3rddegreeheartblocks.

ConsiderAtropine0.5mgIVP,repeatevery3minutesifindicated(maxcumulativedose3mg).


IfnoresponsetoAtropine:

o ConsiderGlucagon3mgIV/IO,slowpush.

Ifnoresponsetoprevioustreatments:

o ConsidertranscutaneouspacingperClinicalProcedure:ExternalCardiacPacing.

SingleAgentMedication CombinationMedication

Propranolol(Inderal)

Atenolol(Tenormin)

Metoprolol(Lopressor,Toprol)

Nadolol(Corgard)

Timolol(Blocadren)

Labetolol(Trandate)

Esmolol(Brevibloc)

Corzide(Nadolol/bendroflumethlazide)

Inderide(Propranolol/HCTZ)

LopressorHCT(Metoprolol/HCTZ)

Tenoretic(Atenolol/Chlorthalidone)

Timolide(Timolol/HCTZ)

Ziac(Bisoprolol/HCTZ)

Overdose and Poisoning: Calcium Channel Blocker


Ove

rdo

se a

nd

Po

ison

ing

: Ca

lciu

m C

ha

nn

el B

loc

ker

All Providers

Medical Control



CommonCalciumChannelBlockerMedications



ForallpatientswithcardiovasculartoxicityinthesettingofsuspectedacuteCalciumChannelBlockertoxicity,definedby:

o ChestPain,SBP<90mmHgorMAP<65,acutelyalteredmentalstatus.

AND

o HeartRate<60or2ndor3rddegreeheartblocks.

AdministerAtropine0.5mgIVP,repeatevery3minutesifindicated(maxcumulativedose3mg).


IfnoresponsetoAtropine:


ContraindicatedifpatienttakingDigoxin(Lanoxin).


o ConsiderGlucagon3mgIV/IOslowIVP.


o ConsidertranscutaneouspacingperClinicalProcedure:ExternalCardiacPacing.

CommonMedications

Amlodipine(Norvasc)

Felodipine(Plendil,Renedil)

Isradipine(DynaCirc)

Nicardipine(Cardene)

Nifedipine(Procardia,Adalat)

Verapamil(Calan)

Diltiazem(Cardizem)

Overdose and Poisoning: Carbon Monoxide


Ove

rdo

se a

nd

Po

ison

ing

: Ca

rbo

n M

on

oxid

e

All Providers

Medical Control


WearappropriatePPE(SCBA)asindicated.

Removethepatientfromthecontaminatedsource.

AssessCarboxyhemoglobinlevelutilizingavailableCO‐oximeter.

Supplemental100%O2viaNRBorBVM(ifnecessary).

o DocumenttimeO2started.

RefertoClinicalProcedure:CarboxyhemoglobinMonitoring.




Forsmokeinhalationpatients,alsoconsiderCyanidepoisoning.

o RefertoHazardousMaterialsExposure:CyanideToxicityandSmokeInhalation.

Overdose and Poisoning: Cholinergic/Organophosphates


Ove

rdo

se a

nd

Po

ison

ing

: Ch

olin

erg

ic/O

rga

no

ph

osp

ha

tes

All Providers

Medical Control


Wearprotectiveclothingincludingatminimummasks,gloves,andeyeprotection,refertodepartmentpolicyregardingPPE.

o Toxicitytoprovidersmayresultfrominhalationortopical/dermalexposure.

Considerrequestingadditionalresources,includingHazMatResponse.

o RefertoHazardousMaterialsExposure:NerveAgentWMDifindicated.

DecontaminatepatientperFRApolicyregardinghazardousmaterialsdecontaminationofvictims.


ConsultOn‐DutyHAZMATTECHbeforeattemptingtohandleanytoxicchemicalexposurepatient.

ContacttheRegionalPoisonControlCenter(1‐800‐222‐1222)uponidentifyingapossibletoxic

exposureoroverdose.ConsidercontactingCHEMTREC(1‐800‐424‐9300)forassistance.



Forhypotension(systolicBP<90mmHgorMAP<65)notimprovedbyfluidboluses,orwhenfluidresuscitationiscontraindicated.

o AdministerDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

Ifseveresignsoftoxicity,(severerespiratorydistress,bradycardia,heavyrespiratorysecretions):

o AdministerAtropine2mgIV/IO,repeatevery5minutes.

Titratedosingbyassessingimprovementinrespiratoryeffort/bronchialsecretions.Donotrelyonpupillaryconstrictiontodiagnoseortitratemedications.

RefertoMedical:AlteredMentalStatusifindicated.

RefertoMedical:Seizureifindicated.

Pain Management: Medical/Trauma


Pa

in M

an

ag

em

en

t: Me

dic

al/T

rau

ma

All Providers


Assessanddocumentbaselinepainlevel(0‐10scale:0=nopain;10=worstpain).



Analgesicagentsmaybeadministeredunderstandingordersforpatientsexperiencingmoderate/severepain(typically≥5/10).

o Commoncomplaints:

Trauma/Isolatedextremityinjury(e.g.,fractures).

Burns(withoutairway,breathing,orcirculationcompromise).

Sicklecellcrisis.

Acutechestpain,inaccordancewiththeCardiacEmergencies:AcuteCoronarySyndrome.

Kidneystonehighlysuspected,inaccordancewiththeMedical:AbdominalPain.

Agentsforpaincontrol:

o AdministerFentanyl1mcg/kgslowIV/IN/IO(maxdose50mcg),repeatevery5minutesifindicated(maxcumulativedose200mcg).



ConsiderMorphineSulfate0.1mg/kgIV/IO(maxdose5mg),repeatevery5minutesifindicated(maxcumulativedose15mg).


Aftereachdrugdosageadministration:

o Reassessanddocumentthepatient’spainlevel(0‐10scale).

o Noteadequacyofventilationandperfusion.

o Assessvitalsigns.


Medical Control ContactOLMCforanyadditionalordersorquestions.


Adult Trauma Protocols

General Patient Care Protocol - Adult Trauma


Ge

ne

ral P

atie

nt C

are

Pro

toc

ol – A

du

lt Tra

um

a

All Providers


RefertoAdministrativeProcedure:TraumaTriageCriteria.

Treatlifethreateningemergenciesimmediately.

PerformarapidtraumaassessmentandestablishinitialGCS.

o Reevaluateevery5minutes.

Controlactivebleedingutilizingdressings,directpressure,hemostaticagents,andtourniquetsasindicated.

o RefertoClinicalProcedure:WoundCare/HemorrhageControlifindicated.

ConsiderSelectiveSpinalMotionRestriction(SSMR).

o RefertoClinicalProcedure:SelectiveSpinalMotionRestriction(SSMR)ifindicated.

Supplemental100%O2ifevidenceofmajortraumaticinjuryorrespiratorysymptoms.

o RefertoappropriateRespiratoryEmergenciesProtocolasindicated.

Restrainpatientifindicated,refertoAdministrativeProcedure:Restraints.


Assess all patients for major trauma criteria. Major trauma patients should have transport initiated

within 10 minutes of arrival on scene whenever possible. In the setting of major trauma, DO NOT

prolong scene time to perform procedures unless immediately necessary to stabilize patient (e.g.,

hemorrhage control). Initiate all other procedures enroute to the trauma center.

Thefollowingmeasureswillserveasthe“GeneralPatientCareProtocol–AdultTrauma”and

apply tothemanagementofalladulttraumapatients.




o Assessfortensionpneumothorax.

Pleuraldecompressionfortensionpneumothoraxshouldonlybeperformedwhenall3ofthefollowingcriteriaarepresentorinthesettingofresuscitationintraumaticcardiacarrest.

Severerespiratorydistresswithhypoxia.

Unilateraldecreasedorabsentlungsounds(mayseetrachealdeviationawayfromcollapsedlungfield).

Evidenceofhemodynamiccompromise(e.g.,shock,hypotension,alteredmentalstatus).

o Ifindicatedperformpleuraldecompression,refertoClinicalProcedure:ChestDecompression.

General Patient Care Protocol - Adult Trauma


Ge

ne

ral P

atie

nt C

are

Pro

toc

ol – A

du

lt Tra

um

a

Medical Control

Forentanglement/entrapmentorcrushinjuries≥ 4 hours:

o ConsiderAlbuterol5mgvianebulizer.

o ConsiderSodiumBicarbonate1mEq/kgIV/IOover5minutes(maxdose100mEq).



RecordandmonitorSpO2.

ContinuouslymonitorETCO2.

EstablishIVNSKVOorIVlockifindicated.

o Ifpatientisunstableandtimepermits,establishasecondIV.

AdministerNS:

o IfSBP<90mmHgand/orMAP<65administer250bolusesofNSatawideopenIVrateuntilSBP≥90mmHgorMAP≥65(maxcumulativedose2L).

Suspectedhemorrhageinthesettingoftrauma(withoutanisolatedheadinjury):

o SBP≤90mmHgORsustainedHR>110.

AdministerTranexamicAcid1gdilutedinto100mlIV/IOover10minutes.

Mustbeadministeredwithin3hoursofinjury(maxbenefitin1sthour).

NOTAUTHORIZEDFORPEDIATRICPATIENTS.

ConsiderPainManagement:Medical/TraumaProtocolifindicated.

Trauma: Abdominal Injuries


Tra

um

a: A

bd

om

ina

l Inju

ries

All Providers

Medical Control



RefertoAdministrativeProcedure:TraumaTriageCriteria

Forevisceration,applyamoistdressingandcover.

o Donotattempttoplaceorgansbackinplace.

Foranimpaledobject,stabilizeinplace.

o Donotremovetheimpaledobject.




RefertoPainManagement:Medical/TraumaProtocolifindicated.

Trauma: Burns


Tra

um

a: B

urn

s

All Providers


GeneralPatientCareProtocol–AdultTrauma.

RefertoHazardousMaterialsExposure:CyanideToxicityandSmokeInhalationifindicated.

RefertoClinicalProcedure:SelectiveSpinalMotionRestriction(SSMR)ifindicated.

RefertoAdministrativeProcedure:BurnCenterCriteria.








Stoptheburningprocess,removeorcoolheatsourceifpresent(e.g.,clothing,tar).

Removeallclothing,contactlenses,andjewelry(especiallyrings)neartheinjurysite.

EstimateTBSA(onlyinclude2ndand3rddegreeburns).

o RuleofNines.

o Alternatively,usethepalmofpatient’shand,includingfingers,toequal1%TBSA.

If<10%TBSA:

o Coolwithmoistroomtemperaturesteriledressings.

o NEVERCOOLWITHICE!Thegoalistobringtheburntoroomtemperature.

If≥10%TBSA:

o Coverwithdrysteriledressings,plasticwrap,orchuxpad.

Maintaincoretemperature.Keeppatientwarmanddrywithsheetsandblankets.

Ifinhalationinjurysuspected:

o Placepatienton100%O2–DONOTDECREASE.

o ContinuouslymonitorSpO2andETCO2.



RefertotheappropriateRespiratoryEmergenciesProtocolsifindicated.

Trauma: Burns


Tra

um

a: B

urn

s

Medical Control


PlacelargeboreperipheralIV’sinunburnedskinifpossible.

o If≥20%TBSA:

AdministerNS,500mlbolus.

Consider250mlIVNSbolusatwideopenrateuntilSBP≥90mmHgorMAP≥65(maxcumulativedose2L).

o If≥30%TBSA:

PlacesecondlargeboreperipheralIV.

o RefertoPainManagement:Medical/TraumaProtocolifindicated.

Paramedic Only


67

Inadults,prehospitalendotrachealintubationfollowingacuteburnsisgenerally

unnecessaryunlesssignsofrespiratoryfailurearepresent.

Trauma: Chest Injuries


Tra

um

a: C

he

st Inju

ries

All Providers










Considerearlypositivepressureventilationinthesettingofimpendingrespiratoryfailurewithaflailsegment.

Assessbreathsoundsfrequently.

AssessforventilatorycompromiseandassistwithBVMasneeded.

Foropen”sucking”chestwounds,applyocclusivedressingsealedon3sidesorcommerciallyavailablechestseal.

o Removetemporarilytoventairifrespiratoryormentalstatusworsens.

Forimpaledobject,stabilizeinplace.

o Donotremoveimpaledobject.






Pleuraldecompressionfortensionpneumothoraxshouldonlybeperformedwhenall3ofthefollowingcriteriaarepresentorinthesettingofresuscitationinTraumaticCardiacArrest.




o Ifindicatedperformpleuraldecompression,refertoClinicalProcedure:ChestDecompression.

Trauma: Chest Injuries


Tra

um

a: C

he

st Inju

ries

Medical Control ContactOLMCforanyadditionalordersorquestions.


Trauma: Extremity Injuries


Tra

um

a: E

xtrem

ity Inju

ries

All Providers

Medical Control



Removeorcutawayclothingtoexposeareaofinjury.

Controlactivebleeding:

o RefertoClinicalProcedure:WoundCare/HemorrhageControl.


Suspectedfracture/dislocation:

o Assessanddocumentdistalpulses,capillaryrefill,sensation/movementpriortosplinting.

Ifpulsepresent:

Splintinpositionfound,ifpossible.

Ifpulseabsent:

Attempttorealigntheinjuryintoanatomicalposition.

o Openwounds/fracturesshouldbecoveredwithsteriledressingsandimmobilizedinthepresentingposition.

o Dislocationsshouldbeimmobilizedtopreventanyfurthermovementofthejoint.

o Reassessanddocumentdistalpulses,capillaryrefillandsensationaftersplinting.





Trauma: Eye Injuries


Tra

um

a: E

ye In

jurie

s

All Providers

Medical Control



Assessgrossvisualacuity.

Ifinjuryissecondarytoachemicalexposure:

o Removepatientfromsource,ifsafetodoso.

o Removecontactlensesifappropriate;transportwithpatient.

o IrrigatetheeyeswithNSforaminimumof20minutes.

o Determinechemicalinvolved,bringtheSafetyDataSheet(SDS)ifavailable.

Ifeyeinjuryisduetotrauma:

o Donotirrigate.

o Stabilizeanypenetratingobjects.

o Donotremoveanyimpaledobject.

o Preventpatientfrombendingorstanding.

o Ifbloodobservedinanteriorchamber,transportwithheadelevated60°.

Neverapplypressuretotheeyeballorglobe.

Bandagebotheyeswithbulkydressing.

Donotusechemicalcoldpacksontheface.






Trauma: Head Injuries


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Ifnormotensiveorhypertensive.

o Elevateheadofstretcher15°–30°.


Airway interventions can be detrimental to patients with head injury by raising intracranial pressure, worsening hypoxia (and secondary brain injury) and increasing risk of aspiration. Whenever possible these patients should be managed in the least invasive manner to maintain O2 saturation > 92% (e.g., NRB, BVM with 100% O2).







Forpatientswithassistedventilation:

o TitratetotargetanETCO2of40mmHg.

o Acuteherniationshouldbesuspectedwhenthefollowingsignsarepresent:

Acuteunilateraldilatedandnon‐reactivepupil.

Abruptdeteriorationinmentalstatus.

Abruptonsetofmotorposturing.

Abruptincreaseinbloodpressure.

Abruptdecreaseinheartrate.

o Ifsignsofherniationdevelop,increaseventilationrateto20/minute.TitrateETCO2between30‐35mmHg(temporarymeasureonly).



Trauma: Head Injuries


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ContactOLMCforanyadditionalsedationforcombativepatients.


Ifseverelyagitated/combativeandunabletode‐escalatebyanyothermeans,consider:

o Age<65:

ConsiderMidazolam5mgIV/IM/IN/IO,repeatin5minutesifindicated(maxcumulativedose10mg).

o Age>65:

ConsiderMidazolam2.5mgIV/IM/IN/IO,repeatin5minutesifindicated(maxcumulativedose5mg).

Trauma: Sexual Assault


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Forvictimsofsexualassaultwhomeetmajortraumacriteria:

o Transporttotraumacenter,refertoAdministrativeProcedure:TraumaTriageCriteria.

Forallothercases:

o TransporttonearestappropriateEmergencyDepartment.

Providesupportivecareasindicatedbypatient’scondition.

Preserveevidence.




Trauma: Traumatic Amputations


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Controlactivebleeding.



Ifamputationincomplete:

o Attempttostabilizewithbulkypressuredressing.

o Splintin‐line.

Ifamputationcomplete:

o Cleanseamputatedpartwithsterilesaline.

o Wrapinsteriledressingmoistenedinsterilesaline.

o Placeinplasticbagifpossible.

o Attempttocoolwithcoldpackduringtransport.Donotplacedirectlyonice.




RefertoPainManagement:MedicalTraumaProtocolifindicated.


Pediatric Protocols

General Patient Care Protocol - Pediatric


Thefollowingmeasureswillserveasthe“GeneralPatientCareProtocol–Pediatric”andapply

tothemanagementofallpediatricpatients.

ANeonateshallbedefinedas:

o Birthto1monthofage.

Aninfantshallbedefinedas:

o 1monthto1yearofage.

AChildshallbedefinedas:

o 1yearto<18yearsofage.

o Ifageisunknown,

1yeartopuberty(secondarysexualcharacteristics).

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Assessthepatient’smentalstatusandnatureofillness.

o Formentalstatus,usetheAVPUscale:

A–ThepatientisAlertandoriented(ageappropriate).

V–ThepatientisresponsivetoVerbalstimulus.

P–ThepatientisresponsivetoPainfulstimulus.

U–ThepatientisUnresponsivetoanystimulus.

Assessthepatient’scirculationforpresenceofpulse,rate,andquality.Ifnocentralpulseis

palpable,initiateCPR.RefertoPediatricCardiacArrest:GeneralApproach.

Incasesofcardiacarrest,initiatecontinuouschestcompressions,placeanOPAandNRB

maskonthepatientat15LPMandwithholdpositivepressureventilationperprotocoluntil

resourcesallow.

o Initiate15:2rescuerCPRassoonasresourcesallow.

Ifcardiacarrestisnotevident,ensureapatentairwayutilizingBLSstandardswithleast

invasivemeansnecessary.

Assessthepatient’srespiratorystatustoincludelungsounds,respiratoryrate,andworkof

breathing.UtilizepulseoximetrytoobtainSpO2.

ProvidesupplementalO2tomaintainSpO2≥92%,orifanyrespiratorysignsorsymptoms

present.Useadjunctsasnecessary.

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Note:FalseSpO2readingsmayoccurinthefollowingsituations:hypothermia,hypoperfusion

(shock),carbonmonoxidepoisoning,andperipheralvasoconstriction.

AssessperfusionbymeasuringHR,anobservingskincolor,temperature,capillaryrefill

andthequalityofcentral/peripheralpulses.

Measurebloodpressureinchildrenolderthan3yearsofage.

Ifsuspicionoftrauma,refertoClinicalProcedure:SelectiveSpinalMotionRestriction

(SSMR).

Manageanyprofusebleedingandexamineforsignsofpoorperfusion.Ifevidenceof

trauma,refertoGeneralPatientCareProtocol–PediatricTrauma.

Ifapatient’sconditioniscriticalorunstable,initiatetransportwithoutdelay.

o Performprocedures,history,anddetailedphysicalexamenroutetothehospital.

Attempttoobtainthepatient’scurrentmedicalcomplaintandpertinentmedicalhistory.

UtilizeSAMPLEhistoryandOPQRST.Ifnecessary,utilizefamilyorbystanders.

Evaluatementalstatusincludingpupillaryreaction,motorfunction,sensation,andGCS.

IfappropriateperformanddocumentacompleteneurologicalassessmentandCincinnati

PrehospitalStrokeScale,includingtimethepatientwaslastseennormal.

Recordandmonitorvitalsignsincludinglevelofconsciousness,pulse,respiratoryrate,skin

(color,condition,andtemperature),bloodpressure,bloodglucose,continuousSpO2,and

ETCO2(whenappropriate).

o Reassessanddocumentevery5minutesforcriticalpatientsor15minutesfornon‐

criticalpatients.

Ifsuspicionofacuteallergicreactionwithseveresymptoms(hypoxia,(SpO2<92%),severe

respiratorydistress,anaphylacticshock,stridor)”

o RefertoPediatricMedical:AllergicReaction.

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OxygenSaturation Range PatientCareGuidelines

92%‐100% Normal Ifsymptomatic,oxygenbyNC.

90%‐91% MildHypoxia O2 byNC asnecessary.

86%‐89% ModerateHypoxia O2 byNRB.

<86% SevereHypoxia O2 byNRB.ConsiderBVMorairway

adjunctasnecessary.



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Whenconditionwarrants(specifiedas“FullPediatricALSAssessmentandTreatment”in

individualprotocols).


Performcardiacmonitoring.


EstablishIVNSKVOorIVlockifindicated(severesymptomsorformedicationaccess).

AdministerbolusesofNSIV/IO.

o Ifsignsofshock,administerbolusesofNSat20ml/kguntilsignsofshockresolveor60ml/kgtotal.

Ifpatientexhibitssignsofseverecardiopulmonarycompromise(poorsystemicperfusion,hypotension,alteredconsciousnessand/orrespiratorydistress/failure)andIVattemptsunsuccessful:

o EstablishIOrefertoClinicalProcedureVenousAccessIntraosseous.

Allmedicationdosagesandequipmentsizesshallbecalculatedusingacommercially

availablelength/weightbasedsystem.

Forpatientswithseverenauseaorvomiting:

o AdministerOndansetron2mg(8–15kg)or4mg(>15kg)ODT(breakinhalftoadminister2mg).

OR

RecordBGLforanypatientexperiencingweakness,alteredmentalstatus,orhistoryof

diabetesperClinicalProcedure:BloodGlucoseAnalysis.

o Hypoglycemia:

Neonates<40mg/dL.

Allotherpatients<60mg/dL.

RefertoPediatricMedical:DiabeticEmergenciesifindicated.

o Hyperglyemia>250mg/dL:


Unlessauthorizedbyprotocol,nothingbymouth.


TransportpatienttonearestappropriateEmergencyDepartment.

Minimizeon‐scenetimewhenpossible.

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o AdministerOndansetron0.1mg/kgIV/IO(maxdose4mg).

Forpatientswithmoderateorseverepain,refertoPediatricPainManagement:Medical/

Trauma.

Forpatientswithsuspectedopioidoverdosewithrespiratorydepressionand/or

significantlyalteredmentalstatus:

o AdministerNaloxone0.1mg/kgIN/IV/IM/IO(maxdose2mg),titratedto

maintainadequaterespiratoryrate(maxcumulativedose2mg).

Reassessthepatientfrequently.

Ensurethepatientissecuredappropriatelyinunitpriortotransport.

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Pediatric Respiratory Emergencies: Dyspnea


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GeneralPatientCareProtocol–Pediatric.

Sitpatientuprightorinpositionofcomfortunlesscontraindicated.

Observeforsignsofimpendingrespiratoryfailure,refertoPediatricRespiratoryEmergencies:RespiratoryFailureifindicated.






Ifwheezing:


RefertoappropriateRespiratoryEmergenciesprotocol/procedure:

o PediatricRespiratoryEmergencies:AcuteBronchospasm.

o PediatricRespiratoryEmergencies:Stridor.

o PediatricRespiratoryEmergencies:SubmersionInjury.

o ClinicalProcedure:ObstructedAirway.


FullPediatricALSAssessmentandTreatment.

Medical Control

ContactOLMCforadditionalordersorquestions.

Pediatric Respiratory Emergencies: Acute Bronchospasm


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GeneralPatientCareProtocol–Pediatrics.

RefertoPediatricRespiratoryEmergencies:Dyspnea.

RefertoPediatricMedical:AllergicReaction.


Ifwheezing/dyspnea:

o AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated.

AtroventisonlycontraindicatedinthesettingofknownallergytoAtroventorAtropine.

Ifwheezingpersists:


If>2yearsoldwithhistoryofasthmaandwheezing/dyspneapersistsafterfirstnebulizertreatment:

o AdministerMethylprednisolone2mg/kgIV/IM/IO(maxdose125mg).

Ifwheezing/dyspneaisnotimproving(refractorytopatient/EMSadministeredalbuterol):

o AdministerMagnesiumSulfate50mg/kgdilutedin100mlNSIV/IOover10minutes(maxdose2g).

Contraindicatedifhistoryofrenalfailure(e.g.,dialysispatient).

ContactOLMCforpatientswithseveresymptoms(notspeaking,littleornoairmovementornotimproving):

o AdministerEpinephrine(1mg/ml)0.01mg/kgIM(maxdose0.3mg).


Pediatric Respiratory Emergencies: Stridor


Stridoristypicallycausedbyupperairwayobstruction/narrowing.Croupistypicallyaviral

infectionthatinvolvestheupperairway.Itismostprominentinchildrenages3monthsto6yearsof

age.Caremustbetakentoattemptdifferentiationbetweencroupandepiglottitis.Epiglottitisis

morecommonbetween2yearsto8yearsofageandisapotentiallylifethreateningbacterial

infection.

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Donothingtoupsetthechild.

Performcriticalassessmentsonly.

Haveparentassistwithblow‐bysupplementaloxygen.

Placepatientinpositionofcomfort.

Expeditetransport.



Ifpartialupperairwayobstruction(suspectedcroup)orstridoratrestwithrespiratory

distress:

o AdministerRacemicEpinephrine2.25%/0.5mlmixedwith3mlNSvia

nebulizer.

Donotattemptvascularaccess.

Croup Epiglottitis

Age 3months–5years 2– 6years

Sex Malemorethanfemale MaleandFemale

Onset Gradual Rapid

Infection Viral Bacterial(HinfluenzatypeB)

Fever Lowgrade High

Breathing Retractions Tripodposition

Sounds Barkingcough Inspiratorystridor

Voice Hoarseness Muffledvoice

OtherS/S Drooling,painfulswallowing

Treatment NebulizedRacemicEpi,

Steroids

O2,positionofcomfort,keepcalm,preparefor

intubation


Medical Control


Ifcompleteairwayobstructionorsevererespiratorydistress,failure,orarrest:

o Advancedairway/ventilatorymanagementifindicated.

o RefertoPediatricRespiratoryEmergencies:RespiratoryFailureifindicated.

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Pediatric Respiratory Emergencies: Submersion Injury


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Protectfromheatloss.

Patientsmaydevelopdelayedonsetrespiratorysymptoms:

o Encouragetransportforevaluation.

o ConsiderBVMventilationsforpatientswithsignificantdyspneaorhypoxia.

Medical Control



Pediatric Respiratory Emergencies: Respiratory Failure


PEDIATRICINTUBATIONISNOTINCLUDEDINTHEVIRGINIASCOPEOFPRACTICEFORINTERMEDIATESANDTHEREFOREISONLYAUTHORIZEDATTHEPARAMEDIC

LEVEL

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All Providers GeneralPatientCareProtocol–Pediatric.


Ifsignsofairwayobstruction,refertoClinicalProcedure:ObstructedAirway.


Observeforsignsofimpendingrespiratoryfailure:






Suctionalldebris/secretionsandremoveanyvisibleforeignbodyfromairway.

ProvidesupplementalO2tomaintainSpO2≥92%orifanyrespiratorysignsorsymptomspresent.Useadjunctsasnecessary.

Performbasicairwaymaneuvers:

o Openairway,insertNPA/OPAanduseBVMifneeded.

Ventilateonceevery3seconds(20times/minute)forallages.

VentilatewithBVMforatleast2minuteswith100%O2toachieveSpO2>92%.

Ifpatientdoesnotrespondtoabovemeasuresordeterioratesconsiderventilationsvia

LTA.



o RefertoClinicalProcedure:ConfirmationofPlacement/Effectivenessof

Ventilation.


IfLTAalreadyinplace,confirmproperplacement.

o RefertoClinicalProcedure:ConfirmationofPlacementandEffectivenessof

Ventilation.




IfunabletomanageairwaybyANYOTHERMEANS,considerETT(usecommercially

availablelength/weightsystemtoselectappropriateequipment):

RefertoClinicalProcedure:OrotrachealIntubation.

FollowingplacementofETTconfirmproperplacement.

o RefertoClinicalProcedure:ConfirmationofPlacementandEffectivenessof

Ventilation.

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Paramedic Only

Medical Control

Ifnoinvasiveairway,ventilatewithBVMforatleast2minuteswith100%O2toachieve

SpO2>92%.

Inunabletomaintainoxygenationandventilation,placeLTA.



RefertoClinicalProcedure:ConfirmationofPlacement/EffectivenessofVentilation.

Pediatric Cardiac Arrest: General Approach


Successfulresuscitationrequiresplanningandclearroledefinition.

Good,fast(100‐120),hardanddeepcompressionswithadequaterecoilandminimalinterruptionsareessentialtoasuccessfulresuscitation.Ametronomeshallbeutilizedtoaidinmaintainingacorrectcompressionrate.

Compressorsshouldberotatedevery2minutes.

ApplytheAED/Monitorasquicklyaspossibletodeliverenergytoshockablerhythms.

IntheeventapatientsufferscardiacarrestinthepresenceofEMS(EMSwitnessedCardiacArrest),theabsolutehighestpriorityistoapplytheAED/Defibrillatorwhilecompressionsareongoinganddeliverashockimmediatelyifindicated.

Managementofairwayandbreathingisimportantbutsecondarytocompressionsanddefibrillation.

Ifunabletomanageairwaybyanyothermeans,asingleattemptatLTAorETT(ParamedicOnly)placementmaybemadeonlyiftimeallows.Donotprolongtransportorscenetimetoattemptinvasiveairwayinterventions.

Reassessairwayfrequentlyandwitheverypatientmove.

DONOTINTERRUPTCHESTCOMPRESSIONS!

Designateaprovidertocoordinatetransitions,defibrillationandpharmacologicalinterventions.Theprovidershouldtypicallynothaveanyproceduraltasks.Iftheproviderisneededforaspecifictask,anewprovidermustbedesignated.

Neonate/Infant/ChildPatientsdonotmeettheCriteriaforTerminationofResuscitation.

PEDIATRICINTUBATIONISNOTINCLUDEDINTHEVIRGINIASCOPEOFPRACTICEFORINTERMEDIATESANDTHEREFOREISONLYAUTHORIZEDATTHEPARAMEDICLEVEL.

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GeneralPatientCareProtocol—Pediatric.

Checkresponsiveness,breathing,andapulse.

Announce“CPRinprogress”toincomingunitsandCommunications.

ApplyAEDassoonasavailable.

o Frombirthto8yearsofage(max25kg)usepediatricAEDtherapypadsifavailable.

o IfpediatricAEDtherapypadsareunavailable,useadultAEDtherapypads.

Ifadequatebystandercompressionsareongoing,havebystandercontinuecompressionsuntilmonitorpadsareinplaceandthemonitorischarged.Stopcompressionsforrhythmanalysisfornomorethan10seconds.

Ifcompressionsarenotbeingperformeduponarrivalorifcompressionsarenotdeemed

adequate,immediatelyperformcompressionsatarateof100‐120compressionsper

minutewhileapplyingdefibrillator.

Pediatric Cardiac Arrest: General Approach


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Afteranalysisand(possible)defibrillation,immediatelyresumechestcompressions.Donotpauseforpost‐shockrhythmanalysis.Stopcompressionsonlyforsignsoflife(patientmovement)orpre‐defibrillationrhythmanalysisevery2minutes.AgonalrespirationsareabrainstemreflexandNOTanindicationtostopcompressions.

Asresourcesallowmaintainadequateairwayandventilate.

o UseBLSadjunctsandsuctionasnecessary.

o Establishadvancedairway(LTA)ifindicated,refertoClinicalProcedure:LaryngealTubeAirway(KINGLTS‐D).

Donotpausecompressionstoinsertadvancedairway.

Donotpausecompressionstoventilate.


o FollowingplacementofLTAconfirmproperplacement.

RefertoClinicalProcedure:ConfirmationofPlacement/EffectivenessofVentilation.


Refertorhythmappropriateprotocol.

Establishvascularaccess.


o Neonates<40mg/dL.

o Allotherages<60mg/dL.

o RefertoPediatricMedical:DiabeticEmergenciesifindicated.

Duetothechild’scriticalcondition,initiatetransportwithin10minutes.


IfunabletomanageairwaybyANYOTHERMEANS,asingleattemptatanETTmaybe

madeonlyiftimeallows.Donotprolongtransportorscenetimetoattemptinvasiveairway

interventions(usecommerciallyavailablelength/weightsystemtoselectappropriate

equipment):

o FollowingplacementofETTconfirmproperplacement.

RefertoClinicalProcedure:ConfirmationofPlacementandEffectiveness

ofVentilation.

Paramedic Only

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PediatricCardiacArrest:GeneralApproach.


Considerandtreatpossiblecauses.

Minimizeanyinterruptionsincompressions.

Usingthemostreadilyavailableroute(duringCPR):

o AdministerEpinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeat

every3‐5minutes.


Hyperkalemiasuspected(dialysispatient):

o AdministerCalciumChloride20mg/kgIV/IO(maxdose1g).

o AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq).

SodiumBicarbonateandCalciumChlorideshallnotbeadministeredinthe

sameline.Ifsecondlineunavailable,ensurelineisadequatelyflushed.

Iftoxicingestionsuspected:

o RefertoPediatricMedical:OverdoseandPoisoning.

PotentialCausesofPEA Treatment

Hypovolemia NormalSaline20ml/kgIV/IO,repeat

twice(maxcumulativedose60ml/kg).

Hypoxia Secureairwayandventilate.

HydrogenIon(acidosis) SodiumBicarbonate1mEq/kgIV/IO.

Hyperkalemia(endstagerenaldisease) SodiumBicarbonate1mEq/kgIV/IO.

CalciumChloride20mg/kgIV/IO.

Hypothermia Activerewarming.

Tamponade,Cardiac NormalSaline20ml/kgIV/IO,repeat

twice(maxcumulativedose60ml/kg).

Expeditetransport.

Tensionpneumothorax Needlethoracostomy.

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Applytherapypads,printstrip,andpre‐chargeto4J/kg(max360J).

ConfirmthepresenceofV‐Fib/PulselessV‐Tach.

Initiate/continuecompressionswhiledefibrillatorcharges.

DefibrillateV‐Fib/PulselessV‐Tachat4J/kg(max360J).

o ImmediatelyresumeCPRaftershock(donotstoptocheckpulse).


o Administer(duringCPR)Epinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeatevery3‐5minutes.


o IfV‐Fib/PulselessV‐Tachpersistsdefibrillateat4J/kg(max360).




o Administer(duringCPR)Amiodarone5mg/kgbolusIV/IO(maxdose300mg).

ForpersistentV‐Fib/PulselessV‐Tach,mayrepeatevery3‐5minutes,

Amiodarone5mg/kgIV/IO(maxcumulativedose15mg/kgnottoexceed

450mg).

o Suspectedpolymorphicventriculartachycardia/torsadesdepointes:

AdministerMagnesiumSulfate50mg/kgIV/IO(maxdose2g).


o IfV‐Fib/PulselessV‐Tachpersistdefibrillateat4J/kg(max360J).



Continuecycle(Defibrillate→CPR→Medication→Analyzeevery2min).

Medical Control



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Notegestationalageandiftwingestationisknown.

AssessAPGARscoresat1and5minutesafterbirth.Continuetonotescoresevery5

minutesuntilvitalsignshavestabilized.

Assessforpresenceofmeconium.

Providewarmth.

Spontaneouslybreathing,well‐appearingneonatesdonotrequiresuctioning.Provideonly

supportivecareandkeeppatientwarm.

Forneonateswithdifficultybreathing,obstructedbreathing,orthatrequireBVM

ventilation:

o Opentheairwayandsuctionwithbulbsyringe.

Suctionmouthfirst,thennasopharynx.

Dry,stimulate,andreposition.

Administersupplementalblow‐byoxygen.

Evaluaterespirations,heartrate,andcolor.

HR<100,apnea,orgaspingrespirations:

o Providepositivepressureventilation(40–60perminute)usingBVMinitiallyon

roomaironly(FiO221%).

o Reassessin20–30seconds.

HR60–100:

ContinuetoprovideventilatorysupportviaBVMwith100%O2.

Reassessin20–30seconds.


Sign Score0 Score 1 Score2

Appearance Pale/Blue Blueextremities Pink

Pulse Absent <100perminute >100perminute

Grimace Noresponse Grimace CoughorSneeze

Activity Flaccid Someflexion Wellflexed

Respiration Absent Weak Goodcry

Pediatric Cardiac Arrest: Neonatal Resuscitation


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HRremains<60after30secondsofpositivepressureventilation:

ContinuetoprovideventilatorysupportviaBVMwith100%O2.

Immediatelybeginchestcompressions.

CompressiontoVentilationRatioof3:1.



IVNSKVOorlock.

o IfnoIVaccessisreadilyobtainable,proceeddirectlytoIOaccess.

o AdministeraNS10cc/kgIV/IObolus.

AdministerEpinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeatevery3‐

5minutes.

Ifrespiratorydepressionisnotedintheneonateofamotherwhoreceivednarcoticswithin

4hoursofdelivery:

o AdministerNaloxone0.1mg/kgIV/IO.

Administer10%Dextrose2ml/kg.

o ThereisnoneedtocheckBGLpriortoadministration.

Rapidtransport.

Paramedic Only

MeconiumAspirator.

o Thetrachealsuctioningprocedureisnotintendedforthevigorousnewbornwith

meconium‐stainedfluidthatdoesnotdevelopapneaorrespiratorydistress.

Intheeventsevererespiratorysymptomsdevelop,proceedwithtracheal

suctioning.

o Foranon‐vigorousinfant(thenewbornhasabsentordepressedrespirations

decreasedmuscletone,orHR<100bpm),withfluidcontainingmeconium,perform

trachealsuctioning(60–80mmHg).

Performdirectlaryngoscopyandsuctionanyvisiblemeconiumfromthe

airway.

PassETTbeyondthecordsandwithdrawslowlyassuctionisapplieddirectly

totheETtube(thetubewillactasasuctioncatheter).


Pediatric Cardiac Arrest: Neonatal Resuscitation


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Aftertubeisremoved,performpositivepressureventilationusingaBVMand

100%O2.Donotre‐attemptintubationunlesspatientexhibitssevererespiratory

failureorapnea.

Pediatric Cardiac Arrest: Post Resuscitation Care


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GeneralPatientCareProtocol‐Pediatric.

Maintainassistedventilationasneeded.

o MonitorETCO2,goalis40mmHg,DONOTHYPERVENTILATE!

o TitrateO2tomaintainSpO2of92%‐99%.

Obtain12‐leadECG.


MonitorETCO2,goalis40mmHg,DONOTHYPERVENTILATE!

Forhypotensionnotimprovedbyfluidboluses,orwhenfluidadministrationiscontraindicated:

o AdministerDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainminimumSBP.

Medical Control



Pediatric Cardiac Arrhythmia: Bradycardia


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Assistventilationasneededwithbagvalvemask.

Lookforsignsofobstruction.

o Absentbreathsounds,tachypnea,intercostalretractions,stridorordrooling,

choking,bradycardia,orcyanosis.

o IfaforeignbodyobstructionissuspectedrefertoClinicalProcedure:Obstructed

Airway.

o Openairwayusingheadtilt/chinliftifnospinaltraumaissuspected.Ifspinal

traumaissuspected,usemodifiedjawthrust.

Ifsignsofseverecardiopulmonarycompromisearepresentinaneonate/infant(<1year)

andtheHRremainsslowerthan60BPMdespiteoxygenationandventilation:

o Initiatechestcompressionsandreferto:


PediatricCardiacArrest:Asystole/PEA.


Ifsignsofseverecardiopulmonarycompromisepersist(usemostreadilyavailableroute):

o AdministerEpinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeat

every3‐5minutesuntileitherthebradycardiaorseverecardiopulmonary

compromiseresolves.

DetermineBGLandtreat:

o Hypoglycemia:

Neonates<40mg/dL.

Allotherpatients<60mg/dL.


Identifyandtreatpossiblecausesofbradycardia:

o Hypoxic:

Secureairwayandassistventilation.

o Hypothermic:

Activerewarming.

Pediatric Cardiac Arrhythmia: Bradycardia


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o Ifacutelydeterioratingheadinjury:

HyperventilateandtitrateETCO2between30–35mmHg.

o Iftoxiningestion,refertoPediatricOverdoseandPoisoning.

IfsignsofseverecardiopulmonarycompromisepersistdespiteEpinephrine(Increased

vagaltone,heartblocks)andabovemeasures:

o AdministerAtropine0.02mg/kgIV/IO(minimumdose0.1mgwithamaxdose

0.5mg),repeatoncein3‐5minutes.

Initiatetranscutaneouspacingforhighdegree(2ndand3rddegree)heartblock,historyof

heartblock,historyofhearttransplant,orbradycardiawithseverecardiopulmonary

compromisedespiteEpinephrine/Atropine.

o RefertoClinicalProcedure:ExternalCardiacPacing.

Pediatric Cardiac Arrhythmia: Tachycardia


Infantswithheartrates<220andchildrenwithheartrates<180typicallywillrespondwhenthe

precipitatingcauseistreated(e.g.,fever,dehydration).

SupraventricularTachycardia:

Infants:Rateusually>220/min.

Children:Rateusually>180/min.

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Supplemental100%O2.


DetermineBGLandrefertoPediatricMedical:DiabeticEmergency.

SinusTachycardia:

o Identifyandtreatpossiblecauses(e.g.,fever,dehydration).

RegularNarrowComplexTachycardia(SVT):

o AttemptvagalmaneuversandcontactOLMC.

Ifabletofollowinstructions,mayattemptValsalvamaneuver.

Ifunabletofollowinstructions(age),mayattemptcoldstimulitoface(ice

packortowelsoakedinicewater).

RegularNarrowComplexTachycardia(SVT)withseverecardiopulmonarycompromise:

o Iftimeandpatientconditionpermits,contactOLMC.

o Ifvascularaccessisavailable:

AdministerAdenosine0.1mg/kgrapidIV/IO(maxdose6mg)over1‐3

secondswitha10mlNSflush.

IVaccessintheantecubitalspaceispreferred.

RepeatAdenosine0.2mg/kgrapidIV/IO(maxdose12mg)over1‐3

secondswitha10mlNSflush,ifindicated.

o IfAdenosineisunsuccessfulandpatientstillhasseverecardiopulmonary

compromise:

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ContactOLMCforIrregularNarrowComplexTachycardia(A‐Fib).

ContactOLMCfor2failedattemptsatcardioversion.


PerformSynchronizedCardioversionat1J/kg(max360J),refertoClinical

Procedure:SynchronizedCardioversion.

Iftimeandpatientconditionallows,considerOLMCconsultationpriortocardioversion.

Sedationifpatientcondition(e.g.,SBP)andtimeallows.

AdministerFentanyl1mcg/kgIV/IO(maxdose50mcg).

AdministerMidazolam0.1mg/kgIV/IO(maxdose2mg).

Repeatsynchronizedcardioversionat2J/kg(maxdose360J),ifindicated.

VentricularTachycardiawithapulse:

o Ifthepatientisstable,monitorandrapidtransport.

o Ifthepatientisunstable:

PerformSynchronizedCardioversionat1J/kg(max360J),refertoClinical

Procedure:SynchronizedCardioversion.

Iftimeandpatientconditionallows,considerOLMCconsultationprior

tocardioversion.

Sedationifpatientcondition(e.g.,SBP)andtimeallows.

AdministerFentanyl1mcg/kgIV/IO(maxdose50mcg).


Repeatsynchronizedcardioversionat2J/kg(maxdose360J),ifindicated.

IfPolymorphicVentricularTachycardia/TorsadedePointesissuspected:

o AdministerMagnesiumSulfate50mg/kgdilutedin10mlNSIV/IOover2

minutes(maxdose2g).

IfvascularaccessisunavailableornoresponsetoMagnesiumSulfate,and

patientremainsunstable:

Defibrillateat4J/kg(maxdose360J).RefertoClinicalProcedure:

DefibrillationManual.

Iftimeandpatientconditionallows,considerOLMC

consultationpriortodefibrillation.


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Pediatric Hazardous Materials Exposure: Cyanide Toxicity and Smoke Inhalation


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Cyanidepoisoningmayresultfrominhalation,ingestionordermalexposuretocyanidecontaining

compounds,includingsmokefromclosed‐spacefires.Thepresenceandextentofthepoisoningare

oftenunknowninitially.Treatmentdecisionsmustbemadeonthebasisofclinicalhistoryandsigns

andsymptomsofcyanideintoxication.

Notallpatientswhohavesufferedsmokeinhalationfromaclosed‐spacefirewillhavecyanide

poisoning.Otherconditionssuchasburns,traumaorothertoxicinhalations(e.g.,carbonmonoxide)

maybethecauseofsymptoms.Whensmokeinhalationisthesuspectedsourceofcyanideexposure

assessthepatientforthefollowing:

Exposuretofireorsmokeinanenclosedspace.

Presenceofsootaroundthemouth,noseororopharynx.

Alteredmentalstatus.

CommonSignsandSymptomsofCyanideToxicity

Symptoms Signs

Headache Alteredmentalstatus

Confusion Seizuresorcoma

Shortnessofbreath Dyspnea/Tachypnea

ChestPainortightness Respiratorydistress/Apnea

Nausea/Vomiting Hypertension(early)

Hypotension(late)

Cardiovascularcollapse/Cardiacarrest

GeneralPatientCareProtocol–Pediatrics.

Supplemental100%O2.

Considerpatientdecontamination.


EvaluatethepatientfortheclinicalsuspicionofCyanidepoisoning.

o Expeditetransportandtreatotherconditionsasperappropriateprotocol.

o RefertoPediatricRespiratoryEmergencies:RespiratoryFailureifindicated.

Medical Control


Pediatric Medical: Allergic Reaction


Mild Reaction: Itching/Hives.

Moderate Reaction: Dyspnea, Wheezing, Chest Tightness.

Severe Systemic Reaction (Anaphylaxis): Throat Complaints, Stridor, Severe Respiratory Distress.

Gastrointestinal Symptoms (vomiting and abdominal pain).

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ContactOLMCforadditionalEpinephrine(1mg/ml)0.01mg/kgIM(maxdose0.3mg).

ContactOLMCforEpinephrineinfusion2mcg/mintitratedupbasedonOLMCparameters(e.g.,acceptablebloodpressureorimprovementofmentalstatus).




Assistpatientinself‐administrationofpreviouslyprescribedepinephrineauto‐injector

(e.g.,Epi‐Pen,Epi‐PenJr).

Ifwheezingispresent:


Givenothingbymouth.

FullPediatricALSAssessmentandTreatment. MildReaction:


ModerateReactionorSevereSystemicReaction:

o AdministerEpinephrine(1mg/ml)0.01mg/kgIM(maxdose0.3mg),repeatonce

in5minutesifindicated.



o AdministerMethylprednisolone2mg/kgIV/IM/IO(maxdose125mg).

o Ifsignsofshock,administerbolusesofNSat20ml/kguntilsignsofshockresolveor

60ml/kgtotal.


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FullPediatricALSAssessmentandTreatment. Ifcardiacarrhythmiapresent,refertotheappropriatecardiacemergenciesprotocol.


ObtainBGLandrefertoPediatricMedical:DiabeticEmergencies.

Obtain12‐LeadECG.

IfheadinjuryissuspectedrefertoPediatricTrauma:HeadInjuries.

Ifsepsisissuspected(highriskforinfection,febrile),refertoPediatricMedical:Sepsis.

Ifsuspectedpoisoning:

o RefertoPediatricOverdoseandPoisoning.


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Pediatric Medical: Apparent Life-Threatening Event (ALTE)

AnApparentLifeThreateningEvent(ALTE),oftenreferredtoasa“nearmissSIDS”,isanepisodethat

isfrighteningtotheobserver/caregiver,andinvolvessomecombinationofthefollowing:

Apnea(centralorobstructive).

Colorchange(cyanosis,pallor,erythema,plethora).

Markedchangeinmuscletone(e.g.,limpness/rigid).

Chokingorgagging.

ABriefResolvedUnexplainedEvent(BRUE),issimilartoanALTEasitisanobservedeventinan

infant(<1yearsofage)inwhichasudden,brief(lessthan1minute)ofanyoftheabovesignsmaybe

witnessedaswellasanychangedlevelofresponsiveness.HistoryofanALTEorBRUEmayrepresent

seriousillness,eveniftheinfantappearsentirelywellbythetimeofevaluation.Theapparentwell‐

beingshouldnotbeconsideredevidencethatapotentiallylifethreateningeventwithsuccessful

resuscitationdidnotoccuriftheclinicalhistoryindicatesotherwise.

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Assumethehistorygivenisaccurateandreliable.

Determinetheseverity,nature,anddurationoftheepisode.

Obtainamedicalhistory:

o Knownchronicdiseases.

o Historyofpretermdelivery.

o Evidenceofseizureactivity.

o Currentorrecentinfections.

o Gastroesophagealreflux.

o Inappropriatemixtureofformula.

o Recenttrauma.

Performathoroughphysicalassessmentthatincludesthegeneralappearance,skincolor,

levelofinteractionwithenvironment,evidenceoftrauma,andbloodglucosecheck.

Transporttothenearestappropriatereceivingfacility.

Forpatients<1yearsofage:

o InthesettingofanALTEorBRUE,iftheparent/guardianisrefusingmedicalcare

and/orEMStransport,OLMCmustbecontactedpriortoacceptingarefusal.


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Medical Control ContactOLMCforrefusalofmedicalcare/EMStransportinapatient<1yearofage.



Pediatric Medical: Diabetic Emergencies


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Hypoglycemia(BG<60mg/dL):

o ConsiderOralGlucoseGel15gorglucosecontainingbeverage(e.g.,orangejuice)if

ageappropriate.




o Neonates<40mg/dL:

Administer10%Dextrose2ml/kgIV/IO,titratetoimprovedmentalstatus

andBGL.

o Allotherages<60mg/dL:

Administer10%Dextrose5ml/kgIV/IO(maxdose100ml),titrateto

improvedmentalstatusandBGL.

IfunabletoobtainIV/IOaccess:

AdministerOralGlucoseGel15gorglucosecontainingbeverage

(e.g.,orangejuice)ifageappropriate.


Ifbloodglucoseremains<80mg/dL(<60inaneonate)aftertreatmentorunableto

determinebloodglucoseandpersistentalteredmentalstatus:

o Neonates:

Administer10%Dextrose2ml/kgIV/IO,titratetoimprovedmentalstatus

andBGL.

o Allotherages:

Administer10%Dextrose5ml/kgIV/IO(maxdose100ml),titrateto

improvedmentalstatusandBGL.

Ifunabletoadministerglucosebymouth:

o AdministerGlucagon0.1mg/kgIM(maxdose1mg).

Pediatric Medical: Diabetic Emergencies


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Hyperglycemia(BG>250mg/dL).

o AdministerNS:

Ifevidenceofdehydration(tachycardia,drymucousmembranes,poorskin

turgor)orhypovolemia,administerbolusesofNSat20ml/kguntilsignsof

shockresolve(maxdose60ml/kg).

Medical Control


Pediatric Medical: Seizure


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Protectpatientfrominjury.

ObtainBGLperClinicalProcedure:BloodGlucoseAnalysis.

O2viaNCissufficientifnoactiveseizuresandnorespiratorysignsorsymptoms.


Medical Control




Foractiveseizures(>3‐5minutes):

o DonotdelaytreatmenttoobtainIVaccess:

AdministerMidazolam0.2mg/kgIN(maxindividualdose5mg),repeatin

5minutesifindicated(maxcumulativedose10mg).

OR

AdministerMidazolam0.1mg/kgIV/IM/IO(maxindividualdose2.5mg),

repeatin5minutesifindicated(maxcumulativedose5mg).

Pediatric Medical: Sepsis


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Sepsisisarapidlyprogressinglife‐threateningcomplicationofsystemicinfection.Itoccurswhenan

inflammatoryresponsecalledSystemicInflammatoryResponseSyndrome(SIRS)istriggeredin

responsetoinfection.Sepsismustberecognizedandtreatedaggressivelytopreventprogressionto

shockanddeath.SepsiscanbeidentifiedwhenthefollowingSIRSmarkersarepresentinapatient

withsuspectedinfection.

Feverorhypothermia(>101.3For<96.8F).

Tachypnea(respiratoryrate>20).

Tachycardia(heartrate>90).

InadditiontophysiologicsignsofSIRS,severesepsismaycausehypoxiaandinadequateorgan

perfusion,resultinginmetabolicacidosismarkedbyelevatedserumlactatelevelsanddecreased

ETCO2(measuredbycapnography).

All Providers




AgeAdjustedHypotension

Neonate SBP<601month–1year SBP<70>1year–10years SBP<70+2(ageinyears)

>10years SBP<90

AgeSpecificVitalSigns

Age HeartRateinBPM RespiratoryRate/Minute

OD–1week <100,>180 >50

1week–1month <100,>180 >40

1month–1year <90,>180 >34

2years–5years >140 >22

6years–12years >130 >18

13years‐<18years >110 >14

Pediatric Medical: Sepsis


Medical Control

Notifyhospitalofa“CODESepsis”priortoarrivalpertheAdministrativeProcedure:Code

Sepsis.

AdministerNS:

o Neonate:

Administer10ml/kgNSbolus.

o Allotherpediatricpatients:

Administer20ml/kgNSbolus.

Repeatifindicatedtomaintainperfusion(acceptableBP)(max

cumulativedose60ml/kg).

UsecautioninpatientswithESRD/Dialysis.

ContactOLMCifpersistenthypotensionafterNSBolusadministration.

ContactOLMCforDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP.


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Pediatric Overdose and Poisoning


Foranyoverdoseorpoisoning,contactshouldbemadewiththeRegionalPoisonControlCenter,

1‐800‐222‐1222.Wheneverpossible,determinetheagent(s)involved,thetimeoftheingestion/

exposure,andtheamountingested.Bringemptypillbottles,etc.,tothereceivingfacility.

Treatmentforspecifictoxicexposuresisindicatedonlywhenpatientsareclearlysymptomatic.Inthe

absenceofsignificantsymptoms,monitorcloselyandexpeditetransport.

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Medical Control

ConsultRegionalPoisonControlCenterpriortotreatmentforOrganophosphatesOverdose.

o Symptomsoforganophosphateoverdoseincludedyspnea,bronchorrhea,

lacrimation,vomiting/diarrhea,weakness,paralysis,and/orseizures.

o AdministerAtropine0.02mg/kgIV/IO(minimumdose0.1mgwithamaxdose2

mg),repeatevery2minutesifindicated(max6mg).

ContactOLMCforspecifictreatmentforsuspectedcalciumchannelblockerorbeta

blockeroverdose.



NothingbymouthunlessadvisedbyRegionalPoisonControlCenter.


Ifrespiratorydepressionispresentandanarcoticoverdoseissuspected:

o AdministerNaloxone0.1mg/kgIN/IV/IM/IO(maxdose2mg),titratedto

maintainadequaterespiratoryrate(maxcumulativedose2mg).

DystonicReactions(acuteuncontrollablemusclecontractions):

o AdministerDiphenhydramine1mg/kgIV/IM(maxdose25mg).

InsulinOverdose(Hypoglycemiaorunknownbloodglucoseandalteredmentalstatus):

o RefertoPediatricMedical:DiabeticEmergencies.

Ifseizureispresent:

o RefertoPediatricMedical:Seizure.


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GeneralPatientCareProtocol‐Pediatric


Analgesicagentsmaybeadministeredunderstandingordersforpatientsexperiencing

moderate/severepain(≥5/10).

o Commoncomplaints:

Isolatedextremityinjury.

Burns(withoutairway,breathing,orcirculationcompromise).

Sicklecellcrisis.

Agentsforpaincontrol:

o AdministerFentanyl1.5mcg/kgINwithhalfofthevolumeadministeredtoeach

nare(maxdose100mcg),repeathalftheoriginaldosein10minutesifindicated.

OR

o AdministerFentanyl1mcg/kgIV/IO(maxdose50mcg),repeatevery5minutesif

indicated(maxcumulativedose200mcg).


ConsiderMorphineSulfate0.1mg/kgIV/IO(maxdose5mg),repeatevery

5minutesifindicated(maxcumulativedose15mg).


Assesbaselinepainlevel(0‐10scale:0=nopain;10=worstpain).



Medical Control ContactOLMCforadditionalordersorquestions.

Pediatric Pain Management: Medical/TraumaP

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Aftereachdrugdosageadministration:

o Reassessthepatient’spainlevel.

o Noteadequacyofventilationandperfusion.

o Assessanddocumentvitalsigns.



Pediatric Trauma Protocols

General Patient Care Protocol – Pediatric Trauma


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RefertoTraumaTriageCriteriaProcedure.


PerformaRapidTraumaAssessmentandestablishinitialGCS.

o Reevaluateevery5minutes.

Controlactivebleedingutilizingdressings,directpressure,hemostaticagents,andtourniquetsasindicated.

o RefertoClinicalProcedure:WoundCare/HemorrhageControlifindicated.

ConsiderSpinalMotionRestriction(SMR).

o RefertoClinicalProcedure:SelectiveSpinalMotionRestriction(SSMR)ifindicated.

Supplemental100%O2ifevidenceofmajortraumaticinjuryorrespiratorysymptoms.

o RefertoappropriatePediatricRespiratoryEmergenciesProtocolasindicated.



Assessallpatientsformajortraumacriteria.Majortraumapatientsshouldhavetransportinitiated

within10minutesofarrivalonscenewheneverpossible.Inthesettingofmajortrauma,DONOT

prolongscenetimetoperformproceduresunlessimmediatelynecessarytostabilizepatient(e.g.,

hemorrhagecontrol).Initiateallotherproceduresenroutetothetraumacenter.

Thefollowingmeasureswillserveasthe“GeneralPatientCareProtocol–PediatricTrauma”

andapply tothemanagementofallpediatrictraumapatients.





Iftimeandpatientconditionallows,contactOLMC.

Pleuraldecompressionfortensionpneumothoraxshouldonlybeperformedinthesettingoftraumawhenall3ofthefollowingcriteriaarepresentorinthesettingofresuscitationinTraumaticCardiacArrest.





Medical Control

o Ifindicatedperformpleuraldecompression,refertoClinicalProcedure:Chest

Decompression.


RecordandmonitorSpO2.

ContinuouslymonitorETCO2.

EstablishIVNSKVOorIVlockifindicated.

AdministerbolusesofNSIV/IO.

o Ifsignsofshock,administerbolusesofNSat20ml/kguntilsignsofshockresolveor60ml/kgtotal.

ConsiderPediatricPainManagement:Medical/TraumaProtocolifindicated.


General Patient Care Protocol – Pediatric TraumaG

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ADMINISTRATIONOFTRANEXAMICACIDISNOTINDICATEDFORPATIENTS<18

Pediatric Trauma: Abdominal Injuries


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GeneralPatientCareProtocol–PediatricTrauma.

RefertoAdministrativeProcedure:TraumaTriageCriteria

Ifconcernsforevisceration,applyamoistdressingandcover.

o Donotattempttoplaceorgansbackinplace.

Ifconcernsforanimpaledobject,stabilizeinplace.

o Donotremovetheimpaledobject.


Medical Control



RefertoPediatricPainManagement:Medical/TraumaProtocolifindicated.

Pediatric Trauma: Burns


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RefertoPediatricHazardousMaterialsExposure:CyanideToxicityandSmokeInhalationifindicated.


RefertoAdministrativeProcedure:BurnCenterCriteria.








Stoptheburningprocess,removeorcoolheatsourceifpresent(e.g.,clothing,tar).

Removeallclothing,contactlenses,andjewelry(especiallyrings)neartheinjurysite.

EstimateTBSA(onlyinclude2ndand3rddegreeburns).

o RuleofNines.

o Alternatively,usethepalmofpatient’shand,includingfingers,toequal1%TBSA.

If<10%TBSA:

o Coolwithmoistroomtemperaturesteriledressings.

o NEVERCOOLWITHICE!Thegoalistobringtheburntoroomtemperature.

If≥10%TBSA:

o Coverwithdrysteriledressings,plasticwrap,orchuxpad.

Maintaincoretemperature.Keeppatientwarmanddrywithsheetsandblankets.

Ifinhalationinjurysuspected:

o Placepatienton100%O2–DONOTDECREASE.

o ContinuouslymonitorSpO2andETCO2.



RefertotheappropriatePediatricRespiratoryEmergenciesProtocolsifindicated.

.


Pediatricairwaysaresmallerthanadultairwaysandrequirethoroughandfrequent

evaluationforsignsofrespiratorycompromise.

If≥20%TBSA:

o AdministerbolusesofNSIV/IOat20ml/kguntilsignsofshockresolveor60ml/kgtotal.

o AfterNSbolusiscomplete,administerNSinfusion:

<5years,administerNS125ml/hour.

6–13years,administerNS250ml/hour.

>13years,administerNS500ml/hour.

o SpecificfluidresuscitationbasedonTBSAwilloccuratreceivinghospitalorburncenter.


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ContactOLMCforadditionalordersorquestions.Medical Control

Pediatric Trauma: Chest Injuries


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Considerearlypositivepressureventilationinthesettingofimpendingrespiratoryfailurewithaflailsegment.

Assessbreathsoundsfrequently.

AssessforventilatorycompromiseandassistwithBVMasneeded.

Foropen”sucking”chestwounds,applyocclusivedressingsealedon3sidesorcommerciallyavailablechestseal.

o Removetemporarilytoventairifrespiratoryormentalstatusworsens.

Forimpaledobject,stabilizeinplace.

o Donotremoveimpaledobject.



Assessfortensionpneumothorax.

o Iftimeandpatientconditionallows,contactOLMC.

o Pleuraldecompressionfortensionpneumothoraxshouldonlybeperformedinthesettingoftraumawhenall3ofthefollowingcriteriaarepresentorinthesettingofresuscitationinTraumaticCardiacArrest.




o Ifindicated,performpleuraldecompression,refertoClinicalProcedure:ChestDecompression.




Medical Control


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RefertoPediatricPainManagement:Medical/Traumaifindicated.

Pediatric Trauma: Extremity Injuries


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Removeorcutawayclothingtoexposeareaofinjury.

Controlactivebleeding:



Suspectedfracture/dislocation:

o Assessanddocumentdistalpulses,capillaryrefill,sensation/movementpriortosplinting.

Ifpulseispresent:

Splintinpositionfound,ifpossible.

Ifpulseisabsent:

Attempttorealigntheinjuryintoanatomicalposition.

o Openwounds/fracturesshouldbecoveredwithsteriledressingsandimmobilizedinthepresentingposition.

o Dislocationsshouldbeimmobilizedtopreventanyfurthermovementofthejoint.

o Reassessanddocumentdistalpulses,capillaryrefill,andsensationaftersplinting.




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Assessgrossvisualacuity.

Ifinjuryissecondarytoachemicalexposure:

o Removepatientfromsource,ifsafetodoso.

o Removecontactlensesifappropriate;transportwithpatient.

o IrrigatetheeyeswithNSforaminimumof20minutes.

o Determinechemicalinvolved,bringSafetyDataSheet(SDS)ifavailable.

Ifeyeinjuryisduetotrauma:

o Donotirrigate.

o Stabilizeanypenetratingobjects.

o Donotremoveanyimpaledobject.

o Preventpatientfrombendingorstanding.

o Ifbloodisobservedinanteriorchamber,transportwithheadelevated60degrees.

Neverapplypressuretotheeyeballorglobe.

Donotusechemicalcoldpacksontheface.


Medical Control





Pediatric Trauma: Head Injuries


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Ifnormotensiveorhypertensive:

o Elevateheadofstretcher15°–30°.


Airway interventions can be detrimental to patients with head injury by raising intracranial pressure, worsening hypoxia (and secondary brain injury), and increasing risk of aspiration. Whenever possible, these patients should be managed in the least invasive manner to maintain O2 saturation > 92% (e.g., NRB, BVM with 100% O2).

Observeforsignsofimpendingrespiratoryfailure,refertoPediatricRespiratoryEmergencies:RespiratoryFailureprotocolifindicated.






Forpatientswithassistedventilation:

o TitratetotargetanETCO2of40mmHg.

o Acuteherniationshouldbesuspectedwhenthefollowingsignsarepresent:

Acuteunilateraldilatedandnon‐reactivepupil.

Abruptdeteriorationinmentalstatus.

Abruptonsetofmotorposturing.

Abruptincreaseinbloodpressure.

Abruptdecreaseinheartrate.

o Hyperventilationisatemporarymeasurewhichisonlyindicatedintheeventofacuteherniation.

Ifsignsofherniationdevelop,increaseventilationrateasindicated.TitrateETCO2between30–35mmHg.

<1yearofage,ventilateatrateof35.

≥1yearofage,ventilateatrateof25.


Medical Control


Pediatric Trauma: Head Injuries P

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Ifseverelyagitated/combative:

o DonotdelaytreatmenttoobtainIVaccess:

AdministerMidazolam0.2mg/kgIN(maxdose5mg).

OR

AdministerMidazolam0.1mg/kgIM/IV/IO(maxdose5mg).

Monitorforrespiratorydepression.


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Forvictimsofsexualassaultwhomeetmajortraumacriteria:

o TransporttoPediatricCapableTraumaCenter,refertoAdministrativeProcedure:TraumaTriageCriteria.

Forallothercases:

o TransporttonearestappropriateEmergencyDepartment.

Providesupportivecareasindicatedbypatient’scondition.

Preserveevidence.

RefertoAdministrativeProcedure:Abuse/Neglect.




Pediatric Trauma: Traumatic Amputations


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Controlactivebleeding.



Ifamputationisincomplete:

o Attempttostabilizewithbulkypressuredressing.

o Splintin‐line.

Ifamputationiscomplete:

o Cleanseamputatedpartwithsterilesaline.

o Wrapinsteriledressingmoistenedinsterilesaline.

o Placeinplasticbagifpossible.

o Attempttocoolwithcoldpackduringtransport.Donotplacedirectlyonice.






Administrative/Clinical Procedures

Administrative Procedure: Abuse and Neglect


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I. AuthorizedPersonnel

A. ActiveALSandBLSproviders.

II. Definitions

A. Child:

1. Forthepurposeofthisdirective,achildisdefinedasanyperson<18years

ofage.

B. Adult:

1. Forthepurposeofthisdirective,anadultisdefinedasanyperson≥18years

ofage.

C. IncapacitatedAdult:

1. Forthepurposeofthisdirective,anincapacitatedadultmeansanyperson≥

18yearsofagewhoisimpairedbyreasonofmentalillness,mental

impairment,physicalillness,ordisability,advancedageorothercausesto

theextentthattheadultlackssufficientunderstandingorcapacitytomake,

communicate,orcarryoutresponsibledecisionsconcerninghisorherwell‐

being.

D. PhysicalandMentalAbuse:

1. Whenacaretakerorotherpersoncreatesorinflicts,threatenstocreateor

inflict,orallowstobecreatedorinflicteduponsuchaphysicalormental

injurybyotherthanaccidentalmeans,orcreatesasubstantialriskofdeath,

disfigurementorimpairmentofbodilyormentalfunctionsuponthepatient.

2. Whenacaretakerorotherpersoncommitsorallowstobecommitted,any

actofsexualexploitationoranysexualactuponthepatient.

3. Whenacaretakerorotherpersoncreatesasubstantialriskofphysicalor

mentalinjurybyknowinglyleavingachildaloneinthesamedwelling,

includinganapartment,withapersontowhomthechildisnotrelatedby

bloodormarriageandwithwhomtheparent,orotherresponsibleperson,

knowshasbeenconvictedofanoffenseagainstaminorforwhich

registrationisrequiredasaviolentsexualoffender.

E. FinancialExploitation:

1. Theillegaluseofanadultorincapacitatedadultortheirresourcesfor

another'sprofitoradvantage.

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F. Neglect:

1. Childneglectoccurswhenthereisafailuretoprovidefood,clothing,shelter,

orsupervisionforachildtotheextentthatthechild’shealthorsafetyis

endangered.Thisalsoincludesabandonmentandsituationswherethe

parentorcaretaker’sownincapacitatingbehaviororabsencepreventsor

severelylimitstheperformingofchildcaringtasks.

2. Adultneglectoccurswhenanadultislivingundersuchcircumstancesthat

he/sheisnotabletoprovideforhimself/herselforisnotbeingprovided

servicesnecessarytomaintainhis/herphysicalandmentalhealthandthis

failuretoreceivesuchnecessaryservicesimpairsorthreatenstoimpairhis/

herwell‐being.

G. RequiredReporter:

1. AllactiveEMSprovidersarerequiredreportersandaremandatedtoreport

anysuspectedabuseorneglect.

III. Indications

A. Forusewhenconfrontedwithsuspectedsituationsdefinedinthisdirective.

IV. Procedure

A. PatientCareConsiderations.

1. Donotdelayappropriatetreatmentand/ortransportofpatient(s)dueto

reportingrequirementsassociatedwiththesecases.Reportingrequirements

maybefulfilledfollowingpatientcare.

2. Handledeceasedpatient(s)inaccordancewiththeClinicalProcedure:

TerminationofResuscitationandfollowthenotificationproceduresbelow.

B. Whenadult/childabuse,neglect,and/orexploitationaresuspectedatthesceneof

anemergency,thefollowingreportingcriteriashouldbeemployedimmediately

upondiscovery.

1. AdviseCommunicationsofneedforthepolicedepartment,ifnotalready

dispatched.

a. Ifthesceneissafe,assessandtreatthepatient.Initiatetransportas

soonaspractical.

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b. Whenpolicearrive,eitheratthesceneoratthehospital,advise

theofficer(s)ofthesuspectedabuseorneglectandanyscene

observations youhad.

2. NotifyPrinceWilliamCountyDepartmentofSocialServices.

a. Ifduringnormalbusinesshours(MondaythroughFriday0800‐1700),

contact(703)792‐4200.

b. Ifoutsideofnormalbusinesshours,requestCommunicationstopage

theon‐callSocialServicesrepresentative.

c. Foradultvictims,contactthe24‐hourVirginiaDSSAdultProtective

Serviceshotlineat1‐888‐832‐3858.

d. Forpediatricvictims,contactthe24‐hourVirginiaChildProtective

Servicesat1‐800‐552‐7096.

3. AdditionalNotifications.

a. Transportedpatients:notifythereceivingnurseandphysicianof

yoursuspicions,includedetailedobservationsandactions.

b. Forvictimswhoarepatients/residentsinahospital,nursingfacility,

orsimilarinstitution:notifytheindividualinchargeoftheinstitution

orhis/herdesignee,includedetailedobservationandactions.

C. Documentation.

1. DocumentsceneobservationsandpatientinformationonthePCR.The

PCRwillonlybereleasedtooutsideagenciesinaccordancewiththe

provider’sdepartmentalguidelines.

2. Thepolicedepartmentand/orsocialservicecaseworkermayrequestyour

observationsandbasisforsuspicioninwriting.

D. Guidelinesforsuspectedsexualassaultcases.

1. Advisethepatientnottobath,void,douche,brushteeth,drink,change

theirclothes,etc.

2. Preservethecrimescene.Nothingshouldbetouchedormovedintheareaof

thesuspectedassault.

3. AdvisepatientthattheycancontacttheA.C.T.S.Helplineat(703)368‐4141.

TheA.C.T.S.Helplinewillcontacttherapecrisiscounselorondutyfor

assistanceandsupportathome,duringmedicalexaminationsat

thehospital,andduringlawenforcementinterviewsthroughtocourt

proceedingsandappearances.

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Administrative Procedure: Americans With Disabilities Act


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B. Anymemberwhoisof“activestatus”andapprovedbytheirrespectiveagencyto

rideonemergencyresponseequipment.

II. Definitions

A. ServiceAnimal:

1. Anyanimalindividuallytrainedtodoworkorperformtasksforthebenefitof

apersonwithadisability.Aserviceanimalisnotconsideredapetbutrather

ananimaltrainedtoprovideassistancetoapersonbecauseofadisability.

B. DirectThreat

1. Asignificantrisktothehealthorsafetyofothersthatcannotbemitigatedor

eliminatedbymodifyingpolicies,practices,orprocedures.

III. Indications

A. Situationswhereapatientisaccompaniedbyaserviceanimal.

IV. Contraindications

A. Apublicentitymayaskanindividualwithadisabilitytoremoveaserviceanimal

fromthepremisesif:

1. Theanimalisoutofcontrolandtheanimal'shandlerdoesnottake

effectiveactiontocontrolit.

OR

2. Theanimalisnothousebroken.

V. RequirementsofProvidersandMembers

A. General.

1. Generally,apublicentityshallmodifyitspolicies,practices,orproceduresto

permittheuseofaserviceanimalbyanindividualwithadisability.

B. Ifananimalisproperlyexcluded(meetscontraindications).

1. Ifapublicentityproperlyexcludesaserviceanimalforreasonsnotedin

SectionIV,itshallgivetheindividualwithadisabilitytheopportunityto

participateintheservice,program,oractivitywithouthavingtheservice

animalonthepremises.

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C. Careorsupervision.

1. Apublicentityisnotresponsibleforthecareorsupervisionofaservice

animal.

D. Inquiries

1. Apublicentityshallnotaskaboutthenatureorextentofaperson's

disability,butmaymaketwoinquiriestodeterminewhetherananimal

qualifiesasaserviceanimal.Apublicentitymayask:

a. iftheanimalisrequiredbecauseofadisability.

AND

b. Whatworkortasktheanimalhasbeentrainedtoperform.

2. Apublicentityshallnotrequiredocumentation,suchasproofthatthe

animalhasbeencertified,trained,orlicensedasaserviceanimal.

Generally,apublicentitymaynotmaketheseinquiriesaboutaservice

animalwhenitisreadilyapparentthatananimalistrainedtodoworkor

performtasksforanindividualwithadisability(e.g.,thedogisobserved

guidinganindividualwhoisblindorhaslowvision,pullingaperson's

wheelchair,orprovidingassistancewithstabilityorbalancetoan

individualwithanobservablemobilitydisability).

E. Accesstoareasofapublicentity.

1. Individualswithdisabilitiesshallbepermittedtobeaccompaniedbytheir

serviceanimalsinallareasofapublicentity'sfacilitieswheremembersof

thepublic,participantsinservices,programsoractivities,orinvitees,as

relevant,areallowedtogo.

VI. Procedure

A. EMSprovidersandmembersmustbepreparedtosafelytransportserviceanimals

alongsidetheirhandlers.

B. Often,EMSprovidersandmemberswillcomeacrossserviceanimalsintheformof

canines.Therearenoregulationstospecifywhereaservicecanineshouldbeplaced

duringtransport.Thefollowingaregeneralrecommendationsforthesafetransport

ofcanines.

1. Aservicecaninemaybeplacedalongsideacenterframestretcher,remaining

clearoftheprovider.

2. Ensurethecanineissecuretoastationarydevice(e.g.,stretcher,seatbeltthat

hasaretractorthathasbeenpre‐crashedlocked).

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3. Securethestretcherpriortoplacingthecanineinthepatientcompartment.

Removethecaninepriortoremovingthestretcher.

4. Ifpossible,placetheleashontheappropriatecollarringtopreventinjuryor

asphyxiationwhensecuringthedog.

C. Whenapatient’sconditionrequireslife‐savinginterventionsorifspaceprohibits

transportofthecanineinthepatientcompartment,thecabofthevehiclemaybe

consideredasasecondarylocationtosecurethecanine.

VII. SpecialConsiderations

A. Intheeventaserviceanimalcannotbetransportedwiththepatientduetothe

criticalnatureofthepatient(e.g.,cardiopulmonaryarrest,illnessorinjuryrequiring

transporttofacilitybyhelicopter),providersshallarrangetransportationofthe

serviceanimaltothetransportdestinationofthepatient.Careoftheanimalcanalso

betakenbyafamilymemberorfriendattherequestofthepatient.

B. Miniaturehorses.

1. Reasonable modifications.

a. A public entity shall make reasonable modifications in policies, practices,

or procedures to permit the use of a miniature horse by an individual with

a disability if the miniature horse has been individually trained to do work

or perform tasks for the benefit of the individual with a disability.

2. Assessment factors.

a. In determining whether reasonable modifications in policies, practices, or

procedures can be made to allow a miniature horse into a specific facility,

a public entity shall consider:

1) The type, size, and weight of the miniature horse and whether the

facility can accommodate these features;

2) Whether the handler has sufficient control of the miniature horse;

3) Whether the miniature horse is housebroken; and

4) Whether the miniature horse's presence in a specific facility

compromises legitimate safety requirements that are necessary for

safe operation.

3. Other requirements

a. Sections V, “If an animal is properly excluded” to sections V, “Care

or supervision” shall also apply to miniature horses.

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Administrative Procedure: Burn Center Criteria


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II. Indications

A. Thefollowingshallbetransportedtoaburncenter.

1. 3rddegreeburns(fullthickness).

2. 2nddegreeburns(partialthickness)>10%TBSA.

a. 2nddegreeburnsontheface,neck,hands,feet,majorjoints,genitalia,

orperineum.

3. Circumferentialburns.

4. Burnswithassociatedtrauma.

a. Considerpatienttransporttoafacilitythatmanagesburnsand

trauma(e.g.,MedStarforadults,Children'sforpediatrics).

5. Burnsinpatientswithsignificantpre‐existingmedicalillness.

6. Burnsinthesettingofsuspectedinhalationinjuryoftoxicsmoke.

7. Electricalburns,includinglightning,orcontactwithhighvoltage

(greaterthan120V).

a. Spinalimmobilizationrequiredifhighvoltageelectricalinjury.

8. Chemicalburns(mustbedecontaminated).

a. Removeclothing.

b. Ifdrypowderispresent,brushawaybeforeirrigating.

c. Flushwithcopiousamountsofwateronsceneandcontinueirrigation

enroutetohospital.

d. ChemicalinjuriestoeyesareanEMERGENCY.Removecontactsand

irrigatecontinuouslywithnormalsalineforatleast30minutes.

e. Avoidhypothermia.

III. Procedure

A. GroundTransport.

1. Considersituationalawareness(e.g.,inclementweather,patientsrequiring

decontamination)andrelativetraveltimebygroundtoappropriate

treatmentfacility(traumacenter,burncenter,pediatricburncenter).

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B. MedevacTransport.

1. UnitofficersorincidentcommandwillrequestaMedevacthrough

Communicationsinaccordancewithoperationalpolicy.

C. UnstablePatientsorAirwayCompromise.

1. TransportpatienttothenearestemergencydepartmentandnotifyOLMC.

D. TransportDestination.

1. Iftheproviderhasanyquestionregardingappropriatetransportation

destination,OLMCshouldbecontacted.

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Administrative Procedure: Code Sepsis


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II. Definitions

A. CodeSepsis:

1. Terminologyusedtoprovidepre‐arrivalEmergencyDepartmentnotification

inordertofacilitaterapidassessmentandtreatmentofasuspectedsevere

sepsispatient.

III. Indications

A. Patientswhomeettheparametersasdefinedinthisprocedure.

IV. Procedure

A. AdultCriteria.

1. ThereceivingEmergencyDepartmentshouldbenotifiedofa“CodeSepsis”

whenanadultpatientmeetsthefollowing3criteria.

a. Suspectedinfection.

b. ETCO2≤25mmHg.

c. Twoormoreofthefollowing:

1) Feverorhypothermia(>100.4For<96.8F).

2) Tachypnea(respiratory>20).

3) Tachycardia(heartrate>90).

B. PediatricCriteria.

1. ThereceivingEmergencyDepartmentshouldbenotifiedofa“CodeSepsis”

whenapediatricpatientmeetsthefollowing3criteria.

1) Feverorhypothermia(>101.3For<96.8F).

2) Tachypnea(respiratoryrate>20).

3) Tachycardia(heartrate>90).

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Administrative Procedure: Code STEMI


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II. Definitions

A. CodeSTEMI:


inordertofacilitaterapidassessmentandtreatmentofasuspectedSTEMI

(STSegmentElevationMyocardiaInfarction)patient.

III. Indications

A. Patientswhomeettheparametersasdefinedinthisprocedure.

IV. Procedure

A. ThereceivingEmergencyDepartmentshouldbenotifiedofa“CodeSTEMI”whena

patientwhoishavingchestpainorischemicequivalentsymptomsfor<24hours

withanyofthefollowing:

1. STsegmentelevation≥1mmintwoormorecontiguousleads.

2. Computerinterpretationof“**ACUTEMI**”on12‐leadECG.

3. NewLeftBundleBranchBlock(confirmedbycomparingtopriorECG).

B. ImmediatenotificationandECGtransmissiontothereceivingfacilityisimperative.

Transmissionandnotificationfromthesceneispreferred.

C. Patientsmeeting“CodeSTEMI”criteriashouldbetransportedtoaPercutaneous

CoronaryIntervention(PCI)capablehospital.

1. PCICapablehospitalsinPrinceWilliamCounty:

a. Novant/UVAPrinceWilliamMedicalCenter.

b. SentaraNorthernVirginiaMedicalCenter.

D. Whenoperationallyfeasible,patient’spreferenceshouldbetakenintoaccountwhen

determiningtransportdestination.

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Administrative Procedure: Code Stroke


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II. Definitions

A. CodeStroke:


inordertofacilitaterapidassessmentandtreatmentofasuspectedstroke

patient.

III. Indications

A. Patientswhomeettheparameterasdefinedinthisprocedure.

IV. Procedure

A. TheCincinnatiPre‐HospitalStrokeScaleshouldbecompletedforallsuspected

strokepatients.Ifoneofthefollowingexamcomponentsis“positive,”thenthe

patientstrokescreeningispositive.Alloftheexamcomponentsmustbeperformed.

1. Lookforfacialdroopbyaskingthepatienttosmile.

2. Havepatient,whilesittinguprightorstanding,extendbotharmsparallelto

floor,closeeyes,andturntheirpalmsupward.

a. Assessforunilateraldriftofanarm.

3. Havethepersonsay,“Youcan’tteachanolddognewtricks.”

a. Assessforslurringofwords,wrongwords,orinabilitytospeak.

B. Establishthe“timelastnormal”forthepatient.Thiswillbethepresumedtimeof

onset.Ifpossibleobtainindependentverificationofthistimefromfamily,friends,

co‐workers,etc.

C. Ifthe“timelastnormal”is≤8hours,bloodglucoseisgreaterthan60mg/dL,andat

leastoneofthestrokescreeningispositive,alertthereceivinghospitalofa“Code

Stroke”asearlyaspossible.

D. AssessandtreatsuspectedstrokepatientsperappropriateMedical:Stroke

SuspectedProtocol.

E. ThecompletedCincinnatiPre‐HospitalStrokescreeningshouldbedocumentedin

thePCR.

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Administrative Procedure: Do Not Resuscitate Order


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I. InformationandResponsibilities

A. VirginiaCertifiedEmergencyMedicalService(EMS)Providers:

1. EMSProvidersDONOTneedtoseeanoriginalDurableDNRorOtherDNR

Order.AsofJuly21,2011,legiblecopiesofaDDNRordermaybeacceptedby

qualifiedhealthcareproviders.

2. WhattypesofDDNRformsororderscanbehonoredbyEMSproviders?

a. TheVDH/OEMS“State”DDNRform(oldornew)canbehonoredat

anytime;

b. ADDNRthatwasexecutedinaccordancewiththelawsofanother

state;

c. Authorized“AlternateDDNRJewelry”canbehonoredatanytime,but

itmustcontainequivalentinformationtotheStateform;

d. AverbalorderfromaphysiciancanbehonoredbyacertifiedEMS

provider.Theverbalordermustbefromaphysicianwhoisphysically

presentandwillingtoassumeresponsibilityorfromonlinemedical

control.

e. VirginiaPhysicianOrdersforScopeofTreatment(POST)formis

acceptableasaDDNRorder.

f. “Other”DNROrders:thisisthetermusedtodefineaphysician’s

writtenDNRorderwhenitisinaformatotherthantheStateform.

“Other”DNROrdersshouldbehonoredbyEMSproviders’whenthe

patientiswithinalicensehealthcarefacility,beingtransported

betweenhealthcarefacilities,orreceivinghospiceorhealthcare

servicesathome.Examplesof“Other”DNRordersincludefacility

developedDNRformsorotherdocumentsthatcontaintheequivalent

informationastheStateform.

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II. Definitions

III. Procedure

A. Begineachtransmissionwiththefollowing:

1. UnitIdentifier.

2. TriageCategory(e.g.,Trauma,Medical,CodeSTEMI,etc.).

3. Estimatedtimeofarrival(ETA).

B. Afterthereceivingfacilityacknowledgestheinitialinformation,giveaconcise

reportwhichincludesthefollowing:

1. Ageandgenderofpatient.

2. Chiefcomplaintorproblem.

3. VitalSigns.

4. Levelofconsciousness(includingGCSifalteredorsuspectedstroke).

5. Natureofillness/mechanismofinjury(iftrauma).

6. Descriptionofinjury(iftrauma).

7. Treatmentprovidedandpatientresponse.

8. Anyanticipateddelayintransport(e.g.,extrication,distance).

9. RepeatETA.

TriageCategories Definitions

Trauma Indicatespatientisatraumapatient.

Medical Indicatespatientisamedicalpatient.

CodeSTEMI PatientmeetsSTEMIcriteriaperCodeSTEMIProcedure.

CodeStroke PatientmeetsStrokecriteriaperCodeStrokeProcedure.

CodeSepsis PatientmeetsSepsiscriteriaperCodeSepsisProcedure.

Pediatric IndicatesPatientislessthan18yearsofage.

CPR CardiopulmonaryArrest

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Administrative Procedure: Extraordinary Care


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II. ScopeofPractice

A. InVirginia,EMSprovidersmayonlyprovideemergencymedicalcarewhileacting

undertheauthorityoftheOperationalMedicalDirector(viawrittenprotocolsor

PhysicianOLMC)andwithinthescopeoftheEMSagencylicense(e.g.ALSand/or

BLS)(12VAC5‐31‐1040).InPrinceWilliamCounty,thescopeofpracticeforall

providersisdefinedbyendorsementlevelandtheseprotocols.Thatis,providers

shallexercisegoodclinicaljudgmentbasedontrainingandexperienceandapply

appropriateFRAprotocolstospecificpatientencounters.Itisrecognizedthat

writtenprotocolscannotprovideguidanceforeverypossiblesituationproviders

mayencounter.Protocolsaremeanttoguideprovidersinachievingconsistently

excellentprehospitalcare,nottoreplacejudgmentorinitiative.Inroutinecases

whenwrittenprotocolsdonotaddresstheuniquepatientcareordisposition

needs,physicianOLMCisalwaysavailableandappropriateforsuchcircumstances.

III. ExtraordinaryCare

A. Inrarecases,whenthereisanimmediatethreattolifeorlimbnotaddressedby

protocol,treatmentsorinterventionsoutsideroutineprotocolmayberequired.

UndersuchcircumstancesthisextraordinarycaremustbeauthorizedbyPhysicain

OLMC(inaccordancewith12VAC5‐31‐1070).Casesrequiringsuchextraordinary

carewillbeexceedinglyrare.Mostproviderswillneverencountersuchacase

throughouttheircareer.Nothinginthisprotocolshouldbeinterpretedas

empoweringproviderstocircumventexistentprotocolorpracticebeyondtheir

scope.Inallsituations,boththeEMSprovidersandthePhysicianOLMCare

accountablefortheiractionsanddecisions.

IV. Procedure

A. ProcedureforAuthorization(extraordinarycarecannotoccurwithoutOLMC):

1. BoththeOLMCphysicianandtheprovidermustacknowledgeandagreethat:

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a. Thepatient’sconditionand/ortherequired/requestedextraordinary

carearenotaddressedelsewhereintheprotocols.

AND

b. Theorderisnecessarytomaintainthelife/limbofthepatient.

2. Theprovidermustfeelcapableofcorrectlyperformingthecaredirectedby

thephysician,basedonavailableequipment,priortraining,experience,and/

ortheinstructionsgivenbytheOLMCphysician.

3. Theprovidermustverballyconfirmtheorderandagreetoproceed.

B. InabilitytoCarryOutPhysicianOLMCOrders.1. Inrarecircumstances,providersmayreceiveordersfromOLMCthattheyare

unabletocarryout.Providersmayrefusetoperformspecificproceduresortreatments(inaccordancewith12VAC5‐31‐1080):a. Ifnotadequatelytrainedandproficienttoperformtheprocedure.b. Iftheprocedureisnotfullyunderstood.c. Iftheprocedureisjudgedtobenotinthebestinterestsofthepatient.d. Nothingprecludestheproviderandphysicianfromreaching

agreementonanotherorderifwithinthescopeofthisdocument.2. Iftheprovidercannotcarryoutanorder,PhysicianOLMCmustbe

immediatelynotifiedandgiventhereasontheordercouldnotbecarriedout.

C. Procedurefordocumentation.1. Theprovidermustinformthereceivingphysician(ifnotOLMC)oftheaffects

oftreatmentorsituationsurroundingtheinabilitytocarryoutOLMCordersassoonaspossible.

2. TheprovidermustalsonotifytheEMSOperationsandtheOMDassoonaspossible.

3. TheprovidershallfullydocumentthecallonthePCR,detailingallspecificsofthematterinthenarrative.

4. AllsuchinstancesshallautomaticallybereviewedbytheOMD.

D. InabilitytoContactPhysicianOLMC.1. IntherareeventprovidersareunabletocontactPhysicianOLMC,the

providershould:a. Usegoodclinicaljudgmentanddowhatisreasonableandwithintheir

scopeofpracticeandtraining.b. Documenttheevents,assessment,andinterventions.c. MakenotificationstotheBattalionChief,EMSOperations,andthe

OMDassoonasitisreasonabletodoso.

Nothingcontainedhereinimplicitlyorexplicitlyauthorizestheprovisionofcareexceedingtrainingorscopeofpractice.

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Administrative Procedure: Lights and Siren Use During Transport


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Research has shown that the routine use of emergency lights and siren during patient transport

increases the risk of accidental injury to patients, providers, and the community. The purpose of this

procedure is to provide guidelines for the appropriate usage of emergency warning lights and siren

when transporting a patient from the scene to the hospital.

Outlined below are some of the criteria that would justify the usage of lights and sirens that the

emergency medical providers should consider when determining the need to respond to the hospital.

This list is not inclusive, and it is imperative that the EMS providers weigh the risks versus benefits

before making a decision regarding emergency response to a receiving facility.


A. ActiveALSandBLSproviderswhoareEVOCcertifiedandhavecompletedallapplicableturn‐overprocessesasrequiredbytheirrespectiveagency.

II. Indications

A. Atthediscretionofthetransportingcrew,drivingwithlightsandsirenmaybe

consideredwhenthefollowingclinicalconditionsorcircumstancesexist:

1. Difficultyinmaintainingthepatient’sABCs(airway,breathingcirculation)

including(butnotlimitedto):

a. Inabilitytoestablish/maintainanadequateairwayorprovide

adequateventilations.

b. Severerespiratorydistressorinjurynotresponsivetoavailablefield

treatment.

2. Acutecoronarysyndromewithoneormoreofthefollowing:

a. STEMI.

b. Acutecongestiveheartfailure.

c. Hypotension.

d. Bradycardia.

e. WideComplexTachycardia.

f. Signsofimpendingdeterioration.

3. Anaphylaxiswithevidenceofshock.

4. Cardiacdysrhythmiaaccompaniedbysignsofimpendingoractualinstability

whichisunresponsivetoavailablefieldtherapysuchas:

a. Hypotension.

b. AcuteCHF.

c. Alteredlevelofconsciousness.

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d. Syncope.

e. Postcardiacarrest.

5. Severeuncontrolledhemorrhage.

6. Shock,unresponsivetoavailabletreatment.

7. Severetraumaincluding(butnotlimitedto):

a. Penetratingwoundstohead,neck,torso.

b. Twoormoreproximallongbonefractureswithhypotension.

c. MajorAmputations(proximaltowristorankle).

d. Neurovascularcompromiseofanextremity.

8. Severeneurologicalconditionsincluding(butnotlimitedto):

a. Statusepileptic.

b. Substantialorrapidlydeterioratinglevelofconsciousness.

c. Acutestroke‐likesymptomswhenlastseennormal≤8hoursprior.

9. Obstetricalemergenciesincluding(butnotlimitedto):

a. Laborcomplicationsthatthreatensurvivalofthemotherorfetus,suchas:

Prolapsedcord.

Breechpresentation.

Arresteddelivery.

Suspectedrupturedectopicpregnancy.

10. Crewdiscretionbasedonpatientcondition.

11. Foranytransportwherereducingtimetodefinitivecareisclinicallyindicated,

consideruseofaMedevac.

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Administrative Procedure: Medication Administration Cross Check


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II. Indications

A. AMedicationAdministrationCrossCheck(MACC)shallbeperformedbyendorsed

EMSproviderspriortotheadministrationofanymedication.

B. TheMACCshallbeperformedinitsentiretyandpriortorepeatdosesof

medications.

III. Procedure

A. Provider1initiatestheprocedurebystating“MedicationCrossCheck.”

B. Provider2responds“Ready.”

1. Itisimportanttoavoidusingambiguousstatementssuchas“okay”asthey

maybeinterpretedmanydifferentwaysandtheydonoteffectivelyreflect

Provider2'sactualstateofreadiness.

2. ItiscriticalthatProvider2isactivelyengagedintheMACC.

C. Provider1states“Iamgoingtogive”andprovidesthefollowinginformation:Dose,

MedicationName,Route,Rate,andReasonforAdministration.

1. IfandonlyifthereisconcurrenceonProvider2'sbehalf,doestheMACC

procedurecontinue.

D. IfProvider2agrees,theyshouldrespondwiththequestion“Contraindications?”

E. Provider1shallchecktheexpirationdate,verifythatthepatient’svitalsignsare

appropriate,andcheckforpatientallergies.Provider1shallrespondwith“No

Contraindications”or“ContraindicationsPresent.”

F. IfProvider2concurs,theyshouldrespondwiththequestions“Volume?”or

“Quantity?”

G. Provider1shouldstatethedrugconcentration,thevolumetheyintendtodeliver,

andshowthevitalstoProvider2.

H. Ifprovider2agreesandmakesapositivevisualverification,theyshouldrespond

with“Iagree.”

1. Itisimportanttoavoidusingambiguousstatementssuchas“okay”asthey

maybeinterpretedmanydifferentwaysandtheydonoteffectivelyreflect

Provider2'sactualstateofreadiness.

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IV. SpecialConsiderations

A. ItisbestpracticetohaveasecondendorsedEMSprovidervisuallyconfirmand

completetheMACCprocedurepriortoadministeringmedicationtoapatient.

Theremaybeaninstancewhenthesecondprovidercannotvisuallyconfirmthe

medication.Anexampleofthiswouldbeduringthetransportofapatientwherethe

secondproviderisoperatingtheambulance.Inthissituation,averbalverification

shouldbeconductedbetweenProviders1and2.Safetyofthecrewisparamount

andtheoperatorofthevehicleshouldnotbedistractedfromtheirresponsibilities

ofdriving.

1) Intheeventaverbalverificationcannotbeconductedwithasecond

provider,aloneprovidermuststillprocessthroughtheMACCprocedure.

Thisistheleastpreferredmethodandpresentsthegreatestchancefor

medicationerrorstooccur.

B. BLSProviderVerification

1) WhenALSprovidersareperformingaMACCforanALSmedication,itis

preferredthattheProvider2alsobeanendorsedALSprovider.Intheevent

asecondendorsedALSproviderisnotpresent,anendorsedBLSprovider

mayperformtheMACC.TheendorsedBLSprovidermaynotbeabletoverify

doseofmedicationbutcanconfirmthemedicationname,concentration,and

date.

2) WhenBLSprovidersareperformingaMACCforaBLSmedication,Provider2

mustbeataminimumanendorsedBLSprovider.

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Administrative Procedure: Patient Care During Interfacility Transport


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Althoughprimaryresponsibilityisnotforinter‐facilitytransports,situationsmayarisenecessitating

suchtransport.Theyrequireuniqueskillsandcapabilities,bothinclinicalandoperations

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II. Procedure

A. Inter‐facilitytransportdecisions(includingbutnotlimitedto,transportstaffing,

equipment,andtransportdestination)shouldbebasedonthepatient’smedical

needs.

1. EMSprovidersshouldensurethetransportisemergent.Anyconcerns

regardingtheemergentneedfortransportshouldbediscussedwiththe

sendingphysician.

2. ContacttheondutyBattalionChiefwithanyconcerns.

B. Matchproviderskillsandequipmentwithpatientcareneeds.

C. Coordinationbetweenhospitalsandinter‐facilitytransportersisessentialbefore

transportisinitiatedtoensurethatpatientcareisprovidedattheappropriatelevel

anddoesnotexceedthecapabilitiesoftheinter‐facilitytransportprovider.

D. Ifdevices/medicationsarenotlistedintheseprotocolsandmustbecontinued

duringtransport,anadequatelytrainedlicensed/careproviderfromthe

transferringfacilitywhosecredentialsareacceptabletothetransportingagency

mustaccompanythepatientduringtransport.

E. Allpatientsshouldbetransportedtothereceivingfacility’sEmergencyDepartment.

F. Thesendingfacilityshouldcall911torequesttransport.Thisiscriticalfor

thefollowingreasons:

1. AnewincidentiscreatedbyCommunications.

2. AnewincidentiscreatedinSafetyPad.

3. Billingrelatedissuesaresimplified.

G. EnsureondutyBattalionChiefisawareandnotifythemofanyconcerns.

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Administrative Procedure: Physician on Scene


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II. Indications

A. Forusewhenamedicalphysicianatthescenewishestodirectorassumepatient

care.

III. ProcedureA. Thephysiciandesiringtoassumecareofthepatientmust:

1. Providedocumentationofhis/herstatusasaphysician(MDorDO)toinclude

acurrentcopyofhis/herlicensetopracticemedicineintheCommonwealth

ofVirginia.

2. Assumecareofthepatientandallowdocumentationofhis/herassumption

ofcareonthePCR.

3. Agreetoaccompanythepatientduringtransporttothehospital.

4. Agreetoassumeresponsibilityforoutcomesrelatedtohis/heroversightof

patientcare.

B. ContactwithOLMCmustbeestablishedassoonaspossible.TheOLMCphysician

mustagreeandrelinquishtheresponsibilityofpatientcaretothephysicianon

sceneinorderforcaretobetransferred.

C. Ordersprovidedbythephysicianassumingresponsibilityforthepatientshouldbe

followedaslongastheydonot,inthejudgmentoftheEMSprovider,endanger

patientwell‐being.Theprovidermayrequestthephysiciantophysicallyprovide

patientcareduringtransportifthesuggestedtreatmentvariessignificantlyfrom

standingorders.

D. Ifthephysician’scareisjudgedbytheEMSprovidertobepotentiallyharmfultothe

patient,theEMSprovidershould:

1. Politelyvoicehis/herobjection.

2. Immediatelyplacetheon‐scenephysicianincontactwiththeOLMC

physician.

E. WhenconflictsarisebetweenthephysicianonsceneandtheOLMCPhysician,the

EMSprovidershould:

1. FollowthedirectivesoftheOLMCphysician.

2. Offernoassistanceincarryingouttheorderinquestion;offerno

resistancetothephysicianperformingthiscare.

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3. Ifthephysicianonscenecontinuestocarryouttheorderinquestion,

offernoresistanceandenlisttheaidoflawenforcement.

F. Allinteractionswithphysiciansonthescenemustbecompletelydocumented

inthePCR,includingthenameandlicensenumberoftheon‐scenephysician.

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Administrative Procedure: Police Custody Patient Care Standards


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II. Indications

A. Treatmentofpatientswhoareinthecustodyofalawenforcementofficer(LEO).

III. Procedure

A. Whencalledtoascenetoassessapersoninpolicecustody,performallassessment

andtreatmentconsistentwiththestandardssetforthetypical,non‐detained

patient.EMSprovidersarenotequippedtoperformformalmedicalclearancefor

patientsinpolicecustodypriortojailtransport.

B. Afterassessingthepatientandtreatinganyobviousconditions,transporttothe

emergencydepartmentshouldbeofferedinamannerconsistentwiththePrince

WilliamCountyEMSProtocols.

C. Ifthedetainedpatientrefusestransport,executeastandardpatientcarerefusalas

outlinedintheAdministrativeProcedure:RefusalofMedicalCare.

1. AdvisetheLEOofthepatient’sdecision,andifallcriteriaaremet,releasethe

patienttotheLEO.

D. Ifthepatientdoesnotmeetrefusalcriteria,advisetheLEOthattransportis

indicatedandcoordinateasafetransportofthedetainedpatientinaccordancewith

thefollowing:

1. IfthepatientremainsinLEOcustody,aLEOmustridewiththepatient,inthe

backofthetransportingEMSunit,tothehospital.

2. Donothogtieorrestrainthepatientinamannerthatinhibitsone’sabilityto

breathe.

3. IfthepatientremainsrestrainedbyaLEO,ensuretherestraintsdonot

inhibitthepatient’sabilitytobreathe.

4. Whenrestraintsneedtobemovedtofacilitatepatientcare,enlistthe

assistanceoftheLEO.

E. IftheLEOrequiresEMStransportofthepatientwhenthepatienthas

refusedEMScareand/ortransporttotheEmergencyDepartment:

1. ComplywiththeLEO’srequestandtransportthepatienttothenearest

appropriateED.

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F. InscenarioswhereaLEOisunwillingtoallowtransportofadetainedpatientafter

EMSprovidershavedeterminedtransportisindicated(e.g.,requestedtransport,is

notacandidateforrefusal,orobviousmedicalnecessity)adheretothefollowing:1. AssurethattheLEOunderstandstransportisindicatedandthatmedical

clearancepriortoincarcerationisnotaprocedureperformedbyEMS.2. RequestthattheLEOhaveasupervisordispatchedtotheincident.3. ContactOLMCforfurtherinputandassistanceifindicated.4. Iftheseactionsfailtoresolvetheissue,defertotheofficer’slegalauthorityto

retaincustodyofthepatient.5. Documenttheinteractionwell,includingthelawenforcementagencyand

officerinvolved.

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Administrative Procedure: Refusal of Medical Care


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II. Definitions

A. Patient:

1. ApatientisdefinedbytheVirginiaDepartmentofHealthOfficeofEMSas:

“apersonwhoneedsimmediatemedicalattentionortransport,orboth,whose

physicalormentalconditionissuchthatheisindangeroflossoflifeorhealth

impairment,orwhomaybeincapacitatedorhelplessasaresultofphysicalor

mentalconditionorapersonwhorequiresmedicalattentionduringtransport

fromonemedicalcarefacilitytoanother.”‐12VAC5‐31‐10

B. CourtAppointedorDurablePowerofAttorney:

1. Adultpatientswithimpaireddecision‐makingcapacitymayhavecourt‐

appointedrepresentativesorarepresentativewithdurablepowerof

attorney(DPA)whomakedecisionsonthepatient’sbehalf.Undersuch

circumstances,thenameof thepatient’sdecision‐makingrepresentative

shouldbedocumentedonthePCR.Notethatpatientsdonotforfeit

theirrightscompletelytoaDPA;ifthepatientislucidanddemonstrating

intactdecision‐makingcapacity,thepatient’swishesshouldberespected.

TheDPAonlycomesintoplaywhenthepatientisimpaired.

C. Impaireddecision‐makingcapacity:

1. Patientsdemonstrateimpaireddecision‐makingcapacityiftheyareunableto

understandtheirconditionorourrecommendationsoriftheyhave

unreasonableexcusesforrefusingtreatmentortransport.Forexample,ifit

appearsthatapatientunderstandsourrecommendationsbutdoesnotwish

togototheEDbecauseheisdelusional,hisdecision‐makingcapacityis

impaired.Delusionalreasoningand/orinabilitytounderstandtheir

conditionandourrecommendationmayrenderpatientsunabletomake

medicaldecisions,toincludeinformedconsentandrefusal.

D. Impaireddecision‐makingcapacityduetophysicalillness/injury:

1. IftheEMSproviderhasreasontobelievethatapatient’sdecision‐making

abilityisimpairedduetoillnessorinjury,PhysicianOLMCmaybeableto

obtainaMedicalEmergencyCustodyOrder(ECO)throughaMagistrate.

ThisMedicalECOcanbepickedupanddeliveredtothescenebyalaw

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enforcementofficer,onwhoseauthorityandinwhosecustodythepatientis

involuntarilytransportedforfurtherevaluationandmanagement.

E. Impaireddecision‐makingcapacityduetopsychiatricillness:

1. IftheEMSproviderhasreasontobelievethatapatienthasanillnessor

injuryandthepatient’sdecision‐makingcapacityisimpairedbypsychiatric

illness,thepoliceshouldberequestedimmediatelytoevaluatethepatient.

Onarrival,officerswilldetermineifthepatientrepresentsathreattoself,

others,orpublicsafetyusingtheirowncriteriaandjudgment.Ifthepatientis

deemedathreat,theofficersmaytakethepatientintocustodyontheirown

authorityforeighthours“8hourrule”duringwhichprovidersandofficers

maycoordinatetransporttohospitalorotherfacility.Notethatthepolicedo

notmakemedicaldecisionsortakeourmedicalassessmentresultsinto

consideration.Theyhaveaformalprocesstheyfollowwithrespecttomental

capacity.Analternativetousingthepolicedirectlyistopetitionthe

MagistrateforanECO.Anyresponsiblepersonmaydothis,anditispossible

thattheMagistratemaygrantanOrderwherethepolicewillnotinterveneof

theirownaccord.

F. Intactdecision‐makingcapacity:

1. Patients’decision‐makingcapacityisdependentupontheirabilityto

understandtheircondition,therecommendedtreatment,andtherisks,

benefits,andalternativestoourtreatment.Ausefultechniqueforassessing

decision‐makingcapacityistohavepatientsrestatetheircondition,provider

recommendations,andtherisks,benefits,andalternativesassociatedwith

refusal,andthenasktheirreasonsforrefusal.Alanguagebarriermaymake

informedconsentandassessmentofdecision‐makingcapacitydifficult.

Therefore,anapprovedtranslatorviathelanguagelineshouldbeused

ifclinicalconditionallowsandcallcircumstancesrequireit.Itshouldbe

apparentthatillness,injury,orintoxicationmayimpairapatient’sdecision

makingcapacity.

III. Procedure

A. Apatientcareencounterandaprovider‐patientrelationshipisestablished

whenevertheEMSproviderhasdeterminedthatassessmentoftheindividualis

necessarytoensurenoillnessorinjuryexistsandtoensuretheindividual’scapacity

todeclineassessmentorcareisnotimpairedbyillness,injury,orintoxication.

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B. Allpatientsshallbeassessedandofferedtransportbyambulancetothenearest

appropriateemergencydepartment,regardlessofthenatureofthecomplaint.

C. Intheeventapatient,orhis/herguardian,refusestransporttothehospital,a

properlyexecutedrefusalprocessmustbecompleted.

D. PediatricRefusals.

1. OLMCconsultationisrequiredpriortocompletingtherefusalprocessforany

pediatricpatientwheresignificantvitalsignorphysicalexamabnormalities

arepresent.

2. Intheeventtheparent/guardianrefusesmedicalcareforaminorwhen

thereisreasonableconcernthattherefusalwillposeathreattothewell‐

beingoftheminor:

a. RequestPDforpatientandcrewsafety.

b. Ifanimmediatelifethreateningconditionexists,

transportthepatienttothenearestappropriateED.

E. ThreesteprefusalprocessforEMSproviderstocompletewhenacceptingarefusal

ofcare:

Step1Determineifthepatient/guardianislegallyrecognizedasaninformed

decisionmaker.Ifnot,norefusalwillbeaccepted.Thepatientshould

beoneofthefollowing:

a. Aperson≥14yearsofage.

1) Ifpatientisoftheageof14andunder18andaparent/legal

guardianarepresent,theyarethelegaldecisionmakerfor

determinationofmedicalcare.

2) Ifnoparent/legalguardianisavailable,thepatientmustbe

abletoproducepictureidentificationtoverifyage.If

verificationisunavailable,treatasifthepatientislessthan14

yearsofage.

3) Ifidentificationispresentandtherefusalisacceptable,

documenttheincidentonthePCRandattempttoadvisethe

parent/legalguardianofthesituation.

b. Acourt‐emancipatedminor.

c. Alegallymarriedpersonofanyage.

d. Aminorpregnantfemaleonlywhenthemedicalconcernrelatestoher

pregnancy.

e. Afemaleundertheageof18whoisaparentwillbetreatedasan

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f. Aparent(ofanyage)/orlegalguardianonbehalfoftheirchildwhen

therefusalofcaredoesnotplacethechildatrisk.

g. InvolveOLMC/lawenforcementforanyrefusalinvolvingaminor

(<14)whentheparent/legalguardiancannotbe contacted.

Step2Determineifthepatient’sdecision‐makingcapacityappearsto

beintact.Toundergotheinformedrefusalofmedicalcareprocess,the

patient/legalguardian’sdecision‐makingprocesscannotbeimpairedby

medicalorpsychiatricconditions.Thepatientmustexhibitallofthe

following:

1. Awake,alertandorientedtoperson,place,time,andsituation.

2. Normalgaitandcoordination.

3. Normalspeechpattern.

4. Apparentlynormalthoughtprocess

a. Nosuicidalideation.

b. Nohomicidalideation.

c. Nohallucinationsordelusions.

5. Apparentlyintactinsightandjudgment.

Step3Documenttheinteractionwell.Thefollowingitemsshouldbedocumented

foreveryrefusal:

1. AmentalstatusexaminationasdetailedinStep2.

2. Aphysicalassessment(includingvitalsigns).

a. Performbloodglucoselevelandoxygensaturationwhen

appropriate.

IFTHEPATIENTDOESNOTMEETREFUSALCRITERIAASDESCRIBEDINSTEPS1AND

2,THENTHEYARENOTACANDIDATEFORREFUSAL.ENLISTTHEASSISTANCEOF

OLMCAND/ORLAWENFORCMENTFORCONSIDERATIONSOFEMERGENCYCUSTODY

ORDER.DOCUMENTTHESEINTERATIONSINDETAIL.

F. Refusaloftransportaftercarehasbeeninitiated.

1. ContactOLMCforsituationsthatarisethatarenotaddressedinthis

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IV.SpecialConsiderations/OptionsforInvoluntaryTransport

A. EmergencyCustodyOrderMedicalprocess:

1. ContactOLMCtodiscussandrequestjustificationfortheECO.

2. ObtaintheECOthroughtheMagistrate.

3. DeliveryofECObylawenforcementtothehospitalfortheOLMCsignature.

4. DeliveryofECObylawenforcementtotheincidentscene.

5. InvoluntarypatienttransportofpatientbyEMStoED.

B. EmergencyCustodyOrderPsychiatricIllnessprocess:

1. Notifylawenforcement.

2. ContactOLMCtodiscussandrequestjustificationfortheECO.

3. OLMCpetitionsthemagistrateforanECO.

4. DeliveryofECObylawenforcementtotheincidentscene.

5. InvoluntarypatienttransportofpatientbyEMStoED.


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Administrative Procedure: Refusal of Transport After Treatment


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II. Procedure

A. Refusaloftransport:Bronchospasmresolvedafternebulizertreatment.

1. Aftertreatmentofbronchospasm,andreturntoanasymptomatic

state,somepatientswillrefusetransporttothehospital.The

followingitemsshouldbeaccountedforandincludedinthe

assessmentanddocumentation:

a. Theinitialpresentationisconsistentwithamildbronchospasm.

b. Noseveredyspneaatonset.

c. Nopain,changeinsputum,fever,orhemoptysis.

d. Notclinicallyhypoxic(SpO2<92%).

e. Significantimprovementafterasinglenebulizertreatment.

f. Vitalsignswithinnormallimitsaftertreatment(BP,pulse,

respiratoryrateandSpO2).

2. Additionalpatientsafetymeasuresthatshouldbeconsidered:

a. Afamilymemberorcaregivershouldbeavailabletostaywith

thepatientandassistifarelapseoccurs.

b. Assurethepatientunderstandstransporthasbeenofferedand

subsequentlyrefused.

c. Informthepatienttofollow‐upwiththeirphysicianassoonas

possibleand/ortore‐contact911ifsymptomsreoccur.

3. Iftheaboveareaccountedfor,aproperlyexecutedrefusalofmedicalcare

canbeacceptedbyanALSprovider,fromthepatient/legalguardian,

withoutcontactingOLMC.

a. Iftheabovearenotaccountedfor,OLMCmustbecontactedpriorto

obtainingapatientrefusal.

1) AdviseOLMCofthepatient’spresentillness,treatments

provided,patient’sresponsetotreatments,andcurrentvitals.

2) ProvidepatientwiththeOLMC’srecommendationsforcare

and/ortransport.DocumentOLMC’snameandinteractionin

PCR.

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B. Refusaloftransport:Insulindependentdiabeticpatientsaftertheresolution

ofinsulin‐inducedhypoglycemiabytheadministrationofintravenousglucose.

1. Thisprocedurecannotbeusedifthepatienttakesanyoraldiabetes

medications.

2. Aftertreatmentofinsulin‐inducedhypoglycemia,andreturntoan

asymptomaticstate,somepatientswillrefusetransporttothehospital.The

followingitemsshouldbeaccountedforandincludedintheassessmentand

documentation.

a. ThepatientisonInsulinonly(doesnottakeanyoraldiabetes

medications‐metformin,glipizide,Januvia).

b. Thepresentationisconsistentwithhypoglycemia.

c. Rapidimprovementandcompleteresolutionofsymptomsafter

glucose.

d. Vitalsignswithinnormallimitsafterglucosegiven(BP,pulse,

respiratoryrate,oxygenationandbloodsugar>60).

e. Thereisnoindicationofanintentionaloverdoseordosingerror.

3. Additionalpatientsafetymeasuresthatshouldbeconsidered:

a. PatientmustbeevaluatedbyanALSprovider.

b. Afamilymemberorcaregivershouldbeavailabletostaywiththe

patientandassistifarelapseoccurs.

c. Assurethepatientunderstandstransporthasbeenofferedand

subsequentlyrefused.

d. Informthepatienttofollow‐upwiththeirphysicianassoonas

possibleand/ortore‐contact911ifsymptomsreoccur.

4. Iftheaboveareaccountedfor,aproperlyexecutedrefusalofmedicalcare

canbeacceptedbyanALSprovider,fromthepatient/legalguardian,without

contactingOLMC.

a. Iftheabovearenotaccountedfor,OLMCmustbecontactedpriorto

obtainingapatientrefusal.

1) AdviseOLMCofthepatient’spresentillness,treatments

provided,patient’sresponsetotreatments,andcurrentvitals.

2) ProvidepatientwiththeOLMC’srecommendationsforcare

and/ortransport.DocumentOLMC’snameandinteractionin

PCR.

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Administrative Procedure: Restraints


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II. Indications

A. Anypatientwhoisdeemedathreattothemselvesorothersmaybegently

restrainedtopreventinjurytothepatientorcrew.Thisrestraintmustbeina

humanemannerandusedonlyasalastresort.Othermeanstopreventinjurytothe

patientorcrewmustbeattemptedfirst.Theseeffortscouldincludereality

orientation,distractiontechniques,orotherlessrestrictivetherapeuticmeans.

Physicalorchemicalrestraintshouldbeusedasalastresort.

III. Contraindications

A. Apatientwhomeetsrefusalcriteriaforrefusalofmedicalcareand/ortransport.

IV. Procedure

A. Attemptlessrestrictivemeansofmanagingthepatient.

B. Ensurethattherearesufficientpersonnelavailabletophysicallyrestrainthepatient

safely.

C. Restrainthepatientinalateralorsupineposition.Nodevicessuchasbackboards,

splints,orotherdeviceswillbeontopofthepatient.

D. Thepatientwillneverberestrainedintheproneposition.

E. ThepatientmustbeunderconstantobservationbytheEMScrewatalltimes.This

includesdirectvisualizationofthepatientaswellascardiac,SpO2,andETCO2

monitoring.Ensurerestraintsaresecuredtoanon‐moveablepartofthestretcher.

F. Theextremitiesthatarerestrainedwillhaveacirculationcheckatleastevery15

minutes.Thefirstofthesechecksshouldoccurassoonafterplacementofthe

restraintsaspossible.ThisMUSTbedocumentedonthePCR.

G. Iftheaboveactionsareunsuccessfulorifthepatientisresistingtherestraints,

considerchemicalrestraintperAdultMedical:BehavioralEmergencies/Excited

Delirium.

H. Ifapatientisrestrainedbylawenforcementpersonnelwithhandcuffs,orother

devicesEMSproviderscannotremove,aLEOmustaccompany thepatienttothe

hospitalinthetransportingEMSvehicle.

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Administrative Procedure: Trauma Triage Criteria


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II. Procedure

A. AssesstraumapatientsanddeterminetransportdestinationperTraumaTriage

Algorithmonthefollowingpage.

1. TheTraumaTriageAlgorithmwasadaptedfromtheCDCGuidelinesfor

FieldTriageofInjuredPatients,VirginiaStateTraumaTriagePlan,and

NorthernVirginiaEMSCouncilRegionalTraumaPlan.

Intentionally Left Blank

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Step 1: Measure Vitals and LOC

GCS < 14 Systolic BP < 90 Respiratory Rate < 10 or > 29

(<20 in infant < 1 year of age)

Step 2: Assess Anatomy of Injury

Penetrating injury to head, neck, torso, and extremities (proximal to knee/elbow)

Flail Chest Two or more long bone fractures Crushed, degloved, or mangled extremity Amputation proximal to wrist or ankle Pelvic Fracture Open or Depressed Skull Fracture Paralysis

Step 3: Assess Mechanism of Injury and Evidence of High Energy Impact

Falls Older Adults: > 20 Feet (one story = 10 feet) Children: > 10 Feet (or 2-3 times the height of the

child)High Risk Auto Crash

Intrusion > 12 in. occupant side; > 18 in. any site Ejection (partial or complete) from automobile Death in the same passenger compartment Vehicle automatic crash notification data consistant

with high risk injuryAuto vs. Pedestrian/Bicyclist Thrown, Run Over, or with Significant Impact (>20 mph)Motorcycle Crash > 20mph

TT

Transport to Trauma Center

Transport to a Trauma Center may be achieved by either Medevac or Ground

Transport.

Inova Fairfax Regional Trauma Center (FFX) is the primary Level 1 Trauma Center.

HCA Reston Hospital is a Regional adult Level II Trauma Center.

Mary Washington Hospital is a Regional adultLevel II Trauma Center.

Washington Hospital Center/MEDSTAR is the regional adult Burn Center and a Level I Trauma Center.

Children’s National Medical Center is the regional pediatric Burn Center and a Pediatric Level 1 Trauma Center.

Other Facilities may be considered on a case-by-case basis.

Step 4: Assess Special Patient or System Considerations

Age Older Adults: Risk of injury death increase after age

55 Children: Should be triaged preferentially to a

pediatric-capable trauma centerAnticoagulation or bleeding disordersBurns

Without other Trauma Mechanism: o Triage to burn facility

With Trauma Mechanism: o Triage to Trauma Center

Time Sensitive Extremity InjuryEnd-Stage Renal Disease Required DiaylsisEMS Provider Judgement

TT

Transport to closest appropriate hospital (may be

local facility or Trauma Center) capable of timely

and thorough initial evaluation and management

of potentially serious injuries. Consider

consultation with OLMC if transporting to local

facility.

YES

YES

YES

YES

Transport according to normal operational procedures.

Administrative Procedure: Trauma Triage CriteriaA

dm

inistra

tive P

roc

ed

ure

: Tra

um

a T

riag

e C

riteria

NO

NO

NO

NO

159




II. Indications

A. Fireand/orEMSpersonnelhavenotinitiatedcardiopulmonaryresuscitation.

B. Thepatienthasnotbeenexposedtoanenvironmentlikelytopromotehypothermia.

AND

C. Thepatientisexperiencingoneofthefollowing.

1. Obvioussignsofdeath.

a. Decapitation.

b. Rigormortis(postmortemstiffingofthebody’smuscles.Itmayor

maynotinvolvesomedegreeofactualshorteningofthemuscles.In

mostcases,rigormortisbeginswithin1‐2hoursafterdeath;itbegins

topassafter24hours).

c. Decompositionofbodytissue.

d. Dependentlividity(purple‐redcolorationthatappearsondependent

portionsofthebodyotherthanareasexposedtopressureafterthe

heartceasestobeat.Itresultsfromthesettlingofthebloodunderthe

forceofgravity).

c. Injuriesincompatiblewithlife(e.g.,incineration,decapitation,

hemicorporectomy).

2. Bluntorpenetratingtrauma(allcriteriamustbemet).

a. Pulseless,apneic,andnoothersignsoflifepresent.

b. Lackofpupillaryreflexorspontaneousmovement.

c. Asystoleoragonalrhythm<20oncardiacmonitor(ifALSpresent).

3. ValidDNR,DDNR,orPOSTformispresent.

a. RefertoAdministrativeProcedure:DoNotResuscitateOrderfor

moreinformationonacceptableforms.

III. Contraindications.

A. CardiopulmonaryresuscitationhadbeeninitiatedbyFireand/orEMSpersonnel.

B. Mechanismofinjuryisinconsistentwithatraumaticarrest.

C. ThepatienthasbeenmovedtoatransportingEMSunitortransporthasbeen

initiated.

Administrative Procedure: Withholding ResuscitationA

dm

inistra

tive P

roc

ed

ure

: With

ho

ldin

g R

esu

scita

tion

160

Administrative Procedure: Withholding Resuscitation


Ad

min

istrative

Pro

ce

du

re: W

ithh

old

ing

Re

susc

itatio

n

IV. Procedure

A. Ifthepatientmeetstheindicationsforwithholdingresuscitation(e.g.,medical/traumaticinnatureorvalidDNR,DDNR,POST),thefollowingshouldbeperformedanddocumentedonthePCR.1. Hearttonesshallbeauscultatedforatleast30seconds.2. NotifycommunicationsoftheconfirmedDOAandrequestLEO,ifnotalready

present.3. PreservethesceneandawaitarrivalofLEO.Inordertopreservetrace

evidence,avoidcoveringthebodywhenitisprudentandreasonabletodoso.Whenapatientisdeceasedataresidenceorotherprivatearea,partitionofforotherwiserestrictaccesstotheareawherethebodyis.LEOonthesceneshouldbeinvolvedinthedecisiononhowtobestrespectthepatient’sdignitywithoutcompromisinginvestigativeneeds.Thereisnostrictcontraindicationtocoveringthedeceased,especiallywhencrewsaretryingtoprotectthedignityofthedeceasedorthementalstateofthefamily.

4. Providecomfortmeasurestofamilymembers.5. BepreparedtoprovideLEOwiththefollowing,ifapplicable:

a. Initialfindings.b. Timeofdeath.c. Nameofproviderthatdeterminedresuscitationisnotindicated.d. Patient’smedicalhistory.e. Patient’smedications.f. Patient’sprimaryphysician.

6. Transportationofdeceasedbodieswillbehandledbyprivatefuneralhomes.ArrangementquestionsshouldbedirectedtoLEO.

IV. SpecialConsideration

A. InitiatecardiopulmonaryresuscitationandcontactOLMCinthefollowingsituations.1. Lightingorhighvoltageelectricalinjuries.2. Drowning.3. Suspectedhypothermia.

B. IfCPRhasbeeninitiatedbyother(bystanders,lawenforcement)priortoEMSarrival,resuscitativeeffortsmaybeterminatedprovidedthepatientmeetstheindications.

C. IfCPRhasbeeninitiatedbyEMS/Fire,OLMCmustbecontactedforauthorizationtoterminateresuscitativeeffortspriortoterminatingresuscitation.

161

Clinical Procedure: Advanced Suctioning


Clin

ica

l Pro

ce

du

re: A

dva

nc

ed

Su

ctio

nin

g



II. Indications

A. Obstructionoftheairway(secondarytosecretions,blood,oranyothersubstance)

inapatientcurrentlybeingassistedwithanairwayadjunctsuchasanendotracheal

tube,tracheostomytube,oracricothyrotomytube.


A. None.

IV. Procedure

A. Ensuresuctiondeviceisinproperworkingorder.

B. Pre‐oxygenatethepatient.

C. Attachsuctioncathetertosuctiondevice,keepingsterileplasticcoveringover

catheter.

E. Thesuctioncathetershouldnotbeadvancedpasttheendoftheairway.Forall

devices,usethesuprasternalnotchastheendoftheairway.Measurethedepth

desiredforthecatheter(judgmentmustbeusedregardingthedepthofsuctioning

withcricothyrotomyandtracheostomytubes).

F. Ifapplicable,removeventilationdevices(e.g.,bag‐valvemask)fromtheairway.

G. Withthethumbportofthecatheteruncovered,insertthecatheterthroughthe

airwaydevice.

H. Oncethedesireddepth(measuredin“E”above)hasbeenreached,occludethe

thumbportandremovethesuctioncatheterslowly.

I. Smallvolume(<10ml)ofnormalsalinelavagemaybeusedasindicated.

J. Reattachventilationdevice(e.g.,bag‐valve‐mask)andventilatethepatient.

K. DocumenttimeandresultinthePCR.

162

Clinical Procedure: Basic Suctioning


Clin

ica

l Pro

ce

du

re: B

asic

Su

ctio

nin

g



II. Indications

A. Obstructionoftheairway(secondarytosecretions,blood,oranyothersubstance)inapatientwhocannotmaintainorkeeptheairwayclear.


A. None.

IV. Procedure

A. Ensuresuctiondeviceisinproperworkingorderwithsuctiontipinplace.

B. Setmechanicalsuctiondevicetoappropriatesetting(Adult:120‐150mmHgOR

Pediatric:80‐100mmHg).

C. Measuresuctiontipfromcornerofmouthtoearlobeandmarkmaximuminsertion

depth;ORensuretipofcatheterisalwaysinsightduringuse.

D. Pre‐oxygenatethepatient.

E. Explaintheproceduretothepatientiftheyarecoherent.

F. Examinetheoropharynxandremoveanypotentialforeignbodiesormaterialthat

mayoccludetheairway.

G. Ifapplicable,removeventilationdevices(e.g.,bag‐valvemask)fromtheairway.

H. Usethesuctiondevicetoremoveanysecretions,blood,orothersubstance.

I. Maximumsuctiontime:a. Adult‐15seconds

b. Pediatric‐10seconds

c. Infant‐5seconds

J. Reattachventilationdevice(e.g.,bag‐valvemask)andventilateorassistthepatient.

K. RecordthetimeandresultofthesuctioninginthePCR.

163

Clinical Procedure: Carboxyhemoglobin Monitoring


Clin

ica

l Pro

ce

du

re: C

arb

oxyh

em

og

lob

in M

on

itorin

g



II. Indications

A. Smokeinhalation.

B. SuspectedCOpoisoning.

C. Firefighterrehabilitation.

D. Patientsexhibitingsymptomssuchas:

1. Headache.

2. Flu‐likesymptoms.

3. Weaknessorfatigue.

4. Nauseaand/orvomiting.

5. AlteredLOC.

6. Multiplepatientsdisplayingsimilarsymptoms.


A. None.

IV. Equipment

A. PhysioControlLifepak15withSpCOmonitoringandrainbowsensor.

OR

B. RAD‐57withSPCOmonitoringandrainbowsensor.

V.Procedure

A. Performinitialassessment.

B. ObtainCarboxyhemaglobin(SPCO)readings;confirmabnormalreadingsbytaking

measurementsintwoadditionalfingersandaveragingresults.

C. CompletetheCarboxyhemaglobinWorksheetanddeliveralongwiththepatientto

thereceivingfacility,iftransported.

D. IfreadingsonLifepak15orRAD57arepositiveforpossibleCOpoisoning,the

patientmustbemovedtoasafeenvironment.Providersafetyisparamount.

164


DuetothepotentialforpatientstobelocatedinanIDLHatmosphere,itmaybe

necessarytoutilizeSCBAandobtainatmosphericsamplespriortoaccessing

patients.Utilizationofadditionalresourcesmaybenecessarytofacilitatepatient

accessorextrication.

E. Treatmentandtransportrecommendations.

1. Refertoappropriatemedicalprotocolbasedonpatients’signsand

symptoms.

2. SPO2readingswillbeunreliableinpatientswithabnormalSPCOlevels.

F. AtmosphericmonitoringshallbeperformedanytimeCOpoisoningissuspectedor

thepatientexhibitsabnormalCOlevels.Requestadditionalresourcestoperform

atmosphericmonitoringwhenindicated.

G. IfabnormalSPCOlevelsarepresentandatmosphericreadingsarewithinnormal

limits(<35PPM),attempttoidentifyalternatesourceofpoisoningandrequest

assistancethroughCommunicationstocheckremotesourcelocations.

Clinical Procedure: Carboxyhemoglobin MonitoringC

linic

al P

roc

ed

ure

: Ca

rbo

xyhe

mo

glo

bin

Mo

nito

ring

165

CarbonMonoxideReadings

0‐5% Normalfornon‐smokers Treatsignsandsymptoms

5‐10% Normalforsmokers Treatsignsandsymptoms

5‐10% Abnormalfornon‐smokers HighflowO2andtransport

10‐15% Abnormalforanypatient Highflow02andtransport

>15% Significantlyabnormal ALSindicated,Highflow02andtransport

Clinical Procedure: Carboxyhemoglobin Monitoring


Clin

ica

l Pro

ce

du

re: C

arb

oxyh

em

og

lob

in M

on

itorin

g

166

Clinical Procedure: Chest Decompression


Clin

ica

l Pro

ce

du

re: C

he

st De

co

mp

resssio

n


A. ActiveALSproviders.

II. Indications

A. Pleuraldecompressionfortensionpneumothoraxshouldbeperformedwhenall3ofthefollowingcriteriaarepresentORinthesettingofatraumaticcardiacarrestinanadultpatient.1. Severerespiratorydistresswithhypoxia.

2. Unilateraldecreasedorabsentlungsounds(mayseetrachealdeviationaway

fromcollapsedlungfield).

3. Evidenceofhemodynamiccompromise(e.g.,shock,hypotension,altered

mentalstatus).

III. Equipment

A. 14gauge3.25inchover‐the‐needle‐catheter(Adult).

B. 18gauge1.25inchover‐the‐needle‐catheter(Pediatric).

C. Tape.

D. Sterilegauzepadsandrollergauze.

E. Alcoholswabs.

IV. Procedures

A. Locatedecompressionsite.

1. Identifythe2ndintercostalspaceinthemid‐clavicularlineonthesameside

asthesuspectedpneumothorax.

B. Preparethesitewithanalcoholswabandallowtoairdry.

1. Firmlyintroducecatheterimmediatelyabovedistalribofselectedsite

perpendiculartochestwall.

C. Insertthecatheterintothethorax,andlistenforairtoexit(maynotalwaysbe

audible).

D. Advancecatheterandremoveneedle.

E. Securethecathetertakingcarenottoallowittokink.

167

Clinical Procedure: Chest Decompression


Clin

ica

l Pro

ce

du

re: C

he

st De

co

mp

resssio

n

F. Reassesslungsounds,patientcondition,vitalsigns,andrespiratorystatus.

G. Monitorforreoccurrenceoftensionpneumothorax.Ifsignsorsymptomsreoccur,

repeattheprocedureleavingtheinitialcatheterinplace.

168

Clinical Procedure: Confirmation of Placement/Effectiveness of Ventilation


Clin

ica

l Pro

ce

du

re: C

on

firma

tion

of P

lac

em

en

t/Effe

ctive

ne

ss of V

en

tilatio

n



II. Procedure

A. Capnography/ETCO2Monitoring.

1. Digitalcapnography(waveform)isthesystemstandardforETCO2monitoring.

2. Intheeventdigitalcapnographyisnotavailableorduetoon‐scene

equipmentfailure,continuouscolorimetricmonitoringofETCO2isan

acceptablealternative.

3. Withtheexceptionofon‐sceneequipmentfailure,patientsshouldnotbe

routinelyswitchedfromdigitalcapnography(monitor)toacolorimetric

deviceformonitoringend‐tidalCO2.

4. ContinuousETCO2monitoringisaMANDATORYcomponentofinvasive

airwaymanagement.

a. IfETCO2monitoringcannotbeaccomplishedbyeitheroftheabove

methods,theinvasivedeviceMUSTbeREMOVED,andtheairway

managednon‐invasively.

b. Ifanalveolarwaveformisnotpresentwithinthefirst3‐6

breaths(e.g.,flatline)ordisappearsafterawaveformwaspresent,

brieflycheckthefilterlinecouplingtoassureitissecurelyinplace

thenremovetheETTorLTAandmanagetheairwaybyalternate

means.

5. Additionalconfirmationmeasures:

a. Assessforabsenceofepigastricsounds,presenceofbreathsounds,

andchestriseandfall.

6. Recordtubedepthandsecureinplaceusingacommercialholderif

applicable.

7. Utilizeheadrestraintdevices(i.e.“head‐blocks”)orrigidcervicalcollarand

longspineboardasindicatedtohelpsecureairwaydeviceinplace.

169

Clinical Procedure: Continuous Positive Airway Pressure (CPAP)


Clin

ica

l Pro

ce

du

re: C

on

tinu

ou

s Po

sitive A

irwa

y Pre

ssure

(CP

AP

)



II. Indications

A. ForadultpatientswithAcuteBronchospasticDisorders(acuteorchronicbronchitis,emphysema,orasthma)orAcutePulmonaryEdema,whohavehypoxemiaand/orrespiratorydistressthatdoesnotquicklyimprovewithpharmaceuticaltreatment.

B. ConsiderCPAPif2ormorepresent:1. Retractionofintercostaloraccessorymuscles.2. Wheezingorsignsbronchospasm.3. Rales.4. Respiratoryrate>25perminute.5. Oxygensaturation<92%onhighflowoxygen.


A. Respiratoryarrest.B. Agonalrespirations.C. Unconsciousorobtunded.D. Shockassociatedwithcardiacinsufficiency.E. Trauma.F. Persistentnauseaandvomiting.G. Facialanomalies.H. Currenttracheostomy.I. Inabilitytocooperatewiththeprocedure.J. Pediatricpatients(<18yearsofage)K. Resentgastric,laryngeal,tracheal,oresophagealsurgery.

IV. Equipment

A. O2MAXBiTracEDMask,w/Nebulizer,AdultMediumMask,w/3‐Set(5,7.5,10)PEEP

ValveandOhmedaQuickConnector.

B. SpareMasks

1. Small

2. Medium

3. Large

170


V. Procedure

A. Performprimaryandsecondarysurveys.

B. Attachcardiacmonitor,capnography,andSpO2.

1. ContinuousETCO2monitoringismandatory(AdvancedLifeSupport).

C. Verballyinstructpatient(thisisacriticalitem).

1. Patientswillsometimesrequireverbalassurancewhenusingthisdevice.

2. SetupCPAPdeviceaspermanufacturer’sinstructions.

3. Instructpatienttoslowlybreatheinthroughthenoseandexhalethroughthe

mouth(exhalationphaseshouldbeabout4seconds).

D. ForpulmonaryedemauseaninitialCPAPsettingof5cmH20,titrateupto10cm

H20basedonclinicalresponse(decreasedworkofbreathing,improved

oxygenation/ ventilation).

1. TitrationofCPAPpressurecanonlybeperformedbyanendorsedALS

Provider.

E. ForAsthma/COPDuseaninitialCPAPsettingof5cmH20.

F. Typically,treatmentshouldbecontinuedthroughouttransporttotheED.

G. IfhypoxiapersistswhileonCPAP,O2viacapnography‐nasalcannulashouldbeused

inadditiontoCPAPtoincreasetheamountofoxygendelivered.ExpectFiO2to

increaseapproximately4%witheachadditionallitterofO2flow.

H. Briefinterruptionstoadministermedicationsisacceptable.

I. Recordandmonitorvitalsigns,ETCO2,andO2saturationasindicated/available.

J. Intheeventofprogressiverespiratoryfailure:

1. Offerreassurance.

2. Stoptreatmentifnecessary.

3. InstituteBLSandALScareperappropriateprotocols.

4. DocumentadversereactionsandreasonswhyCPAPwasdiscontinuedin

PCR.

K. Thefollowingitemsshouldalsobedocumented:

1. CPAPsettingused(PEEP).

2. FiO2levelused.

Clinical Procedure: Continuous Positive Airway Pressure (CPAP)C

linic

al P

roc

ed

ure

: Co

ntin

uo

us P

ositive

Airw

ay P

ressu

re (C

PA

P)

171

Clinical Procedure: Cricothyrotomy


Clin

ica

l Pro

ce

du

re: C

rico

thyro

tom

y

CONTACTMEDICALCONTROLPRIORTOPERFORMINGCRICOTHYROTOMYIFTIMEPERMITS



II. Indications

A. Whenallairwaymanagementmeasureshavefailedandthepatientneedsan

advancedairwayimmediately,considerperformingcricothyrotomy.

B. Ifintheparamedic’sjudgement,thetimenecessarytocontactmedicalcontrolwill

compromisethepatient'schanceofsurvivalANDitisnotpossibletoventilatethe

patientwithabag‐valve‐maskduringtransport,cricothyrotomymaybeperformed

withoutMedicalControl.


A. Abilitytoventilatepatientwithanoral‐pharyngeal/nasal‐pharyngealairway,bag‐

valve‐mask,LTA,orendotrachealtube.

IV. Equipment

A. QuicktrachII.

B. AdultBVM.

C. In‐linecapnography.

D. 10mlsyringeforpilotballoon.

E. 10mlsyringefilledwith5mlNS.

V. Procedure

A. Filla10mlsyringewith5mlNS.

B. RemoveQuicktrachIIfromthepackageandassemblepermanufacturer’s

instructions:

1. Removevalveopener,attachsyringe,test,andevacuateairfromthecuff.

C. Hyperextendtheheadofthepatientwhenpossible.Cleanseanteriorneck.

D. Identifyandmarkcricothyroidmembraneasthedepressionbetweenthethyroid

cricoidcartilage.

172


E. Stabilizethelarynxwiththeindexfingerandthumb.

F. PuncturetheskinandcricothyroidmembranewiththeQuicktrachII,perpendicular

(90degreeangle)totheskinwhilegentlyaspiratingwiththesalinefilledsyringe.

1. Duetothesharpconicalneedle,apriorincisionisnotnecessary.The

openingofthetracheaisobtainedbydilation.

G. InserttheQuicktrachIIata45degreeanglefurthertowardsthetrachea.Advance

untilthestoppercontactstheskin(thestopperhelpstopreventtheneedlefrom

beinginsertedtoodeep).

H. Aspirateairwiththesalinefilledsyringetohelpdeterminethepositionofthe

cannula.

1. Trachealplacementisconfirmedbyairaspiration,evidencedbybubbles

intothesyringe.

2. Thesyringeshouldaspirateeasilyconfirmingtrachealairspace.

a. Ifaspirationisnotpossiblebecauseofanobeseneck,removethe

stopperandcarefullyadvancethecannulawiththemetalneedleuntil

airaspirationispossible.

b. Ifaspirationisstillnotpossible,reassesslandmarksandconsideran

additionalattempt.

I. Removethestopperfromthecannula.

J. Advancetheplasticcannulaforwardwiththethumbuntilthesafetyclipaudibly

clicksintoposition.Thisindicatesthatthetipofthemetalneedleiscoveredbythe

plasticcannulatopreventtrauma.

K. FurtherinserttheQuicktrachIIuntiltheflangerestsontheneck.Themetalneedle

maynowberemoved.

L. InflatethecuffwiththeTru‐cuff,ensurepressureisinthe“GreenZone.”Useupto

10mLofAIRONLY.Checkforproperinflationbypalpationofthepilotballoon.

M. Securetheplasticcannulawiththefoamnecktape.

N. AttachETCO2andBVM.

1. Ventilatethepatientdirectlyviathe15mmstandardconnectororviathe

includedflexibletubing.

O. Confirmplacementwithgentleventilationviabag‐valve‐mask,continuous

capnographyandphysicalmeans.

1. Besureairmovementisfluidwithbilateralsymmetricchestriseandthatno

visiblenecksoft‐tissuedistortionisnoted.

Clinical Procedure: CricothyrotomyC

linic

al P

roc

ed

ure

: Cric

oth

yroto

my

173


P. Considersedationifpatientbecomescombative:

o AdministerFentanyl1mcg/kg/IV/IO(maxdose50mcg),repeatevery5

minutesifindicated(maxcumulativedose200mcg).

o AdministerMidazolam2.5mgIV/IO,repeatin5minutesifindicatedand

monitorforhypotension(maxcumulativedose5mg).

Q. Ifnotpreviouslydone,immediatelynotifymedicalcontrolphysician.

R. Atcompletionofthecall,EMSOPSandOMDnotificationismandatory.

Clinical Procedure: CricothyrotomyC

linic

al P

roc

ed

ure

: Cric

oth

yroto

my

174

Clinical Procedure: End Tidal CO2 Monitoring


Clin

ica

l Pro

ce

du

re: E

nd

Tid

al C

O2 M

on

itorin

g



II. Equipment

A. Adult/Pediatricnasalcapnographycannula.

B. In‐linecapnographydevice.

III. Indications

A. Assessmentandmonitoringofnon‐intubatedpatientsexperiencing

respiratorydistressviaAdult/Pediatricnasalcapnographycannula.

B. Assessmentandmonitoringofmedicalandtraumapatientswithout

respiratorydistresswhereETCO2readingswillprovideadditionalinformationinto

thepatient’sconditionandaffecttreatmentperformedbyproviders(e.g.,suspected

sepsis,isolatedheadinjuries,stroke,cardiopulmonaryarrest).

C. Toconfirmplacementofadvancedairwaysviain‐linecapnographydevice.

IV. Procedure

A. NasalCannulaETCO2.1. Attachcapnographytubingtomonitoringdevice(LP‐15).

2. Attachtubingtopatient(maysupplementwithNRBmaskifneeded).

3. Documentreadingsinitiallyandthroughouttreatmentaswithothervital

signs.

B. In‐linecapnographydevice.

1. AttachcapnographysensortoBVMoradvancedairway.

2. Documentreadingsinitiallyandthroughouttreatmentaswithothervital

signs.

3. AnylossofETCO2detectionofwaveformindicatesanairwayproblem.

a. Rechecktubeplacementandremoveifappropriate.

4. ETCO2goalis40mmHg.

a.. Above45mmHg,increaseventilationrate.

b. Below35mmHg,slowdownventilationrate.

5. DocumenttheprocedureandresultsonthePCR.

175

Clinical Procedure: General Airway Management


Clin

ica

l Pro

ce

du

re: G

en

era

l Airw

ay M

an

ag

em

en

t



II. Indications

A. Inadequateoxygenationorventilation.

B. Unabletoremove/relieveobstructingforeignbody.


A. Seespecifictechniqueforcontraindicationstospecificprocedures.

IV. Equipment

A. BVM(appropriatebagandmaskforpatientsize).

B. Oxygensource.

C. Suctiondevicewithyankuer.

D. OPAsandNPAs.

E. KingLTairway.

F. Endotrachealtube(prepareestimatedcorrectsizeandonesizesmallerasbackup).

G. Styletforendotrachealtube(ifnotpre‐loaded).

H. SpO2monitor.

I. ETC02detectiondevice.

J. Capnography(waveform).

K. Colorimetricdevice(back‐updevice).

V. Procedure

A. Selectandreadyequipment,tubesizes,ETC02,suction,non‐visualizeddevices

(LTA).

B. Ifsuspicionoftrauma,maintainc‐spineimmobilization.

C. Haveassistantapplycricoidpressure.

D. Suctionalldebrisandsecretionsfromairway.

176

Clinical Procedure: General Airway Management


Clin

ica

l Pro

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re: G

en

era

l Airw

ay M

an

ag

em

en

t

E. BVMorspontaneousventilationsfor2‐5minuteswith100%oxygenattemptingto

keeptheoxygensaturation>92%.

F. InsertETTtakingnomorethan30secondsperattempt.

1. RefertoClinicalProcedure:OrotrachealIntubation.

G. Ifunsuccessfulorpatient’sSpO2drops92%,bagmaskventilateforadditional2

minutessothatSpO2maintains>95%.

H. Ifunsuccessful,insertlaryngealtubeairway(LTA)followingpracticeparameters.

I. IfunabletoinsertLTAandcannototherwiseventilateusinganyofabovetechniques

(includingBVM)andunabletomaintainSpO2byanyothermeans(BVM,OPA,NPA)

at90%considercricothyrotomy.

1. RefertoClinicalProcedure:Cricothyrotomy.

177

Clinical Procedure: Laryngeal Tube Airway (KING LTS-D)


Clin

ica

l Pro

ce

du

re: L

aryn

ge

al T

ub

e A

irwa

y (KIN

G L

TS

-D)



II. Indications

A. Whenanalternativeairwaydeviceisneededinthemanagementofrespiratory

failure,airwaycontrolorcardiacarrestinpatients4feettallorgreater.


A. Intactgagreflex.

B. Patientswithknownesophagealdisease.

C. Patientswhohaveingestedcausticsubstances.

D. Patientswithknowntrachealobstruction.

E. Patientswithatracheostomyorlaryengectomy.

F. Patientslessthan4feettall.

IV. Equipment

A. CorrectlysizedLTA(seechartbelow).

B. BVM.

C. Suctiondevice.

D. Biteblockand/orendotrachealtubeholder(ifavailable).

E. Appropriatelysizedsyringesforexpandingcuff.

F. ETCO2detectiondevice(capnographypreferred).

G. SpO2monitor.

178

KingLTS‐DAirwaySizes

Airway

Size

Connector

Color

Patient

Height

OuterDiameter/

InnerDiameter

Cuff

Volume

Gastric

Tube

3 Yellow 4‐5feet 18/10mm 50‐60ml Upto18Fr.

4 Red 5‐6feet 18/10mm 70‐80ml Upto18Fr.

5 Purple >6feet 18/10mm 80‐90ml Upto18Fr.


V. Procedure

A. Pre‐oxygenatepatientwith100%02viaBVMtoachieveSpO2of>95%ifpossible.

B. Checktheintegrityofthecuffinflationsystemandpilotballoon.

C. Tightlydeflatethecuffwiththesyringe.

D. LubricatetheposteriordistaltipoftheLTAwithawatersolublelubricant.

E. Placepatientinneutralsniffingposition(ifnoC‐spine/spinalinjurysuspected):

1. ForpatientswithsuspectedC‐spineinjury,performtwo‐personinsertion

technique.

a. Onepersonmaintainsmanualin‐linecervicalspinestabilizationwhile

theotherpersonproceedswiththeprocedure.

F. Pullmandibledowntoopenmouth.

G. InsertuninflatedLTAintooralcavitywithalateraltechnique.Thetubeshouldbe

rotatedlatterly45to90degreessuchastheblueorientationlineistouchingthe

cornerofthemouth.

H. Advancethetipbehindthebaseofthetonguewhilerotatingtubebacktomidlineso

thattheblueorientationlinefacesthechinofthepatient.

I. Withoutexertingexcessiveforce,advancetubeuntilbaseofthecoloredconnectoris

alignedwithteethorgums.

J. InflatetheLTAwiththeappropriatevolume:

1. IfuninflatedKingAirwayinsertionisdifficult,performajawthrust,pulling

thetongueforward.

K. AttachtheBVMandETCO2totheLTA.

L. Whilebaggingthepatient,gentlywithdrawthetubeuntilventilationbecomeseasy

andfreeflowing(largetidalvolumewithminimalairwaypressure).

M. Adjustcuffinflationifnecessarytoobtainasealoftheairwayatthepeakventilatory

pressureemployed.

N. ObtainETCO2,(capnographypreferred),listenforbreathsoundsbilaterally,lookfor

chestexcursion,andcheckoxygensaturation.

O. Secureinthemidlinetohelpmaintainagoodsealoverthelarynx.

P. Placebiteblock,oralairway,orendotrachealtubeholder(ifavailable)between

teethtopreventbitingtube.

Q. Ifapplicable,ensurec‐spinemotionremainsrestricted.

R. Ifanadditionalattemptisnecessary,oxygenatewith100%O2for2minutes

betweenattempts.Eachattemptshouldlastlessthan30seconds.Medicalpatients

arelimitedto2attempts,traumapatientsarelimitedto1attempt.

Clinical Procedure: Laryngeal Tube Airway (KING LTS-D)C

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Clinical Procedure: Obstructed Airway


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II. Procedure

A. ForeignBodyAirwayObstruction–Birthto1yearofageandconscious.

1. Ifcoughing,wheezingandexchangingair,donotinterferewiththevictim’s

effortstoexpeltheforeignbody.

2. Ifunabletocryorspeak,weakorabsentcough,ornoairexchange:

a. Supportthevictimintheheaddownpositionwithyournon‐dominant

handandforearm.

b. Perform5backblowswiththeheelofyourdominanthandbetween

theshouldblades.

c. Perform5chestthrustswithtwofingersinthecenterofthechest.

d. Repeatthestepsaboveuntiltheobjectisexpelledorthevictim

becomesunresponsive.

B. ForeignBodyAirwayObstruction–>1yearofageandconscious.

1. Ifcoughing,wheezingandexchangingair,donotinterferewiththepatient’s

effortstoexpeltheforeignbody.

2. Ifunabletospeak,weakorabsentcoughORnoairexchange,perform

abdominalthrusts(HeimlichManeuver).

C. ForeignBodyAirwayObstruction–allages,unconscious.

1. Ifpatientwasresponsiveandthenbecameunresponsive:

a. LowerthevictimtothegroundandbeginCPR,startingwith

compressions(donotcheckforapulse).

b. Everytimeyouopentheairwaytogivebreaths,openthemouthwide

andlookfortheobject.

c. Ifyouseeanobjectthatcaneasilyberemoved,removeitwithyour

finger.

d. Ifyoudonotseeanobject,continueCPR.

2. Ifaforeignbodyisvisualizedbutcannotberemovedwithfinger,attemptto

removeitunderdirectvisualizationusingtheLaryngoscopebladeandMagill

forceps(ALSONLY).

a. Assemblelaryngoscopeandcheckbulbonblade.

b. Holdlaryngoscopeinlefthand.

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c. Placepatientinsniffingposition.

d. Usetongue‐jawliftorcross‐fingertechniquetoopenmouth.

e. Insertlaryngoscopebladeintorightcornerofmouthandmoveto

midline,sweepingtongueoutofway.

f. Elevatemandibletovisualizeobstructionwithoutusingteethorgums

asafulcrum.

g. GraspMagillforcepsinrighthandandremoveobstructionunder

directvisualization.

h. Providesuctionasneeded.

i. ResumeappropriateCPRandairwaymanagement.

j. Iftheobstructionisnotvisualizedorcannotberetrieved,attempt

endotrachealintubationwithappropriatesizeETTor0.5

smaller(Paramediconlyforpediatricpatient).

k. Ifthepatientisanadult,anETTcannotbepassed,andthepatient

isunabletobeventilatedbyanyothermeans,consider

cricothyrotomy.RefertoClinicalProcedure:Cricothyrotomy

(Paramediconly).

Clinical Procedure: Obstructed AirwayC

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181

Clinical Procedure: Orotracheal Intubation/Bougie


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AuthorizedPersonnel


Indications

A. Respiratoryorcardiacarrest.B. InadequateventilationwithBVM.C. Impendingrespiratoryfailure:

1. Decreasedlevelofconsciousnesswithhypoxia(SpO2<90%)despite100%O2therapy,apnea,and/orrespiratoryrate<8.

2. Poorventilatoryeffort(withhypoxiadespite100%O2therapy).3. Inabilitytomaintainpatentairway.4. Symptomaticairwayobstruction.

Contraindications

A. Pediatricintubationscannotbeperformedbyintermediateproviders.

Equipment

A. AppropriatePPE(Mask,eyeprotection,gloves).B. AirtraqSPsystemwithappropriatesizeblade.C. Laryngoscopehandlewithappropriatesizeblade.D. PropersizeETT(withStylet)andback‐upETT0.5–1.0mmsmaller.E. Bougie10or15FrenchCoudetip.F. Forpediatrics,utilizeanappropriatelength/weightbasedsystemtodetermine

appropriatesize.G. Water‐solublelubricationgel(lubricatedistalendoftubeatcuff).H. Tru‐Cuffsyringe.I. ThomasETHolderortapewithproperOPA.J. BVMandO2source.

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K. Suctiondevice.L. Stethoscope.M. Digitalwaveformcapnography.N. SpO2monitor.

A. Patient/EquipmentPreparation.1. Maintaincervicalalignmentandimmobilizationifindicated.2. Auscultateforpresenceofbilaterallungsoundsbeforeintubation.3. Preparesuctionforimmediateuse.4. Attachproperbladetolaryngoscopehandleandchecklight.5. PlaceTru‐CuffsyringeonpilotbulbandchecktheETTCuff.6. LubricatedistalETTcuffandbottom½ofBougie(ifutilized).7. Properlypositionthepatienttofacilitateprocedure(i.e.,raisethestretcher

sothepatient’snoseisattheintubatingprovider’sxiphoid).8. Pre‐oxygenatepatientwith100%O2(BVMorNRB)beforeintubation.

AttempttoachieveO2saturation>92%for5minutes.9. AttachpatienttocardiacmonitorandSpO2monitor.10. ReadyETC02detectiondevice.11. Specifypersonneltoassistwith:

a. Applycricoidpressure(ifrequired).b. Keepneckimmobile(ifrequired).c. MonitorcardiacrhythmandSpO2saturation.

B. TubePlacement.1. IntubationutilizingAirtraqSP

a. SelecttheappropriatesizeAirtraqSPbasedonthesizeoftheETTtobeused.TurnONthelight.(thelightstopsblinkingoncetheanti‐fogsystemisfullyactivated).

b. AttachtheAirtraqcameratotheappropriatelyselectedblade.c. RemoveETTstylet,lubricatetheETT,andplaceintothelateral

channeloftheAirtraqSPwithoutcontactingthelens.d. AlignthetipoftheETTwiththeendofthelateralchannel.e. InserttheAirtraqSPintothemidlineofthepatient’smouth.f. Beforeitreachestheverticalplane,beginlookingtoidentifyairway

structures.g. Continueinsertionuntiltheepiglottisisidentified.Placethetipofthe

AirtraqSPintothevallecula.Alternatively,thetipcanbeplacedundertheepiglottis,liftingitoutoftheway.

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h. GentlyliftuptheAirtraqSPtoexposethevocalcords.i. Alignthevocalcordsinthecenterofthevisualfield.j. GentlyadvancetheETTinthelateralchannel.Ifneeded,rotatethe

ETTinsidethechannel.Checkinsertiondepth.k. InflatetheETTcuffwiththeTru‐Cuffsyringeuntilpressureisinthe

greenzone,approximately20‐25cmH20,andremovethesyringefrominflationvalve.Checkforproperpositioning.

l. CarefullyseparatetheETTfromtheAirtrqSPbypullingitlaterallyawayfromtheETT,whileholdingtheETTinposition.

m. RemovetheAirtraqSPfromthepatient’sairwayfollowingthemidline.

2. Intubationutilizingstylet:a. Removeallforeignobjects,(e.g.,dentures,OPA,etc.)andsuctionthe

patient'sairwayifneeded.b. Grasplaryngoscopehandleinlefthand.c. GraspETTtubeinrighthand.d. Insertthebladeintotherightsideofthepatient'smouthsweepingthe

tonguetotheleftside.e. Visualizethevocalcordswhileavoidinganypressureontheteeth.f. Ifneededtoimprovetheviewoftheglotticopening,applyordirect

anotherprovidertoapplylaryngealpressureorBimanualLaryngoscopyTechnique.

g. InserttheETTuntilthecuffpassesthevocalcords,typicaldepth=tubesize(ID)X3 ( e.g.24foran8.0mmtube).

h. Removethelaryngoscopeblade.i. Removestylet.j. InflatetheETTcuffwiththeTru‐Cuffsyringeuntilpressureisinthe

greenzone,approximately20‐25cmH20,andremovethesyringefrominflationvalve.

3. IntubationutilizingBougie.a. Removeallforeignobjects,(e.g.,dentures,OPA,etc.)andsuctionthe

patient'sairwayifneeded.b. Grasplaryngoscopehandleinlefthand.Alternatively,theAirTraqSP

canbeusedwithaBougiethroughthelateralchannel.c. GraspBougieinrighthand.d. Insertthebladeintotherightsideofthepatient'smouthsweepingthe

tonguetotheleftside.e. Visualizethevocalcordswhileavoidinganypressureontheteeth.f. Ifneededtoimprovetheviewoftheglotticopening,applyordirect

anotherprovidertoapplylaryngealpressureorBimanualLaryngoscopyTechnique.

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g. VisualizethevocalcordsandinserttheBougiewithcurvedtip

anteriorlyandvisualizethetippassingthevocalcordsorabovethe

arytenoidsifthecordscannotbevisualized.

h. Onceinserted,gentlyadvancetheBougie.Tactileconfirmationof

trachealclickingshouldbefeltasthedistaltipoftheintroducer

bumpsagainstthetrachealrings.Iftrachealclickingcannotbefelt,

continuetogentlyadvancetheBougieuntilyoumeetresistanceor

“hold‐up”.Ifyoudonotmeetresistance,youhaveaprobable

esophagealintubation.Insertionshouldbere‐attempted.

i. WithdrawtheBougieONLYtoadepthsufficientenoughtoallow

loadingoftheETTwhilemaintainingproximalcontrolofthe

Introducer(adepthofapproximately25cmtypicallyensuresthatthe

distaltipliesatleast2to3cmbeyondtheglotticopening).

j. Withouttakingeyesofftheglottisopening,havetheassistantgently

advancetheETTovertheproximaltipoftheBougie.

k. OncetheETTtipapproachestheglotticopening,rotatetheETT90°

counterclockwise(1/4turntotheleft)sothattheETTbeveldoesnot

catchonthearytenoidcartilage.

l. InserttheETTuntilthecuffpassesthevocalcords,typicaldepth=

tubesize(ID)X3 ( e.g.24foran8.0mmtube).

m. RemoveBougie.

n. Removethelaryngoscopeblade.

o. InflatetheETTcuffwiththeTru‐Cuffsyringeuntilpressureisinthe

greenzone,approximately20‐25cmH20,andremovethesyringefrom

theinflationvalve.

C. Placementconfirmation.

1. Confirmtubeplacementwithcapnographyfirstfollowedwithclinicalmeans.

a. VentilatewithBVMand:

1) Observeimmediate(within6breaths)ETCO2waveformand

numberwithcapnography.

2) Watchforchestrise.

2. ListentoabdomentoensuretheETTisnotintheesophagus.

3. IfbowelsoundsheardwithbaggingorETCO2devicedoesnotindicateproper

ETTplacement,deflatecuff,removetube,andventilatewithBVMfor2

minutes.

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4. Listenforbilateralbreathsounds.5. ObserveSpO2.

Regardlessoftheapparentpresenceoflungsounds,tubemistingandchestrise,or

lackof gastricsounds;ifETCO2doesnotindicatepropertubelocation(alveolarwaveform),ETTmustberemoved.

6. Ifunilateralrightsidedbreathsoundsareheardconsiderrightmainstemintubation:a. Ifpresent,deflatethecuffandwithdrawtube1‐2cm.b. Reassessforbreathsounds.

7. Ifintubationattempt(s)unsuccessfulrefertotheappropriateRespiratoryEmergencies:FailedAirwayprotocol.

8. Ifintubationattemptissuccessful:a. SecurewithThomasETHolderortapewithproperOPA.b. Documentdepthoftubeatteeth.c. Reassesslungsoundsandpatientclinicalstatus.d. Ensurec‐spinemotionisrestricted,ifindicated.e. Utilizeheadrestraintdevices(headblocks,cervicalcollar)tominimize

displacementofairway.f. Continueventilations.g. DocumentETCO2waveformandreadingscontinuouslyandattimeof

eachpatientmovement,includingwaveformandreadingattimeoftransferofcareattheED.

VII. VideoFileUseandRequirements

A. FollowingtheuseoftheAirtraq,thevideofileshallbeemailedtotheOMDandtheQualityManagementLieutenant@[email protected]. RefertotheAirtraqVideoDownloadingInstructionslocatedintheReference

Documentssection.B. Videofilescanbereviewedbyproviderswhowereinvolvedinpatientcareorwith

providerswhohavereceivedpatientcare(i.e.,physician).C. Atnotimeshallthevideobedownloaded/senttoanon‐countycomputerordevice.

ProvidersshallensureallapplicableHIPPAlawsandassociateddepartmentpoliciesandproceduresarefollowed.

186

Clinical Procedure: Pulse Oximetry


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II. Indications

A. Patientswithsuspectedhypoxemia,alteredlevelofconsciousness,orrespiratory

issues.

III.. Procedure

A. Applyprobetopatient’sfingeroranyotherdigitasrecommendedbythedevice

manufacturer.

B. Allowmachinetoregistersaturationlevel.

C. Recordtimeandinitialsaturationpercentonroomairifpossible.

D. Verifypulserateonmachinewithactualmanualpulseofthepatient.

E. Monitorcriticalpatientscontinuouslyuntilarrivalatthehospital.Ifrecordinga

one‐timereading,monitorpatientsforafewminutesasSpO2canvary.

F. Documentpercentofoxygensaturationeverytimevitalsignsarerecordedandin

responsetotherapytocorrecthypoxemia.

G. Ingeneral,normalsaturationis>92%.

H. Usethepulseoximetryasanaddedtoolforpatientevaluation.Treatthepatient,not

thedataprovidedbythedevice.

I. Thepulseoximeterreadingshouldneverbeusedtowithholdoxygenfromapatient

inrespiratorydistressorwhenitisthestandardofcaretoapplyoxygendespite

goodSpO2readings.

J. Factorswhichmayreducethereliabilityofthepulseoximetryreadinginclude:

1. Poorperipheralcirculation(bloodvolume,hypotension,hypothermia).

2. Excessivepulseoximetersensormotion.

3. Fingernailpolish(mayberemovedwithacetonepad).

4. Carbonmonoxideboundtohemoglobin.

5. Cyanidetoxicity.

6. Irregularheartrhythms(atrialfibrillation,SVT,etc.).

7. Jaundice.

8. PlacementofBPcuffonsameextremityaspulseoxprobe.

187

Clinical Procedure: 12-Lead ECG


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II. Indications

A. Suspectedcardiacpatient.B. Suspectedoverdose.C. Electricalinjuries.D. AlteredMentalStatus/Syncope.E. CHF.F. Abdominalpainabovetheumbilicus.G. Undifferentiatedrespiratorycomplaints.H. Suspectedstroke.

III. Procedure

A. Assesspatientandmonitorcardiacstatus.

B. Ifpatientisunstable,definitivetreatmentisthepriority.Ifpatientisstableor

stabilizedaftertreatment,performa12‐LeadECG.

C. PrepareECGmonitorandconnectpatientcabletoelectrodes.

D. Exposechestandprepasnecessary.Modestyofthepatientshouldberespected.

E. Applychestleadsandextremityleadsusingthefollowinglandmarks:

1. RA Rightarm.

2. LA Leftarm.

3. RL Rightleg.

4. LL Leftleg.

5. V1 4thintercostalspacetotherightofthesternum.

6. V2 4thintercostalspacetotheleftofthesternum.

7. V3 DirectlybetweenleadsV2andV4.

8. V4 5thintercostalspaceatmidclavicularline.

9. V5 LevelwithV4atleftaxillaryline.

10. V6 LevelwithV5atleftmidaxillaryline.

F. Minimizeartifact(instructpatienttoremainstill,stopmotionofambulanceif

necessary).

G. Acquirethe12‐LeadECG(completeageandgenderquestionscorrectly).

H. Transferthe12‐leadECGtothePCR.Placethenameofthepatientonthepaper

copyoftheECG.

188


I. ALSProvider:

1. IfSTEMIidentified,notifySTEMIReceivingCenterimmediately.Report

CodeSTEMI.Detailedreporttofollow.Ifequipped,transmit12‐leadECG

assoonasobtained.

J. BLSProvider:

1. IfALSisnotonscene,transmit12‐leadECGassoonasobtainedandconfirm

thatEDreceivedthetransmission.

2. IfALSisonscene,documentthenameofthereviewingALSproviderand

timereviewed.

K. Documenttheprocedure,timeandresultson/withthePCR.

L. ABLSProvidermayperforma12‐LeadECG;anALSProvider,however,should

reviewitbeforeimplementinganytreatmentmodalities.

LimbLeadElectrodeSites

Whenacquiringa12‐LeadECG,limbleadelectrodesaretypicallyplacedonthewristsand

anklesasshownbelow.Thelimbleadelectrodescanbeplacedanywherealongthelimbs.

Chest Lead Electrode Sites

The six chest leads are placed on specific locations as shown below. Proper placement is

important for accurate diagnosis.

Clinical Procedure: 12-Lead ECGC

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G

LEAD LOCATION

V1 Fourth intercostal space to the right of the sternum

V2 Fourth intercostal space to the left of the sternum

V3 Directly between leads V2 and V4

V4 Fifth intercostal space at midclavicular line

V5 Level with V4 at left anterior axillary line

V6 Level with V5 at left midaxillary line

189

Clinical Procedure: Cardiopulmonary Resuscitation


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II. Indications

A. Pediatricarrest.

B. Suspectednon‐cardiacarrest/respiratoryarrestinadultpatients(e.g.,overdose,

drowning).

III. Procedure

A. Assessthepatient’slevelofresponsiveness(shakeandshout).

B. Assesspulse(carotidforadultsandpediatrics,brachialforinfants)fornomorethan

10seconds,whileobservingformovementorbreathing.

C. Ifnopulse,beginchestcompressions/ventilationspercurrentAHAguidelines.

D. Onlybriefinterruptionsareallowedforrhythmanalysisanddefibrillation.

E. Refertoappropriatecardiacarrestprotocol.

H. DocumentthetimeandproceduresinthePCR.

Age Location Depth Rate

Infant Oversternum,betweennipples(inter‐

mammaryline),2‐3fingers

1.5inches(1/3theanterior‐

posteriorchestdimension)

100‐120/minute

Child Oversternum,betweennipples,heelof

oneortwohands

2inches(1/3theanterior‐

posteriorchestdimension)

100‐120/minute

Adult Oversternum,justabovethexyphoid

process,handswithinterlockedfingers

Atleast2inches(1/3the

anterior‐posteriorchest

dimension)

100‐120/minute

190

Clinical Procedure: Cardioversion


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II. Indications

A. Unstablepatientwithatachydysrhythmia(rapidatrialfibrillation,supraventricular

tachycardia,ventriculartachycardia).

B. Patienthasapalpablepulse.

III. Procedure

A. AttachECGelectrodesandmonitorthroughleadIIorleadwiththegreatestQRS

amplitude.

B. Press“SYNC”buttonandobserverfor“sensemarker”inmiddleofeachQRS

complex.

C. AdjustECGsizeorleadifrequired.

D. Bepreparedfordefibrillationifthepatientfailssynchronizedcardioversionandthe

conditionworsens.

E. Applyhands‐freepadstothepatient’schestintheproperposition.

F. Consideranalgesiaandsedationperprotocol.

G. Placetherapypadsintheproperposition.

H. Setenergyselectiontotheappropriatesettingperprotocolandcharge.

I. Makecertainallpersonnelareclearofpatient.

J. ConfirmECGrhythmandavailableenergy.

K. Pressandholdtheshockbuttonuntilenergyhasbeendelivered.Stayclearofthe

patientuntilyouarecertaintheenergyhasbeendelivered.NOTE:Itmaytakethe

monitor/defibrillatorseveralcardiaccyclesto“synchronize”,sotheremaybea

delaybetweenactivatingthecardioversionandtheactualdeliveryofenergy.

L. Notepatient’sresponseandperformimmediatedefibrillationifthepatient’srhythm

hasdeterioratedintopulselessventriculartachycardia/ventricularfibrillation.

FollowtheClinicalProcedure:DefibrillationManual.

M. Ifthepatient’sconditionisunchanged,repeatstepsBtoKabove,usingescalating

energysettingsperprotocol.

N. Repeatperprotocoluntilmaximumsettingoruntileffortssucceed.

O. Noteprocedure,response,andtimesinthePCR.

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Clinical Procedure: Defibrillation Automated


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II. Indications

A. Patientsincardiacarrest(pulseless,non‐breathing).


A. Pediatricpatientswhosebodyhabitusissuchthatthetherapypadscannotbe

placedwithouttouchingoneanother.

IV. Procedure

A. Ifmultiplerescuersareavailable,onerescuershouldprovideuninterruptedchest

compressionswhiletheAEDisbeingpreparedforuse.

B. TurnontheAED.

C. Applytherapypadstothepatient,permanufacturer’srecommendations.

1. Usealternateplacementwhenimplanteddevices(pacemakers,ICDs)

occupypreferredpadpositions.

2. Removeanymedicationpatchesonthechestandwipeoffanyresidue

medication.

3. Usepediatrictherapypads(ifavailable)iflessthan8yearsofageandless

than30kg.

D. PlugthepadsintotheAEDandfollowAEDprompts.

E. StopCPRandclearthepatientforrhythmanalysis.KeepinterruptioninCPRas

briefaspossible.

F. Defibrillateifappropriatebydepressingthe“shock”button.Assertivelystate

“CLEAR”andvisualizethatnoone,includingyourself,isincontactwiththepatient

priortodefibrillation.

G. Beginchestcompressionsimmediatelyafterthedeliveryofthedefibrillation.

H. After2minutesofCPR,analyzerhythmanddefibrillateifindicated.Repeatthisstep

every2minutes.

I. If“noshockadvised”checkforapulse.Ifnopulse,performCPRfortwominutesand

thenreanalyze.

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J. Transportandcontinuetreatmentasindicated.

K. KeepinterruptionofCPRcompressionsasbriefaspossible.AdequateCPRisakey

tosuccessfulresuscitation.

L. IfpulsereturnsrefertoappropriatePost‐Resuscitationprotocol.

1. DonotdisconnecttheAEDfromthepatient.

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Clinical Procedure: Defibrillation Manual


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II. Indications

A. Cardiacarrestwithventricularfibrillationorpulselessventriculartachycardia.

III. Procedure

A. Ensurechestcompressionsareadequateandinterruptedonlywhennecessary.

B. Clinicallyconfirmthediagnosisofcardiacarrestandidentifytheneedfor

defibrillation.

C. Applytherapypadstothepatient’schestintheproperposition.

D. Chargethedefibrillatortothemaximumenergylevel.Continuechestcompressions

whilethedefibrillatorischarging.

1. Adults360J.

2. Pediatric4J/kgtoamaximumof360J.

E. Pausecompressions,assertivelystate,“CLEAR”,andvisualizethatnoone,including

yourself,isincontactwiththepatient.

F. Defibrillatebydepressingtheshockbutton.

G. Immediatelyresumechestcompressionsandventilationsfor2minutes.After2

minutesofCPR,analyzerhythmandcheckforpulseonlyifappropriateforrhythm.

H. RepeattheprocedureeverytwominutesasindicatedbypatientresponseandECG

rhythm.

I. Keepinterruptionofcompressionsasbriefaspossible.Adequatecompressionsare

thekeytosuccessfulresuscitation.

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Clinical Procedure: External Cardiac Pacing


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II. Indications

A. Monitoredheartratelessthan50BPMwithunstableseveresymptomssuchas:

1. Acutealteredmentalstatus.

2. Hypotension(SBP<90mmHgorMAP<65).

3. Ischemicchestdiscomfort.

4. Acuteheartfailure.

5. Othersignsofshock.

PatientscanoftentolerateHRmuchlessthanthetextbookrateof60BPM.If

symptomsaremildwithnosignsofshock,providesupportivecareandexpedite

transport.

III. Procedure

A. Attachcardiacmonitoringleads.1. Maintainthemonitoringleadstoallowthepacertoworkindemandmode.

B. Printa6–secondECGstriptodocumenttherhythmpriortopacing.

C. Ifthepatient’sconditionallows,performa12‐leadECG.

D. Forconsciouspatients,explaintheprocedureandwhatwilloccur.

E. Applydefibrillation/pacingpads.

F. Consideranalgesiaandsedation.

1. RefertoCardiacEmergencies:Bradycardia.

G. Turnonthepacerbypressingthepacerbutton.Observethepacingmarker()aboveeachQRS.

H. Ifnecessary,adjustECGamplitudeuntilpacersensestheQRScomplex.

I. Adults:Selectarateof80BPM.

1. Considerthestartingrateof60inthecaseofanacuteMIorpost

resuscitation.

J. Pediatrics:Selectarateof100BPM.

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K. IncreasecurrentinmAuntilelectricalandmechanicalcaptureisachieved.

1. Thedialincreasesinincrementsof5mAandthecurrentbuttonincreasesin

10mA.

L. ElectricalcaptureisevidentbyawideQRSandbroadT‐wave.

M. Mechanicalcaptureisachievedbyobservingthefollowing:

1. Palpablefemoralpulse.

2. Riseinbloodpressure.

3. Improvedlevelofconsciousness.

4. Improvedskincolorandtemp.

5. PlethwaveonSpO2.

N. Aftermechanicalcapture,increasemAby10%.

O. Ifyoureachmaximumenergy(200mA)withoutmechanicalcapture,discontinue

pacing.Mayreattempttopacefollowingfurthermedicationorotherappropriate

ALStherapiesareperformed.ConsultOLMC.

P. Reassesspatientforcomfortandconsideranalgesia/sedation.

Q. Thepatient’sresponsetopacingcouldchangetoincludelossofcapture.Providers

mustprovideconstantmonitoringofthepatienttoincludeETCO2andSpO2.Iflossof

captureoccurs,returntostepH.

1. SpO2waveformwillgiveinstantfeedbackonthepresenceofmechanical

pulse.

2. ETCO2willgiveinstantfeedbackonperfusionstatus.

R. Usingthedefibrillatorwillcancelpacing.Ifpacingisneededfollowingdefibrillation,

pacingwillneedtobeinitiated.RefertostepG.

S. TransplantedheartswillnotrespondtoAtropine.

T. Externalcardiacpacingisthepreferredtreatmentin2nddegreetypeIIand3rd

degreeheartblocks.

U. Ifacardiacmonitoringleadfallsoff,thepacerconvertstonon‐demandpacing.

Reattachtheleadtoreturntodemandpacing.

V. DocumentthedysrhythmiaandtheresponsetoexternalpacingwithECGstripsin

thePCR.

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A. ActiveALS,BLS,andCPRtrainedproviderswhohavecompletedanOMDapproved

HPCPRcourse.

II. Indications

A. PatientsInCardiacArrest,>12yearsofage(>40kgorwithsignsofpubertyifage

unknown).


A. Patientsundertheageof12.

B. PatientswhoareDOAandarenotcandidatesforresuscitationduetoclinical

findingswhichareincompatiblewithlife.

IV. Procedure

A. Quicklyassesspatient’sLOCwhilecheckingforacarotidpulse.

B. Ifpatientisunconsciousandpulseless,initiateresuscitation.

C. EffectiveCompressions.

1. Manualchestcompressionsshouldbeinitiatedimmediatelyupon

identificationofcardiacarrest.Compressorsshallberotatedevery2

minutes,duringrhythmanalysis.Chestcompressionswillbeperformedata

depthof2”‐2.4”allowingforcompleterecoilofthechestaftereach

compression.Chestcompressionsshouldbeaccomplishedwithequaltime

allowedforcompressionandrecoil(upstroke),whilemaintainingarateof

100–120/min.Ametronomeshallbeutilizedtoaidinmaintainingacorrect

compressionrate.

D. ContinuousCompressions.

1. Chestcompressionstakepriorityoverotherallinterventionsexceptfor

defibrillation.Compressionswillbepausedeverytwominutestoanalyzethe

rhythmandtodeliverashockasindicated.Compressionswillbedelivered

whilethedefibrillatorcharges.Compressionswillbeimmediatelyresumed

followingdefibrillation.

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E. Defibrillation.

1. Defibrillatorswillbeutilizedassoonasavailable.Rhythmanalysiswillbe

performedfollowingeverytwominutesofCPR.

2. AutomaticExternalDefibrillation.

a. TheAEDwillbepoweredonassoonasthecardiacarrestis

confirmed.Donotinterruptchestcompressionstoremoveclothingor

placedefibrillationpads.

1) ShockAdvised–Ifashockisadvised,thecompressorwill

ImmediatelystartcompressionswhiletheAEDischarging.

OncetheAEDhascharged,theAEDOperatorwillcall“Clear”

andvisuallyverifyitissafetoshock.Thecompressorwill

hoveroverthechestuntiltheshockisdelivered,then

immediatelyresumecompressionsoncetheshockisdelivered.

Thereisnopulsecheck.

2) NoShockAdvised‐Whenthereis“NoShockAdvised,”apulse

checkwillbeperformedbyoneprovider.Ifapulseisnot

palpatedbythisproviderwithin10seconds,compressions

shallresume.

3. ManualCardiacMonitor/Defibrillator(ALSOnly)‐WhentheCodeManager

announces“15seconds”,thedefibrillatoroperatorwillactivatethe“Print”

buttonandchargethedefibrillatortotheappropriateenergy.

Attheendofthetwo‐minutecycle,thepatientwillbeclearedwhen

announced.AnALSproviderwillassesstherhythm.IfV‐Fib(orpulselessV‐

Tach)ispresent,thepatientwillbedefibrillated.Thecompressorwillhover

overthechestuntiltheshockisdelivered,thenimmediatelyresume

compressions.Thereisnopulsecheck.

IfVForPulselessVTarenotpresent,theenergychargewillbecancelledby

depressingthe“speeddial”.

IfAsystoleispresentontheECG,immediatelyresumecompressions.

Checkingtherhythminalternateleadsisnotindicated.

Ifthepatientisinanorganizedrhythm,checkapulse.Ifnopulse,begin

compressions.Interruptionsincompressionwillnotexceed10seconds.

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F. Ventilations.

1. Ventilationswillbeperformedwithoutstoppingchestcompressions.One

ventilationwillbegivenevery10thcompressionduringchestrecoil

(upstroke).Onceanadvancedairwayisinplace,ventilationswillbe

asynchronouswithcompressions(1ventilationevery6seconds).Ensure

BVMisattachedto100%oxygenandproduceschestrise.Placementofan

advancedairwayshallnotinterferewithcompressions.

G. PassiveVentilation.

1. Passiveventilationisrecommendeduntiladequateresourcesareavailableto

provideventilationswithoutinterferingwithchestcompressionsor

defibrillation.PassiveventilationisperformedbyinsertinganOropharyngeal

Airwayandapplyinganon‐rebreathingoxygenmaskflowingat15lpmon

thepatient.BVMventilationsinconjunctionwithabasicairwayadjunct

(OPA,NPA)shouldbeinitiatedassoonasadequatestaffisavailable.

H. AdvancedLifeSupport.

1. ALSproviderswilladdressdefibrillation,IV/IOaccess,medication

administration,andadvancedairwayplacement,asindicatedwithin

protocols.Highperformance,continuouscompressionsremainahigh

priority.Placementofanadvancedairwaywillnotinterruptchest

compressions.Digitalwaveformcapnographyandpulseoximetryshallbe

utilizedtoevaluatetheeffectivenessofCPRperformanceandtheoccurrence

ofROSC.Ifanadvancedairwayisnotplaced,digitalwaveformcapnography

willbeutilizedwithbag‐valve‐mask(BVM)ventilation.

I. CodeResourceManagement(CRM).

1. Crewsshouldcoordinatetheirdutieskeepingthecallprioritiesinmind.

Interventionprioritiesare(inorderofhighesttolowest):


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J. Thenumberofpersonnelonagivenincidentandthequalificationsofthose

personnelcanvary;however,theprioritiesremainthesame.Appropriatecrewroles

areoutlinedbelow(refertoattachmentsA‐G).

1. CrewRoles.

a. 2providercrew:

Provider1–Compressor

Provider2–AED/MonitorOperator,Ventilator,CodeManager

*Providers1and2rotateeverytwominutes.Rolesremainthe

sameevenifprovidersareALSequipped.

b. 3providercrew:


Provider2–AED/MonitorOperator,CodeManager

Provider3–Ventilator

*Providers1and3rotateeverytwominutes.Rolesremainthe

sameevenifprovidersareALSequipped

c. 4providercrew:


Provider2–AED/MonitorOperator

Provider3–Ventilator

Provider4–CodeManager

*Providers1,2,and3rotateeverytwominutes.

d. Greaterthan4providers‐Utilizethesameinitialassignmentsasthe

fourprovidercrew.

1) Thefifthproviderwillliaisewiththefamily,informingthe

familyofpatientstatus,gatheringpatientinformation,and

documentingthemedicalinterventionsperformedonthecall.

2) Anyadditionalpersonnelshallprovidelogisticalsupport,such

asassistingwithadditionalpatienttreatmentorpatient

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K. RolesandResponsibilities.

1. CodeManager‐TheCodeManagershall:

a. Callremainingtimeforeachcycle.Announcementsoftimeshalloccur

asfollows.“Oneminute”,“30seconds”,“15seconds”,“5,4,3,2,1”

b. Ensurerotationofpersonneldoingcompressionseverytwominutes.

c. AssessqualityofCPRandgiverealtimefeedback.

d. Assurecompressionsresumefollowingassessmentordefibrillation.

e, Assurethatonlythecompressororventilatorareincontactwiththe

patientwhenanAEDormanualdefibrillatorisbeingcharged.

f. Recordinterventionsperformedduringthearrest,ifascribeisnot

available.

2. Compressor.

a. Thecompressorwillpromptlybeginchestcompressionsfollowing

determinationofanabsentpulseandfollowinganydefibrillations.

Compressionwillbeprovidedatarateof100‐120perminute.A

compressiondepthof2”‐2.4”shallbemaintained.Fullchestrecoil

mustbeallowedfollowingeachcompression.Thecompressorwill

countthe8ththrough10thcompressionsaloudtocoordinate

ventilation(“8,9,Bag”).

3. AEDOperator.

a. TheAEDOperatorwillperformtheinitialassessmentandpulsecheck.

Ifpulseless,theAEDoperatorwilldirectthecompressortobegin

chestcompressionsandthenstartthemetronome.TheAEDOperator

willonlyattachtheAEDpadsaftercompressionshavebegun.

ApplicationofAEDpadsshouldnotinterruptchestcompressions.

Oncethepadsareplacedandpluggedin,theAEDwillbeginanalysis.

OncepromptedbytheAED,CPRshouldbewithheldtoallowfor

rhythmanalysis.Ifashockisindicated,compressionswillberesumed

whilethedefibrillatorcharges.TheAEDOperatorwillassurethe

patientisclearedpriortodefibrillationbyannouncing“clear”and

assuringthecompressorandventilatorareclear.

4. Ventilator.

a. Theventilatorshallassuretheairwayisopenandclear(suctionas

needed).Theyshallinitiallyplaceanoropharyngeal(O.P.)airway.

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willbeventilatedwithaBVMandsupplementaloxygen,following

every10thcompressionduringtherecoil(upstroke).Ventilations

shouldresultinchestriseonly.Excessiveventilationorvolumes

shouldbeavoided.

5. FamilyLiaison.

a. TheFamilyLiaisonwillinterfacewiththepatient’sfamilyor

acquaintancestoobtainpertinentmedicalhistoryandtokeepthe

familyapprisedofthesituation,throughouttheresuscitation.

L. PatientMovementandTransport.

1. Resuscitationswillbeperformedwherethepatientisfound.Immediately

placethepatientonthefloorandbegincompressions.Ifspaceisinadequate

(e.g.,bathroom),thepatientshouldberapidlyrelocatedtoanearbyopen

space.Clearingfurnishingstocreateadequatespacemaybepreferable.

a. Routinely,resuscitationsthatappeartobecardiacinnature,willbe

conductedonthescene.

b. IncaseswherethearrestisNOTthoughttobeduetoacardiac

etiology,beginimmediateresuscitation.Rapidpatientpackagingand

transport,withongoingresuscitation,shallbeinitiatedonceadequate

resourcesareavailable.Examplesinclude:

1) Traumaticcardiacarrest,withongoingresuscitation.

2) SystemicHypothermia.

3) Pediatricpatients.

4) Pregnancy,estimated≥24weeksgestation.

5) Unrelievedairwayobstruction.

c. Incaseswhereonsceneresuscitationisnotpossibleduetoan

untenableenvironment,EMSprovidersshouldmovetotheclosest

appropriateareatoconducttheresuscitation.

d. Cardiacarrestpatientswillnormallyreceiveaminimumof30

minutesofresuscitativeattempts,toincludedeliveryofall

appropriateALSinterventionsaccordingtoprotocol.

e. After30minutesofresuscitation,EMSproviderswillconsider;

1) Continuedon‐sceneresuscitativeattempts.

2) TerminationofresuscitationperClinicalProcedure:

TerminationofResuscitation.

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M. ALSInteractions.

1. WhenanALScrewisthefirsttoarrivetoapatientincardiacarrest,initiate

HPCPRfollowingtheCodeResourceManagement“CrewRoles”.Donot

initiateALScareuntiladequatepersonnelareavailabletotakeoverHPCPR.

a. TheLP‐15shouldbeutilizedinamanualmodeinlieuofanAEDand

operatedbyanALSProvider.OnlyendorsedALSProviderswill

assesstheprintedrhythmstripsanddetermineifashockisadvised.

TheLP‐15willbeoperatedinthepaddlesmodeduringcardiac

resuscitations.

b. ALSskillswillbeperformedwithoutinterferingwithHPCPRandonly

ifthereareatleast4providers.

c. Attachin‐linecapnography.Ifanadvancedairwayisnotinplace,

attachittotheBVM.

d. AttachandmonitorPulseOximetrywaveform.

e. Whensufficientpersonnelareavailable,thefollowingskillsaretobe

performedwithouthinderingHPCPR.

1) Vascularaccess.

2) IVaccessispreferredoverIO.Useofalargeperipheralvein

preferred.

3) IOaccessshouldbeattemptedifIVaccesscannotbereadily

establishedorfollowing2unsuccessfulIVattempts.

4) Airway.

Assesstheairwayadjunctsinplaceanddeterminetheneed

foranadvancedairway.

Intubationshallbeperformedwithongoingcompressions.

5) Medications–Allmedicationsshouldbeadministeredper

protocol.

N. CODE‐STAT.

1. Obtainingpromptandcompletedataofcardiacarrestcasesisanimperative

componentoftheresuscitationprogram.

a. LP‐1000:Manualdownloadingisrequired;promptlyemailtheEMS

OPSResuscitationCoordinatorformanualdownload.

b. LP‐15(usedinAEDorManualmode):Attheconclusionofthe

incident,theincidentdatawithbeelectronicallytransmittedtotheE‐

PPCRandCODE‐STATviatheTransmitfunction.


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Clinical Procedure: Implanted Cardiac Device


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II. Indications

A. Patientswiththefollowingimplantedcardiacdevices.

1. Pacemaker.

2. ImplantedCardiacDefibrillator(ICD).

3. VentricularAssistDevice(VAD).

III. ProcedureandDeviceInformation

A. Whenevaluatingandassessingpatientswiththesedevices,remembertoplace

therapyelectrodesatleastone‐inchawayfromtheimplanteddevicetohelpprevent

damage.

B. Pacemakers.

1. Internalpacemakerbatterypacksmaybeimplantedsubcutaneouslyinthe

upperchestorabdominalregion.

2. WhenoperatingintheAEDmode,pacemakerpulsesmayprevent

advisementofanappropriateshock,regardlessofthepatient’sunderlying

rhythm.

C. ICD.

1. PerformCPRasrequired.Iftheinternaldefibrillatordischargeswhilea

provideristouchingthepatient,theymayfeela“light”shock,butitisnot

dangerous.

2. Applytherapyelectrodesorpaddlesintheanterior‐lateralposition,andtreat

patientasanyotherpatientrequiringemergencycare.

3. Ifdefibrillationisunsuccessful,considerplacingtherapyelectrodesinan

anterior‐posteriorplacement.

4. Internalbatterypacksmaybeimplantedsubcutaneouslyintheupperchest

orabdominalregion.

D. VAD.

1. AVADisamechanicalpumpthatisusedtosupportheartfunctionandblood

flowinpeoplewhohaveweakenedhearts.SomecommonreasonsforVAD

implantationareMI,HeartFailure,myocarditis,cardiomyopathyandheart

surgery.

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2. WhattypesofpatientsreceiveaVAD?

a. BridgetoTransplant–TheVADisplacedtosupportthepatient’s

circulationuntilasuitabledonorheartisfoundfortransplant.

b. BridgetoRecovery–VADisplacedtosupportthepatient’scirculation

untilthenativeheartrecoverssufficiently,atwhichtimetheVADwill

besurgicallyremoved.

c. DestinationTherapy–VADisplacedtosupportthepatient’s

circulationfortherestoftheirlife.

3. HowdoesaVADwork?

a. Thedevicetakesbloodfromalowerchamberoftheheartandhelps

pumpittothebodyandvitalorgans,justasahealthyheartwould.

TheVADisimplantedintheabdominalcavityandisattachedtothe

apexoftheleftventricleandupwardstotheascendingaorta.TheVAD

ispre‐loaddependentrequiringanadequateamountofvolumeto

maximizethepump’scapabilities.Placehighcredibilityonyour

patient’sclinicalstatus,suchaslevelofconsciousness,manualheart

rate,andbloodpressurebeforetreatingyourrhythm.

4. WhatarethepartsofaVAD?

a. ThebasicpartsofaVADinclude:asmalltubethatcarriesbloodoutof

yourheartintoapump;anothertubethatcarriesbloodfromthe

pumptoyourbloodvessels,whichdeliversbloodtoyourbody;anda

powersource.

5. Whatisthepowersource?

a. ThepowersourceiseitherbatteriesorACpower.Thepowersourceis

connectedtoacontrolunitthatmonitorstheVADfunctions.The

batteriesarecarriedinacaseusuallylocatedinaholsterinavest

aroundthepatient’sshoulders.

6. Whatdoesthecontrolunit(orcontroller)do?

a. Thecontrolunitgiveswarningsoralarmsifthepowerisloworifit

sensesthatthedeviceisn’tfunctioningproperly.

7. VADCenter.

a. IftheemergencyisdirectlyrelatedtomalfunctionoftheVAD,itis

imperativethatthepatientgetstotheappropriateVADequipment

andpersonneltrainedinusingtheequipmentassoonaspossible,

preferablyatthepatient’shomeVADcenter.ConsideruseofAir‐

MedicalTransport.

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8. VADPatientManagement.

a. Assessthepatient’sairwayandintervenepertheAirwayManagement

Protocol.

b. Auscultateheartsoundstodetermineifthedeviceisfunctioningand

whattypeofdeviceitis.Ifitisacontinuousflowdevice,youshould

heara “whirlingsound.”

c. Lookonthecontrollerlocatedaroundthepatient’swaistorinthe

VADPAKandseewhatdeviceitis.

d. Assessthedeviceforanyalarms.

e. ReferencethemostcurrentMid‐AtlanticRegionalPre‐Hospital

MechanicalCirculatorySupport–FieldGuide.

f. Interveneappropriatelybasedonthetypeofalarmandpatientguide.

g. StartonelargeboreIV.

h. AssessVitalSignsandusetheMeanontheNon‐InvasiveBPcuffasa

pressurereading.Contactmedicalcontrolforpharmacologic

treatmentmodalities.

j. TransporttotheclosestVADCenter.Callthenumberlistedonthe

deviceforadvice.

k. Bringallofthepatient’sequipmentandpaperworktotheEmergency

Department.

l. Allowthetrainedcaregivertorideinthepatientcompartmentwhen

possible.Theymaybeabletoserveasanexpertonthedeviceifthe

patientisunconsciousorunabletoanswerforthemselves.

9. VADPatients‐SpecificIssues.

a. Unrelatedmedical/traumaemergency.

1) Treatasanyotherpatientbasedupontheirclinicalstatusof

LOC,skincolortemperature,andsignsofhypoperfusionas

outlinedinthefieldguide.

2) NotifymedicalcontrolatthereceivingERthatthisisaVAD

patient.Basedonthephysician’sknowledgeofVADsandthe

resourcestomonitorthem,he/shemayalteryour

transportationdestination.

3) Ensurethepatienthastheir“emergencybag”withextra

batteries,ventfilters,andtheirhandpump(ifequipped),in

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additiontotheVADtrainedcompanionthatnormally

accompaniesthempriortoleavingthescene.

b. Hypotension.

1) HypotensiveVADpatientsshouldbetreatedwithvolume

beforeinotropicsupport.Contactmedicalcontrolpriorto

administrationofvasodilators(e.g.,.nitro).

c. CardiacArrest(confirmed).

1) Donotinitiatechestcompressionsunderanycircumstances.

DoingsowilldamagethedeviceorpulltheVADfromthe

ventricle.Assesspatient:auscultateVAD,assessmentalstatus,

perfusionetc.

2) Firstidentifyifthepatienthasapulse(VADpatientscanbein

V‐Fibwithapulse).Iftheyhaveapulse,assesstheirclinical

statusandprovideairwayand/orcirculatorysupportas

indicated.

3) Ifthepatientdoesnothaveapulse,thenidentifyiftheVADis

working.Thisisassessedbythepresenceorabsenceofnoise

fromtheinternalpump.

4) RefertotheVADFieldGuideforspecificinterventions.

5) ContactOLMCandtheVADCoordinator.

6) Un‐witnessedorgreaterthanfourminutes:

o Ifthepatienthasbeeninarrestforgreaterthanfour

minuteswithouthandpumpinitiation,donotinitiate

handpumpingorre‐starttheVAD.Freshbloodwillclot

withinthepumpduringthistime,andinitiationofthe

handpumporre‐startingtheVADwillreleasethese

clotsintocentralcirculation.

7) Witnessedcardiacarrestorarrestperiodslessthanfour

minutes:

o Managetheairwayasyouwouldforanyotherpatient.

o Ifapplicable,usepatient’shandpumpinlieuofchest

compressionsifthedevicehasfailed.

o Followtheinstructioncardfoundwiththehandpump

orenlisttheassistanceofthosetrainedinitsuse(e.g.,

family).

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o Besureandletthebulbfullyinflateaftereachsqueeze;this

willmaximizethepump’soutput.

o Utilizethesameratewiththehandpumpasyouwould

withchestcompressions.

d. VentricularFibrillation/PulselessVentricularTachycardia.

1) VADpatientsmayendupinv‐fibarrestfortworeasons.Initial

treatmentmayvaryfromthenormalv‐fibarrestpatient.

2) IftheVADisworking:

o Cause:Thepotentialcauseforv‐fibisduetothelackof

forwardflow(suckdownstate).Thisisdueto

inadequatevolumefortheVADtoprovideanycardiac

output,causingasignificantischemiccardiacevent.

o Treatment:Provideairwaymanagementandafluid

challenge(ALSonly),re‐assessforpalpablepulsesand

bloodpressure/MAP.(Donotinitiatehandpumpingif

theVADpumpisaudiblyworking.).

o ContactOLMC.

3) IftheVADisnotworking:

o Placetherapypadsonpatient.

o DefertofieldguideforspecificVADcontroller

instructions.

o Delivershockperprotocol.

o Initiatehandpumpingifsoequippedforthedevice.

o Providetreatmentasdirectedbymedicalcontrol(ALS

only).

o Rapidlytransfertopersonnelequippedandtrainedin

managingthispatient’sspecialneeds.

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Clinical Procedure: Posterior ECG


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II. Indications

A. Forusewhenconfrontedwithsuspectedsituationsdefinedinthisdirective.To

detectposteriorSTEMIassociatedwithocclusionofthecircumflexordominant

rightcoronaryartery.Indicationsofaposteriorwallinfarctionmayinclude:

1. InferiororlateralwallMI(especiallyifaccompaniedbySTdepression

orprominentRwavesinleadsV1‐V3).

2. ChangesinV1‐V3onthestandard12‐leadECGpredominantly,whichmay

include:

a. HorizontalSTdepression.

b. Atall,uprightT‐wave.

c. Atall,wideR‐wave.

III. Procedure

A. PrepareECGmonitorandconnectpatientcabletoelectrodes.

B. Exposechestandprepasnecessary.Modestyofthepatientshouldberespected.

C. PlacethreeadditionalECGelectrodes.StartatV9(thelastelectrode)andwork

forward.

1. V9 Leftspinalborder,samehorizontallineasV4‐6.

2. V8 Mid‐scapularline,samehorizontallineasV7andV9.

3. V7 Posterioraxillaryline,samehorizontallineasV4‐6.

D. PlaceECGleadcablesasfollows(usingstandard12‐Lead).

1. LeadcableV6connectstoelectrodeV9.



E. LeadcablesV1‐V3areconnectedthesamewayaswhenobtainingastandard12‐

leadECG.

F. Minimizeartifact(instructpatienttoremainstill,stopmotionofambulanceif

necessary).

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G. AcquiretheposteriorECG(completeageandgenderquestionscorrectly).

H. ProvideposteriorECGtohospitalstaff,transmitwhenappropriate.

1. ClearlyidentifyasaPOSTERIORECG.

I. Transferthe12‐leadECGtothePCR.Placethenameofthepatientonthepaper

copyoftheECG.

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Clinical Procedure: Right Sided ECG


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II. Indications

A. TodetectrightventricularSTEMIassociatedwithocclusionoftheRightCoronary

Artery.

1. IndicationsofaRightVentricleWallinfarctionmayinclude:

a. STelevationintheinferiorleads,II,IIIandaVF.

b. STelevationthatisgreatestinleadIIIisespeciallysignificant.

c. STelevationinleadV4R.

d. STelevationinV1(theonlyprecordialleadthatfacestheRVon

standard12‐leadECG).

e. RightBundleBranchBlock,2ndand3rdDegreeAVBlocks,ST

elevationinV250%greaterthantheSTdepressioninaVF.

III. Procedure

A. PrepareECGmonitorandconnectpatientcabletoelectrodes.

B. Exposechestandprepasnecessary.Modestyofthepatientshouldberespected.

C. Applychestleadsandextremityleadsusingthefollowinglandmarks:

1. V1R 4thintercostalspace,leftsternalborder.

2. V2R 4thintercostalspace,rightsternalborder.

3. V3R HalfwaybetweenV2RandV4R,onadiagonalline.

4. V4R 5thintercostalspace,rightmidclavicularline.

5. V5R Rightanterioraxillaryline,samehorizontallineasV4RandV6R.

6. V6R Rightmid‐axillaryline,samehorizontallineasV5RandV6R.

D. IsolatedV4RtracingisacceptablealternativetoacompleterightsidedECGin

patientortimesensitivescenarios.

E. Minimizeartifact(instructpatienttoremainstill,stopmotionofambulanceif

necessary).

F. AcquiretheECG(completeageandgenderquestionscorrectly).

G. ProvideRightSidedECGtohospitalstaff,transmitwhenappropriate.

1. ClearlyidentifyasaRIGHTsidedECG.

H. Documenttheprocedure,time,andresultsintheelectronicPCR.

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Clinical Procedure: Termination of Resuscitation


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tion



II. Indications

A. CardiacarrestpatientsinwhichCPRhasbeeninitiatedbyEMS,whenitis

contraindicated(BLSorALS).

B. Presumedmedical(non‐traumatic)cardiacarrestpatientswhohavenotresponded

toALSresuscitation(ALSONLY).


A. Transportationhasbeeninitiated.

B. SystemicHypothermia.

C. Coldwaterimmersion.

D. Patients<18yearsofage.

E. Pregnancy,estimated≥24weeksgestation.

F. Unrelievedairwayobstruction.

G. ROSCatanypointduringresuscitation(transientorpermanent).

IV. Procedure

A. TerminationofresuscitationinpatientsinwhichCPRhasbeeninitiatedbyEMS,

whenitiscontraindicated(BLSorALS).

1. Patientshouldpresentwithoneormoreofthefollowing:

a. Rigormortis.

b. Decompositionofbodytissues.

c. Dependentlividity.

d. Obviousinjuriesincompatiblewithlife(decapitation,crushinjury,

penetratingorbluntinjurywitheviscerationofvitalorgans).

e. Incineration(100%fullthicknessburns).

213


B. TerminationofResuscitation(ALSONLY).

1. Resuscitativeeffortsmaybeterminatedwithmedicalcontrolconsentfor

adultpatientsassumedtobe≥18yearsofageprovidedallofthefollowing

criteriaaremet:

a. Patienthasreceivedanappropriateresuscitationbasedontheclinical

presentation.Normally30minutesofresuscitationisconsideredan

adequatetrial.Somesituationsmaydictatealongerorshorter

resuscitation.

b. NoROSC,evenbriefly.

c. Terminalrhythmisasystoleoragonal(witharateof20orless),

confirmedintwoleadsanddocumentedwithaprintedECG.

d. Secureairwayplaced(ETT/KING)andconfirmedbywaveform

capnography.

e. InitiationandmonitoringofContinuousCapnographyandPulse

Oximetry.(ConsistentQuantitativeCapnographyreadings<10mmHg

followingresuscitationisassociatedwithextremelypoorchancesof

survival).

f. PatentIVorIOaccess.

g. Appropriatetreatmentsandmedicationadministrationaccordingto

CardiacArrestprotocolstoincludeatleastthreedosesof

Epinephrine.

C. Iftheabovecriteriainprocedure“A”or“B”aremet,contactOn‐LineMedicalControl

forauthorizationtoterminateresuscitation.Providecompletereporttoinclude

findings,actions,andoutcomestoOn‐LineMedicalControlandrequesttermination.

1. IfauthorizedbyOn‐LineMedicalControl,terminatetheresuscitation.Note

thephysician’snameonPCR.

2. Documenttimeofdeath.

3. Followingtermination,assessanddocumentabsenceofpulseandheart

tones(assessedby30secondsofauscultation).Thisshouldbeconfirmedby

twoEMSproviders.

D. FollowingTerminationofResuscitation:

1. NotifyCommunicationsofthedeath.RequestPD,ifnotalreadypresent.

2. PreservethesceneandawaitarrivalofPD.Donotcoverthepatient’sbodyto

avoidcontaminationofevidence.RefertoFireandRescueAssociation

proceduretitled“PreservationofPotentialCrimeScenes”forfurther

direction.

Clinical Procedure: Termination of ResuscitationC

linic

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: Te

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214


3. Providecomfortmeasurestofamilymembers.Considercontactingclergy,friends,family,orFDChaplainsifagreeabletonextofkinandlawenforcement.

4. Bepreparedtoprovidelawenforcementwithinitialfindings,timeofdeath,

andnameofproviderthatdeterminedthepatient’sdeath,patient’smedical

history,patient’smedications,andpatient’sprimaryphysician.

5. Transportationofthedeceasedwillbehandledbyprivatefuneralhomes.

Arrangementquestionsshouldbedirectedtolawenforcement.

Clinical Procedure: Termination of ResuscitationC

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215

Clinical Procedure: Blood Glucose Analysis


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loo

d G

luc

ose

An

alysis



II. Indications

A. Patientswithsuspectedhypoglycemia(diabeticemergencies,altered/changein

mentalstatus,bizarrebehavior,etc.).

III. Procedure

A. Gatherandprepareequipment.

B. Placecorrectamountofbloodonreagentstriporsiteonglucometerperthe

manufacturer’sinstructions.

C. Timetheanalysisasinstructedbythemanufacturer.

D. Documenttheglucometerreadingandtreatthepatientasindicatedbytheanalysis

andprotocol.

1. Considererrorifpatientsymptomsarediscoordinatewithreadings.Utilizea

differentglucometertoreassess.

E. Repeatglucoseanalysisasindicatedforreassessmentaftertreatmentandper

protocol.

216

Clinical Procedure: Electronic Control Device (Taser)


Clin

ica

l Pro

ce

du

re: E

lec

tron

ic C

on

trol D

evic

e (T

ase

r)

For patients who have been controlled by law enforcement via an ECD/Taser, follow this protocol in

conjunction with any protocol that applies to underlying conditions (e.g., behavioral emergencies,

cocaine/sympathomimetic toxicity, and agitated delirium).



II. Procedure

A. Confirmscenesafetywithlawenforcement.

B. Turnpatientsupineiffoundinaproneposition.

C. Determinelocationofelectrodes:

1. IfremovedbyanLEOpriortoevaluation:

a. Examinesiteforbleeding,expandinghematomaordistalneurological

deficit.

2. Eye,Face,Neck,Groin,SpinalColumn,Axilla:

a. DONOTREMOVEELECTRODES,stabilizeinplace,andtransportas

impaledobject.

3. SuperficialsofttissuesEXCLUDINGEye,Face,Neck,Groin,SpinalColumn,

Axilla:

a. Usescissorstocutthewireatthebaseofeachprobecylinderto

disconnectprobesfromthecartridge.

b. Placeonehandonthepatientintheareawheretheprobeis

embeddedandstabilizetheskinsurroundingthepuncturesite.

c. Grasptheprobewithyourotherhand/pliersatthebaseoftheprobe.

d. Inonefluidmotionpulltheprobestraightoutfromthepuncturesite.

Repeatprocedurewiththesecondprobe.

e. ExaminesiteforBleeding,ExpandingHematoma,orDistal

NeurologicalDeficit.

D. Ifnon‐transport:

1. RefertoAdministrativeProcedure:PoliceCustodyPatientCareStandards.

2.. RefertoAdministrativeProcedure:RefusalofMedicalCare.

217

Clinical Procedure: Eye Irrigation


Clin

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ye Irrig

atio

n



II. Indications

A. Concernforocularchemicalexposurebyeitherhistoryorphysicalexam.

III. Procedure

A. Identifyagentthatvictimwasexposedto.

B. Tiltheadforwardandbrusheyelids/lashesifdrychemicalpresent.

C. Removecontactlensesifpresent.

D. Primemacrodriptubing(10gtt/ccor20gtt/cc)afterhanginga1000mlbagofNS.

Closetubingclamp.

E. Startirrigationwithnormalsalineandcontinuefor30minutesoruntilarrivalatthe

thehospital.

218

Clinical Procedure: Medication Administration


Clin

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ed

ica

tion

Ad

min

istratio

n



II. Indications

A. AsindicatedbyprotocolorOLMC.

III. Procedure

A. AMedicationAdministrationCrossCheck(MACC)shallbeperformedbyendorsed

EMSproviderspriortotheadministrationofanymedication.

1. RefertoAdministrativeProcedure:MedicationAdministrationCross

Check.

B. ConfirmationofOLMCordersarealwaysindicated:

1. EchothemedicationorderbacktoOLMCandreceiveconfirmationof

medicationname,indication,dose,androute.

2. DocumentthenameoftheOLMCphysicianinthePCR.

3. Ifprovidersareunsureastowhetheramedicationiscontraindicatedfor

theirpatient,theyaretocontactOLMC.

a. ObtainanddocumenttheOLMCphysician’snameandordersthat

werereceived.

C. Monitorpatientforadverseeffectsafteradministrationofallmedications.

D. MedicationAdministrationRoutes.

1. AutoInjector(AllProviders).

a. Obtainthepatient’sprescribedautoinjectorandperformaMACC.

b. Placethetipoftheautoinjectoragainstthelateralportionofthemid‐

thigh.

c. Pushtheepinephrineautoinjectorfirmlyagainstthethighandholdin

placeforaminimumof10seconds.

d. RecordtimeofadministrationinthePCRandbringtheusedauto

injector,with thepatient,tothereceivingfacility.

e. ALStransportispreferredunlessthisdelayspatientdeliverytothe

receivingfacility.

219



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istratio

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2. Intra‐muscular(IM)(AdvancedLifeSupport).

a. Determineappropriatedoseofmedicationperappropriateprotocol.

b. Drawmedicationintosyringe(addadditional0.1mlofmedication

duetodeadspace)anddisposeofthesharpsintoasharpscontainer.

b. PerformaMACC.

c. Ensurevolumeofmedicationtobeadministereddoesnotexceedthe

followingmaximumvolumelimits.

1) Adultvastuslateralismuscle=max2mlpersite.

2) Pediatricvastuslateralismuscle=max1mlpersite.

3) Adultdeltoidmuscle=max1mlpersite.

d. Preparethesiteofinjectionwithanalcoholprep.

e. Inserta1"‐1.25"long22‐25gneedleata90degreeangleintothe

vastuslateralismuscle(adultandpediatric)orthedeltoidmuscle

(adultonly).

f. Aspiratetoensurenobloodreturn.

h. Depresstheplungeronthesyringetoinjectthemedication.

i. RecordtimeofadministrationanddocumentinthePCR.

3. Intra‐nasal(IN)(AllProviders).

a. INmedicationadministrationiscontraindicatedinpatientswith

severenasal/facialtrauma,activenasalbleeding,ornasaldischarge.

b. Putprotectiveeyewearon.

c. Determineappropriatedoseofmedicationperappropriateprotocol.

d. Drawmedicationintosyringe(addadditional0.1mlofmedication

duetodeadspace)anddisposeofthesharpsintoasharpscontainer.

e. Donotadministermorethan1mlpernostril.

f. PerformaMACC.

g. AttachtheMucosalAtomizerDevice(MAD)tothesyringe.

h. Withonehand,controlthepatient’shead.

i. GentlyintroducetheMADintothenostril,stopwhenresistanceismet.

j. Aimslightlyupwardsandtowardtheearonthesameside.

k. Brisklycompressthesyringetoadministerthemedication.

l. Providersmayneedtodrawupmedicationintwosyringesinorderto

notexceedthe1mLlimitpernostril(bothnaresmaybeused).

m. RecordtimeofadministrationanddocumentinthePCR.

220



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4. Intravenous(IV)andIntraosseous(IO)(AdvancedLifeSupport).


b. Ifmedicationisnotpre‐filled,drawthemedicationintosyringe(add

additional0.1mlofmedicationduetodeadspace)anddisposeofthe

sharpsintoasharpscontainer.

c. PerformaMACC.

d. AllIV/IOmedicationsshallbeflushedwithanappropriateNSbolus.

1) Adult=20ml.

2) Pediatrics=10ml.

3) Neonates=5ml.

e. RecordtimeofadministrationanddocumentinthePCR.

5. MeteredDoseInhaler(AllProviders).

a. MeterDoseInhaler(MDI)administrationiscontraindicatedifthe

patienthastakentheirmaximumdosageofmedicationinthepast4‐6

hours.

b. Obtainthepatient’sprescribedMDIandperformaMACC.

c. Shaketheinhalervigorously.

d. Instructthepatientto:

1) Inhaleandexhaledeeply.

2) Placemoutharoundtheinhalermouthpiecetocreateatight

seal.

3) Inhaledeeplyasthemedicationcanisterisdepressed.

4) Holdtheirbreathaslongaspossible.

5) Repeattheprocessifthepatient’sprescriptionstatesmultiple

puffs.

e. RecordtimeoftheadministrationanddocumentinthePCR.

f. ALStransportispreferredunlessthisdelayspatientdeliverytothe

receivingfacility.

6. Nebulizer(AllProviders).


b. PerformaMACC.

c. Placemedicationintothenebulizerkit.

d. AttachO2sourcetothenebulizerkit(enoughtopromoteavisabile

mist,typically6‐8lpm).

e. Instructthepatienttobreaththroughtheirmouth,occasionallytaking

inadeepbreathandholdingitforafewmoments.

221



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f. RecordtimeofadministrationanddocumentinthePCR.

7. OrallyDissolving(AllProviders).


b. PerformaMACC.

c. Ensurethepatienthasapatentairwaypriortomedication

administration.

d. Oralglucoseshouldbeadministeredviathebuccalroute(betweenthe

patient’sgumandcheek.

e. OrallyDissolvingTablets(e.g.,Ondansetron)shouldbeplacedonthe

patient’stongue.

f. Instructthepatienttoallowthemedicationtodissolveinthemouth

andthattheyarenottocheworswallowthemedication.

g. RecordtimeofadministrationanddocumentinthePCR.

8. Peros(PO)(AllProviders).


b. PerformaMACC.

c. Ensurethepatienthasapatentairwaypriortomedication

administration.

d. Instructthepatienttochewandswallowthemedication.

e. RecordtimeofadministrationanddocumentinPCR.

9. Sublingual(AllProviders).


b. PerformaMACC.

d. Ensurethepatienthasapatentairwaypriortomedication

administration.

e. Instructpatienttoallowthemedicationtodissolveunderthetongue

andthattheyarenottocheworswallowthemedication.

f. RecordtimeofadministrationanddocumentinPCR.

222

Clinical Procedure: Selective Spinal Motion Restriction (SSMR)


Clin

ica

l Pro

ce

du

re: S

ele

ctive

Sp

ina

l Mo

tion

Re

strictio

n (S

SM

R)

Spinal Immobilization of neurologically intact trauma patients has long been hypothesized to be helpful in

preventing secondary spinal injury and stabilize potential fractures. Research has not necessarily demonstrated

this to be true and has demonstrated it to be harmful in other ways. Spinal Immobilization is not without risk. It

may increase pain, increase risk of aspiration, and respiratory compromise.

Selective Spinal Motion Restriction (SSMR) utilizes validated clinical decision rules to identify those patients at risk

for spinal injury, minimize spinal motion, prevent further injury during extrication and transport, and prevent

unnecessary harm from methods used to restrict spinal motion.



II. Methodsof(SSMR)

A. FullSpinalMotionRestriction.

1. Longbackboardwithcervicalcollar.

B. PatientregulatedSMRwithacervicalcollar.

C. PatientregulatedSMRwithoutacervicalcollar.

III. Procedure

A. Determiningtheneedforspinalimmobilizationandthemethodofimmobilization

requiresacarefulassessmentof:

1. Themechanismofinjury.

2. Thepatient’smentalstatusandabilitytorecognizeandcommunicatethe

presenceofspinalinjurysymptoms.

3. Physicalcomplaintsandoverallcondition.

B. Inthepresenceoftraumawherethereispotentialspinalinjury,immediately

stabilizethecervicalspineandaddressclinicalneedsinstandardorderofpriority

(e.g.,ABC).

IV. PenetratingTrauma

A. ClinicalIndicationsforfullSMR.

1. Thepatientexhibitsevidenceofclinicalintoxication.

2. Thepatientcannotbeassessedduetoanalteredmentalstatus/decreased

levelofconsciousness(GCS<15).

223



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Sp

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strictio

n (S

SM

R)

3. Thepatienthasneurologicaldeficits:

a. Paresthesia/Numbness.

b. Focalweakness.

c. FocalSensorydeficit.

B. Ifthepatientalsohasablunttraumainjury,refertotheblunttraumasection.C. Iftherearenoindicationsasdescribedabove,thennoSMRisrequiredfor

PenetratingTrauma.

V. BluntTrauma

A. ClinicalIndicationsforfullSMR:

1. Alteredlevelofconsciousness(GCS<15,severedementia,evidenceof

clinicalintoxication(alcoholorother).

2. Focalneurologicaldeficit(paralysisorparesis).

3. Hasapainfuldistractinginjury.

4. Patientisunabletocommunicateduetoalanguagebarrier.

5. Patientisunabletoappropriatelyrespondtoquestions(e.g.,youngchild,

speechorhearingimpairment).

B. IftherearenoclinicalindicationsforfullSMR,establishmanualstabilization

foranypatientwithatraumaticinjury.Positiontheheadintheneutral

position.Ifrealignmentcausespainorresistanceisencountered,stabilizethe

c‐spineinthepositionfound.ThenperformanSSMRevaluation.

1. Explaintothepatientthatyouwillbeevaluatingtheirspine,requestingthat

thepatientansweryourquestionsverballyandtoavoidnodding/shaking

theirheadyes/no.

2. IfanytimeduringtheSSMREvaluationthepatientcomplainsofpain,

tenderness,orneurologicalfindings,stoptheprocedure,maintainmanual

stabilization,andplaceacervicalcollaronthepatient.

3. PalpateeachindividualvertebrafromthebaseoftheskulltotheendofT1.

Evaluatethepatientforpain,tenderness,and/ordeformity.Ifnoneare

found,assesscervicalspinerangeofmotionutilizingtheNEXUScriteria:

a. Allrangeofmotionassessmentsmustbeperformedbythepatient

unassisted.

b. Askthepatienttoslowlyrotatetheirnecktoonesideasiftolookover

theirshoulderandthenslowlyreturntotheirheadtoaneutral

position.

224



Clin

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ctive

Sp

ina

l Mo

tion

Re

strictio

n (S

SM

R)

c. Requestthatthepatientrepeattheprocessontheoppositesideby

lookingovertheothershoulder.

d. Askthepatienttoslowlyflextheirneckdownbytouchingtheirchin

totheirchestandthentoslowlyreturntheirheadtoaneutral

position.

e. Askthepatienttoslowlyextendtheirneckandthenslowlyreturn

theirheadtoaneutralposition.

4. Ifthepatientpassesalltheassessmentsthentherearenoindications

forSMRandcervicalspineprecautionsmaybereleased.

5. PatientsthatdonotmeetthecriteriaforFULLSMRbutdonotpassthe

assessmentrequirec‐collarSMR;maintainmanualstabilizationofthe

cervicalspineuntilc‐collarisapplied.

a. Applyaproperlysizedcervicalcollarandreleasemanualstabilization.

b. Ifthec‐collardoesnotfitappropriately,causesdifficultybreathing,or

causesincreasedpainoragitation,immediatelyremovethecollarand

considerusingatowelrolltominimizemovement.

c. Patientsthatareambulatory,standing,orseatedshouldbeallowedto

movetoandsitdownonthecotbythemselvesiftheycan.Provide

stabilityifthepatientrequiresit.

1) Havethecotascloseaspossibletothepatientbeforemoving.

2) Havetheheadofbedraised30degrees.

3) Havethepatientsitonthecotandtransportinpositionof

comfort.

d. Patientsfoundonthegroundshouldbemovedtothestretcherviaa

longbackboard(removebackboardaftermovingpatientto

stretcher).

VI. SpecialSituations

A. Ifspinalmotionrestrictionisindicatedbutrefusedbythepatient:

1. AdvisethepatientoftheindicationforSMRandtherisksofrefusingthe

intervention.

2.. Maintainspinalalignmentasbestascanbeachievedduringtransport.

3. ClearlydocumentrefusalofSMR.

225



Clin

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Sp

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strictio

n (S

SM

R)

B. Forpatientswhocannottoleratesupinepositionduetoclinicalcondition:

1. ApplyallelementsofSMRthatthepatientwilltolerate.

2. Maintainspinalalignmentasbestascanbeachievedduringtransport.

3. ClearlydocumenttheclinicalconditionthatinterferedwithSMR.

C. Patientsofadvancedageorwithpriormedicalconditionsthatwouldmakethem

moresusceptibletospinalinjury,shouldhaveSSMREvaluationperformedifinjury

issuspected.

D. Pediatricpatientsmaybeimmobilizedintheirundamagedcarseatsbyapplyingac‐

collarortowelroll,paddingvoidspaces,andsecuringpatientstothecarseat.

E. Ifplacedonabackboard,pregnantpatients>12weeksgestationshallbe

transportedontheirleftsidebytiltingandstabilizingthebackboardata15°angle.

F. KendrickExtricationDevice(KED)‐maybebeneficialwhenextricatingaseated

patientinaVERTICALmove.Oncemovedtothestretcher,removetheKEDleaving

thecervicalcollarinplace.KEDuseshouldbelimited.

G. Whenprovidingcaretoathleteswithsuspectedspineinjury,generallyequipment

shouldberemovedpriortotransport(e.g.,bothhelmetandshoulderpads).

H. Allnon‐footballhelmetsshouldtoberemovedpriortoimmobilization(e.g.,

motorcyclehelmet,baseballhelmet).

226

Clinical Procedure: Splinting


Clin

ica

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ce

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plin

ting



II. Indications

A. Immobilizationofanextremityfortransport,eitherduetosuspectedfracture,

sprain,orinjury.

B. Immobilizationofanextremityfortransporttosecuremedicallynecessarydevices

suchasintravenouscatheters.

III. Equipment

A. OMDapprovedsplintingdevices.

IV. Procedure

A. Assessanddocumentpulse,sensation,andmotorfunctionpriortoplacementof

thesplint.Ifnodistalpulseispresentandafractureissuspected,consider

reductionofthefracturepriortoplacementofthesplint.

B. Removeallclothingandjewelryfromtheextremity.

C. Selectasitetosecurethesplintbothproximalanddistaltotheareaofsuspected

injuryortheareawherethemedicaldevicewillbeplaced.

D. Donotsecurethesplintdirectlyovertheinjuryordevice.

E. PlacethesplintandsecurewithVelcro,straps,orbandagematerial(e.g.,kling,

kerlex,clothbandage,etc.)dependingonthesplintmanufactureanddesign.

F. Documentpulses,sensation,andmotorfunctionafterplacementofthesplint.If

therehasbeenadeteriorationinanyofthese3parameters,repositionthesplint

andreassess.Ifnoimprovement,removesplint.

G. Ifanisolatedfemurfractureissuspectedandthereisnoevidenceofpelvicfracture

orinstability,placetractionsplint.

H. Considerpainmanagementperprotocol.

I. Documentthetime,typeofsplint,andthepreandpostassessmentofpulse,

sensation,andmotorfunctioninthePCR.

227

Clinical Procedure: Tactical Emergency Casualty Care (TECC)


Clin

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ac

tica

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erg

en

cy C

asu

alty C

are

(TE

CC

)



II. Indications

A. Foruseduringthemanagementofcasualtiesinhighthreatenvironments.

III. Equipment

A. TECCBag.

1. (4)H‐Bandages.

2. (4)METTTourniquets.

3. (4)RescueBlankets.

4. (4)CompressedGauze.

5. (4)HemostaticGauze.

6. (4)ChestSeals.

7. (4)NPAirways.

8. (4)ACEWraps.

9. (4)14gNeedles.

10. (4)Rollsoftape.

IV. Procedure

A. Indirectthreatcare.

1. Indirectthreatcareisprovidedinanareathathasbeenclearedofa

particularhazardthatwouldotherwisepresentadirectthreattoresponders.

2. Mitigatethehazardandmovetoasaferpositionifpossible.

a. Initialactionsshouldbetoaddresstheimmediatelifethreat(e.g.

shoring,firesuppression,extractionfromimmediatestructural

collapse).

3. Lifethreateninghemorrhage.

a. Stoplifethreateningexternalhemorrhage.

1) Applytourniquetovertheclothingasproximalaspossibleto

thesuspectedwoundsite.

2) Donotplaceoverknee,elbow,oropenfracture.

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)

3) Windlessshouldbeaccessiblebyboththecasualty

andotherresponders.

4) Applysecondtourniquet,proximaltothefirst,ifbleedingisnot

controlled.

b. Tightenuntilthebleedingstops.

c. Instructcasualtytoapplydirectpressuretothewoundifno

tourniquetisavailableorconditionspreventtheapplicationofa

tourniquet.

d. Casualtiesshouldbeplacedintoapositionthatfacilitatesapatent

airway.

4. Directthecasualtytomovetocoverandapplyself‐aidifcapable.

5. Assessforunrecognizedlifethreatinghemorrhageandcontrolallsourcesof

majorbleeding.

a. Ifnotalreadyperformed,applytourniquetovertheclothingas

proximaltothewoundaspossible(ifabletoexposeandevaluatethe

wound,applydirectlytotheskin2‐3inchesabovethewound).

b. Fortotalorpartialtraumaticamputations,atourniquetshouldbe

appliedregardlessofbleeding.

c. Forcompressiblehemorrhagenotamenabletotourniquetuse,apply

hemostaticagentinaccordancewithdirectionsforitsuseandan

appropriatepressurebandage.

d. Reassessalltourniquetsthatwereinitiallyapplied.

1) Ifthecasualty’swoundcontinuestohemorrhagedespitethe

previousapplicationofatourniquet,applyasecondtourniquet

immediatelyproximaltothefirsttourniquet.Tightenthe

secondtourniquetuntilthehemorrhagehasbeencontrolled.

2) Iftimeandthesituationallows,adistalpulseshouldbe

assessedonanylimbwhereatourniquetisapplied.Ifbleeding

ispersistent,considertighteningthetourniquetorapplyinga

secondtourniquet.Thegoalistoeliminateadistalpulseinthe

limbwhereatourniquetisapplied.

3) Exposeandmarkalltourniquetsiteswiththeapplicationtime

ofthetourniquet.

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(TE

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)

A. AirwayManagement.

1. Ifnospontaneousbreathingisnotedafterairwayisopened,moveontothe

nextcasualty.

2. Ifcasualtyisbreathingandtheyare:

a. Unconscious:

1) InsertaNPairway.

2) Placecasualtyinarecoverypositionorapositionthatbest

facilitatesthepatencyofthecasualty’sairway.

b. Conscious:

1) Placecasualtyinarecoverypositionorapositionthatbest

facilitatesapatentairway.

3. Breathing.

a. Ifpatienthasanopenchestwound,applyaSAMchestseal.

b. (ENDORSEDALSPROVIDERSONLY)Forasuspectedtension

pneumothorax,decompressthechestwitha14‐gauge,3.25inch

needle.RefertoClinicalProcedure:ChestDecompression.

4. PreventionofHypothermia.

a. Attempttominimizeenvironmentalexposuretotheelements.

b. Removewetclothingifpossible.

c. Placecasualtyontoaninsulatedsurfaceifpossible.

d. Coverthecasualtywitharescueblanketoranythingthatwillretain

heatandkeepthecasualtydry.

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(TE

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)

C. TacticalEmergencyCasualtyCare(TECC)Bag

Tape(4)

METTTourniquet(4)

14gaNeedle(4)

ChestSeal(4)

ACEWrap(4)

CompressedGauze(4)

NPAirway(4)

HemostaticGauze(4) H‐Bandage(4) RescueBlanket(4)

231

Clinical Procedure: Temperature Measurements


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II. Indications

A. Monitoringbodytemperatureinapatientwithsuspectedinfection,hypothermia,

hyperthermia,ortoassistinevaluatingresuscitation.

III. Procedure

A. Ifclinicallyappropriate,allowthepatienttoreachequilibriumwiththesurrounding

environment.

B. Toobtainanoraltemperature,ensurethepatienthasnooraltraumaandplacethe

deviceunderthetongue.

C. Leavethedeviceinplaceuntilthereisindicationanaccuratetemperaturehasbeen

recorded(perthespecificdevice).

D. Recordtime,temperature,method(tympanicororal),andscale(CorF)inPCR.

232

Clinical Procedure: Venous Access Indwelling Catheters


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II. Indications

A. Accessofanexistingvenouscatheter(i.e.,PICCline)formedicationorfluid

administrationonlyinalifethreateningsituationwhennootheraccessisavailable.

B. Centralvenousaccessinapatientincardiacarrest.


A. Non‐externalizedports(subcutaneousortunneledports).

IV. Procedures

A. WearappropriatePPE(i.e.,gloves,maks).

B. Cleantheportofthecatheterwithalcoholwipeandallowtodry.

C. Usingsteriletechnique,withdraw5‐10ccofbloodandplacesyringeinsharpsbox.

D. Cleantheportofthecatheterwithalcoholwipeandallowtodry.

E. Using5ccofnormalsaline,accesstheportwithsteriletechniqueandgentlyattempt

toflushthesaline.

F. Ifthereisnoresistance,noevidenceofinfiltration(e.g.,nosubcutaneous,collection

offluid),andnopainexperiencedbythepatient,thenproceedtostepG.Ifthereis

resistance,evidenceofinfiltration,painexperiencedbythepatient,oranyconcern

thatthecathetermaybeclottedordislodged,donotusethecatheter.

G. BeginadministrationofmedicationsorIVfluidsslowly.Observeforanysignsof

infiltration.Ifdifficultiesareencountered,stoptheinfusionandreassess.

H. Recordprocedure,anycomplications,andfluids/medicationsadministeredinthe

PCR.

233




II. Indications

A. Criticalpatientswhererapid,regularIVaccessisunavailablewithanyofthe

following:

1. CardiacArrest.

2. Multisystemtraumawithseverehypovolemia.

3. Severeburns.

4. Severedehydrationwithvascularcollapseand/orlossofconsciousness.

5. Respiratoryfailure/Respiratoryarrest.

6. Criticalmedicalemergenciesrequiringimmediateaccess.

7. PatientsdeemedappropriatebyMedicalControl.

8. PediatricpatientsincardiacarrestmaygodirectlytoIOifnoperipheral

venousaccesssitesarereadilyavailable.


A. Consciouspatientwithstablevitalsigns.

B. Peripheralvascularorintranasalaccess(whenapplicable)readilyavailable.

C. Fractureproximaltoproposedintraosseoussite.

D. Patientwithhistoryofknownbonedisorder.

E. Infectionoverlyingintendedintraosseoussite.

F. Inabilitytoidentifylandmarks.

G. Previousintraosseousinsertion(within48hours)orjointreplacementatthe

selectedsite.

H. Deepburnsinvolvingboneattheselectedsite.

IV. Procedure

A. Siteselection.

1. Patients<6yearsofageorpatients<40kg,proximaltibia.

2. Patients>40kg,proximalhumerous(preferred),proximaltibia.

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Clinical Procedure: Venous Access Intraosseous


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B. Identifytheappropriatesite.

1. AnteriorTibia.

a. Anteromedialaspectoftheproximaltibia(bonyprominencebelow

thekneecap).

b. Theinsertionlocationwillbe1‐2cm(2fingerwidths)belowthis.

2. ProximalHumerus(MethodA).

a. Keepingtheelbowflatonthefloorandclosetothesideofthebody,

rotatethepalmovertheumbilicusandpalpatethegreatertubercleof

thehumerus.

b. Theinsertionlocationwillbe1‐2cm(2fingerwidths)abovethe

surgicalneck.

3. ProximalHumerus(MethodB).

a. Withthearmfullyextendedandtighttothebody,rotatethehand

medially(inward)untilthepalmisfacingout.

b. Palpatethegreatertubercleofthehumerusapproximately1‐2cm(2

fingerwidths)abovethesurgicalneck.

c. Theinsertionlocationwillbe1‐2cm(2fingerwidths)abovethe

surgicalneck.

C. Wearpersonalprotectiveequipment(gloves,eyeprotection,etc.).

D. Cleansethesite.

E. Formanualpediatricdevices(AnteriorTibia).

1. Holdtheintraosseousneedleata60to90degreeangle,aimedawayfromthe

nearbyjointandepiphysealplate,twisttheneedlehandlewitharotating

grindingmotionapplyingcontrolleddownwardforceuntila“pop”or“give”

isfeltindicatinglossofresistance.Donotadvancetheneedleany

further.

F. FortheEZ‐IOintraosseousdevice.

1. ProximalHumerous

a. Holdtheintraosseousneedleata45°angle,aimedawayfromthe

nearbyjointandepiphysealplate,powerthedriveruntilthehubof

theneedleisflushwiththeskin.

2. ProximalTibia

a. Holdtheintraosseousneedleata90°angle,aimedawayfromthe

nearbyjointandepiphysealplate,powerthedriveruntila“pop”or

“give”isfeltindicatinglossofresistance.Donotadvancetheneedle

anyfurther.

235


G. Removethestyletandplaceinanapprovedsharpscontainer.

H. Attacha10ccsyringefilledwith5ccNS;aspiratebonemarrowtoverifycorrect

placement,theninject5ccofNStoclearthelumenoftheneedle.

I. Forinfusionrelatedpain,ALSProvidersmayadminister:

1. Adults:

a. Administer40mgof2%Lidocaineover2minutes.

1) AllowlidocainetodwellinIOspacefor1minute.

2) Flushwith10ccofNS.

2. Pediatric:

a. Administer0.5mg/kgof2%Lidocaine(nottoexceed40mg)over2

minutes.

1) AllowlidocainetodwellinIOspacefor1minute

2) Flushwith5ccofNS.

J. AttachtheIVline.Useapressurebag.

K. Stabilizeandsecuretheneedlewithdressingsandtape.

L. Iftheproximalhumerussiteisused,ensurethepatient’sarmissecuredinthe

positionthattheIOwasestablished.

M. FollowingtheadministrationofanyIOmedications,flushtheIOlinewith10ccofIV

fluidtoexpeditemedicationabsorption.

N. Recordthetimeonthemanufacturesuppliedarmbandandplacethearmbandon

thewrist.

O. Documenttheprocedure,time,andresult(success)on/withthePCR.

Clinical Procedure: Venous Access IntraosseousC

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236

Clinical Procedure: Venous Access Peripheral


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II. Indications

A. PatientsrequiringIVmedicationsorfluids.

B. Patientswithanypotentialfordeterioration(e.g.seizures,alteredmentation,

trauma,chestpain,difficultybreathing,potentialemergentmedicalcondition).


A. Childwithpartialairwayobstruction(e.g.,suspectedepiglottitis)–whenagitation

fromperformingproceduremayworsenrespiratorydifficulty.

IV. Equipment

A. AppropriatetubingorIVlock.

B. #14‐#24overtheneedlecatheter.

C. Venoustourniquet.

D. Alcoholswab.

E. Gauzepadoradhesivebandage.

F. Tapeorothersecuringdevice.

V. Procedure

A. SalinelocksmaybeusedasanalternativetoIVTubingandfluidatthediscretionof

theALSprovider.

B. ALSprovidersmayuseintraosseousaccesswherethreattolifeexistsasprovided

forintheVenousAccess–Intraosseousprocedure.

C. ALSprovidersmayuseIndwellingcatheterswherethreattolifeexistsasprovided

forintheVenousAccess–IndwellingCatheterprocedure.

D. Usethelargestcatheterborenecessarybaseduponthepatient’sconditionandsize

ofveins.

E. Fluidandsetupchoiceispreferably:

1. NormalSalinewithamacrodrip(10gtt/cc)formedical/traumaconditions.

237

Clinical Procedure: Venous Access Peripheral


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2. NormalSalinewithamicrodrip(60gtt/cc)formedicationinfusionsorfor

patientswherefluidoverloadisofconcern.

F. AssembleIVsolutionandtubing:

1. OpenIVbagandcheckforclarity,expirationdate,etc.

2. Verifycorrectsolution.

3. OpenIVtubing.

4. AssembleIVtubingaccordingtomanufacturer’sguidelines.

G. Insertion

1. ExplaintothepatientthatanIVisgoingtobestarted.

2. PlacethetourniquetproximaltotheIVsite(unlessexternaljugularsite),if

appropriate.

3. Palpateveinsforresilience.

4. Cleantheskinwiththealcoholswabinanincreasingsizedconcentric

circleandallowtoairdry.

5. Stabilizetheveindistallywiththeprovider'sthumb/fingers.

6. Entertheskinwiththebeveloftheneedlefacingupward.

7. Enterthevein,obtainaflash,andadvancethecatheteroffofthecatheter

overtheneedleandremovetheneedlewhilecompressingtheproximaltipof

thecathetertominimizebloodloss.

8. Removethetourniquet.

9. ConnectIVtubingtothecatheter,orsecuretheIVlocktothecatheterand

flushwithappropriatesolution(NS).

10. OpentheIVclamptoassurefreeflow.

11. SetIVinfusionrate.

H. SecuretheIV.

1. SecuretheIVcatheterandtubing.

2. CoverIVsitewithappropriatedressing.

3. RecheckIVdripratetomakesureitisflowingatappropriaterate.

4. TroubleshootingtheIV(iftheIVisnotworkingwell):

a. Makesurethetourniquetisoff.

b. ChecktheIVinsertionsiteforswelling.

c. ChecktheIVtubingclamptomakesureitisopen.

d. Checkthedripchambertomakesureitishalffull.

238

Clinical Procedure: Wound Care/Hemorrhage Control


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II. Indications

A. Patientswithwoundsthatrequirebandaging.

B. Patientswithcontrolledbleedingthatrequiresdressingandbandaging.

C. Patientswithuncontrolledbleedingthatrequiresdressingandbandaging.

III. Procedure

A. Assessthepatientandtreatperthefollowingalgorithm.

*Directpressuremaybeconsideredimpracticalwhenthenumberofpatientsexceed

availablepersonneltodelivercare,numberofcriticalinterventionsprecludessustained

directpressurebyoneprovider,unabletoaccesssiteofbleeding,indirectthreattothe

providersmakesdirectpressureatthesiteofwoundingimpractical,etc.

Wound amenable to tourniquet placement?(e.g. Extremity injury)

Apply direct pressure/pressure dressing to the injury.

Direct pressure effective.(Bleeding controlled)

Apply tourniquet.

Direct pressure ineffective or impractical*.(Bleeding not controlled)

Wound not amenable to tourniquet placement?

(e.g. junctional injury, groin, neck, etc.)

Use wound packing with hemostatic gauze, followed by direct pressure/pressure

dressing

239



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B. Equipmentandapplicationdirections.

1. CeloxRapidHemostaticZ‐foldGauze.

a. Attempttolocatetheareainwhichthebleedingiscomingfrom.

b. Usesterilegauzetoblotexcessbloodfromthewoundtoaidin

locatingwherethebleedinghasoriginatedfrom.

c. FillthewoundwithCeloxRapidGauze.Whenfillingthewound,fillin

thedirectionofthebleedingorgin.

d. Tightlypackthewholespaceandcompressforoneminute.

e. SecureinplaceandconsidertransporttoaLevel1TraumaCenter.

f. Coverwoundwithsterilegauze/dressing.Checkdistalpulses,

sensation,andmotorfunction.

g. DocumentthetimetheCeloxRapidGauzewasplacedinthePCR.

2. H‐Bandage.

a. Centertheabsorbentpadoverthewound.

b. Ensurethe“H”iscenteredoverwhereyouwantthemostpressure.

c. Takethelongendoftheelasticbandageandwrapitaroundthe

extremityandsecuretotheVelcrotab.Thiswillpreventtheelastic

bandagefromsliding.

d. Looptheelasticbandagearoundthe“H”barnearesttheVelcrotab.

e. Holdthe“H”topreventthebandagefromslippingandsimultaneously

pulltheelasticbandagetaught.

f. Wraptheelasticbandagebackaroundtheextremityandloopit

aroundtheopposite“H”bar.

g. Holdthe“H”topreventthebandagefromslippingandsimultaneously

pulltheelasticbandagetaut.

h. Wraptheremainingelasticbandagebackaroundtheextremityand

continuetofollowthepathuntiltheelasticbandagecanbesecured

withthethree‐inchstripofVelcro.

i. SecureinplaceandconsidertransporttoaLevel1TraumaCenter.

j. Checkdistalpulses,sensation,andmotorfunction.

k. DocumentthetimetheH‐BandagewasplacedinthePCRandifable,

writethetimetheH‐BandagewasplacedontheH‐Bandagethatwas

appliedtothepatient.

240



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3. Tourniquet.

a. Applytourniquetasproximaltothewoundaspossible(apply

directlytotheskin2‐3inchesabovethewound).

b. Ifextremityisnottrapped,gotonumber2below.

1) Foratrappedextremity,pullconstrictionbandbackward

throughwindlassandtourniquetbase.Slideconstrictionband

backthroughtourniquetbaseandthroughwindlass.

2) Pulltabupandawayfromthetourniquetbase,workingthe

strapinanupanddownmotionuntiltourniquetbaseand

windlassslidesnugupagainstlimb.

c. Rotatewindlassuntilbleedinghasstopped.

d. Securewindlassbypullingthefixedsecuring‐loopovertheclosest

endoftheendofwindless.

e. Pullsecuring‐loopwithfrictionbuckleoverfreeendofwindlassand

tighten.Thesecuringloopwithfrictionbucklemustbesecuredbefore

movingthepatient.

f. SecureinplaceandconsiderexpeditedtransporttoaLevel1Trauma

Center.

g. Coverwoundwithsterilegauze/dressing.Documentabsenceor

presenceofdistalpulse,sensation,andmotorfunction.

h. Monitorwoundand/ordressingthroughouttransportforbleeding.

i. DocumentthetimethetourniquetwasplacedinthePCR.

j. Ifconditionsallow,physicallywritethetimeonthetourniquetthat

wasappliedtothepatient.

241


PharmacologyThefollowingpagesprovidesupplementalinformationonpharmaceuticalsapprovedforuseinthePrinceWilliamCountyEMSSystem. Thismaterialismeant toprovideadditionalinformation;itdoesnotestablishordersfordeliveryofmedication.RefertothePhysician'sDeskReference(PDR)for

completedruginformation.

Medicationsmayonlybeadministeredasdirectedbyauthorized PrinceWilliamCountyEMSSystemProtocolsorasdirectedbyOLMCorders.

Authorized Pharmaceuticals


Au

tho

rized

Ph

arm

ac

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tica

ls

242

Generic Name Trade Name Route

Adenosine Adenocard IV/IO

Albuterol Proventil, Ventolin Nebulized

Amiodarone Cordarone IV/IO

Aspirin PO

Atropine IV/IO

Calcium Chloride IV/IO

Dextrose IV/IO

Diphenhydramine Benadryl IV/IO/IM

Dopamine Intropin IV/IO

DuoDote IM

Epinephrine 1mg/ml (1:1,000) Adrenaline IM/Nebulized

Epinephrine 0.1mg/ml (1:10,000) Adrenaline IV/IO

Fentanyl Sublimaze IV/IO/IN

Glucagon GlucaGen IV/IM

Glucose, Oral Glutose PO

Hydroxocobalamin CyanoKit IV/IO

Ipratropium Bromide Atrovent Nebulized

Ketamine Ketalar IV/IM

Lidocaine Xylocaine IO

Magnesium Sulfate IV/IO

Methylprednisolone Solu‐Medrol IV/IO

Metoprolol Lopressor IV/IO

Midazolam Versed IV/IO/IM/IN

Morphine Sulfate IV/IO

Naloxone Narcan IV/IO/IM/IN

Nitroglycerin Nitrostat, Nitrolingual SL

Ondansetron Zofran IV/IO/ODT

Promethazine Phenergan IV

Racemic Epinephrine Nebulized

Sodium Bicarbonate 8.4%, 4.2% IV/IO/Nebulized

Tranexamic Acid IV/IO

Adenosine


Ad

en

osin

e

PharmacologicpropertiesAdenosineisanendogenouspurinenucleosidethatslowsconductiontimethroughtheAVnodeandinterruptsAVreentrypathwayswhichrestoresnormalsinusrhythminpatientswithparoxysmalsupraventriculartachycardia(PSVT).Theonsetofactionis20‐30secondsandthedurationofactionis<10seconds.

Indications NarrowComplexTachycardia(SVT). Wide‐complextachycardia(rate>150),stableandSVThighlylikely.

Contraindications 2ndor3rddegreeAVblock. Sicksinussyndrome. Knownhypersensitivity.

Precautions Effectsofadenosineareantagonizedbymethylxanthine(theophyllineandcaffeine). Adenosinecanprovokebronchospasmandshouldbeusedcautiouslyinpatientswithreactiveairwaydisease.

TegretolandPersantinemaypotentiatetheeffectofAdenosine. Adenosineisnoteffectiveinconvertingatrialfibrillationorflutter. Thehalf‐lifeofadenosineis<5seconds‐thedrugshouldbeadministeredviaalargeboreIVintheupperextremity,andattheportclosesttotheIVhub.

Sideeffects/adversereactions Cardiovascular‐transientchestpain,periodsofsinusbradycardia,ventricularectopyorpause.

Facialflushing(transient). Respiratory‐transientdyspnea. Metallictaste.

Dosageandadministration CardiacEmergencies:RegularNarrowComplexTachycardia(SVT)

o Adult:6mgrapidIVPover1‐3secondswith20mLNSflush.

Ifnoresponsein2minutes,administer12mgrapidIVPover1‐3secondswith20mlNSflush.

o Pediatric:0.1mg/kgrapidIV/IOover(maxdose6mg)1‐3secondswitha10mlNSflush.

Ifinadequateresponse,administer0.2mg/kg(maxdose12mg) rapidIV/IOover1‐3secondswitha10mlNSflush.

243

Albuterol Sulfate


Alb

ute

rol S

ulfa

te

PharmacologicpropertiesAlbuterolisprimarilyabeta‐2agonistthatproducesbronchodilationwithlimitedcardiovascularsideeffectsduetoit’shighspecificityforbeta‐2receptors. Onsetiswithin15minutes;peakeffectisin60‐90minutes.Therapeuticeffectsmaybeactiveupto5hours.

Indications Acutebronchospasm(wheezing)duetoasthma,COPDorallergicreation. Knownorsuspectedhyperkalemia(dialysispatient,crushinjury)

Contraindications Knownhypersensitivity.

Precautions Usecautiouslyinpatientswithcoronaryarterydisease,hypertension,hyperthyroidism,diabetes.

Epinephrineshouldtypicallynotbeusedatthesametimeasalbuterol,however,eithermaybeused subsequenttoafailureoftheother.

Sideeffects/adversereactions Nervousness Tremor Tachycardia Hypertension Nausea Vomiting

Dosageandadministration RespiratoryEmergencies:Dyspnea

o AdultandPediatrics(AllProviders):Albuterol2.5mgvianebulizer,repeatoncein5minutesifindicated.

RespiratoryEmergencies:AcuteBronchospasmo AdultandPediatrics(AdvancedLifeSupport):

Albuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated.

Ifwheezingpersist,administerAlbuterol2.5mgvianebulizer,repeatevery5minutesifindicated(maxcumulativedose15mg.)

RespiratoryEmergencies:PulmonaryEdema:o Adult(AdvancedLifeSupport):

Albuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated(maxcumulativeAlbuteroldose15mg).

244


Dosageandadministration CardiacArrest:PostResuscitationCare CardiacEmergencies:WideComplexTachycardia

o Adult(AdvancedLifeSupport):SuspectedHyperkalemia,AdministerAlbuterol5mgvianebulizer.

HazardousMaterialsExposure:GeneralApproacho Adult(AllProviders):

Inhaledtoxinswithacutebronchospasm,administerAlbuterol2.5mgvianebulizer.

o Adult(AdvancedLifeSupport):Inhaledtoxinswithacutebronchospasm,administerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated.

Ifwheezingpersist,administerAlbuterol2.5mgvianebulizer,repeatevery5minutesifindicated(maxcumulativedose15mg).

Medical:AllergicReaction

o AdultandPediatric(AllProviders):Albuterol2.5mgvianebulizer,repeatoncein5minutesifindicated.

o AdultandPediatric(AdvancedLifeSupport):Albuterol2.5mgvianebulizer,repeateveryin5minutesifindicated(maxcumulativedose15mg).

GeneralPatientCareProtocol–AdultTraumao Adult(MedicalControl):

Entanglement/entrapmentorcrushinjuries≥4hours,considerAlbuterol5mgvianebulizer.

Albuterol SulfateA

lbu

tero

l Su

lfate

245

Amiodarone


Am

iod

aro

ne

PharmacologicpropertiesAmiodaroneisconsideredaclassIIIantiarrhythmic. Itpossesseselectrophysiologicalcharacteristicsofsodium,potassiumandcalciumchannelblockade,aswellasalphaandbetaadrenergicblockingactivity.Thesepropertiesprolongactionpotentialsandrepolarization,stabilizingmyocardialmembranes.

Indications Ventricularfibrillation/pulselessventriculartachycardia. Ventriculartachycardiawithoutovertsignsofshock(SBP>90). Widecomplextachycardiaofunknownetiology. Pediatricventricularfibrillation/pulselessventriculartachycardia.

Contraindications Cardiogenicshock Markedsinusbradycardia SecondorthirddegreeAVblock Knownhypersensitivity

Precautions Solutionisextremelyviscous.Donotshake. Administerthemedicationslowly. Uselargeborefilteredneedles,orneedlessfilterstraws.

Sideeffects/adversereactions Hypotension Bradycardia Adverseeffectscanbetreatedbythefollowing:

o Slowtherateofdruginfusiono IVfluidbolus,pressers,chronotropicagents,ortemporarypacing

Dosageandadministration CardiacArrest:V‐Fib/PulselessV‐Tach

o Adult:Amiodarone300mgbolusIV/IO.ForpersistentV‐Fib/V‐Tach,mayrepeatevery3‐5minutes,Amiodarone150

mgIV/IO(maxcumulativedose450mg).o Pediatric:

Amiodarone5mg/kgbolusIV/IO(maxsingledose300mg).ForpersistentV‐Fib/V‐Tach,mayrepeatevery3‐5minutes,Amiodarone5

mg/kgIV/IO(maxcumulativedose15mg/kgnottoexceed450mg).

246

Amiodarone


Am

iod

aro

ne

Dosageandadministration CardiacArrest:PostResuscitationCare

o Adult:IfV‐Fib/V‐TachoccurredduringarrestandnoAmiodaronewasgiven,

administerAmiodarone150mgdilutedin100mlNSIV/IOpiggybackover10minutes.

CardiacEmergencies:RegularNarrowComplexTachycardia(SVT)o Adult(MedicalControl):

ConsiderAmiodarone150mgdilutedin100mlNSIVPiggyback,over10minutes.

CardiacEmergencies:WideComplexTachycardiao Adult–Stablewithmildsymptoms:

AdministerAmiodarone150mgdilutedin100mlNSIVPiggybackover10minutes.

o Adult–Reoccurrencefollowingelectricalcardioversion:AdministerAmiodarone150mgdilutedin100mlNSIVPiggybackover10

minutes,mayrepeatonce.

CardiacEmergencies:PolymorphousV‐Tach(TorsadesdePointes)o Adult–Stablewithmildsymptoms:

NoresponsetoMagnesiumSulfate,administerAmiodarone150mgdilutedin100mlNS,IVPiggybackover10minutes.

247

Aspirin


Asp

irin

PharmacologicpropertiesAspirinisasalicylatewithanti‐plateletactivity.Itinhibitscyclooxygenase,blockingthe synthesisofprostaglandintointerferewithplateletaggregation.Thisactionhasbeen demonstratedtoreducemortalityinpatientssufferingfrommyocardialinfarction. Aspirinalsohasmoderateanalgesicandanti‐pyreticeffects.Theonsetofactionis5‐30minutes,andthe durationofactionis3‐6hours.

Indications ChestPain‐suspectedmyocardialischemia. RespiratoryEmergencies‐Cardiacoriginsuspected.

Contraindications: Knownhypersensitivity. Activeulcerdisease. Pregnant(especiallythirdtrimester)oranursingmother.

AdverseReactions: Anaphylaxis(ifhistoryofhypersensitivity). Abdominaldiscomfort. Gastrointestinalbleeding(ifpreviousconditionexists).

Dosageandadministration: RespiratoryEmergencies:Dyspnea

o Adult(AllProviders):Ifsuspectedcardiacorigin,administerAspirin324mgPO.

RespiratoryEmergencies:PulmonaryEdemao Adult(AdvancedLifeSupport):

AdministerAspirin324mgPO.

CardiacEmergencies:AcuteCoronarySyndromeo Adult(AllProviders):

AdministerAspirin324mgPO.

248

Atropine Sulfate (cardiac indications)


Atro

pin

e S

ulfa

te (c

ard

iac

ind

ica

tion

s)

PharmacologicpropertiesAtropineisapotentparasympatholyticanticholinergic. Itinhibitsmuscarinicreceptoractivity intheparasympatheticsitesinsmoothmuscle,centralnervoussystem,cardiacandsecretory tissue.Thisreducesvagaltone,increasesautomaticityoftheSAnodeandincreasesAVconductions,thusincreasingheartrate. Additionaleffectsincludedryingsecretionsandslowing motilityinthegastrointestinaltract.

Indications Bradydysrhythmias(rate<50)accompaniedbyhemodynamiccompromise,i.e.hypotension(systoliclessthan90mmHg),shock,pulmonaryedema,alteredlevelofconsciousness.

PediatricBradycardia(HR<100inaninfant,HR<60inachild)despiteadequateoxygenation,ventilation,chestcompressions,andrefractorytoepinephrine.

Contraindications Atropinehasnoeffectinpatientswithtransplantedhearts. 3rddegreeAVblockinthesettingofanacuteanteriorwallMI.

Precautions Ifnormaldosepushedtooslowly,oriftoosmalladose(<0.5mg)isgiven,heartratemayinitiallyslowdown.

Atropineispotentiatedbyantihistaminesandantidepressants. CautioususeinTypeIIAVblockand3rddegreeblockwithwideQRScomplexes.

Adversereactions Restlessness. Agitation. Confusion. Pupildilation. Blurredvision. Headache.

Dosageandadministration CardiacEmergencies:Bradycardia

o Adult:AdministerAtropine0.5mgIVP,repeatevery3‐5minutesifindicated(maxcumulativedose3mg).

o Pediatric:AdministerAtropine0.02mg/kgIV/IO(minimumdose0.1mgwithamax

dose0.5mg),repeatoncein3‐5minutes.

249

Atropine Sulfate (antidote for poisoning)


Atro

pin

e S

ulfa

te (a

ntid

ote

for p

oiso

nin

g)

Pharmacologicproperties:Atropineisapotentparasympatholyticanticholinergic. Itinhibitsmuscarinicreceptoractivity intheparasympatheticsitesonsmoothmuscleandthecentralnervoussystem,aswellas cardiacandsecretorytissue.Thisreducesvagaltone,increasesautomaticityoftheSAnode andincreasesAVconductions,thusincreasingheartrate. Additionaleffectsincludedrying secretionsandslowingmotilityinthegastrointestinaltract.

Indications OrganophosphatePoisoning(i.e.parathion,malathion,rid‐a‐bug)andcarbamate

(Baygon, sevin,andmanycommonroachandantsprays). PoisoningSigns.

“SLUDGE”o Salivation.o Lacrimation.o Urination.o Defecation.

GIhypermotility(Emesis,diarrhea). Excessivesweatingandbronchorrhea. Additionalsignsinclude:pinpointpupils andbradycardia.

Nonewhenusedinthemanagementofsevereorganophosphatepoisoning.

Precautions Itisimportantthatthepatientbeadequatelyoxygenatedandventilatedpriorto

using atropine,asatropinemayprecipitateventricularfibrillationinapoorlyoxygenatedpatient.

Donotrelyuponpupilconstrictiontodiscontinueortotitratemedications.

Adversereactions Victimsoforganophosphatepoisoningcantoleratelargedoses(1000mg)of

atropine. Signsofatropinization(flushing,pupildilation,drymouth,tachycardia)arelikely

tooccur.

250

Atropine Sulfate (antidote for poisoning)


Atro

pin

e S

ulfa

te (a

ntid

ote

for p

oiso

nin

g)

Dosageandadministration HazardousMaterialsExposure:NerveAgent/WMD

o Adult:ConsiderAtropine2mgIV/IO/IMevery5minutesuntilsymptoms

resolve.

OverdoseandPoisoning:BetaBlockerToxicityo Adult:

ConsiderAtropine0.5mgIVP,repeatevery3minutesifindicated(maxcumulativedose3mg).

OverdoseandPoisoning:CalciumChannelBlockero Adult:

AdministerAtropine0.5mgIVP,repeatevery3minutesifindicated(maxcumulativedose3mg).

OverdoseandPoisoning:Cholinergic/Organophosphateso Adult:

AdministerAtropine2mgIV/IO,repeatevery5minutesuntilimprovementinrespiratoryeffort/bronchialsecretionsisnoted.

PediatricOverdoseandPoisoningo Pediatric(MedicalControl):

AdministerAtropine0.02mg/kgIV/IO(minimumdose0.1mgwithamaxdose2mg),repeatevery2minutesifindicated(max6mg).

251

Calcium Chloride


Ca

lciu

m C

hlo

ride

Pharmacologicproperties:Calciumisacationthatisessentialforneurotransmission,boneformation,enzymaticreactionsandmuscle(includingcardiac)contraction.Inthemyocardium,itincreasestheforceofcontractionandaugmentscardiacoutput.Calciumalsohasastabilizingeffectonmyocardialmembraneswhendangerouslyhighpotassiumlevelsmaketheheartatriskforfibrillation.

Indications HyperkalemiawithassociatedECGdisturbances. Hypocalcemia(known). Calciumchannelblockertoxicitywithhemodynamiccompromise. Magnesium(MgS04)toxicity.

Contraindications Cardiacarrestnotassociatedwithoneoftheabove. Digoxintoxicity. Hypercalcemia.

Precautions CautioususeinpatientsreceivingDigoxin‐donotadministertopatientswithsuspected

Digoxintoxicityoroverdose. Donotmixwithsodiumbicarbonate‐itwillprecipitate.

Adversereactions Bradycardia(usuallycausedbyrapidadministration). Arrhythmias‐especiallyinpatientsondigoxin. Sclerosisofveins(ifIVinfiltrates).

Dosageandadministration CardiacArrest:AsystolePEA

o Adult(suspectedhyperkalemiaandsuspectedcalciumchannelblockeroverdose):AdministerCalciumChloride1gIV/IO.

o Pediatric(suspectedhyperkalemia):AdministerCalciumChloride20mg/kgIV/IO(maxdose1g).

CardiacArrest:V‐Fib/PulselessV‐Tacho Adult(suspectedhyperkalemia):


CardiacArrest:PostResuscitationCareo Adult(suspectedhyperkalemia):


252

Calcium Chloride


Ca

lciu

m C

hlo

ride

CardiacEmergencies:WideComplexTachycardiao Adult(suspectedhyperkalemia):


OverdoseandPoisoning:CalciumChannelBlockero Adult:


253

Dextrose


De

xtrose

PharmacologicpropertiesDextroseisasimplemonosaccharidealsoknownasglucose.Itprovidescaloriesformetabolicneeds,sparingbodyproteinsandlossofelectrolytes.Dextroseisahypertonicsolutionthatisreadilyexcretedbythekidneysproducingdiuresis.

Indications Hypoglycemiainanadult(<60mg/dL). Hypoglycemiainaneonate(<40mg/dL). Hypoglycemiainapediatric(<60mg/dL). Comaofunknownorigin(alteredlevelofconsciousness),andunabletoperformglucose

check.

Contraindications Strokeoracutebraininjurywithglucose>60mg/dL.

Precautions MaytheoreticallyprecipitateWernicke‐Korsakoffsyndromeifgivenwithoutthiaminein

chronicalcoholdependenceandmalnutrition.

Adversereactions Thrombosis,sclerosingifgiveninaperipheralvein. Tissueirritationifinfiltrates. Hyperglycemia. Hypokalemia.

Dosageandadministration Medical:DiabeticEmergencies

o Adult(BGL<60mg/dL):AdministerOralGlucoseGel15g.Administer100mlof10%Dextrose,titratetoimprovedmentalstatusand

BGL,mayrepeatevery5minutes(maxcumulativedose250ml).o Pediatric(NeonateBGL<40mg/dL):

Administer10%Dextrose2ml/kgIV/IO,titratetoimprovedmentalstatusandBGL.

Repeat10%Dextrose2ml/kgifBGLremains<60afterfirstdose.o Pediatric(AllotheragesBGL<60mg/dL):

AdministerOralGlucoseGel15g.Administer10%Dextrose5ml/kg(maxdose100ml)titratedtoimproved

mentalstatusandBGL.Repeat10%Dextrose5ml/kg(maxdose100ml)ifBGLremains<80after

firstdose.

254

Dextrose


De

xtrose

PediatricCardiacArrest:NeonatalResuscitationo Administer10%Dextrose2ml/kg.

255

Diphenhydramine Hydrochloride


Dip

he

nh

ydra

min

e H

ydro

ch

lorid

e

PharmacologicpropertiesDiphenhydramineisahistamine(H1)‐receptorantagonistthatpreventsthereleaseofhistaminefromeffectormastcells.Histamineisavasoactivesubstancecentraltoallergicreactionsthatinducesvasodilation,vascularpermeability,andbronchoconstriction.Diphenhydraminepreventshistamine‐mediatedresponses,particularlytheeffectsofhistamineonthesmoothmuscleofthebronchialairways,skin,gastrointestinaltract,andbloodvessels.

Indications Acuteallergicreactions(mild,moderate,orsevere). Anaphylaxis. Acutedystonicreactionsassociatedwithingestionofphenothiazinesandrelated

drugs (haloperidol,thorazine,compazine,metaclopromide,ziprasidone).

Contraindications Benadrylisnottobeusedinnewbornorprematureinfantsorinnursingmothers. Knownhypersensitivitytodiphenhydramineorantihistamines.

Precautions Inprematurebabiesandinfants,diphenhydramineinover‐dosagemaycause

convulsionsordeath. Maycausesignificantsedationorparadoxicalexcitation/akathisia. DiphenhydraminehasadditiveeffectswithalcoholandotherCNSdepressants. Antihistaminesmaycausedizziness,confusion,delirium,hallucinations,and/or

hypotensionintheelderly(60yearsorolder). Diphenhydraminehasanatropine‐likeactionandthereforeshouldbeusedwith

cautioninpatientswithahistoryofbronchialasthma,increasedintraocularpressure,hyperthyroidism,cardiovasculardiseaseorhyper‐tension.

Adversereactions Drowsiness,sedation Confusion Vertigo Hyperactivityinchildren Palpitations Tachycardia PVC’s Hypotension

Nausea. Vomiting. Diarrhea. Drymouth. Constipation. Urinaryretention. Thickeningofbronchialsecretion. Wheezing.

256

Diphenhydramine Hydrochloride


Dip

he

nh

ydra

min

e H

ydro

ch

lorid

e

Dosageandadministration Medical:AllergicReaction

o Adult(Mild,Moderate,SevereSystemicReaction,CardiacArrest):AdministerDiphenhydramine1mg/kgIV/IM/IO(maxdose50mg).

o Pediatric(Mild,Moderate,SevereSystemicReaction):AdministerDiphenhydramine1mg/kgIV/IM/IO(maxdose50mg).

OverdoseandPoisoning:Antipsychotics/AcuteDystonicReactiono Adult:

ConsiderDiphenhydramine25mgIV/IM,repeatoncein10minutesifindicated.

PediatricOverdoseandPoisoningo DystonicReactions:

AdministerDiphenhydramine1mg/kgIV/IM.

257

Dopamine Hydrochloride


Do

pa

min

e h

ydro

ch

lorid

e

PharmacologicpropertiesDopamineisanendogenouscatecholaminethatexertsaninotropiceffectonthemyocardiumresultinginincreasedcardiacoutput.Itstimulatesdopaminergic,beta‐adrenergicandalpha‐adrenergicreceptorsofthenervoussysteminadose‐dependentmanner.Lowtomoderate doses(2‐10mcg/kg/min)havepredominantbeta‐adrenergicreceptorstimulatingactionsthat resultinincreasedcardiacoutputandheartratewithminimalvasoconstriction. Athigherdoses (>10mcg/kg/min),dopaminehasalphareceptorstimulatingactionsthatresultinperipheralvasoconstrictionandincreasedbloodpressure.

Indications Cardiogenic,neurogenic,septic,oranaphylacticshock. BradycardiawithhypotensionrefractorytoAtropine. Hemodynamicallysignificant(SBP<90mmHg)overdose. Hypotension(SBP<90mmHg)notsecondarytohypovolemia.

Contraindications Shockduetohypovolemia. Dopamineshouldnotbeadministeredinthepresenceofuncorrectedtachyarrhythmia'sor

ventricularfibrillation. Dopamineshouldnotbeusedinpatientswithpheochromocytoma.

Precautions SignificantlocaltissuenecrosiscanoccurwithextravasationfromperipheralIV. Dopamineisinactivatedinalkalinesolution,donotuseanyalkalinediluent. Patientswhohavebeentreatedwithmonoamineoxidase(MAO)inhibitorswillrequire

substantiallyreduceddosage.

Adversereactions Headache. Ectopicbeats. Tachycardia. Anginapain. Palpitation. Hypotension.

Dosageandadministration RespiratoryEmergencies:PulmonaryEdema

o Adult:ConsiderDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/min

inordertomaintainSBP≥90mmHgorMAP≥65.

Nausea Vomiting Localnecrosiswithextravasation Piloerection Dyspnea

258

Dopamine Hydrochloride


Do

pa

min

e h

ydro

ch

lorid

e

CardiacArrest:PostResuscitationCareo Adult:

AdministerDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

o Pediatric:AdministerDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/

mininordertomaintainminimumSBP.

CardiacEmergencies:Bradycardiao Adult:

ConsiderDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

EnvironmentalEmergencies:BitesandEnvenomationo Adult:

Dopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

Medical:Sepsiso Adult:

ConsiderDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininordertomaintainSBP≥90mmHgorMAP≥65.

o Pediatric(MedicalControl):AdministerDopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/

mininordertomaintainminimumSBP.

OverdoseandPoisoning:Antidepressants OverdoseandPoisoning:Cholinergic/Organophosphates

o Adult:Dopamineinfusionat5mcg/kg/mintitratedupto20mcg/kg/mininorder

tomaintainSBP≥90mmHgorMAP≥65.

259

Epinephrine Hydrochloride (1mg/ml)


Ep

ine

ph

rine

Hyd

roc

hlo

ride

(1m

g/m

l)

PharmacologicpropertiesEpinephrineisasympathomimeticwhichstimulatesbothalphaandbetaadrenergicreceptors.Itseffectsaretoincreasesystemicvascularresistance,arterialbloodpressure,coronaryand cerebralbloodflow,heartrateandcontractility. Thealpha‐adrenergiceffectincreasesvascularresistanceandcoronarybloodflow,whichmaymakethefibrillatingmyocardiummoresusceptibletocounter‐shock.Thebetaadrenergiceffectincreasesheartrateandcardiac output,andinducesbronchodilation.

Indications Anaphylaxisandacuteallergicreactionsassociatedwithseveresystemicsymptoms(BP<

90mmHg,stridor,severerespiratorydistress)inadultsandpediatrics. Bronchospasm(wheezing)withsevererespiratorydistressduringasthmaorCOPD

exacerbation. Cardiacemergencies‐Bradycardia.


Precautions Presenceofhypertension. Historyofheartdisease. Ageover50years. EpinephrineisinactivatedbyalkalinesolutionsandshouldnotbemixedwithSodium

Bicarbonate. Epinephrine1mg/mlcannotbegivenintravenouslyinnon‐cardiacarrestpatients.

Adversereactions Anxiety. Headache. Cerebralhemorrhage. Tachycardia.

Dosageandadministration RespiratoryEmergencies:AcuteBronchospasm

o Adult:ConsiderEpinephrine(1mg/ml)0.3mgIM.

o Pediatric(MedicalControl):AdministerEpinephrine(1mg/ml)0.01mg/kgIM(maxdose0.3mg).

CardiacEmergencies:Bradycardiao Adult(MedicalControl):

ConsiderEpinephrineinfusion2mcg/mintitratedupto10mcg/mintomaintainSBP>90mmHgorMAP≥65.Mix2mg(1mg/ml)in500mlNS.

Ventriculardysrhythmias Hypertension Angina Nauseaandvomiting

260

Epinephrine Hydrochloride (1mg/ml)


Ep

ine

ph

rine

Hyd

roc

hlo

ride

(1m

g/m

l)

Medical:AllergicReactiono Adult:

AdministerEpinephrine(1mg/ml)0.3mgIM,repeatoncein5minutesif

indicated.o Adult(MedicalControl):

Epinephrine(1mg/ml)0.3mgIM.ConsiderEpinephrineinfusion2mcg/mintitratedupto10mcg/minto

maintainSBP>90mmHgorMAP≥65.Mix2mg(1mg/ml)in500mlNS.

o Pediatric:AdministerEpinephrine(1mg/ml)0.01mg/kgIM(maxdose0.3mg),repeat

oncein5minutesifindicated.o Pediatric(MedicalControl):

ConsiderEpinephrine(1mg/ml)0.01mg/kgIM(maxdose0.3mg).ConsiderEpinephrineinfusion2mcg/mintitratedupbasedonOLMC

parameters.Mix2mg(1mg/ml)in500mlNS.

261

Epinephrine Hydrochloride (0.1mg/ml)


Ep

ine

ph

rine

Hyd

roc

hlo

ride

(0.1

mg

/ml)

PharmacologicpropertiesEpinephrineisasympathomimetic,whichstimulatesbothAlphaandBeta‐adrenergicreceptors.Itseffectsaretoincreasesystemicvascularresistance,arterialbloodpressure,coronaryand cerebralbloodflow,heartrateandcontractility. Thealpha‐adrenergiceffectincreasesvascularresistanceandcoronarybloodflow,whichmaymakethefibrillatingmyocardiummoresusceptibletocounter‐shock.Thebeta‐adrenergiceffectincreasesheartrateandcardiac output,andinducesbronchodilation.

Indications CardiacarrestV‐FiborpulselessV‐Tach,Asystole,PEA Symptomaticbradycardia. Anaphylacticshock. Newbornresuscitation/neonatalasystoleorbradycardia. Pediatricbradycardiaandcardiacarrest.

Contraindications Noneinthecardiacarrestsituation.

Precautions EpinephrineisinactivatedbyalkalinesolutionsandshouldnotbemixedwithSodiumBicarbonate.

SeeEpinephrine1mg/mlfornon‐cardiacarrestprecautions.

Adversereactions Cerebralhemorrhage. Tachycardia. Ventriculardysrhythmias. Hypertension. Angina. Nauseaandvomiting.

Dosageandadministration CardiacArrest:Asystole/PEA

o Adult:AdministerEpinephrine(0.1mg/ml)1mgIV/IOevery3‐5minutesduring

arrest.o Pediatric:

AdministerEpinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeatevery3‐5minutes.

262

Epinephrine Hydrochloride (0.1mg/ml)


Ep

ine

ph

rine

Hyd

roc

hlo

ride

(0.1

mg

/ml)

CardiacArrest:V‐Fib/PulselessV‐Tacho Adult:

AdministerEpinephrine(0.1mg/ml)1mgIV/IOevery3‐5minutesduringarrest.

o Pediatric:AdministerEpinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeatevery3‐5minutes.

Medical:AllergicReactiono Adult(ImminentCardiopulmonaryArrest):

ConsiderEpinephrine(0.1mg/ml)0.5mgIV/IO.

PediatricCardiacArrest:NeonatalResuscitationo Pediatric

AdministerEpinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeatevery3‐5minutes.

PediatricCardiacArrhythmia:Bradycardiao Pediatric

AdministerEpinephrine(0.1mg/ml)0.01mg/kgIV/IO(maxdose1mg),repeatevery3‐5minutesuntileitherthebradycardiaorseverecardiopulmonarycompromiseresolves.

263

Fentanyl


Fe

nta

nyl

PharmacologicpropertiesFentanylisasyntheticopioidanalgesicthatsuppressespainbyagonizingopioidreceptorsinthecentralnervoussystem. Fentanylhasfewervasoactiveeffectsthanmorphineanddoesnotinducesignificanthistaminerelease.Asaresult,thedrugdoesnotcausesignificanthypotensioninproperdoses.

Indications Chestpainassociatedwithsuspectedmyocardialischemia. Thermalburns. Frostbite. Isolatedextremityinjury. Painfromsuspectedkidneystone.

Contraindications Hypotension,(SBP<100mmHg)orvolumedepletion. Headtrauma. Acutealcoholintoxication. Acuterespiratorydistress. Knownhypersensitivity.

Precautions Usewithcautioninelderlypatients Fentanylismetabolizedbytheliver,usecautioninpatientswithknownliverdisease Sedativeeffectsarepotentiatedbyalcohol,antihistamines,barbiturates,

benzodiazepines,phenothiazines,andothersedatives.

Adversereactions Euphoria. Drowsiness. Pupillaryconstriction. Respiratoryarrest.

Dosageandadministration CardiaArrest:PostResuscitationCare

o Adult:ConsiderFentanyl1mcg/kgIV/IO(maxdose50mcg),repeatevery5minutes

ifindicated(maxcumulativedose200mcg).

CardiacEmergencies:AcuteCoronarySyndromeo Adult:

AdministerFentanyl1mcg/kgslowIV(maxdose50mcg),repeatevery5minutesifindicated(maxcumulativedose,200mcg).

Decreased gastric motility. Nausea and vomiting. Bradycardia. Chest wall rigidity.

264

Fentanyl


Fe

nta

nyl

Cardiac Emergencies: Bradycardia Cardiac Emergencies: Regular Narrow Complex Tachycardia (SVT) Cardiac Emergencies: Irregular Narrow Complex Tachycardia (A‐Fib) Cardiac Emergencies: Wide Complex Tachycardia Cardiac Emergencies: Polymorphous V‐Tach (Torsades de Pointes)

o Adult:Administer Fentanyl 1 mcg/kg IV/IO (max dose 50 mcg), repeat every 5 minutes if

indicated (max cumulative dose 200 mcg).

Pain Management: Medical/ Traumao Adult:

Administer Fentanyl 1 mcg/kg slow IV/IN/IO (max dose 50 mcg), repeat every 5 minutes if indicated (max cumulative dose 200 mcg).

o Pediatric:Administer Fentanyl 1.5 mcg/kg IN with half of the volume administered to each

nare (max dose 100 mcg), repeat half the original dose in 10 minutes if indicated.Administer Fentanyl 1 mcg/kg IV/IO (max dose 50 mcg), repeat every 5 minutes if

indicated (max cumulative dose 200 mcg).

Pediatric Cardiac Arrhythmia: Tachycardiao Pediatric:

Administer Fentanyl 1 mcg/kg IV/IO (max dose 50 mcg).

265

Glucagon


Glu

ca

go

n

PharmacologicpropertiesGlucagonisanendogenoushormonethatisproducedinthepancreas.Itactsasaninsulinantagonist,acceleratinghepaticglycogenolysisandgluconeogenesis.Thishastheeffectofincreasingbloodglucoseconcentrations. Glucagonalsoeffectivelyrestoresforceandrateofventricularcontractionsinpatientswithsymptomaticbeta‐blockerandcalciumchannelblockeroverdoseviastimulationofintracellularcyclicadenosinemonophosphate(cAMP)production.

Indications Hypoglycemia(whereIVaccesscannotbeobtained). Beta‐blockerandcalciumchannelblockeroverdoses.

Contradictions Knownhypersensitivity.

Precautions Glucagonshouldbeadministeredwithcautioninpatientswithahistoryofinsulinomaor

pheochromocytoma. Awakenpatientfollowingadministrationtoprovideoralglucoseinordertorepleteglycogen

stores.

Adversereactions Occasionalnauseaandvomiting.

Dosageandadministration CardiacArrest:Asystole/PEA OverdoseandPoisoning:BetaBlockerToxicity OverdoseandPoisoning:CalciumChannelBlocker

o Adult:AdministerGlucagon3mgIV/IO,slowpush.

Medical:DiabeticEmergencieso Adult:

AdministerGlucagon1mgIM.o Pediatric:

AdministerGlucagon0.1mg/kgIM(maxdose1mg).

266

Hydroxocobalamin


Hyd

roxo

co

ba

lam

in

PharmacologicpropertiesHydroxocobalaminisaprecursorelement.Theactionofhydroxocobalamininthetreatmentofcyanidepoisoningisbasedontheabilitytobindcyanideions.Eachhydroxocobalaminmoleculecanbindonecyanideionbysubstitutingifforthehydroxoligandlinkedtothetrivalentcobaltiontoformcyanocobalamin(VitaminB12)whichisthenexcretedintheurine.

Indications Moderatetoseveresigns/symptomsofcyanidetoxicityinthesettingofsignificantsmoke

inhalationorotherknowncyanideexposure.


Precautions Mayreddenordiscolortheinjectionsite,skin,andmucusmembranes. Incompatiblewithothermedications;usededicatedline.

Adversereactions Hypertension. Flushingoftheskin.

Dosageandadministration HazardousMaterialsExposure:CyanideToxicityandSmokeInhalation

o Adult:AdministerHydroxocobalmin(Cyanokit®)5gIV/IOover15minutes.

267

Ipratropium Bromide


Ipra

trop

ium

Bro

mid

e

PharmacologicpropertiesIpratropiumbromideisananticholinergicbronchodilatorclassifiedasaquaternaryammoniumcompound.Anticholinergicspreventthebindingofacetylcholinewithmuscarinicreceptors onbronchialsmoothmuscle,inhibitingbronchoconstriction.Thebroncho‐dilatingeffectofipratropiumisprimarilylocalandsitespecific.Sinceitisnotwellabsorbedsystemically,thereislowpotentialfortoxicity.

Indications Acutebronchospasm(wheezing)associatedwithasthmaorCOPDinadultandpediatric

patients.

Contraindications Hypersensitivitytoipratropium,atropineoritsderivatives.

Precautions Usewithcautioninpatientswithnarrowangleglaucoma,prostatichypertrophy,orbladder‐

neckobstruction. Contactwitheyescancauseirritationandprecipitationofnarrowangleglaucoma.

Adversereactions Palpitations. Nervousness. Dizziness. Headache. Nausea. GIdistress. Drymouth. Cough.


o Adult:AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,

repeatoncein5minutesifindicated.o Pediatric:

AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated.

RespiratoryEmergencies:PulmonaryEdemao Adult:

AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeatoncein5minutesifindicated.

268

Ipratropium Bromide


Ipra

trop

ium

Bro

mid

e

HazardousMaterialsExposure:GeneralApproacho AdministerAlbuterol2.5mgandIpratropiumBromide0.5mgvianebulizer,repeat

oncein5minutesifindicated.

269

Ketamine Hydrochloride


Ke

tam

ine

Hyd

roc

hlo

ride

PharmacologicpropertiesKetamineisanonbarbituaterapidactingdissociativeanesthetic.ItactsonthecentralnervoussystemprimarilyasanoncompetitiveantagonistattheNDMAreceptor.Additionallyithasaweakerinteractionwithopioidreceptorsproducinganalgesia.

Indications Deliriumrequiringimmediatebehavioralcontrol.

Contraindications Severecardiovasculardisease(angina,heartfailure,malignanthypertension). Psychosis. Knownhypersensitivity.

Precautions Mayprecipitateemergencereactionsaseffectswane(confusion,delirium,excitement,

hallucinations,irrationalbehavior,vividimagery,pleasantdreamlikestate). MustgiveSLOWIV.RapidIVadministrationincreasestheincidenceofrespiratory

depression.

Sideeffects/adversereactions Cardiovascular‐Tachycardia,hypertension,arrhythmia. CNS‐Hallucinations,delirium,emergencereaction. Respiratory‐respiratorydepression,laryngealspasm(morecommonwithfast

administration).

Dosageandadministration Medical:BehavioralEmergencies/ExcitedDelirium

o Adult(ParamedicOnly):AdministerKetamine3mg/kgIM

ORAdministerKetamine1mg/kgIV.

270

Lidocaine


Lid

oc

ain

e

PharmacologicpropertiesLidocaineisanamidelocalanesthetic.Itstabilizestheneuronalmembranebyinhibitingfast‐gatedsodiumchannelsofthepostsynapticcellmembranepreventingdepolarizationandinhibitingthegenerationandpropagationofnerveimpulses.

Indications LocalanestheticforIOuse.


Sideeffects/adversereactions Burningsensationatthesite. Erythema.

Dosageandadministration ClinicalProcedure:IntraosseousAccess

o Adult:Administer40mgof2%Lidocaineover2minutes.

AllowlidocainetodwellinIOspacefor1minute.Flushwith10ccofNS

o Pediatrics:Administer0.5mg/kgof2%Lidocaine(nottoexceed40mg)over2minutes.

AllowlidocainetodwellinIOspacefor1minute.Flushwith5ccofNS.

271

Magnesium Sulfate


Ma

gn

esiu

m S

ulfa

te

PharmacologicpropertiesMagnesiumisacationthatactsasacofactorofthecellularmembranesodium‐potassium pump,andplaysanintegralroleinmaintainingintracellularpotassiumlevels. Magnesiumisessentialforenergytransferandelectricalstability,andactsasapowerfulantiarrhythmic,particularlyinthesettingofTorsadesdePointes.ItisalsoaCNSdepressanteffectiveinthemanagementofseizuresassociatedwithtoxemiaofpregnancy(eclampsia),anda bronchodilatoreffectiveforasthmaandCOPD.

Indications CardiacArrestassociatedwithsuspectedhypomagnesemicstate. TorsadesdePointes. Eclampsia. Knownhypomagnesemiaassociatedwitharrhythmias. Bronchospasm(wheezing)unresponsivetoalbuterolandipratropiumbromide.

Contraindications RenalFailure.

Precautions AvoidrapidIVPunlessunstable. Mayinducerespiratorydepressionorapnea‐inthissetting,treatwith10%calcium chloride,

5‐10mLIVbolus. Usewithextremecautioninpatientswithmyastheniagravis,neuromusculardisease,orheart

block.

Adversereactions Lossofdeeptendonreflexes. Respiratoryarrest. Hypotension. Drowsiness. Flushing.


o Adult:AdministerMagnesiumSulfate2gdilutedin100mlNSIV/IOover10minutes.

o Pediatric:AdministerMagnesiumSulfate50mg/kgdilutedin100mlNSIV/IOover10

minutes(maxdose2g).

272

Magnesium Sulfate


Ma

gn

esiu

m S

ulfa

te


AdministerMagnesiumSulfate2gIV/IO.o Pediatric:

AdministerMagnesiumSulfate50mg/kgIV/IO(maxdose2g).

CardiacEmergencies:PolymorphousV‐Tach(TorsadesdePointes)o Adult:


OB/GYN:Pre‐Eclampsia/Eclampsiao Adult:


PediatricCardiacArrhythmia:Tachycardiao Pediatric:

AdministerMagnesiumSulfate50mg/kgdilutedin10mlNSIV/IOover2minutes(maxdose2g).

273

Methylprednisolone


Me

thylp

red

niso

lon

e

PharmacologicpropertiesMethylprednisoloneisasystemiccorticosteroidthathasmanydownstreameffectsonthebody.Therapeutically,ithaspotentanti‐inflammatoryproperties. Theonsetofactionisseveralhours.

Indications Acuteexacerbationofasthma/COPD. Anaphylaxis/Acuteallergicreactions.


Precautions Usecautionwhenadministeringtopatientswithdiabetesmellitus,pregnancy,liverdisease,

orsignsofsystemicinfection. Donotadministermethylprednisolonepreservedwithbenzylalcoholtopregnantwomen,

breastfeedingwomen,orneonates.Benzylalcoholisassociatedwithseriousadverseeventsinthispopulation.

Adversereactions AdverseeffectswithsinglebolususeofMethylprednisoloneareuncommon,although

patientson chronicsteroidsareatriskforamultitudeofsideeffects.


o Adult:AdministerMethylprednisolone125mgIV/IM/IO.

o Pediatric>2yearsofage:AdministerMethylprednisolone2mg/kgIV/IM/IO(maxdose125mg).

Medical:AllergicReactiono Adult:

AdministerMethylprednisolone125mgIV/IM/IO.o Adult(CardiacArrest):

AdministerMethylprednisolone125mgIV/IO.o Pediatric:

AdministerMethylprednisolone2mg/kgIV/IM/IO(maxdose125mg).

274

Metoprolol


Me

top

rolo

l

PharmacologicpropertiesMetoprololisalipophilicbeta1selectiveadrenergicreceptorblocker.Itcausesdecreasedrestingheartrate,inhibitionofexercise‐inducedincreasesinheartrate,decreasedmyocardialcontractilityanddecreasedcardiacoutput.

Indications Irregularnarrowcomplextachycardia(A‐Fib).

Contraindications Bradycardia. 2ndor3rddegreeAVblock. Cardiogenicshock. Knownhypersensitivity.

Precautions DuetotheBeta1selectivity,metoprololmaybeusedinbrochospasticdisease.Asthedose

increasestheBeta1selectivitydecreasesthereforeusethelowestdosethatiseffective.

Sideeffects/adversereactions Cardiovascular‐Hypotension,bradycardia,AVblock. CNS‐fatigue,dizziness,headache.

Dosageandadministration CardiacEmergencies:IrregularNarrowComplexTachycardia(A‐Fib)

o ConsiderMetoprolol5mgIV/IOover1‐2minutes,repeatevery5minutesifindicated

(maxcumulativedose15mg).

275

Morphine Sulfate


Mo

rph

ine

Su

lfate

PharmacologicpropertiesMorphineisanopioidanalgesicthatsuppressespainbyagonizingopioidreceptors(primarilymu)inthecentralnervoussystem. Morphineexertsitsprincipalpharmacologicaleffectonthecentralnervoussystemandgastrointestinaltract.Itsprimaryactionsoftherapeuticvalueareanalgesiaandsedation.Morphineappearstoincreasethepatient'stoleranceforpainandtodecreasediscomfort,althoughthepresenceofthepainitselfmaystillberecognized.Inadditiontoanalgesia,alterationsinmood,euphoria,dysphoria,anddrowsinesscommonlyoccur.Opioidsalsoproducerespiratorydepressionbydirectactiononbrainstemrespiratorycenters.MorphinehasmorevasoactiveeffectsthanFentanylandmayinducesignificanthistaminereleaseresultinginvasodilationandhypotension.

Indications Chestpainassociatedwithsuspectedmyocardialischemia. Pulmonaryedemawithhypertension. Thermalburns. Isolatedextremityinjury. Severepainfromsuspectedkidneystone.

Contraindications Hypotension,(SBP<100mmHg)orvolumedepletion. Headtrauma. Acutealcoholintoxication. Acuterespiratorydistress. Knownhypersensitivity.

Precautions Usewithcautioninelderlypatients. Morphineismetabolizedbytheliver,usecautioninpatientswithknownliverdisease. Sedativeeffectsarepotentiatedbyalcohol,antihistamines,barbiturates,

benzodiazepines,phenothiazines,andothersedatives.

Adversereactions Euphoria. Drowsiness. Pupillaryconstriction. Respiratoryarrest. Nauseaandvomiting


o Adult:ConsiderMorphineSulfate.05‐0.1mg/kgIV(maxdose5mg),repeatevery5

minutesforpersistentseverehypertension(maxcumulativedose15mg).

276

Morphine Sulfate


Mo

rph

ine

Su

lfate

CardiacEmergencies:AcuteCoronarySyndromeo Adult:

AdministerMorphineSulfate0.1mg/kgslowIV(maxdose5mg),repeatevery5minutesifindicated(maxcumulativedose15mg).

PainManagement:Medical/Traumao Adult:

ConsiderMorphineSulfate0.1mg/kgIV/IO(maxdose5mg),repeatevery5minutesifindicated(maxcumulativedose15mg).

o Pediatric:ConsiderMorphineSulfate0.1mg/kgIV/IO(maxdose5mg),repeat

every5minutesifindicated(maxcumulativedose15mg).

277

Midazolam


Mid

azo

lam

PharmacologicpropertiesMidazolamisashort‐actingsedativehypnoticofthebenzodiazepinefamilythatincreasesthe actionofgamma‐aminobutyricacid(GABA),themajorinhibitoryneurotransmitterinthecentral nervoussystem.Midazolamdepressesthelimbicsystem,thalamus,andhypothalamusresultinginprofoundsedationandmusclerelaxation.Theinhibitorynatureofthedrugalsoprovides anti‐epilepticactivitythatterminatesandpreventsseizures.

Indications Statusepilepticus. Cocaine(sympathomimetic)toxicity. Behavioralemergenciesinpatientswithsevereagitationoraggressivebehaviorresultingin

interferencewithpatientcareorpatient/crewsafety. Maybeadjunctivetreatmentwithantipsychotics.

Contraindications Acutealcoholintoxication. Donotadministertoneonatalpatients. Respiratoryinsufficiency. Hypotension(SBP<90mmHg). Knownhypersensitivitytobenzodiazepines.

Precautions Useextremecautionwithintravenousadministration‐rapidIVbolusmaycausehypotension

andrespiratorydepression/arrest. Effectsareexacerbatedintheelderly,andwhenadministeredtopatientswhohavealready

ingestedanotherCNSdepressant(ETOH,barbiturates,GHB).

Adversereactions Confusion. Drowsiness. Respiratorydepression/arrest. Hypotension. Nausea. Vomiting.

Dosageandadministration CardiacArrest:PostResuscitationCare

o Adult:ConsiderMidazolam2.5mgIV/IO,repeatin5minutesifindicatedandmonitor

forhypotension(maxcumulativedose5mg).

278

Midazolam


Mid

azo

lam

CardiacEmergencies:Bradycardia CardiacEmergencies:RegularNarrowComplexTachycardia(SVT) CardiacEmergencies:IrregularNarrowComplexTachycardia(A‐Fib) CardiacEmergencies:WideComplexTachycardia CardiacEmergencies:PolymorphousV‐Tach(TorsadesdePointes)

o Adult:AdministerMidazolam2.5mgIV/IO,repeatin5minutesifindicatedand

monitorforhypotension(maxcumulativedose5mg.)

Medical:BehavioralEmergencies/ExcitedDeliriumo Adult(≤65):


o Adult(>65):AdministerMidazolam2.5mgIV/IM/IN/IO,repeatin5minutesifindicated


Medical:Seizureo Adult(≤65):



(maxcumulativedose5mg).o Pediatric:

AdministerMidazolam0.2mg/kgIN(maxindividualdose5mg),repeatin5minutesifindicated(maxcumulativedose10mg).

ORAdministerMidazolam0.1mg/kgIM/IV/IO(maxindividualdose2.5mg),

repeatin5minutesifindicated(maxcumulativedose5mg).

OB/GYN:Pre‐Eclampsia/Eclampsiao Adult:


Trauma:HeadInjurieso Adult(≤65):




279

Midazolam


Mid

azo

lam

PediatricCardiacArrhythmia:Tachycardiao Pediatric:


PediatricTrauma:HeadInjurieso Pediatric:

AdministerMidazolam0.2mg/kgIN(maxdose5mg).OR

AdministerMidazolam0.1mg/kgIM/IV/IO(maxdose5mg).

280

Naloxone


Na

loxo

ne

PharmacologicpropertiesNaloxoneisacompetitivemuopioidreceptorantagonist.Thedrugantagonizestheeffectsofopiatesbycompetingatthesamereceptorsites. Onsetofactionis1‐2minutes,theduration ofactionis1‐4hours.

Indications Naloxoneisindicatedforthereversalofnarcoticintoxicationwithrespiratorydepression. Alteredmentalstatus(unknowncause).


Precautions Usecautionduringadministrationaspatientmaybecomeagitatedorviolentaslevelof

consciousnessincreases. Shouldbeadministeredcautiouslytopersonswhoareknownorsuspectedtobephysically

dependentonopiates,includingnewbornsofdependentmothers–mayprecipitateacutewithdrawal.

Naloxonehasarelativelyshorthalf‐lifecomparedtomanynarcotics,monitorcloselyfortheneedtorepeatdose.

Naloxoneisnoteffectiveagainstarespiratorydepressionduetonon‐opioiddrugs. Patientswhobecomeresponsivesecondarytonaloxoneadministrationarenotauthorized to

refusemedicalcare.

Adversereactions Tremor. Agitation. Belligerence. Pupillarydilation. Seizures. Sweating. Hypertension.

Dosageandadministration GeneralPatientCareProtocol–Adult

o Adult(AllProviders):AdministerNaloxone2mgIN.

o Adult(AdvancedLifeSupport):AdministerNaloxone2mgIN/IM.ConsiderNaloxone0.4mgIV/IOtitratedtomaintainadequaterespiratoryrate


Hypotension Ventriculartachycardia Pulmonaryedema Ventricularfibrillation Nausea Vomiting

281

Naloxone


Na

loxo

ne

CardiacArrest:PostResuscitationCareo Adult(AdvancedLifeSupport):

Naloxone0.4mgIV/IOtitratedtorespiratoryrateupto4mgIV/IO.

OverdoseandPoisoning:GeneralApproacho Adult(AllProviders):

AdministerNaloxone2mgINo Adult(AdvancedLifeSupport):

ConsiderNaloxone2mgIN/IM.ConsiderNaloxone0.4mgIV/IO,titratedtomaintainadequaterespiratoryrate

(maxcumulativedose4mg)

GeneralPatientCareProtocol–Pediatrico Pediatric(AdvancedLifeSupport):

AdministerNaloxone0.1mg/kgIV/IN/IM/IO(maxdose2mg),titratedtomaintainadequaterespiratoryrate(maxcumulativedose2mg).

PediatricCardiacArrest:NeonatalResuscitationo Neonate(AdvancedLifeSupport):

AdministerNaloxone0.1mg/kgIV/IO.

PediatricOverdoseandPoisoningo Pediatric(AdvancedLifeSupport):

AdministerNaloxone0.1mg/kgIV/IN/IM/IO(maxdose2mg),titratedtomaintainadequaterespiratoryrate(maxcumulativedose2mg).

282

Nitroglycerin


Nitro

glyc

erin

PharmacologicpropertiesNitroglycerinisanorganicnitratewhichcausessystemicvasodilationbyenteringvascular smoothmuscle,convertingtonitricoxide,andactivatingcGMP. Thisdose‐dependent actsprimarilyonthevenoussystem,althoughitalsoproducesdirectcoronaryarteryvasodilationaswell. Theoverallresultisadecreaseinvenousreturn,whichdecreasesthe workloadontheheartandthus,decreasesmyocardialoxygendemand. Nitroglycerinalsoimprovesbloodflowtothemyocardiumandlowerssystemicbloodpressure.

Indications Chestpainwithsuspectedcardiacischemia. Suspectedacutemyocardialinfarct. Acutedyspneawithsuspectedpulmonaryedema/congestiveheartfailure.

Contraindications Hypertensionassociatedwithacutestrokeorseverebraininjury. SystolicBP<100mmHgorMAP<65(PulmonaryEdema). SystolicBP<100mmHgorMAP<65orifaSBPdrop≥30mmHg.(AcuteCoronary

Syndrome)‐BLSonly.ALSprovidersusecaution. Phosphodiesterase‐5(PDE5)inhibitorusewithinlast48hours.

Precautions UsewithcautioninacuteinferiorwallMIorrightventricularinfarct(STelevationinV4R).Be

preparedtoadminister250mLNSbolusifhypotensiondevelops. Patientsonchronicnitratetherapymayrequirelargerdosesofnitroglycerineduringacute

anginaepisodes. Nitrotabletsareinactivatedbylight,airandmoistureandmustbekeptinamberglass

containerswithtight‐fittinglids. Alcoholwillaccentuatevasodilationandhypotensiveeffects.

Adversereactions Headache. Hypotension. Tachycardia. Dizziness Flushing. Nauseaandvomiting.


o Adult(AllProviders):ConsiderNitroglycerin0.4mgSL,repeatin5minutesifindicated(max

cumulativedoseof1.2mg).

283

Nitroglycerin


Nitro

glyc

erin

RespiratoryEmergencies:PulmonaryEdemao Adult(AdvancedLifeSupport):

AdministerNitroglycerin0.4mgSL.Ifpatientremainshypertensivewithmoderatetoseveresymptomsin5minutes.

AdministerNitroglycerin0.8mgSL.RepeatNitroglycerin0.8mgSLevery5minuteswithgoalofachieving20%reductioninSBP.

CardiacEmergencies:AcuteCoronarySyndromeo Adult(AllProviders):

ConsiderNitroglycerin0.4mgSL,repeatevery5minutesforcontinuedchestpain(maxcumulativedose1.2mgprovidedbyeitherpatientorprovider).

o Adult(AdvancedLifeSupport):ConsiderNitroglycerin0.4mgSLrepeatevery5minutesforcontinuedchest

pain.

284

Ondansetron Hydrochloride


On

da

nse

tron

Hyd

roc

hlo

ride

PharmacologicpropertiesOndansetronhydrochlorideisananti‐emetic,whichactsasaselectiveinhibitoroftheserotonin5‐HT3‐receptortype.Thedrugbindstobothcentralnervoussystemandperipheralreceptors inthegastrointestinaltracttoexertitseffects. Itsonsetofactionis30minutes,andduration ofactionis2‐7hours.

Indications Severe,persistentvomiting.

Contraindications Knownhypersensitivity. KnownLong‐QTSyndrome. Knownpregnancyorsuspectedpregnancy.

Precautions MaylengthenQTinterval–patientsshouldbeplacedonacardiacmonitorafter

administration. Theuseofondansetroninpatientsfollowingabdominalsurgerymaymaskaprogressiveileus

and/orgastricdistention.

Adversereactions Headache. Fatigue. Diarrhea. Dizziness.

Dosageandadministration GeneralPatientCareProtocol–Adult

o Adult(AllProviders):ConsiderOndansetron4mgODT(contraindicatedinpregnancyorsuspected

pregnancy).o Adult(AdvancedLifeSupport):

AdministerOndansetron4mgODT/IV/IM/IO(contraindicatedinpregnancyorsuspectedpregnancy.Repeatoncein10minutesifindicated(maxcumulativedose8mg).

GeneralPatientCareProtocol–Pediatrico Pediatric(AdvancedLifeSupport):

AdministerOndansetron2mg(8‐15kg)or4mg(>15kg)ODT(breakinhalftoadminister2mg.)

AdministerOndansetron0.1mg/kgIV/IO(maxsingledose4mg).

285

Promethazine


Pro

me

tha

zine

PharmacologicpropertiesPromethazineisaphenothiazinederivativewithantidopaminergiceffects.Itworksbychangingtheactionsofdopaminereceptorsandalpha‐adrenergicreceptorsinthebrain.Itsonsetofactionis3‐5minutes,anddurationofactionis4‐6hours.

Indications Severe,persistentvomitinginpatientswithaknownorsuspectedpregnancy.


Precautions IVadministrationcancauseseveretissueinjury,includingburning,thrombophlebitis,and

gangrene. Mayaltercardiacconduction–patientsshouldbeplacedonacardiacmonitorafter

administration.

Adversereactions Sedation Confusion BlurredVision Tachycardia

Dosageandadministration GeneralPatientCareProtocol

o Adult(AdvancedLifeSupport)AdministerPromethazine12.5mgdilutedin100mlNSIVatawideopenrate

inapatent20gorlargeIV.IVmustbelocatedintheantecubital.

286

Bradycardia Dystonias Photosensitivity Hallucinations

Racemic Epinephrine


Ra

ce

mic

Ep

ine

ph

rine

PharmacologicpropertiesRacemicEpinephrineelicitsagonisticactiononalpha,beta‐2,andbeta‐2receptorsresultinginbronchialsmoothmusclerelaxation,cardiacstimulation,vasodilationinskeletalmuscle,andstimulationofglycogenosisintheliver.

Indications Partialupperairwayobstruction(suspectedcroup)orstridoratrestwithrespiratory

distress.

Contraindications Knownhypersensitivity. Epiglottitis

Precautions Co‐administrationwithMAOI’sorwithin2weeksafterdiscontinuingMAOI. Historyofheartdisease. Historyofhypertension. Historyofthyroiddisease. Historyofdiabetes.

Adversereactions Tachycardia. Arrhythmias Headache. Nausea PulmonaryEdema

Dosageandadministration PediatricRespiratoryEmergencies:Stridor

o AdministerRacemicEpinephrine2.25%/0.5mlmixedwith3mlNSvianebulizer.

287

Sodium Bicarbonate


So

diu

m B

ica

rbo

na

te

PharmacologicpropertiesSodiumbicarbonateisanendogenousanionthatreactswithhydrogenionstoformwater carbondioxide. Itisanalkalizingagentusedtobufferacidspresentinthebodyduringperiodsofmetabolicacidosis.ItseffectistoraisetheserumpH.Thiseffectisfavorableinthetreatmentofpre‐existingmetabolicacidosis,hyperkalemia,tricyclicanti‐depressant/salicylate(aspirin)/orphenobarbitaloverdose,andafterprofoundhypoxia/prolongedcardiacarrest.Sodiumbicarbonateiseffectiveonlywhenadministeredwithadequateventilationand oxygenation.

Indications Bicarbonateresponsivemetabolicacidosisprecipitatingcardiacarrest. Widecomplextachycardia. Hyperkalemia. Tricyclicantidepressantoverdose. Chlorine/Chloramineexpure.

Contraindications Congestiveheartfailure. Alkaloticstates. Hypoxiclacticacidosis.

Precautions Excessivebicarbonatetherapyinhibitsthereleaseofoxygen,induceshyperosmolarityand

hypernatremia,andproducesparadoxicalacidosisinmyocardialandcerebralcells. Bicarbonatedoesnotimprovetheabilitytodefibrillate. Mayinactivatesimultaneouslyadministeredcatecholamines. Willprecipitateifmixedwithcalciumchloride.

Adversereactions Metabolicalkalosis. Hypernatremia/Hyperosmolality. Cerebralacidosis(paradoxicaleffect). Sodiumandfluidretentionwhichcancausepulmonaryedema.

Dosageandadministration CardiacArrest:Asystole/PEA

o Adult:AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq),may

repeatoncein10minutes.o Pediatrics:


288

Sodium Bicarbonate


So

diu

m B

ica

rbo

na

te


AdministerSodiumBicarbonate1mEq/kgIV/IO(maxdose50mEq),mayrepeatoncein10minutes.

CardiacArrest:PostResuscitationCareo Adult:


CardiacEmergencies:WideComplexTachycardiao Adult:


HazardousMaterialsExposure:GeneralApproacho Adult(MedicalControl):

Administer4.2%SodiumBicarbonate5mlviaNebulizer.Mix2.5mlof8.4%SodiumBicarbonatewith2.5mlofNS.

Medical:BehavioralEmergencies/ExcitedDeliriumo Adult(MedicalControl):

ConsiderSodiumBicarbonate50mEqin1,000mlNSIVwideopen.

OverdoseandPoisoning:Antidepressantso Adult:

AdministerSodiumBicarbonate1mEqIV/IO(maxdose50mEq),mayrepeatoncein10minutesifindicated.

GeneralPatientCareProtocol–AdultTraumao Adult(MedicalControl):

ConsiderSodiumBicarbonate1mEq/kgIV/IOover5minutes(maxdose100mEq).

289

Tranexamic Acid


Tra

ne

xam

ic A

cid

PharmacologicpropertiesTranexamicacidisanantifibrinolytic.Itisacompetitiveinhibitorofplasminogenactivationandathigherdosesanoncompetitiveinhibitorofplasmin.Itshiftsthenaturalequilibriuminfavorofclotformationratherthanclotbreakdown.

Indications ADULTSONLY. Severebluntorpenetratingtraumaticinjurywithsignificantbloodlossevidentorstrongly

suspected(hemorrhagicshock).

Contraindications Isolatedclosedheadinjury. Nonhemorrhagicshock. Pediatricpatients. Knownhypersensitivity.

Precautions Shouldonlybegivenforsuspectedhemorrhagicshockwithsustainedvitalsign

abnormalities.

Sideeffects/adversereactions Acutegastrointestinaldisturbance(Nausea,vomiting,diarrhea). Abdominalpain.

Dosageandadministration GeneralPatientCareProtocol–AdultTrauma

o ADULTSONLY:AdministerTranexamicAcid1gdilutedinto100mlIV/IOover10minutes.

290


Reference

Reference Documents: Pediatric Quick Reference


Re

fere

nc

e D

oc

um

en

ts: Pe

dia

tric Q

uic

k Re

fere

nc

e

ModifiedGCSforInfantsandChildren Child Infant Score

EyeOpening

Spontaneous Spontaneous 4

ToSpeech ToSpeech 3

ToPain ToPain 2

None None 1

BestVerbal

Response

Oriented,Appropriate CoosandBabbles 5

Confused Irritable,Cries 4

InappropriateWords CriesinResponsetoPain 3

IncomprehensibleSounds MoansinResponsetoPain 2

None None 1

BestMotor

Response

ObeysCommands MovesSpontaneouslyandPurposely 6

LocalizesPainfulStimulus WithdrawsinResponsetoTouch 5

WithdrawsinResponsetoPain WithdrawsinResponsetoPain 4

FlexioninResponsetoPain AbnormalFlexionPosturetoPain 3

ExtensioninResponsetoPain AbnormalExtensionPosturetoPain 2

None None 1

Equip‐

ment

GRAY

3‐5kg

PINK

Smallinfant

6‐7kg

RED

Infant

6‐9kg

PURPLE

Toddler

10‐11kg

YELLOW

Small

Child

12‐14kg

WHITE

Child

15‐18kg

BLUE

Child

19‐23kg

ORANGE

LargeChild

24‐29kg

GREEN

Adult

30‐36kg

Resuscit

ation

Bag

Infant Infant/Child Infant/Child Child Child Child Child Child Adult

NRB Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric/Ad

ult

OPA 50mm 50mm 50mm 60mm 60mm 60mm 70mm 80mm 80mm

NPA 14F 14F 14F 18F 20F 22F 24F 26F 30F

Laryngos

cope

Blade

1Straight 1Straight 1Straight 1Straight 2

Straight

2

Straight

2

Straight/Cur

ved

2

Straight/Cu

rved

3

Straight/Cur

ved

ETT 3.5UC 3.5UC 3.5UC 4.0UC 4.5UC 5.0UC 5.5UC 6.0Cuff 6.5Cuff

Suction

Catheter

8F 8F 8F 10F 10F 10F 10F 10F 10F‐12F

BPCuff Neonate/

Infant

Infant/Child Infant/Child Child Child Child Child Child SmallAdult

IV

Catheter

24G 22G‐24G 22G‐24G 20G‐24G 18G‐22G 18G‐22G 18G‐20G 18G‐20G 16G‐20G

IO 15mm 15mmor

25mm

15mmor

25mm

15mmor

25mm

15mm

or

25mm

15mm

or

25mm

15mmor

25mm

15mmor

25mm

25mm

291

Reference Documents: Pediatric Quick Reference


Re

fere

nc

e D

oc

um

en

ts: Pe

dia

tric Q

uic

k Re

fere

nc

e

PediatricWeight

Conversion

lbs kg lbs kg

2 0.9 26 11.8

3 1.4 27 12.2

4 1.8 28 12.7

5 2.3 29 13.2

6 2.7 30 13.6

7 3.2 31 14

8 3.6 32 14.5

9 4.1 33 15

10 4.5 34 15.5

11 5.0 35 15.9

12 5.4 36 16.4

13 5.9 37 16.8

14 6.4 38 17.3

15 6.8 39 17.7

16 7.3 40 18.2

17 7.7 41 18.6

18 8.2 42 19.1

19 8.6 43 19.5

20 9.1 44 20

21 9.5 45 20.5

22 10 46 20.9

23 10.4 47 21.4

24 10.9 48 21.8

25 11.3 49 22.3

50 22.7

292

VitalSignsinChildrenAge HeartRate

(BreathsPer

Minute)

Age Respiratory

Rate(Breaths

PerMinute)

Age MinimumSBP

Children

(1‐8yrsold)80‐100 Children

(1‐8yrsold)15– 30 Children

(1‐8yrsold)>70+(2xagein

years)

Infant 100‐120 Infant 25– 50 Infant >70

Neonate 120‐160 Neonate 40– 60 Neonate >60

Reference Documents: Triage Quick Reference


Re

fere

nc

e D

oc

um

en

ts: Tria

ge

Qu

ick R

efe

ren

ce

U.S. Department of Health & Human Services

293

Reference Documents: Triage Quick Reference


Re

fere

nc

e D

oc

um

en

ts: Tria

ge

Qu

ick R

efe

ren

ce

U.S. Department of Health & Human Services

294

Copy 2 – To be kept in patient’s permanent medical record

Durable Do Not Resuscitate Order Virginia Department of Health

Patient’s Full Legal Name _______________________________________________ Date _______________

Physician’s Order I, the undersigned, state that I have a bona fide physician/patient relationship with the patient named above. I have certified in the patient’s medical record that he/she or a person authorized to consent on the patient’s behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest.

I further certify (must check 1 or 2):

The patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. (Signature of patient is required)

ecision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision.

If you checked 2 above, check A, B, or C below:

hat life-prolonging procedures be withheld or withdrawn.

a “Person Authorized to Consent on the Patient’s Behalf” with authority to direct that life-prolonging procedures be withheld or withdrawn. (Signature of “Person Authorized to Consent on the Patient’s Behalf is required.)

lth care). (Signature of “Person Authorized to Consent on the Patient’s Behalf is required)

I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures) from the patient in the event of the patient’s cardiac or respiratory arrest. I further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain.

____________________________ ____________________________ ____________________________ Physician’s Printed Name Physician’s Signature Emergency Phone Number

____________________________ __________________________________________________________ Patient’s Signature Signature of Person Authorized to Consent on the Patient’s Behalf

SAMPLE

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y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

mas

s de

stru

ctio

n is

exe

mpt

from

this

list

.A

ppro

ved:

Nov

embe

r 6, 2

013

Pag

e 1

of 6

PRO

CED

UR

ESK

ILL

PRO

CED

UR

E SU

BTY

PEEM

REM

TAE

MT

- En

hanc

edI

P

AIR

WAY

TEC

HN

IQU

ES

Airw

ay A

djun

cts

Oro

phar

ynge

al A

irway

N

asop

hary

ngea

l Airw

ay

Airw

ay M

aneu

vers

Hea

d til

t jaw

thru

st

Jaw

thru

st

Chi

n lif

t

Cric

oid

Pre

ssur

e

Man

agem

ent o

f exi

stin

g Tr

ache

osto

my

Alte

rnat

e A

irway

Dev

ices

Non

Vis

ualiz

ed A

irway

Dev

ices

Sup

ragl

ottic

Cric

othy

roto

my

Nee

dle

S

urgi

cal

Incl

udes

per

cuta

neou

s te

chni

ques

Obs

truct

ed A

irway

Cle

aran

ceM

anua

l

Vis

ualiz

e U

pper

-airw

ay

Intu

batio

nN

asot

rach

eal

O

rotra

chea

l - O

ver a

ge 1

2

P

harm

acol

ogic

al fa

cilit

atio

n w

ith p

aral

ytic

Adu

lt N

euro

mus

cula

r Blo

ckad

e

Con

firm

atio

n pr

oced

ures

Ped

iatri

c O

rotra

chea

l

Ped

iatri

c pa

raly

tics

P

edia

tric

seda

tion

** E

ndot

rach

eal i

ntub

atio

n is

pro

hibi

ted

for a

ll le

vels

exc

ept I

nter

med

iate

and

Par

amed

ic

Spec

ific

task

s in

this

doc

umen

t sha

ll re

fer t

o th

e Vi

rgin

ia E

duca

tion

Stan

dard

s.

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sSc

ope

of P

ract

ice

- Pr

oced

ures

for E

MS

Pers

onne

l

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

appr

oved

by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

e co

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

are

ask

ed to

pre

sent

thei

r stu

dy p

lans

to th

e M

DC

for

info

rmat

iona

l pur

pose

s so

that

the

com

mitt

ee c

an m

aint

ain

an a

war

enes

s of

on-

goin

g pr

e-ho

spita

l res

earc

h in

the

Com

mon

wea

lth. T

hose

who

des

ire to

con

duct

non

-IRB

revi

ewed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or r

esea

rch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

mas

s de

stru

ctio

n is

exe

mpt

from

this

list

.A

ppro

ved:

Nov

embe

r 6, 2

013

Pag

e 2

of 6

PRO

CED

UR

ESK

ILL

PRO

CED

UR

E SU

BTY

PEEM

REM

TAE

MT

- En

hanc

edI

P

Oxy

gen

Del

iver

y S

yste

ms

Nas

al C

annu

la

Ven

turi

Mas

k

S

impl

e Fa

ce M

ask

P

artia

l Reb

reat

her F

ace

Mas

k

N

on-r

ebre

athe

r Fac

e M

ask

Fa

ce T

ent

Trac

heal

Cuf

f

O

xyge

n H

ood

O2

Pow

ered

Flo

w re

stric

ted

devi

ce

H

umid

ifica

tion

Suc

tion

Man

ually

Ope

rate

d

Mec

hani

cally

Ope

rate

d

Pha

ryng

eal

B

ronc

hial

-Tra

chea

l

O

ral S

uctio

ning

N

aso-

phar

ynge

al S

uctio

ning

End

otra

chea

l Suc

tioni

ng

M

econ

ium

Asp

iratio

n N

eona

te w

ith E

T

Ven

tilat

ion

– as

sist

ed /

mec

hani

cal Mou

th to

Mas

k

Mou

th to

Mas

k w

ith O

2

Bag

-Val

ve-M

ask

Adu

lt

Bag

-Val

ve-M

ask

with

sup

plem

enta

l O2

Adu

lt

Bag

-Val

ve-M

ask

with

sup

plem

enta

l O2

and

rese

rvoi

r Adu

lt

Bag

-Val

ve-M

ask

Ped

iatri

c

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sSc

ope

of P

ract

ice

- Pr

oced

ures

for E

MS

Pers

onne

l

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

appr

oved

by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

e co

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

are

ask

ed to

pre

sent

thei

r stu

dy p

lans

to th

e M

DC

for

info

rmat

iona

l pur

pose

s so

that

the

com

mitt

ee c

an m

aint

ain

an a

war

enes

s of

on-

goin

g pr

e-ho

spita

l res

earc

h in

the

Com

mon

wea

lth. T

hose

who

des

ire to

con

duct

non

-IRB

revi

ewed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or r

esea

rch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

mas

s de

stru

ctio

n is

exe

mpt

from

this

list

.A

ppro

ved:

Nov

embe

r 6, 2

013

Pag

e 3

of 6

PRO

CED

UR

ESK

ILL

PRO

CED

UR

E SU

BTY

PEEM

REM

TAE

MT

- En

hanc

edI

PB

ag-V

alve

-Mas

k w

ith s

uppl

emen

tal O

2 P

edia

tric

B

ag-V

alve

-Mas

k w

ith s

uppl

emen

tal O

2 an

d re

serv

oir P

edia

tric

B

ag-V

alve

-Mas

k ne

onat

e/in

fant

B

ag-V

alve

-Mas

k w

ith s

uppl

emen

tal O

2 N

eona

te/In

fant

B

ag-V

alve

-Mas

k w

ith s

uppl

emen

tal O

2 an

d re

serv

oir N

eona

te/In

fant

N

onin

vasi

ve p

ositi

ve p

ress

ure

vent

.C

PA

P, f

ixed

pre

ssur

e

C

PA

P, B

iPA

P, P

EE

P a

djus

tabl

e

Je

t ins

ufla

tion

M

echa

nica

l Ven

tilat

or (M

anua

l/Aut

omat

ed

Tran

spor

t Ven

tilat

or)

Mai

ntai

n lo

ng te

rm/e

stab

lishe

d

Initi

ate/

Man

age

vent

ilato

r

Anes

thes

ia (

Loca

l)

Pain

Con

trol

& S

edat

ion

Sel

f Adm

inis

tere

d in

hale

d an

alge

sics

Pha

rmac

olog

ical

(non

-inha

led)

P

atie

nt c

ontro

lled

anal

gesi

a (P

CA

)M

aint

ain

esta

blis

hed

E

pidu

ral c

athe

ters

(mai

ntai

n)M

aint

ain

esta

blis

hed

Blo

od a

nd C

ompo

nent

The

rapy

Adm

inis

trat

ion

Mai

ntai

n

In

itiat

e

Dia

gnos

tic P

roce

dure

sB

lood

che

mis

try a

naly

sis

Cap

nogr

aphy

Pul

mon

ary

func

tion

mea

sure

men

t

Pul

se O

xim

etry

Ultr

ason

ogra

phy

Gen

ital/U

rinar

yB

ladd

er c

athe

teriz

atio

nFo

ley

cath

eter

Pla

ce b

ladd

er c

athe

ter

M

aint

ain

blad

der c

athe

ter

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sSc

ope

of P

ract

ice

- Pr

oced

ures

for E

MS

Pers

onne

l

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

appr

oved

by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

e co

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

are

ask

ed to

pre

sent

thei

r stu

dy p

lans

to th

e M

DC

for

info

rmat

iona

l pur

pose

s so

that

the

com

mitt

ee c

an m

aint

ain

an a

war

enes

s of

on-

goin

g pr

e-ho

spita

l res

earc

h in

the

Com

mon

wea

lth. T

hose

who

des

ire to

con

duct

non

-IRB

revi

ewed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or r

esea

rch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

mas

s de

stru

ctio

n is

exe

mpt

from

this

list

.A

ppro

ved:

Nov

embe

r 6, 2

013

Pag

e 4

of 6

PRO

CED

UR

ESK

ILL

PRO

CED

UR

E SU

BTY

PEEM

REM

TAE

MT

- En

hanc

edI

PH

ead

and

Nec

kIC

P M

onito

r (m

aint

ain)

C

ontro

l of e

pist

axis

In

serte

d ep

ista

xis

cont

rol d

evic

es

Toot

h re

plac

emen

t

Hem

odyn

amic

Tec

hniq

ues

Arte

rial c

athe

ter m

aint

enan

ce

Cen

tral v

enou

s m

aint

enan

ce

Acc

ess

indw

ellin

g po

rt

In

traos

seou

s ac

cess

& in

fusi

on

Per

iphe

ral v

enou

s ac

cess

and

mai

nten

ance

U

mbi

lical

Cat

hete

r Ins

ertio

n/M

anag

emen

t

Mon

itorin

g E

xist

ing

IVs

Mec

hani

cal I

V P

umps

Hem

odyn

amic

Mon

itorin

g E

CG

acq

uisi

tion

E

CG

Inte

rpre

tatio

n

In

vasi

ve H

emod

ynam

ic M

onito

ring

V

agal

Man

euve

rs/C

arot

id M

assa

ge

Obs

tetr

ics

Del

iver

y of

new

born

Oth

er T

echn

ique

s

Vita

l Sig

ns

Ble

edin

g co

ntro

l

Tour

niqu

ets

Fo

reig

n bo

dy re

mov

alS

uper

ifici

al w

ithou

t loc

al a

nest

hesi

a

Im

bedd

ed w

ith lo

cal a

nest

hesi

a/ex

plor

atio

n

In

cisi

on/D

rain

age

In

trave

nous

ther

apy

M

edic

atio

n ad

min

istra

tion

Nas

ogas

tric

tube

Oro

gast

ric tu

be

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sSc

ope

of P

ract

ice

- Pr

oced

ures

for E

MS

Pers

onne

l

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

appr

oved

by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

e co

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

are

ask

ed to

pre

sent

thei

r stu

dy p

lans

to th

e M

DC

for

info

rmat

iona

l pur

pose

s so

that

the

com

mitt

ee c

an m

aint

ain

an a

war

enes

s of

on-

goin

g pr

e-ho

spita

l res

earc

h in

the

Com

mon

wea

lth. T

hose

who

des

ire to

con

duct

non

-IRB

revi

ewed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or r

esea

rch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

mas

s de

stru

ctio

n is

exe

mpt

from

this

list

.A

ppro

ved:

Nov

embe

r 6, 2

013

Pag

e 5

of 6

PRO

CED

UR

ESK

ILL

PRO

CED

UR

E SU

BTY

PEEM

REM

TAE

MT

- En

hanc

edI

PP

eric

ardi

ocen

tesi

s

Ple

ural

dec

ompr

essi

on

P

atie

nt re

stra

int p

hysi

cal

Pat

ient

rest

rain

t che

mic

al

S

exua

l ass

ault

vict

im m

anag

emen

t

Tr

ephi

natio

n of

nai

ls

Wou

nd c

losu

re te

chni

ques

Wou

nd m

anag

emen

t

Pre

ssur

e B

ag fo

r Hig

h al

titud

e

Trea

t and

Rel

ease

Vag

al M

aneu

vers

/Car

otid

Mas

sage

Intra

nasa

l med

icat

ion

adm

inis

tratio

nFi

xed/

unit

dose

med

icat

ions

Dos

e ca

lcul

atio

n/m

easu

rem

ent

Res

usci

tatio

nC

ardi

opul

mon

ary

resu

scita

tion

(CP

R) (

all a

ges)

C

ardi

ac p

acin

g

D

efib

rilla

tion/

Car

diov

ersi

onA

ED

P

ost r

esus

cita

tive

care

Skel

etal

Pro

cedu

res

Car

e of

the

ampu

tate

d pa

rt

Frac

ture

/Dis

loca

tion

imm

obili

zatio

n te

chni

ques

Fr

actu

re/D

islo

catio

n re

duct

ion

tech

niqu

esM

anip

ulat

ion

of a

ngul

ated

/pul

sele

ss e

xtre

miti

es

Jo

int r

educ

tion

tech

niqu

es

S

pine

imm

obili

zatio

n te

chni

ques

Tho

raci

cTh

orac

osto

my

(ref

er to

"Oth

er T

echn

ique

s")

Bod

y Su

bsta

nce

Isol

atio

n / P

PE

Lifti

ng a

nd m

ovin

g te

chni

ques

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sSc

ope

of P

ract

ice

- Pr

oced

ures

for E

MS

Pers

onne

l

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

appr

oved

by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

e co

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

are

ask

ed to

pre

sent

thei

r stu

dy p

lans

to th

e M

DC

for

info

rmat

iona

l pur

pose

s so

that

the

com

mitt

ee c

an m

aint

ain

an a

war

enes

s of

on-

goin

g pr

e-ho

spita

l res

earc

h in

the

Com

mon

wea

lth. T

hose

who

des

ire to

con

duct

non

-IRB

revi

ewed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or r

esea

rch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

mas

s de

stru

ctio

n is

exe

mpt

from

this

list

.A

ppro

ved:

Nov

embe

r 6, 2

013

Pag

e 6

of 6

PRO

CED

UR

ESK

ILL

PRO

CED

UR

E SU

BTY

PEEM

REM

TAE

MT

- En

hanc

edI

PG

astr

o-In

test

inal

Tec

hniq

ues

Man

agem

ent o

f non

-dis

plac

ed g

astro

stom

y tu

be

Oph

thal

mol

ogic

alM

orga

n Le

nses

Cor

neal

Exa

m w

ith fl

uore

scei

n

O

cula

r irr

igat

ion

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sS

cope

of P

ract

ice

- Fo

rmul

ary

for E

MS

Per

sonn

el

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

app

rove

d by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

eco

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

ar

e as

ked

to p

rese

nt th

eir s

tudy

pla

ns to

the

MD

C fo

r inf

orm

atio

nal p

urpo

ses

so th

at th

e co

mm

ittee

can

mai

ntai

n an

aw

aren

ess

of o

n-go

ing

pre-

hosp

ital r

esea

rch

in th

e C

omm

onw

ealth

. Tho

se w

ho d

esire

to c

ondu

ct n

on-IR

B r

evie

wed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or

rese

arch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

m

ass

dest

ruct

ion

is e

xem

pt fr

om th

is li

st.

Appr

oved

Nov

embe

r 6, 2

013

Page

1 o

f 4

CAT

EGO

RY

EMR

EMT

AEM

T -

Enha

nced

IP

Anal

gesi

csAc

etam

inop

hen

Non

ster

oida

l ant

i-inf

lam

mat

ory

Opi

ates

and

rela

ted

narc

otic

s

Dis

soci

ativ

e an

alge

sics

K

etam

ine

0.5

mg/

kg o

r les

s IV

/IN

Anes

thet

ics

Otic

G

ener

al -

initi

ate

Ket

amin

e gr

eate

r tha

n 0.

5 m

g/kg

G

ener

al -

mai

nten

ance

Ocu

lar

In

hale

d-se

lf ad

min

iste

red

Loca

l

Antic

onvu

lsan

ts

Glu

cose

Alte

ring

Agen

tsG

luco

se E

leva

ting

Agen

ts

G

luco

se L

ower

ing

Agen

ts

Antid

otes

Antic

holin

ergi

c An

tago

nist

s

Antic

hole

nest

eras

e An

tago

nist

s

Benz

odia

zepi

ne A

ntag

onis

ts

Nar

cotic

Ant

agon

ists

Non

depo

lariz

ing

Mus

cle

Rel

axan

t An

tago

nist

Beta

/Cal

cium

Cha

nnel

Blo

cker

Ant

idot

e

Tric

yclic

Ant

idep

ress

ant O

verd

ose

Cya

nide

Ant

idot

e

Cho

lines

tera

se R

eact

ivat

or

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sS

cope

of P

ract

ice

- Fo

rmul

ary

for E

MS

Per

sonn

el

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

app

rove

d by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

eco

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

ar

e as

ked

to p

rese

nt th

eir s

tudy

pla

ns to

the

MD

C fo

r inf

orm

atio

nal p

urpo

ses

so th

at th

e co

mm

ittee

can

mai

ntai

n an

aw

aren

ess

of o

n-go

ing

pre-

hosp

ital r

esea

rch

in th

e C

omm

onw

ealth

. Tho

se w

ho d

esire

to c

ondu

ct n

on-IR

B r

evie

wed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or

rese

arch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

m

ass

dest

ruct

ion

is e

xem

pt fr

om th

is li

st.

Appr

oved

Nov

embe

r 6, 2

013

Page

2 o

f 4

CAT

EGO

RY

EMR

EMT

AEM

T -

Enha

nced

IP

Antih

ista

min

es &

Com

bina

tions

Bio

logi

cals

Imm

une

Seru

ms

Antib

iotic

s

Blo

od/B

lood

pro

duct

sIn

itiat

e

Mai

ntai

n

Blo

od M

odifi

ers

Antic

oagu

lant

s

Antip

late

let A

gent

s

Hem

osta

tic A

gent

s

Thro

mbo

lytic

s

Anti-

fibrin

olyt

ics

(eg

trane

xam

ic a

cid)

Car

diov

ascu

lar A

gent

sAl

pha

Adre

nerg

ic B

lock

ers

Adre

nerg

ic S

timul

ants

Antia

rrhy

thm

ics

Beta

Adr

ener

gic

Bloc

kers

Cal

cium

Cha

nnel

Blo

cker

s

Diu

retic

s

Inot

ropi

c Ag

ents

Vaso

dila

tory

Age

nts

Vaso

pres

sors

Epin

ephr

ine

for a

llerg

ic re

actio

n

Ad

ded

per M

DC

dis

cuss

ion

10-1

0-13

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sS

cope

of P

ract

ice

- Fo

rmul

ary

for E

MS

Per

sonn

el

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

app

rove

d by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

eco

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

ar

e as

ked

to p

rese

nt th

eir s

tudy

pla

ns to

the

MD

C fo

r inf

orm

atio

nal p

urpo

ses

so th

at th

e co

mm

ittee

can

mai

ntai

n an

aw

aren

ess

of o

n-go

ing

pre-

hosp

ital r

esea

rch

in th

e C

omm

onw

ealth

. Tho

se w

ho d

esire

to c

ondu

ct n

on-IR

B r

evie

wed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or

rese

arch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

m

ass

dest

ruct

ion

is e

xem

pt fr

om th

is li

st.

Appr

oved

Nov

embe

r 6, 2

013

Page

3 o

f 4

CAT

EGO

RY

EMR

EMT

AEM

T -

Enha

nced

IP

Cen

tral

Ner

vous

Sys

tem

Antip

sych

otic

Seda

tives

Benz

odiz

epin

es

Ad

ded

per M

DC

dis

cuss

ion

10-1

0-13

Die

tary

Sup

plem

ents

/Ele

ctro

lyte

Vita

min

s

Min

eral

s - s

tart

at a

hea

lth c

are

faci

lity

See

sec

tion:

Intra

veno

us F

luid

sSa

lts -

star

t at a

hea

lth c

are

faci

lity

Elec

troly

tes

Solu

tions

- st

art a

t a h

ealth

car

e fa

cilit

yH

yper

toni

c Sa

line

Gas

Oxy

gen

H

elio

x

Gas

troi

ntes

tinal

Anta

cids

O

TC

Antid

iarr

heal

s

Antie

met

ics

E

MT

SL/P

O ro

ute

only

H2

Bloc

kers

Hor

mon

esSt

eroi

ds

Intr

aven

ous

Flui

dsis

oton

ic

hypo

toni

c

hype

rtoni

c

M

= M

aint

enan

ce

I = In

itiat

eC

ryst

allo

id, +

/- D

extro

se/L

acta

teM

I/MI/M

I/Mw

ith M

ulti=

vita

min

sM

MM

Mw

ith T

hiam

ine

MM

MM

Neu

rom

uscu

lar B

lock

ers

Res

pira

tory

Antic

holin

ergi

cs

Sym

path

omim

etic

s

B

eta

agon

ists

Virg

inia

Offi

ce o

f Em

erge

ncy

Med

ical

Ser

vice

sS

cope

of P

ract

ice

- Fo

rmul

ary

for E

MS

Per

sonn

el

This

SO

P re

pres

ents

pra

ctic

e m

axim

ums

.

“Inv

estig

atio

nal m

edic

atio

ns a

nd p

roce

dure

s w

hich

hav

e be

en r

evie

wed

and

app

rove

d by

an

Inst

itutio

nal R

evie

w B

oard

(IR

B)

will

be

cons

ider

ed to

be

app

rove

d by

the

Med

ical

Dire

ctio

n C

omm

ittee

sol

ely

with

in th

eco

ntex

t of t

he a

ppro

ved

stud

y. In

vest

igat

ors

invo

lved

in IR

B a

ppro

ved

rese

arch

ar

e as

ked

to p

rese

nt th

eir s

tudy

pla

ns to

the

MD

C fo

r inf

orm

atio

nal p

urpo

ses

so th

at th

e co

mm

ittee

can

mai

ntai

n an

aw

aren

ess

of o

n-go

ing

pre-

hosp

ital r

esea

rch

in th

e C

omm

onw

ealth

. Tho

se w

ho d

esire

to c

ondu

ct n

on-IR

B r

evie

wed

pilo

t pro

ject

s, d

emon

stra

tion

proj

ects

, or

rese

arch

are

aske

d to

pre

sent

thos

e pr

opos

als

to th

e M

DC

prio

r to

thei

r im

plem

enta

tion

for r

evie

w a

nd a

ppro

val b

y th

e M

DC

.”

Use

of m

edic

atio

n no

t lis

ted

whi

ch is

indi

cate

d by

med

ical

con

trol

and

/or

the

oper

atio

nal m

edic

al d

irec

tor

due

to th

e us

e of

a w

eapo

n of

m

ass

dest

ruct

ion

is e

xem

pt fr

om th

is li

st.

Appr

oved

Nov

embe

r 6, 2

013

Page

4 o

f 4

CAT

EGO

RY

EMR

EMT

AEM

T -

Enha

nced

IP

Epi

neph

rine

(neb

uliz

ed)

cla

rific

atio

n - r

efer

s to

neb

uliz

ed n

ot s

yste

mic

epi

neph

rine

MD

C 1

0-10

-13

Dos

age

and

Con

cent

ratio

n C

alcu

latio

n

M =

Mai

nten

ance

I = In

itiat

eN

ote:

EM

T's

may

adm

inis

ter m

edic

atio

ns

with

in th

eir s

cope

of p

ract

ice

in a

dditi

on to

as

sist

ance

in a

dmin

istra

tion

of th

ose

med

icat

ions

. EM

T's

may

acc

ess

a dr

ug k

it to

acc

ess

thos

e m

edic

atio

ns. M

DC

di

scus

sion

s.

EMS Guide January 2015

This guide is produce by MCSO – The Mechanical Circulatory Support OrganizationIt is produced by VAD Coordinators from some of the largest and most successful VAD implantation hospitals in the US. It has been vetted by experts

on VADS in Air Medical Transport and EMS. It should not replace the operator manual as the

primary source of information.

Reprinted with the permission of Thoratec Corporation

MC

SO

ECHANICAL

IRCULATORY

UPPORT

RGANIZATION

What is a Ventricular Assist Device (VAD)?

A ventricular assist device (VAD) is a mechanical pump that’s used to support heart function and blood flow in people who have weakened hearts.

How does a VAD work?

The device takes blood from a lower chamber of the heart and helps pump it to the body and vital organs, just as a healthy heart would.

What are the parts of a VAD?

The basic parts of a VAD include: a small tube that carries blood out of your heart into a pump; another tube that carries blood from the pump to your blood vessels, which deliver the blood to your body; and a power source.

What is the power source?

The power source is either batteries or AC power. The power source is connected to a control unit that monitors the VAD’s functions. The batteries are carried in a case usually located in a holster in a vest wrapped around the patients shoulders.

What does the control unit or controller do?

The control unit gives warnings, or alarms, if the power is low or if it senses that the device isn’t working right. It is a computer.

JANUARY 2015

Questions and AnswersVentricular Assist Device

The portability of the HeartMate II enables patients to resume many of their normal daily activities.

MOST patients have a tag located on the controller around their waist that says what type of device it is, what institution put it in and a number to call. Most importantly is the color of the tag – it matches this EMS Field Guide and allows you to quickly locate the device you are caring for.

JANUARY 2015

Color Coding System

JANUARY 2015

Patient Management For VADs

1. Assess the patients airway and intervene per your usual protocol.

2. Auscultate Heart Sounds to determine if the device is functioning and whattypeofdeviceitis.Ifitiscontinuousflowdevice,youshouldhear a “whirling sound”.

3. Assess the device for any alarms.

4. Look on controller found around the waist of the patient or in the VAD PAK and to see what color tag and device it is. 5. Match the color on the device tag to the EMS Guide.

6. Intervene appropriately based on the type of alarm, tag (device) and EMS Guide.

7. Start Large Bore IV.

8. Assessvitalsigns–UseMeanBPwithDoppler–withthefirstsoundyou hear is the Mean Arterial Pressure (MAP).

9. If no Doppler, use the Mean on the non invasive blood pressure machine.

10. Transport to closest VAD center. Call the number on the device to get advice.

11. Bring all of the patient’s equipment. 12. Allow the trained caregiver to ride in the transport vehicle if possible to act as a expert on the device in he absence of consciousness in the patient.

ORANGE ORANGE ORANGE ORANGE ORANGE ORANGE ORANGE ORANGE

ORANGE ORANGE

ORANGE ORANGE

ORANGE

ORAN

GE

ORAN

GE

ORAN

GE

ORAN

GE

ORAN

GE

JANUARY 2015

1. Can I do external CPR? Only if absolutely necessary2. If not, is there a “hand pump” or external device to use? No.3. Ifthedeviceslowsdown(lowflowstate),whatalarmswillgooff? A red heart alarm light indicator and steady audio alarm will sound if less than 2.5 lmp. Can give a bolus of normal saline and transport to an LVAD center.4. How can I speed up the rate of the device? No,itisafixedspeed.5. Do I need to heparinize the patient if it slows down? Usually no, but you will need to check with implanting center.6. Canthepatientbedefibrillatedwhileconnectedtothedevice? Yes.7. Ifthepatientcanbedefibrillated,isthereanythingIhaveto disconnectbeforedefibrillating? No. 8. Does the patient have a pulse with this device? May have weak pulse or lack of palpable pulse.9. Whatareacceptablevitalsignparameters? MAP 70 - 90 mm Hg with a narrow pulse pressure10.Canthispatientbeexternallypaced? Yes.

HeartMate II® with Pocket Controllers

Adapted from Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport in ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010 in press.

FAQsl May not be able to obtain cuff

pressure(continuosflowpump).

l Pump connected to electric line exitingpatient’sabdominalareaandis attached to computer which runs the pump.

l Pump does not affect EKG

l All ACLS drugs may be given.

l No hand pump is available.

l A set of black batteries last approximately3hours,graybatteries last 8-10 hours.

l Any emergency mode of transportation is ok. These patients arepermittedtofly.

l Be sure to bring ALLofthepatient’sequipment with them.

Trouble Shooting HeartMate II® with Pocket ControllersWhen the Pump Has Stopped

lBesuretobringALLofthepatient’sequipmentwiththem.

l Fixanylooseconnection(s)torestartthepump.l If the pump does not restart and the patient is connected to batteries replace the current batteries with a new, fully-charged pair. (see changing batteries section on next page)

l If pump does not restart, change controllers. (see changing controllers section on next page)

Alarms: Emergency Procedures

YelloworRedBatteryAlarm:Need to Change Batteries. See changing batteries section on nextpage.

RedHeartFlashingAlarm:This may indicate a Low Flow Hazard. Check patient--theflowmaybetoolow.Ifpatientishypovolemic,givevolume.Ifpatient is in right heart failure-- treat per protocol. If the pump has stopped check connections, batteries and controllers as instructed in the section above.

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Thisguidedoesnotsupersedemanufacturerinstructions.Copywithpermissiononly.March2011 ORANGE ORANGE ORANGE ORANGETrouble Shooting HeartMate II® with Pocket Controllers

l Place the replacement Controller within easy reach, along with the batteries/battery clips. The spare Controllerisusuallyfoundinthepatient’stravelcase.

l Make sure patient is sitting or lying down since the pump will momentarily stop during this procedure.

l Attach the battery clips to the spare controller by lining up the half moons and gently pushing together and attach the batteries to the spare controller by aligning the RED arrows.

l On the back of the replacement controller, rotate down the perc lock so the red tab is fully visible. Repeat this step on the original controller until the red tab is fully visible.

l Disconnect the drive line from the original controller by pressing down on the red tab and gently pulling on the metal end. The pump will stop and an alarm will sound. Note:The alarm will continue until the original controller is put to sleep. You can silence the alarm by holding down the silence button. Gettingthereplacementcontrollerconnectedandpumprestartedisthefirstpriority.

l Connect the replacement Controller by aligning the BLACK ARROWS on the driveline and replacement Controller and gently pushing the driveline into the replacement Controller. The pump should restart, if not complete the following steps:

Step 1. Firmly press the Silence Alarm or Test Select Button to restart the pump.

Step 2. Check the powersource to assure that power is going to the controller.

Step 3. Assure the perc lead is fully inserted into the socket by gently tugging on the metal end. DO NOT pull the lead.

l After the pump restarts, rotate up the perc lock on the new controller so the red tab is fully covered. If unable to engage perc lock to a fully locked position, gently push the driveline into the controller to assure proper connection. Retry to engage perc lock.

l Disconnect power from the original Controller. The original Controller will stop alarming once power is removed.

l Hold down battery symbol for 5 full seconds for complete shutdown of old controller.

WARNING: At least one power lead must be connected to a powersourceATALLTIMES. Do not remove both batteries at the same time or the pump will stop.

l Obtain two charged batteries frompatient’saccessorybagor battery charger. The charge level of each gray battery can be assessed by pressing the battery button on the battery. (Figures 1 and2)

l Remove only ONE battery from the clip by pressing the button on the grey clip to unlock the battery.(Figure3)

l Controller will start beeping, flashyellowsignalsandwillread power disconnect on the front screen.

l Replace with new battery by lining up RED arrows on battery andclip.(Figure4)

l Slide a new, fully-charged battery (Figure2)intotheemptybatteryclip by aligning the RED arrows. The battery will click into the clip. Gently tug at battery to ensure connection. If battery is properly secured, the beeping and yellow flashingwillstop.

l Repeat previous steps with the second battery and battery clip.

Figure 1Not Charged

Figure 2Fully Charged

Figure 4

Figure 3

Changing Batteries

Changing Controllers

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1. Can I do external CPR? Only if absolutely necessary2. If not, is there a “hand pump” or external device to use? No.3. Ifthedeviceslowsdown(lowflowstate),whatalarmswillgooff? A red heart alarm light indicator and steady audio alarm will sound if less than 2.5 lmp. Can give a bolus of normal saline and transport to an LVAD center.4. How can I speed up the rate of the device? No,itisafixedspeed.5. Do I need to heparinize the patient if it slows down? Usually no, but you will need to check with implanting center.6. Canthepatientbedefibrillatedwhileconnectedtothedevice? Yes.7. Ifthepatientcanbedefibrillated,isthereanythingIhaveto disconnectbeforedefibrillating? No. 8. Does the patient have a pulse with this device? May have weak pulse or lack of palpable pulse.9. Whatareacceptablevitalsignparameters? MAP 70 - 90 mm Hg with a narrow pulse pressure10.Canthispatientbeexternallypaced? Yes.

HeartMate II®

Adapted from Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport in ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010 in press.

FAQsl May not be able to obtain cuff

pressure(continuosflowpump).

l Pump connected to electric line exitingpatient’sabdominalareaandis attached to computer which runs the pump.

l Pump does not affect EKG


l No hand pump is available.

l A set of black batteries last approximately3hours,graybatteries last 8-10 hours.

l Any emergency mode of transportation is ok. These patients arepermittedtofly.

l Be sure to bring ALLofthepatient’sequipment with them.

Trouble Shooting HeartMate II®

When the Pump Has StoppedlBesuretobringALLofthepatient’sequipmentwiththem.

l Fixanylooseconnection(s)torestartthepump.l If the pump does not restart and the patient is connected to batteries replace the current batteries with a new, fully-charged pair. (see changing batteries section on next page)

l If pump does not restart, change controllers. (see changing controllers section on next page)


YelloworRedBatteryAlarm:Need to Change Batteries.Seechangingbatteriessectiononnextpage.

RedHeartFlashingAlarm:This may indicate a Low FlowHazard.Checkpatient--theflowmaybetoolow.If patient is hypovolemic, give volume. If patient is in right heart failure-- treat per protocol. If the pump has stopped check connections, batteries and controllers as instructed in the section above.


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Thisguidedoesnotsupersedemanufacturerinstructions.Copywithpermissiononly.March2011 ORANGE ORANGE ORANGE ORANGETrouble Shooting HeartMate II®

l Place the replacement Controller within easy reach, along with the batteries/battery clips. The spare Controllerisusuallyfoundinthepatient’stravelcase.


l Attach the battery clips to the spare controller by lining up the half moons and gently pushing together and attach the batteries to the spare controller by aligning the RED arrows. ALARMSWILLSOUND-THISISOK.

l Depress the silence alarm button (upside-down bell withcircle)untilthealarmissilencedonthenew,replacement Controller.

l Rotate the perc lock on the replacement controller in the direction of the “unlocked” icon until the perc lock clicks into the fully- unlocked position. Repeat this same step for the original Controller until the perc lock clicks into the unlocked position.

l Disconnect the perc lead/driveline from the original controller by pressing the metal release tab on the connector socket. The pump will stop and an alarm will sound.

Note:The alarm will continue until power is removed from the original Controller. Getting the replacement Controller connected and the pump restarted is the first priority.

l Connect the replacement Controller by aligning the BLACK LINES on the driveline and replacement Controller and gently pushing the driveline into the replacement Controller. The pump should restart, if not complete the following steps:

Step1. Firmly press the Silence Alarm or Test Select Button to restart the pump.

Step2. Check the powersource to assure that power is going to the controller.

Step3. Assure the perc lead is fully inserted into the socket by gently tugging on the metal end. DONOT pull the lead.

l After the pump restarts, rotate the perc lock on the new controller in the direction of the “locked” icon until the perc lock clicks into the fully-locked position. If unable to engage perc lock to the locked position, gently push the driveline into the controller to assure a proper connection. Retry to engage perc lock.


WARNING: At least one power lead must be connected to a powersourceATALLTIMES. Do not remove both batteries at the same time or the pump will stop.

lObtaintwochargedbatteriesfrompatient’saccessorybagorbattery charger. The charge level of each gray battery can be assessedbypressingthebatterybuttononthebattery.(Figures3and4)

l Remove only ONE battery from the clip by pressing the button on thegreycliptounlockthebattery.(Figure1)

lControllerwillstartbeepingandflashinggreensignals.l Replace with new battery by lining up RED arrows on battery and

clip.(Figure2)lSlideanew,fully-chargedbattery(Figure4)intotheemptybattery

clip by aligning the RED arrows. The battery will click into the clip. Gently tug at battery to ensure connection. If battery is properly secured,thebeepingandgreenflashingwillstop.

l Repeat previous steps with the second battery and battery clip. Figure 3 Figure 4

Figure 2

Figure 1

Changing Batteries


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Chest compressions may pose a risk of dislodgment – useclinical judgment. If chest compressions are administered,confirm function and positioning of the pump.

2. If not, is there a “hand pump” or external device to use?

No.

3. Ifthedeviceslowsdown(lowflowstate),whatalarmswillgo off?

The device runs at a fixed speed. If a low flow state occurs,an alarm will be heard, and the controller display will show ayellow triangle and “Low Flow – Call” message.

4. How can I speed up the rate of the device?

It is not possible to adjust the pump speed in the prehospitalsetting. Okay to give IV fluids.

5. Do I need to heparinize the patient if it slows down?

Call the accepting VAD facility for guidance.

6. Canthepatientbedefibrillatedwhileconnectedtothedevice?

Yes.

7. Ifthepatientcanbedefibrillated,isthereanythingIhavetodisconnectbeforedefibrillating?

No, defibrillate per protocol.

8. Does the patient have a pulse with this device?

The patient may not have a palpable pulse. Depending on thepatient’s own heart function, you may be able to feel a threadypulse.

9. What are acceptable vital sign parameters?

Goal Mean Arterial Pressure (MAP) is <85 mmHg. Use a Doppler asthe first option to assess blood pressure. If you are using a Doppler,place the blood pressure cuff on the patient arm. As you release thepressure in the blood pressure cuff, the first sound you hear with theDoppler is the MAP. If that is not available, use a non-invasive BP(NIBP).

10. Canthispatientbeexternallypaced?

YesAdapted from Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport in ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010 in press.

FAQs• May not be able to obtain cuff

pressure (continuous flow pump)

• Pump connected to electricline (driveline) exiting patient’sabdominal area and is attachedto computer (controller) whichruns the pump.

• Pump does not affect EKG,but patient may or may notbe symptomatic even iwthventricular arrhythmias.

• All ACLS drugs may be given.

• No hand pump is available.This is a rotary (continuousflow) pump with typical speedranges of 2400 – 3200 RPMs.The patient should have back-upequipment.

• The controller draws power fromone battery at a time. A fullycharged battery will provide 4-6hours of power. Both the batteryand controller have status lightsto indicate the amount of powerremaining.

• Transport by ground toimplanting facility if possible.

• Be sure to bring ALL of thepatient’s equipment with them.

HeartWare® Ventricular Assist System

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DRIVELINE CONNECTION To Connect to Controller: lAlign the two red marks and push together. An audible

click will be heard confirming proper connection. (Figure A)

lThe Driveline Cover must completely cover the Controller’s silver driveline connector to protect against static discharge. (Figure B)

lNOTE: an audible click should be heard when connecting the Driveline or Driveline extension to the controller. Failure to use the Driveline Cover may cause an Electrical Fault Alarm.

HeartWare® Ventricular Assist System Emergency Operation

Figure A Figure B

Controller

CONNECTING POWER TO CONTROLLERToConnectaChargedBattery:lGrasp the cable of the charged battery at the back end

of the connector (leaving front end of connector free to rotate)

l Line up the solid white arrow on the connector with the white dot on the Controller.

lGently push (but DO NOT twist) the battery cable into the Controller until it naturally locks into place; you should hear an audible click.

lConfirm that the battery cable is properly locked on the controller by gently pulling the cable near the controller power connector.

lDO NOT force the battery cable into the controller connector without correct alignment as it may result in damaged connectors .

TO DISCONNECT A DEPLETED BATTERYlMake sure there is a fully charged battery available to

replace the depleted one.lDisconnect the depleted battery by turning the connector

sleeve counterclockwise until it stops.lPull the connector straight out from the controller.

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ALARM ADAPTERl Used to silence the internal NO POWER ALARM. l ShouldonlybeusedonacontrollerthatisNOTconnectedtoa

patient’s pump.l Must be inserted into the blue connector of the original controller

after a controller exchange BUT before the power sources are disconnected or the NO Power alarm will sound for up to two hours.

Batterytest button

BatteryCharge Indicator

Monitor

Power Source #1

Power Source #2

Driveline

BatteryCharge Indicator

CONTROLLER BATTERY


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HeartWare® Ventricular Assist SystemEmergency Operation

Step 4

Step 3

Step 6

Step 10

Step 9

STEPS TO EXCHANGE THE CONTROLLER

Step 1: Have the patient sit or lie down.

Step 2: Place the new controller within easy reach.

Step 3: Connect back-up power sources (batteries or AC Power) to the new controller.

lConfirm that the power cables are properly locked on the controller by gently pulling on the cable near the connector.

lA “Power Disconnect” alarm will activate if a second power source is not connected to the new controller within 20 seconds of controller power up

lA “VAD Stopped” alarm will activate if the pump driveline is not connected to the new controller within 10 seconds - this alarm will resolve once the pump driveline is connected

Step 4: Pull back the white driveline cover from the original controller’s silver connector.

Step 5: Disconnect the driveline from the original controller by pulling the silver connector away from the controller. Do not disconnect by pulling on the driveline cable. A “VAD Stopped” alarm may activate. Don’t panic. You can silence the alarm after restarting the pump, which is the

priority.

Step 6: Connect the driveline to the new controller (align the two red marks and push together). If the “VAD Stopped” alarm was active on the new controller, it will now resolve.

Step 7: The pump should restart. Verify the pump is working (RPM, L/min, Watts).

Step 8: IF THE PUMP DOES NOT RESTART, CALL FOR MEDICAL ASSISTANCE IMMEDIATELY.

Step 9: Insert the Alarm Adapter into the blue connector on the original controller.

lDisconnect both power sources from the original controller.

l The controller will be turned off and all alarms silenced.

Step 10: Slide the white driveline cover up to cover new controller’s silver connector.

Step 11: Contact the VAD Center or Implanting hospital for a new backup controller.

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HeartWare® Ventricular Assist System Troubleshooting

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Jarvik 2000 with Abdominal exit site.

BloodPump

OutflowGraft

PowerLead

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1. Can I do external CPR?Yes, only as a last resort.

2. If not, is there a “hand pump” or external device to use?No.

3. Ifthedeviceslowsdown(lowflowstate),whatalarms will go off?No alarm for low flow. If pump is off, the red “PumpStop” symbol will light with a continuous alarm.

4. How can I speed up the rate of the device?There is a speed dial on the side of the controller (seepicture on next page). Turning the dial in the directionof the arrow increases the speed. Each incrementis 1,000 RPM. It is recommended not to change thespeed without consulting the implanting center.

5. Do I need to heparinize the patient if it slowsdown?Typically yes, if the pump is stopped (red “Pump Stop”alarm). Check with the implanting center.

6. Canthepatientbedefibrillatedwhileconnectedtothe device?Yes.

7. Ifthepatientcanbedefibrillated,isthereanythingIhavetodisconnectbeforedefibrillating?No.

8. Does the patient have a pulse with this device?Most patients have a faint palpable pulse. If thecontroller is marked “ILS” (see below), the speed isautomatically reduced every minute for 8 seconds &the patients pulse may increase during this time.

9. What are acceptable vital sign parameters?MAP 65 - 80mm Hg.

10.Canthispatientbeexternallypaced?Yes.

Jarvik 2000® VAS

Adapted from Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport in ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010 in press. This guide does not supersede manufacturer instructions. Copy with permission only. March 2015 Jarvik 2000®

Jarvik 2000 with Post-Auricularexit site.


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The Jarvik 2000® VAS is available in two models: the Jarvik 2000® VAS, Post-Auricular Cable (JHI-001) and the Jarvik 2000® VAS, Abdominal Cable (JHI-002). The main difference between the two models is the exit site of the drive cable. The drive cable of the Jarvik 2000® VAS, Abdominal Cable exits the abdomen and the drive cable of the Jarvik 2000® VAS, Post-Auricular Cable exits at a Pedestal surgically attached to the skull behind the ear.

Jarvik 2000® VAS

Jarvik 2000® VAS, Post-Auricular Cable.

External Equipment for Jarvik 2000® VAS, Abdominal Cable.

Jarvik 2000® VAS, Abdominal Cable.

External Equipment for Jarvik 2000® VAS, Post-Auricular Cable.

NOTE: This Field Guide is NOT intended to replace the Operator Manual and Patient Handbook.


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Reserve Battery/Charger.Li-ion Battery.

Jarvik 2000® VAS

The FlowMaker Controller provides:1. power to the implanted blood pump,2. user settable speeds at which the pump runs, and3. alarms and warnings.The FlowMaker® Controller does not monitor the actual blood flow that the Jarvik 2000® Ventricular Assist Device (VAD) is pumping. In general, the higher the setting number the more blood the Jarvik 2000 VAD will pump. The tabulated flow estimates are based on research measurements in healthy animals. The actual blood flow may vary and will depend on several factors including blood pressure and the condition of the natural heart.

DialSetting

Speed Rpm

FlowL/min

PowerWatts

1 8,000 1-2 3-4

2 9,000 2-3 4-5

3 10,000 4-5 5-6-7

4 11,000 5-7 7-8-9

5 12,000 7-8.5 8-9-10

FlowMaker® Controller. Diagram of FlowMaker® Controller Top Panel.


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Only one control adjustment to the Jarvik 2000® VAD can be made. The Jarvik 2000® VAD speed can be selected by turning the knob on the side of the FlowMaker® Controller. The setting number appears in the window on the top panel. The arrow indicates the direction to turn the knob to increase the speed.

Power Indicator Lights The numbers indicate the electrical power (Watts) that the VAD is using. One, two, or three numbers may be lit at any moment, and the lights may change rhythmically with the heartbeat of the natural heart. A power measure of 13 watts or more indicates

malfunction. The High Power Indicator, number 13, will light yellow. This condition should receive prompt medical attention.

When the battery powering the Jarvik 2000® VAD is low, the LowBatteryAlarm on the FlowMaker®Controllerlightsyellow and the alarm sound beeps. Remaining running time with the portable Li-ion Battery is about 5-10 minutes; with the Reserve Battery/Charger for approximately 15 minutes

If the Jarvik 2000® VAD stops or if the VAD speed drops to below 5,000 RPM for any reason, a steady alarm sound is heard and the Pump Stopped Alarm on the FlowMaker® Controller lights red. The Pump Stopped Alarm will also sound if the intermittent low speed featured on the ILS FlowMaker® Controller fails to function for any reason. Immediate attention is required. Follow the

Pump Stopped Alarm procedure for the appropriate Jarvik 2000® VAS model (Post-Auricular Cable or AbdominalCable)whichisincludedinthisFieldGuide.

The UnderspeedIndicatorlightwillglowyellow when the Flowmaker® Controller detects that the Jarvik 2000 ® VAD speed is slower than the dial setting selected. The most common reason is the battery voltage is too low.

In this case, corrective actions are to: 1 Select a lower speed setting on the Flowmaker® Controller and/or 2 Change the battery to a fully charged Li-ion Battery. If the underspeed indicator light is still lit, then the cause may be a fault in the system. Replace all external components; and if the underspeed light is still on after replacing all external components, treat the situation as an emergency and seek immediate medical attention. See Patient Handbook and Operator Manual for more details.

A non-rechargeable AlarmBattery is used to assure that the FlowMaker Controller has enough power for the alarms if the main battery fails, if the battery cable fails, or if the main battery becomes accidentally disconnected.

This AlarmBattery is located in a small housing on the end of the FlowMaker® Controller between the connectors for the cables. Be sure that the AlarmBatteryCap holding the Alarm Battery in place on the FlowMaker® Controller is screwed on finger tight whenever the FlowMaker® Controller is used. If the AlarmBatteryCap is not screwed finger tight in place, the backup power for the alarms will not function. Every time the AlarmBatteryCap is tightened, the Controller’s back-up Alarm needs to be tested. With a caregiver present, briefly disconnect the main battery (Li-ion Battery or Reserve Battery/Charger) to be sure the Pump Stopped Alarm sounds. The disconnection should be brief and the main battery should be reconnected almost immediately. If the Pump Stopped Alarm does not sound, retighten the Alarm Battery Cap and repeat the test.

Contact the implant center immediately if the alarm does not sound during this test.

Speed Setting, Alarms, and Warnings

Jarvik 2000® VAS


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1. Be sure the alarm is not an intermittent beepingwhich only indicates a low battery. If the alarm isbeeping, change the battery as usual.

2. If the Jarvik 2000® VAD is stopped (steadyalarm sounding, red light on):

a. Disconnect the Pedestal Cable from thePedestal at the skull, and set aside all theattached components. Disconnect the Li-ion Battery Cable and also partially unscrewthe Alarm Battery Cap on the FlowMaker®Controller to silence the alarm.

b. Plug in a backup Pedestal Cable into thePedestal and into a backup FlowMaker®Controller. Make sure the FlowMaker®Controller is set at speed setting 1. Makesure to tighten the Alarm Battery Cap on thebackup FlowMaker® Controller to activatethe alarm.

c. Using the backup Li-ion Battery Cable,plug a fully charged Li-ion Battery into theFlowMaker® Controller.

d. If the Jarvik 2000® VAD now runs, and thepatient is feeling well, red tag the originalcomponents that were set aside in step 2a.

e. Set the FlowMaker® Controller back at thespeed the user was using prior to the alarm.

3. IftheJarvik2000VAD(pump)isstillstoppedcallthemedicalemergencynumberimmediately.

4. Red tag all components of the system thatwere set aside before changing to the backupcomponents in step 2a. This should be donewith the assistance of a medical support personif possible.

5. It is possible that one of the connectors is notfully plugged in and is not making contact.Recheck all connectors.

6. If the Jarvik 2000® VAD still has not started, thepatient should lie down and the support personshould double check batteries and connectors.Try changing batteries again. It is possiblethat a discharged battery was removed andthe same discharged battery was accidentallyplugged back into the system. It is possible thatneither battery is charged. If no lights illuminateon either battery, use a third battery. It is alsopossible that one of the connectors is not fullyplugged in and is not making contact. Recheckall connectors.

7. If all of the above steps have been followedand all cables and components have beenreplaced without successfully restarting theJarvik 2000® VAD, disconnect the power totheJarvik2000®VADbyunpluggingthebattery. Also partially unscrew the Alarm BatteryCap on the FlowMaker® Controller. (The alarmshouldstopsounding). If the Li-ion Battery orReserve Battery/Charger is not disconnected,the FlowMaker® Controller will apply power tothe Jarvik 2000® VAD which could be harmful.Disconnecting the battery reduces the chanceof a clot forming inside the Jarvik 2000® VAD byallowing the rotor to spin as blood flows across it.

Note:Returnanyfailedorsuspectcomponent(s)toyourClinicalCenterforevaluationbyJarvikHeart,Inc.

Jarvik 2000® VASProcedure to Resolve Pump Stopped Alarm

Jarvik 2000® VAS, Post-Auricular CableThe most likely reason for the Jarvik® 2000 VAD (pump) to stop is a completely dischargedbattery or a disconnected or damaged cable. If the cause of a component failure is clearly identifiable (i.e. low battery, physical damage, etc.) replace that cable or component first.If the cause is unknown, follow these step-by-step instructions with the assistance of a support person. The patient should sit down or lie down. This procedure should be completed quickly. Back-up equipment must be immediately available.


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1. Be sure the alarm is not an intermittent beepingwhich only indicates a low battery. If the alarm isbeeping, change the battery as usual.

2. If the Jarvik 2000® VAD is stopped (steadyalarm sounding, red light on):

a. Disconnect the Extension Cable from thedrive cable at the abdomen, and set asideall the attached components. Disconnect theLi-ion Battery Cable and also partially unscrewthe Alarm Battery Cap on the FlowMaker®Controller to silence the alarm.

b. Plug the drive cable (the cable exiting theskin at the abdomen) directly into the backupFlowMaker® Controller (eliminating theExtension Cable). Make sure the FlowMaker®Controller is set at speed setting 1. Make sureto tighten the Alarm Battery Cap on the backupFlowMaker® Controller to activate the alarm.

c. Using the backup Li-ion Battery Cable, plug afully charged Li-ion Battery into the FlowMaker®Controller.

d. If the Jarvik 2000® VAD now runs and thepatient is feeling well, red tag the originalcomponents that were set aside in step 2a.

e. Set the FlowMaker® Controller back at thespeed the user was using prior to the alarm.

3. IftheJarvik2000®VAD(pump)isstillstoppedcallyourmedicalemergencynumberimmediately.

4. Red tag all components of the system thatwere set aside before changing to the backupcomponents in step 2a.

5. Be sure that all external cables and connectorshave been changed and check to see if theconnector at the end of the drive cable exitingthe skin at the abdomen is broken. If it is brokenand has come apart – try to put it back togetherwhere it is broken. If the Jarvik 2000® VAD

does not run, take the connector apart again – rotate the parts 90° and put the connector back together again. Repeat three times. The Jarvik 2000 VAD may start. The connector may then be held together with tape while the patient is transported to the hospital for it to be repaired.

6. It is possible that one of the connectors is notfully plugged in and is not making contact.Recheck all connectors.

7. If the Jarvik 2000® VAD still has not started, thepatient should lie down and the support personshould double check batteries and connectors.Try changing batteries again. It is possiblethat a discharged battery was removed andthe same discharged battery was accidentallyplugged back into the system. It is possible thatneither battery is charged. If no lights illuminateon either battery, use a third battery. It is alsopossible that one of the connectors is not fullyplugged in and is not making contact. Recheckall connectors.

8. If all of the above steps have been followedand all cables and components have beenreplaced without successfully restarting theJarvik 2000® VAD, disconnect the powertotheJarvik2000VADbyunpluggingthebattery. Also partially unscrew the Alarm BatteryCap on the FlowMaker® Controller. (The alarmshouldstopsounding). If the Li-ion Battery orReserve Battery/Charger is not disconnected,the FlowMaker® Controller will apply power tothe Jarvik 2000® VAD which could be harmful.Disconnecting the battery reduces the chanceof a clot forming inside the Jarvik 2000® VAD byallowing the rotor to spin as blood flows across it.Note:Returnanyfailedorsuspectcomponent(s)toyourClinicalCenterforevaluationbyJarvikHeart,Inc.

Jarvik 2000® VASProcedure to Resolve Pump Stopped Alarm

Jarvik 2000® VAS, Abdominal CableThe most likely reason for the Jarvik 2000® VAD (pump) to stop is a completely dischargedbattery or a disconnected or damaged cable. If the cause of a component failure is clearly identifiable (i.e. low battery, physical damage, etc.) replace that cable or component first.If the cause is unknown, follow these step-by-step instructions with the assistance of a support person. The patient should sit down or lie down. This procedure should be completed quickly. Back-up equipment must be immediately available.


LAVENDER LAVENDER

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DER

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JANUARY 2015

Jarvik® 2000

Adapted from Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport in ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010 in press. This guide does not supersede manufacturer instructions. Copy with permission only. March 2015 Jarvik 2000®

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biVAD

January 2015

1. Can I do external CPR?No.

2. If not, is there a “hand pump” or external device to use?Yes,findtheblueorredhandbulbs.

3. Ifthedeviceslowsdown(lowflowstate),whatalarmswillgooff?Lowflowalarms:Lossoffillalarmwilloccur

4. How can I speed up the rate of the device?GivevolumeofIVfluids.

5. Do I need to heparinize the patient if it slows down?Onlyifitstops.PatientwillbeanticoagulatedonCoumadin.Onlyheparinizeifthepumpstops.

6. Canthepatientbedefibrillatedwhileconnectedtothedevice?Yes. Nothingneedstobedisconnected.PatientshouldbeplacedonbatterypowerBEFOREdefibrillation.

7. Ifthepatientcanbedefibrillated,isthereanythingIhavetodisconnectbeforedefibrillating?No. Ifthedefibrillationisunsuccessful,disconnectpumpandcontinuetodefibrillate.

8. Does the patient have a pulse with this device?Yes.

9. Whatareacceptablevitalsignparameters?Normalbloodpressureparameters.

10. Can this patient be externally paced?UsuallyinBiVADconfiguration,ifyestheECGnotimportanttotreat.Becausebothsidesoftheheartaresupported,thereislittleneedtopaceregardlessoftherhythmseenonECG.

Thoratec PVAD™ w/TLC II Driver

IVAD is implanted inside the abd cavity and is attached to the same TLC II driver on the outside.Adapted from Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport in ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010 in press.

l Thesepatientshavebiventricularsupportthrough2pumps:rightandleft.

l EKGwillNOTcorrelatewiththepatient’spulse.

l Patientmaybeinanyarrhythmia,butbecausetheyhavebiventricularsupport—DONOTTREATarrhythmias.OnlyRVADorLVADpatientsshouldbetreatedforarrhythmias.

l Bringallextrabatteries&electricaladaptoralongduringtransport.Thissystemiselectricallydriven.

l ThepumpsaredrivenbyacompressorcalledtheTLCIIdriver.ThepneumatichosesandcablesplugintothetopoftheTLCIIdriver.

l IftheDriverlosespower,malfunctions,orstops,usethehandpump(s).(handpumpinstructionsonbackofthispage)

l Continuehandpumpingandthen,assoonaspossible,replacetheTLCIIDriverwiththebackupDriver.

l BackupDriveraccompaniesthepatientatalltimes.(Driverreplacementinstructionsonbackofthispage)

l WARNING:Ifthepumphasstoppedandbloodisstagnantinthedeviceformorethanafewminutes(dependingonthecoagulationstatusofthepatient),thereisariskofstrokeorthromboembolism.BEFOREthedeviceisrestartedorhandpumpingisinitiated,contacttheimplantingcenterforanticoagulationdirection.

AC Power adapter – plug into yellow port on driver

Battery Charger

Batteries loaded into battery slots on TLC-II Driver

TCL-II Driver




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PVAD/IVADType of Device: pulsatile

IVAD is implanted inside the abd cavity and is attached to the same TLC II driver on the outside.

Questions:

1. CPR:NO2. Handpump:yescalledhandbulbs3. lowflowalarms:LossofFillalarm4. speedupdevice:fluids5. heparin:onlyifitstops.Patienthastobeon

Coumadin6. defib:yes7. disconnectfordefib:no8. pulse:yes9. Vitalsigns:NormalBPparameters10. externallypace:UsuallyinBiVADconfiguration

ifyestheECGnotimportanttotreat

What is an LVAD?Left Ventricular Assist Devices are pumps surgically attached to patients’ hearts to pump blood for the ventricle. There are three basic parts to all VAD systems. The pump, a computer with lamps and alarms, and a power source.

WhydopatientsgetVADs?Patient who have been treated for heart failure but in spite of optimal care continue to suffer from life limiting heart failure. Patients may be on the heart transplant list but the transplant team is worried the patient may die before a suitable donor is found, bridge to transplant. Pts who are not candidates for transplant but suffer from end stage heart failure may also be implanted as destination therapy.

How do VADs work?Most vads implanted nationally create continuous flow. Blood comes from patients own ventricle into the pump then a turbine like spinning fan pushes the blood out into the aorta then the body. A cable connects the pump inside with the computer/controller and batteries outside the body. The pump needs a constant power supply.

Do’s1. PagetheOnCallPerfusionist.CalltheTowerORat3316toaskforthebeepernumber.

2. Givewhatevermedicationsyouwant.(nomedicationcontraindication)

3. Defibrillateifindicated4. Handpumponlyifthedevisehasstoppedpumping,leftfasterthanright.

Don’ts1. NOCHESTCOMPRESSIONS.2. NOMRI.3. Don’tpaniciftheECGisatonerate.TheLVADrateisatanother,andtheRVADrateisathird.

biVAD

JANUARY 2015




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Hand Pumping Instructions

Switching to Backup TLC-II Driver

JANUARY 2015

Step 1:Obtainhandpump(s)fromcarryingcase.Note:One(1)handpumpisneededforeachVAD.

Step 3:Connectthehandpump(s)tothepneumaticlead(s).

Step 4:Squeezehandpump(s)oncepersecond.Useyourfootifnecessary.Note:For2VADs(BiVADs),squeezeeachhandpumpatthesamerate.NeverhandpumptherightVAD(RVAD)fasterthantheleftVAD(LVAD),asthismaycausepulmonaryedema.

Step 2:Depressmetalclip(s)todisconnectthepneumaticlead(s)fromtheTLCIIDriver.

Step 1:Insertafully-chargedbattery(storedincarryingcase)intoeachbatteryslotofbackupTLC-IIdriver.

Step 2:Turnonkeyswitch

Step 3:Depressmetalclip(s)toremovewhiteoccluderfrompneumaticport(s):

lLVADportisRED.

lRVADportisBLUE.

lNote:forBiVADS,switchLVADfirst.DoNOTremoveoccludercapsfrombothportsatthesametime(orfromunusedportduringsingleVADsupport),orsystemwilldepressurize.

Step 4:Disconnectpneumaticlead(s)fromprimaryDriver(orhandpump)andconnecttobackupDriver.

Step 5:Disconnectelectriclead(s)fromprimaryDriverandconnecttobackupDriver.

Step 6:PlaceDriverinAUTOmode,ifnecessary.Note:BackupDriversarepreprogrammedwithapatient’suniquesettings.

Step 7:Verifyfullsignal(s)is/areejectingcompletely.

Step 8:Removekeyandplaceincarryingcasepocket.

Step 9:Connecttoexternalpower,ifavailablebyusingtheACpoweradaptercord.

All modes of emergency transport are acceptable for VAD patients. Aviation electronics will NOT interfere with VAD operation (and vice versa).

Air Transport Consideration: In rotor wing and fixed wing aircraft flying at heights lower than 10,000 feet-when using the hand pump for external CPR, you must re-purge the bulb every 2000

feet in ascent and 1000 feet in descent. This will assure you have consistent cardiac output.

PURPLE PURPLE PURPLE PURPLEPURPLE PURPLE PURPLE PURPLE

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JANUARY 2015

DuraHeart™ System®

1. Can I do external CPR?• Onlyifnecessary;treatperphysiciandiscretion.• ClosedchestCPRiscontraindicated• Maybeperformedasneededatthediscretionoftheattendingphysician• Externalchestcompressionsmaycausethedislocation/damageofpumpInflow/Outflowconduits

• ExternaldefibrillationanybeperformedonapatientwiththeDuraHeart™System®withoutdisconnectinganyofthesystemcomponents

2. If not, is there a “hand pump” or external device to use?No.

3. Ifthedeviceslowsdown(lowflowstate),whatalarmswillgooff?Anemergencyalarmwillsoundandtheemergencyalarmindicator(REDLIGHT)willlightup.

4. How can I speed up the rate of the device?Therateofthedevicecanonlybemodifiedinahospitalsetting.Forlowflowrates,checkforhypovolemiaorRHFandtreataccordingly.

5. Do I need to heparinize the patient if it slows down?CalltheacceptingVADfacilityforguidance.

6. Canthepatientbedefibrillatedwhileconnectedtothedevice?Yes.

7. Ifthepatientcanbedefibrillated,isthereanythingIhavetodisconnectbeforedefibrillating?No,defibrillateperprotocol.

8. Does the patient have a pulse with this device?Ifthepatient’sownhearthassomeresidualfunction,youmaybeabletofeelapulse.

9. Whatareacceptablevitalsignparameters?MeanArterialPressure(MAP)80-90mmHg.

10. Can this patient be externally paced?Yes,asneeded.

PURPLE PURPLE PURPLE PURPLEPURPLE

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TheDuraHeart™LVASisthelatest-generationrotarybloodpumpdesignedforlong-termpatientsupport.Thesystemincorporatesacentrifugalflowrotarypumpwithanactivemagneticallylevitatedimpellerfeaturingthreepositionsensorsandmagneticcoilsthatoptimizebloodflow.Theimpeller’smagneticlevitationisdesignedtoeliminatefrictionbyallowingawidegapbetweenbloodcontactingsurfaceareas,enablingbloodtoflowthroughthepumpunimpededinasmoothnon-turbulentfashion.

JANUARY 2015


TheDuraHeart™ SystemconsistsofanimplantablePumpandseveralcomponentsthatsupportthefunctionofthePump.Thesystemismadeupofsevenmaincomponents(seephotobelow)whichinclude:

External BatteriesLi-ion batteries provide power tot the pum for untethered operation for up to 3-1/2 hours per battery. Each battery can be recharged up to 200 times.

“Sweet,L.andWolfe,Jr.,A.MechanicalCirculatoryDevicesinTransport.ASTNA:PatientTransportPrinciplesandPractice,4thed.,Mosby,2010

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Controller and Batteries

JANUARY 2015

l Communicateswithconsoleforsystemsetup,monitoringandtroubleshooting

l Controlsandmonitorspumpfunction,storessystemdata

l Interfaceswithexternalpowersources(Console,Batteries,Charger,EmergencyBackupBattery)

l Displayssystemstatus–PumpFlowRate– PumpRate– MotorCurrent– SystemalarmsandAlerts– PowerSupplyStatus


PatientswillbeonCoumadinwiththisdeviceTargetINRrangeshouldbebetween2.0to3.0CombinationantiplatelettherapyofASA81mgdailyandPersantine25-75mgTID

SiLEncing ALARmS

contRoLLER

ALARM MESSAGE PROBLEMReplaceController ThePumpmaynotberotatingConnectPumpcable/Pumpdisconnected ThePumpcableisdisconnectedControllerError PossibleseriousproblemwiththecontrollerPumpFailure PumpmotormayhaveseriousproblemMag-Failure Theimpellermaynotbelevitated

EmERgEncy ALARmS

EmergencyAlarms• Mutebuttonsilencesaudiblealarmfor

2minutes• Audiblealarmreturnsafter2minutes

Caution Alerts• Mutebuttonsilencesaudiblealarmfor5

AnticoAgULAtion

lEmergency AlarmslHighPriority.lFlashingREDlightandcontinuousEmergency

Alarmtone.lRequiresimmediatecarebymedicalspecialistandcontrollerexchange.

“Sweet,L.andWolfe,Jr.,A.MechanicalCirculatoryDevicesinTransport.ASTNA:PatientTransportPrinciplesandPractice,4thed.,Mosby,2010”

CALLHOSPITAL

EmergencyAlarmIndicator (RED)

Caution Alarm Indicator (YELLOW)

Display MUTE Button

MENU Button andPowerLight

EmergencyAlarmIndicator (RED)

MENU Button andPowerLight

EmErgEnCy ALArm mESSAgES

BATTERIES

CONTROLLER

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SEPTEMBER 2016

1. Can I do external CPR?

Only if absolutely necessary

2. If not, is there a “hand pump” or external device to use?

No.

3. If the device slows down (low flow state), what alarms will go off?

A red heart alarm light indicator and steady audio alarm will sound if less than

2.5 lpm. Can give a bolus of normal saline and transport to an LVAD center.

4. How can I speed up the rate of the device?

No, it is a fixed speed.

5. Do I need to heparinize the patient if it slows down?

Usually no, but you will need to check with implanting center.

6. Can the patient be defibrillated while connected to the device?

Yes.

7. If the patient can be defibrillated, is there anything I have to

disconnect before defibrillating?

No.

8. Does the patient have a pulse with this device?

Likely they will not because it is a continuous flow device, however some

patients may have a pulse as this pump was designed with an “artificial

pulse.”


MAP 70 - 90 mm Hg with a narrow pulse pressure.

10. Can this patient be externally paced?

Yes.

HeartMate III® with Pocket Controllers

FAQs

l Pump has “artificial pulse” created by speeding up & slowing down of pump. This can be heard when auscultating the heart and differs from other continuous flow devices.

l May not be able to obtain cuff pressure (continuous flow pump).

l Pump connected to electric line exiting patient’s abdominal area and is attached to computer which runs the pump.

l Pump does not affect EKG.


l A set of batteries last 14 – 16 hours

l Any emergency mode of transportation is ok. These patients are permitted to fly.

l Be sure to bring ALL of the patient’s equipment with them.

Trouble Shooting HeartMate III® with Pocket ControllersWhen the Pump Has Stopped

l Be sure to bring ALL of the patient’s equipment with them.

l Fix any loose connection(s) to restart the pump.

l If the pump does not restart and the patient is connected to batteries replace the current batteries with a new, fully-charged pair. (see Changing Batteries section on next page)

l If pump does not restart, change controllers. (see Changing Controllers section on next page)


Yellow or Red Battery Alarm:

Need to Change Batteries. See

changing batteries section on

next page.

Red Heart Flashing Alarm: This may indicate a Low Flow Hazard. Check

patient--the flow may be too low. If patient is hypovolemic, give volume. If

patient is in right heart failure-- treat per protocol. If the pump has stopped

check connections, batteries and controllers as instructed in the section above.

This guide does not supersede manufacturer instructions. Copy with permission only.


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SEPTEMBER 2016This guide does not supersede manufacturer instructions. Copy with permission only.

Trouble Shooting HeartMate III®

WARNING: At least one power lead must be

connected to a power source AT ALL TIMES.

Do not remove both batteries at the same time or

the pump will stop.

l Obtain two charged batteries from patient’s

accessory bag or battery charger. The charge

level of each gray battery can be assessed

by pressing the battery button on the battery.

(Figures 1 and 2)

l Remove only ONE battery from the clip by

pressing the button on the grey clip to unlock

the battery. (Figure 3)

l Controller will start beeping and flashing yellow

signals and will read POWER DISCONNECT

on the front screen. (Figure 4)

l Replace with new battery by lining up RED

arrows on battery and clip. Gently tug on

battery to ensure connection. If battery is

properly secured, the beeping and yellow

flashing will stop. (Figure 5)

l Slide a new, fully-charged battery (Figure 4)

into the empty battery clip by aligning the

RED arrows. The battery will click into the clip.

Gently tug at battery to ensure connection. If

battery is properly secured, the beeping and

green flashing will stop.

l Repeat previous steps with the second battery

and battery clip.

Figure 1 Figure 2

Figure 5

Figure 3

Changing Batteries

Figure 4

CAUTION—Investigational device. Limited by Federal (or United States) law to investigational use.

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with Pocket Controllers

l Place the replacement Controller within easy reach, along with the batteries/battery clips. The spare Controller is usually found in the patient’s travel case.


l Attach the battery clips to the spare controller by lining up the half moons and gently pushing together and attach the batteries to the spare controller by aligning the RED arrows.

l On the back of the replacement controller, rotate down the perc lock so the red tab is fully visible. Repeat this step on the original controller until the red tab is fully visible.

l Disconnect the drive-line from the original controller by pressing down on the red tab and gently pulling on the metal end. The pump will stop and an alarm will sound. Note: The alarm will continue until the original controller is put to sleep. You can silence the alarm by pressing the silence button. Getting the replacement controller connected and pump restarted is the first priority.

l Connect the replacement Controller by aligning the BLACK ARROWS on the driveline and replacement Controller and gently pushing the driveline into the replacement Controller. The pump should restart, if not complete the following steps:

Step 1. Firmly press the Silence Alarm or Test Select Button to restart the pump.

Step 2. Check the power source to assure that power is going to the controller.

Step 3. Assure the perc lead is fully inserted into the socket by gently tugging on the metal end. DO NOT pull the lead.

l After the pump restarts, rotate up the perc lock on the new controller so the red tab is fully covered. If unable to engage perc lock to a fully locked position, gently push the driveline into the controller to assure proper connection. Retry to engage perc lock.


l Hold down battery symbol for 5 full seconds for complete shutdown of old controller.


Adapted from Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport

in ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010 in press.




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The HeartMate 3 has a modular

cable connection near the exit site of

the driveline (Figure 1). This allows

a damaged driveline to be quickly

replaced (if damage is external).

l When disconnecting a driveline,

NEVER use the modular cable

connection.

l If this section of the driveline requires

replacement, this must be performed

at and by the implanting center.

Patients are not given a back-up

modular cable.

l If the connection is loose, there

will be a yellow/green line at the

connection showing (Figure 2). If the

line is visible, it can be retightened by

turning with the arrow in the locked

direction. It will ratchet and stop

turning once tight.


with Pocket ControllersModular Cable


Figure 2

Figure 1

TOTAL ARTIFICIAL HEART TOTAL ARTIFICIAL HEART TOTAL ARTIFICIAL HEARTTOTAL ARTIFICIAL HEART TOTAL ARTIFICIAL HEART TOTAL ARTIFICIAL HEART

TOTAL ARTIFICIAL HEART TOTAL ARTIFICIAL HEART TOTAL ARTIFICIAL HEART TOTAL ARTIFICIAL HEARTTOTAL

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EMS Guide January 2015

This guide is produce by MCSO – The Mechanical Circulatory Support Organization. It is produced by VAD Coordinators from some of the largest and most successful VAD implantation hospitals in the US. It has been vetted by experts on VADS in Air Medical Transport and EMS. It should not replace the operator manual as the primary source of information.

Reprinted with the permission of Thoratec Corporation

MC

SO

ECHANICAL

IRCULATORY

UPPORT

RGANIZATION

Total Artificial Heart

MOST patients have a tag located on the controller around their waist that says what type of device it is, what institution put it in and a number to call. Most importantly is the color of the tag – it matches this EMS Field Guide and allows you to quickly locate the device you are caring for.

JANUARY 2015

Color Coding System

What Is A Total Artificial Heart?

A total artificial heart (TAH) is a device that replaces the two lower chambers (ventricles) of the heart. You might benefit from a TAH if both of your ventricles don’t work due to end-stage heart failure.

What are the parts of a TAH?

The SYNCARDIA has tubes that, through holes in the abdomen, run from inside the chest to an outside power source.

What is the power source?

Shortly after the TAD is implanted, the patient is switched to the Freedom driver. This is a mobile “driver” for patients to who are ambulatory. The patient considered discharge from the hospital while awaiting a transplant but ultimately received a heart transplant while still an inpatient. Higher rates of survival to transplant have already been proved with the TAH. Potential benefits for the portable Freedom driver include increased mobility, decreased cost, and improved quality of life.

January 2015

Questions and Answersfor Total Artificial Heart

The portability of the Total Artificial Heart (TAH) enables patients to resume many of their normal daily activities.

January 2015

Patient Management For TAHs

1. Assess the patients airway and intervene per your protocol.

2. Auscultate heart sounds but you can usually hear them without a stetho scope. Since this is pulsatile you should hear two sounds if properly functioning.

3. Assess the device for any alarms.

4. Look on controller usually found around the waist of the patient and to see what color tag and device it is. The backpack or freedom driver should have a pink tag on it. It will have the type of device this is and contact information to the implantation center. 5. Match the color on the device tag to the EMS Guide. The tag on the backpack or freedom driver’s colored tag should matches the ems guide. This will tell you how to manage any alarms.

6. Intervene appropriately based on the type of alarm, tag (device) and EMS Guide.

7. Start Large Bore IV.

8. Assess Vital Signs. REMEMBER THERE IS NO EKG. THE PATIENT IS ASYSTOLIC.

9. YOU SHOULD BE ABLE TO GET A SYSTOLIC AND DIASTOLIC BLOOD PRESSURE.

10. Transport to the closest center that can care for a TAH. Look on the PINK tag to find out this information.

11. Bring all of the patients equipment. 12. Bring the significant other if possible to act as a expert on the device in the absence of consciousness in the patient.

PINK PINK PINK PINK

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PINK

PINK PINK PINK PINKTotal Artificial Heart Freedom™ Driver System

1. Can I do external CPR? No. Will need to rapidly exchange to the backup driver.2. Is there a “hand pump” or external backup device to use? No.3. Can I give vasopressive IV drugs like epinephrine,

dopamine or dobutimine? Never give vasopressive drugs, especially epinephrine. These

patients primarily have sysmptomatic hypertension and rarely have symptoms of hypotension. Most IV vasopressive drugs can be fatal to a TAH (Total Artificial Heart) patient.

4. Can I speed up the rate of the device? No. The device has a fixed rate between 120-140-BPM.5. What is the primary emergency intervention for a TAH (Total

Artificial Heart)? Nitroglycerin sublingual for symptomatic hypertension.6. Can the patient be defibrillated or externally paced while

connected to the device? No. There is no heart.7. What if the patient is symptomatic and the Freedom Driver

is alarming with a continuous alarm and the red light ? If the pump has failed or a line is disconnected or kinked,

the patient may pass out within 30 seconds. Even when alarming, the device should continue to pump. When in doubt, immediately change out he Freedom™ Driver immediately. Then quickly check for loose or kinked connections.

8. Does the patient have a pulse with this device? Yes. The device

produces Pulsatile flow. The device is pneumatically driven and is normally loud.


The BP will vary. Normal range 100-130 systolic and 60-90 diastolic.

10. What kind of Cardiac rhythm should be displayed?

Asystole.

This Patient is on an ARTIFICIAL HEART(not a left ventricular assist device-LVAD)

“Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport .ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010”

JANUARY 2015FILTER COVERPOWER

ADAPTOR PLUG

POWER ADAPTOR

GREEN RECEPTACLE

POWER ADAPTOR

POWER ADAPTOR

GREEN LIGHT

DRIVE LINES

PINK PINK PINK PINK

PINK PINK

PINK PINK

PINK

PINK

PINK

PINK

PINK

PINK

This guide does not supersede manufacturer instructions. Copy with permission only. March 2011 PINK PINK PINK PINKTrouble Shooting Freedom™ Driver System

BEATS PER MINUTE, FILL VOLUME AND CARDIAC OUTPUT

POWER ADAPTOR PLUG FILTER COVER

POWER ADAPTOR GREEN RECEPTACLE

POWER ADAPTOR

POWER ADAPTOR GREEN LIGHT

DRIVE LINES

BATTERY FUELGAUGE

BATTERY CHARGEBUTTON

BATTERY RELEASEBUTTON

REDLIGHT

VISUAL ALARM

YELLOWLIGHT

VISUAL ALARM

YELLOWLIGHT

VISUAL ALARM


This Patient is on an ARTIFICIAL HEART(not a left ventricular assist device -LVAD)

January 2015

IN THE EVENT OF AN EMERGENCY

Immediately notify VAD coordinator listed on the medical alert bracelet or tag attached to the console - please identify the device as a total artificial heart.

Freedom™ Driver System

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“Sweet, L. and Wolfe, Jr., A. Mechanical Circulatory Devices in Transport .ASTNA: Patient Transport Principles and Practice, 4th ed., Mosby, 2010”January 2015

There is no way to mute an Alarm.HOW TO RESPOND TO FREEDOM™ DRIVER ALARMS

ALARM HEAR SEE MEANING WHAT YOU SHOULD DO

Battery AlarmLoud

Intermittent Tone

Yellow Battery LED

Flashing

One or both of the Onboard Batteries have less than 35% remaining charge (only two green lights display on the

Battery Fuel Gauge).

Replace each low Onboard Battery, one at a time, with a charged Onboard Battery

or connect to external power (NOTE: Once the batteries are charged above

35% the Battery Alarm will stop) .

Onboard Battery is incorrectly installed.

Reinsert Onboard Battery until locked in place. If Battery Alarm continues, insert a

new Onboard Battery.

One Onboard Battery missing.Insert charged Onboard Battery into

Freedom™ Driver until locked in place.

TemperatureAlarm

Loud Intermittent

Tone

Red Alarm LED

Flashing

The temperature of the Driver is too hot or too cold.

Remove any objects that are blocking the Filter Cover and/or Fan and check the

filter.

Move the Freedom Driver to a cooler or warmer area.

The internal temperature of the Driver is too hot.

Fault Alarm Loud

Continuous Tone

Red Alarm LEDSolid

Valsalva Maneuver: Strenuous coughing or laughing,

vomiting, straining during a bowel movement, or lifting a

heavy weight.

Relax/interrupt Valsalva Maneuver.

Kinked or disconnected drive lines.

Straighten or connect drive lines.

Driver is connected to External Power without at least one correctly inserted Onboard

Battery.

Insert a charged Onboard Battery into the Freedom™ Driver until locked into place.

One or both of the Onboard Batteries have less than 30%

remaining charge.

Replace each low Onboard Battery, one at a time, with a charged Onboard Battery or connect to external power. (NOTE: the Fault Alarm will continue and will change

into a Battery Alarm as the Onboard Batteries recharge. Once the Onboard Batteries are charged above 35%, the

Battery Alarm will stop.)

Malfunction of the DriverIf the steps above do not stop the Fault

Alarm, switch to Backup Freedom Driver. Return to implant hospital.

TemperatureAlarm

LoudIntermittent

Tone

RedAlarmLED

Flashing

The internal temperatureof the Driver is too hot.

Remove any objects that areblocking the Filter Cover

and / or Fan and check filter.

The temperature of theOnboard Batteries is too

hot or too cold.

Move the Freedom Driver to acooler or warmer area.

You must immediately address the issue that caused the Alarm.


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FIGURE 1

FIGURE 2

FIGURE 3


January 2015

Switching from Primary to Backup Freedom™ Driver

Setting up the Backup Freedom™ Driver1. Remove the drive line caps from the ends of the Drive lines.

2. Insert one charged Onboard Battery. The driver will immediately start pumping. (Figure 1)

3. Remove the Orange Dummy Battery. (Figure 1)

4. Insert the second charged Onboard Battery. (Figure 2)

5. If possible, connect the backup Driver into a wall power outlet.

6. Your Freedom™ Driver is now ready to connec to the patient.

CAUTION: It is recommended to have TWO people exchange the primary Freedom Driver for the backup Freedom Driver. Make sure all items and accessories are closely available before attempting to exchange Drivers.

Continued on next page.

BEATS PER MINUTE, FILL VOLUME AND CARDIAC OUTPUT


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1. With the Wire Cutter Tool, cut the Wire Tie under the metal release button of the CPC Connector that secures the RED TAH-t Cannula to the RED Freedom Drive line. Gently pull to remove the Wire Tie and discard. DO NOT DISCONNECT THE CANNULA FROM THE DRIVE LINE YET.

2. With the Wire Cutter Tool, cut the Wire Tie under the metal release button of the CPC Connector that secures the BLUE TAH-t Cannula to the BLUE Freedom Drive line. Gently pull to remove the Wire Tie and discard. DO NOT DISCONNECT THE CANNULA FROM THE DRIVE LINE YET.

3. Disconnect the RED Cannula from the RED Drive line of the primary Freedom Driver:• Press and hold down the metal release button. Pull the RED Cannula away from the RED Drive line.• Immediately insert the RED Cannula into the new RED Drive line from the backup Freedom Drive

Insert until a click is heard and lightly tug on the connection to make sure that it is secure.4. Simultaneously disconnect the BLUE Cannula from the BLUE Drive line of the primary Freedom Driver:• Press and hold down the metal release button. Pull the BLUE Cannula away from the BLUE Drive line.• Immediately insert the BLUE Cannula into the new BLUE Drive line from the backup Freedom Driver. • Insert until a click is heard and lightly tug on the connection to make sure that it is secure.5. Slide a Wire Tie under the metal release button of each CPC connector. Create a loose loop in the tie,

taking care not to depress and disconnect the connectors. Cut off the excess length of both Wire Ties.6. Patient must notify Hospital Contact Person of the switch.7. The Hospital should notify SynCardia Systems that the Driver has been switched and return the faulty Driver.

January 2015

CAUTION: Before disconnecting the Drive lines of the primary Freedom Driver, you must have the Drive lines of the backup Freedom Driver within reach. The backup Driver must be turned on. Perform steps 3 and 4 simultaneously.

Wire Tie

Push InPull

Press

Switching from Primary to Backup Freedom™ DriverContinued on from previous page

CPC Connectors

Metal ReleaseButton with Wire Tie

Blue Cannula

Red Cannula

Blue Drive line

Red Drive line

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Position 1 (Compressor)Position on patients right side1. Initiates compressions (100-120 per min)2. Rotates to position “2” during analysis and

follows the direction of the AED

Position 2 (AED Operator/Code Manager)Initial duties1. Patient assessment and states “Start CPR”2. Starts metronome3. Sets up and operates the AED immediately4. Rotates to position “1” during analysis, prepares for

compressions

ATTACHMENT A

Position 2 (AED Operator/Code Manager)Duties when positioned at patients head1. Operate AED, ensure compression resume during charge2. Inserts an OPA and manages airway, use passive

ventilations (may interpose ventilations with BVM)3. Rotates to position “1” during analysis, prepares for compressions

Passive ventilation is recommended until adequate resources are available to provide ventilations without interfering with chest compressions or defibrillation.

Initial Duties

AED Operator positions at head after initial duties

Position 1 (Compressor)Position on patients right side1. Initiates compressions (100-120)2. Counts aloud the final three

compressions “8,9,bag”3. Rotates to position “3” during analysis

Position 2 (AED Operator/Code Manager)Position on patients left side1. Patient assessment and states “Start CPR”2. Starts metronome3. Sets up and operates the AED immediately4. Announces intervals 5. Verbalizes upcoming assignments6. Gives feedback on CPR

Position 3 (Airway)Position at patients head1. Opens airway and Inserts an OPA2. Assist with AED as needed3. Assembles BVM and interposes ventilation (1:10)4. Assess and provides definitive airway, as needed5. Rotates to position “1” during analysis, prepares for compressions

ATTACHMENT B

Position 1 (Compressor)Position on patients right side1. Initiates compressions (100-120)2. Counts aloud the final three

compressions “8,9,bag”3. Rotates to position “3" during analysis

Position 2 (AED Operator)Position on patients left side1. Patient assessment and states “Start CPR”2. Starts metronome3. Sets up and operates the AED immediately4. Clears the patient for analysis and defibrillation5. Gives command to resume compressions

Position 3 (Airway)Position at patients head1. Opens airway and Inserts an OPA2. Assists with AED as needed3. Assembles BVM and interposes ventilation (1:10)4. Rotates to position “1” during analysis, prepares

for compressions

Position 4 (Code Manager)Position just outside of triangle1. Announces interval updates2. Verbalizes assignments for next rotation3. Assures quality of CPR and gives feedback4. Scene management / Family Liaison

ATTACHMENT C

Position 1 (Compressor)Position on patients right side1. Initiates compressions (100-120 per min)2. Rotates to position “2” during analysis and

follows the direction of the AED

The LP15 should be placed in AED mode.

ATTACHMENT D

Position 2 (AED Operator/Code Manager)Initial duties1. Patient assessment and states “Start CPR”2. Starts metronome3. Sets up and operates the AED

3a. Apply combo pads3b. Press Analyze

4. Rotates to position “1” during analysis, prepares for compressions

Position 2 (AED Operator/Code Manager)Duties when positioned at patients head1. Follows prompt to deliver a shock or resume CPR2. Inserts an OPA and manages airway, uses passive

ventilations (may interpose ventilations with BVM)3. Rotates to position “1” during analysis, prepares for compressions

AED Operator positions at head after initial duties

Initial Duties

Position 1 (Compressor)Position on patients right side1. Initiates compressions (100-120)2. Rotates to position “3” when relieved

Position 3 (Airway)Position at patients head1. Opens airway and Inserts an OPA2. Assists with defib pads as needed3. Assembles BVM and interposes ventilation (1:10)4. Assess and provides definitive airway, as needed5. Rotates to position “1” at the 15 second mark

and prepares for compressions

ATTACHMENT E

Position 2 (LP15 Operator ALS Only /Code Manager)Position at patients left side1. Patient assessment and states “Start CPR”2. Starts metronome3. Attaches combo pads and starts defibrillation

sequence4. Announces intervals 5. Verbalizes upcoming assignments6. Gives feedback on CPR

FOR EACH SUBSEQUENT ANALYSIS START THE DEFIBRILLATION SEQUENCE AT THE 15 SECOND MARK.

DEFIBRILLATON SEQUENCE1. Start Printing2. Charge Defibrillator3. “Stop CPR”3. Analyze Rhythm5. Deliver Shock or Dump Charge6. “Start CPR”

Position 1 (Compressor)Position on patients right side1. Initiates compressions (100-120)2. Rotates to position 3 when relieved

Position 2 (LP15 Operator ALS Only)Position at patients left side1. Patient assessment and states “Start CPR”2. Starts metronome3. Attaches combo pads and begin defibrillation

sequence4. Makes ALS treatment decisions

FOR EACH SUBSEQUENT ANALYSIS, START THE DEFIBRILLATION SEQUENCE AT THE 15 SECOND MARK.

Position 3 (Airway)Position at patients head1. Opens airway and Inserts an OPA2. Assists with defib pads as needed3. Assembles BVM and interposes ventilation (1:10)4. Rotates to position 1 during rhythm assessment

and prepares for compressions


ATTACHMENT F


Position 1 (Compressor)Position on patients right side1. Provides compressions2. Alternates compressions with

position “2”3. During off cycle may assist with

other care

Position 2 (Airway)Position at patients head1. Opens airway and Inserts an OPA2. Assembles BVM and interposes ventilation (1:10)3. Rotates to “On Deck” at 15 second mark


Position 5 (ALS provider)Position outside of triangle1. Intubates as needed2. Obtains IV/IO access as needed3. Draws medications requested by Lead Provider4. Other Care as needed

ATTACHMENT G


Position 4 (LP15 Operator Lead ALS Provider)Position at patients left side1. Patient assessment and states “Start CPR”2. Starts metronome3. Attaches pads/begin defibrillation sequence4. Initiates IV/IO access5. Makes ALS treatment decisions6. Administers medications

FOR EACH SUBSEQUENT ANALYSIS STARTS THE DEFIBRILLATION SEQUENCE AT THE 15 SECOND MARK.

Additional Provider (when available)1. Positions “On Deck” to relieve compressor2. During off cycle may assist with other care3. “Hovers” in preparation for compressions

Downloading Instructions for the Airtraq Camera

Step 1:Open Airtraq software on the station computer. The station computer that has the software downloaded on it is marked with an P‐Touch Label that says “AED DOWLOAD” on the computer monitor.

Step 2:Plug in the Airtraq camera using the included USB cable.

Step 3:Click on the “DOWNLOAD VIDEOS TO PC”

Step 4:Highlight the video you want to download.

Step 5:Clcik the download video button as shown below.

Step 6:Click the back button to return to the main menu.

Step 7:Click on “VIDEO GALLERY ON PC”.

Step 8:Click on “Open” in upper right corner.

Step 9:Rename the selected video with the medic unit number and incident number (ex. M512 FD170000000). Email the video file to [email protected]