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Contra Costa County Prehospital Care Manual – January 2010 Page 57

TABLE OF CONTENTS

Adult Treatment Guidelines

A1 – Adult Patient Care A2 – Chest Pain / Suspected ACS A3 – Cardiac Arrest – Initial Care and CPR A4 – Ventricular Fibrillation / V. Tachycardia A5 – PEA / Asystole A6 – Symptomatic Bradycardia A7 – Ventricular Tachycardia with Pulses A8 – Supraventricular Tachycardia A9 – Other Dysrhythmias A10 – Shock

General Treatment Guidelines

(All Patients) G1 – Allergy and Anaphylaxis G2 – Altered Level of Consciousness G3 – Behavioral Emergency G4 – Burns G5 – Childbirth G6 – Dystonic Reaction G7 – Envenomation G8 – Heat Illness / Hyperthermia G9 – Hypothermia G10 – Pain Management G11 – Poisoning / Overdose G12 – Respiratory Depression or Apnea G13 – Respiratory Distress G14 – Seizure G15 – Stroke G16 – Trauma

Pediatric Treatment Guidelines

P1 – Pediatric Patient Care P2 – Cardiac Arrest – Initial Care and CPR P3 – Neonatal Resuscitation P4 – Ventricular Fibrillation / V. Tachycardia P5 – PEA / Asystole P6 – Symptomatic Bradycardia P7 – Tachycardia P8 – Shock

Procedures and Patient Care References Spinal Immobilization Vascular Access 12-Lead ECG and STEMI Key Paramedic Procedures Pediatric Assessment Pediatric Vital Signs and GCS Scoring ABC Maneuvers for Adults, Children and Infants

Policy Summaries / Hospital References

Base Hospital and Receiving Facilities Destination Determination Destination - 5150 and Obstetric Patients Trauma Triage Criteria Trauma Base Call-In Criteria Helicopter Transport Criteria Rule of Nines (Burn Surface Area) Burn Patient Destination Burn Centers Declining Medical Care or Transport (AMA) Determination of Death Restraints

Drug References

Adult Drug Reference Dopamine Drip Chart Pediatric Drug Reference Pediatric Drug Dosage Charts

Contra Costa County Prehospital Care Manual – January 2010

INSTRUCTIONS FOR USE

This field manual is intended to provide Contra Costa EMS prehospital personnel with quick reference to treatment guidelines and other critical reference materials for patient treatment.

The Contra Costa Prehospital Care Manual includes the contents of this field manual as well as additional reference materials not in this manual. The entire Prehospital Care Manual can be accessed at www.cccems.org. Updates and corrections to this manual may also be posted at this website.

Treatment Guidelines are divided into three main groupings: Adult, Pediatric, and General Guidelines. The General Guidelines include treatment guidelines that pertain to both adult and pediatric treatments.

Treatment Guidelines A1 (Adult General Care) and P1 (Pediatric General Care) address basic concepts of care that are pertinent to all patients. This information is not repeated in other treatment guidelines.

Policy summaries reflect critical information for field personnel. For full policies, please refer to www.cccems.org.

http://www.cccems.org/

http://www.cccems.org/


A1 ADULT ADULT PATIENT CARE

These basic concepts should be addressed for all adult patients (age 15 and over)

Scene Safety Body Substance Isolation

Use universal blood and body fluid precautions at all times

Systematic Assessment

• Assure open and adequate airway. Management of ABC’s is a priority. • Place patient in position of comfort unless condition mandates other position (e.g.

shock, coma) • Consider spinal immobilization if history or possibility of traumatic injury exists

Determine Primary Impression

• Apply appropriate field treatment guideline(s) • Explain procedures to patient and family as appropriate

Base Contact • Contact base hospital if any questions arise concerning treatment or if additional

medication beyond dosages listed in treatment guidelines are considered • Use SBAR to communicate with base

Transport • Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure • Transport patient medications or current list of patient medications to the hospital • Give report to receiving facility using SBAR

Document Document patient assessment and care per policy


A2 ADULT

CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME

OXYGEN Low flow

PRECAUTION Caution: Do not administer or allow patient to take Nitroglycerin if patient has taken erectile dysfunction meds Viagra or Levitra within 24 hrs or Cialis within 36 hrs. In these situations, severe hypotension may occur as a result of NTG administration.

Nitroglycerin BLS Personnel: Allow patient to take own if BP greater than 90

CARDIAC MONITOR

12 – LEAD ECG STEMI Alert if appropriate. Perform right-sided lead (V4R) if inferior MI noted. Repeat ECGs are encouraged.

ASPIRIN 325 mg po to be chewed by patient – DO NOT administer if patient has allergies to aspirin or salicylates or has apparent active gastrointestinal bleeding

IV TKO

NITROGLYCERIN 0.4 mg sl if systolic BP above 90. May repeat every 5 minutes until pain subsides, maximum 6 doses or BP less than 90 systolic.

Do not administer Nitroglycerin if Right Ventricular MI suspected

Consider MORPHINE SULFATE

2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90 and NTG not effective. Consider earlier administration to patients in severe distress from pain.

Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. If persistent pain, continue NITROGLYCERIN to maximum of 6 doses.

Do not administer Morphine Sulfate if Right Ventricular MI suspected

Consider FLUID BOLUS

250 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May repeat X 1. Patients with Right Ventricular MI may require multiple fluid boluses.

Key Treatment Considerations • Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder

or arm, nausea, diaphoresis, dyspnea, anxiety • Diabetic, female or elderly patients frequently present atypically • Atypical symptoms can include syncope, weakness or sudden onset fatigue • Rapid identification of STEMI to speed intervention is the goal of 12-lead ECG • 12-lead ECG should be acquired as soon as possible after arrival (ideally within 5 minutes) • 12-lead ECG should be acquired before initial NTG administration • Minimize scene time in STEMI patients • If STEMI noted and ST elevation is noted in inferior distribution (leads II, III, and aVF), the possibility for

right ventricular MI (RVMI) exists o Perform ECG with right-sided lead (V4R) mirrored in the same orientation as V4. RVMI should be

suspected if ST elevation of 1 mm or greater in V4R. o Patients with RVMI may present with shock or poor perfusion in the presence of clear lungs and

may have JVD. o Nitroglycerin and Morphine should not be administered in the setting of RVMI. Trendelenburg

positioning and fluid bolus is appropriate treatment for shock in this setting. • If STEMI noted and ST elevation is noted in anterior distribution (V1-V4), patient is at higher risk for

pump failure and CHF on presentation • Many STEMI’s evolve during prehospital period and are not noted during first ECG, so repeat 12-lead

ECGs are encouraged (avoid artifact by patient or vehicle movement) • IV placement prior to NTG recommended in patients who have not taken NTG previously


A3 ADULT CARDIAC ARREST – INITIAL CARE AND CPR

AIRWAY Open airway and utilize BLS airway for initial management • If ResQPOD available, King Airway should be used as soon as possible but

should not interfere with compressions - keep interruption less than 10 seconds

VENTILATIONS Ventilations: • Give 2 breaths initially • Administer each breath over 1 second and observe for chest rise

COMPRESSIONS

CPR for 2 minutes or 5 cycles before rhythm analysis if: • Witnessed arrests with 5 minutes or more time elapsed without CPR • Unwitnessed arrests CPR until defibrillator available for rhythm analysis for all other witnessed arrests Compressions: • Depth - 1.5-2 inches in adults – allow full recoil of chest • Rate - 100/minute • Compression/ventilation ratio - 30:2 • Rotate compressors every 2 minutes if manual compression used Apply mechanical compression device (if available) after first 2-minute cycle of CPR To minimize CPR interruptions: • Perform CPR during charging of defibrillator • Resume CPR immediately after shock (do not stop for pulse or rhythm check)

CARDIAC MONITOR Determine cardiac rhythm and follow specific treatment guideline

IV / IO ACCESS

• Preferred IV site - antecubital vein • If antecubital access not apparent or if unsuccessful, use IO access • IO access is preferable to external jugular • Hand veins and other smaller veins should be avoided in cardiac arrest

ADVANCED AIRWAY

Advanced airway management is not essential early in resuscitation and should not interfere with resuscitation in the first 2-3 CPR cycles (two minutes per cycle)

• Exception: If ResQPOD used, early use of King Airway is appropriate • King Airway may be inserted more rapidly and causes less CPR interruption

than endotracheal intubation efforts • Placement of King Airway or endotracheal tube should not interrupt

compressions for more than 10 seconds • For endotracheal intubation, position and visualize airway prior to cessation of

compressions for tube passage • Ventilation rate with advanced airway – 8-10 breaths/minute • Provide initial and continuous confirmation of tube placement with end-tidal

carbon dioxide monitoring

TREATMENT ON SCENE

• Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions, which may be detrimental to patient outcome

• Provide resuscitative efforts on scene up to 30 minutes to maximize chances of return of spontaneous circulation (ROSC)

• If resuscitation efforts do not attain ROSC, consider cessation of efforts per policy

2 Contra Costa County Prehospital Care Manual – January 2010

A4 ADULT

VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3) DEFIBRILLATION 200 joules (low energy 120 joules) CPR For 2 minutes or 5 cycles between rhythm check and shock

VENTILATION/AIRWAY • If ResQPOD available, utilize King Airway early • If no ResQPOD available, use BLS airway in first 2-3 cycles of CPR

o Defer advanced airway unless BLS airway inadequate IV or IO TKO. Should not delay shock or interrupt CPR DEFIBRILLATION 300 joules (low energy 150 joules) EPINEPHRINE 1:10,000 - 1 mg IV or IO every 3-5 minutes CPR For 2 minutes or 5 cycles between rhythm check and shock DEFIBRILLATION 360 joules (low energy 200 joules) AMIODARONE 300 mg IV or IO CPR For 2 minutes or 5 cycles between rhythm check and shock DEFIBRILLATION 360 joules (low energy 200 joules) as indicated after every CPR cycle ADVANCED AIRWAY Should not interfere with first 2-3 CPR cycles – minimize interruptions Consider repeat AMIODARONE If rhythm persists, 150 mg IV or IO, 3-5 minutes after initial dose

TRANSPORT If indicated Consider SODIUM BICARBONATE

1 mEq/kg IV or IO for suspected hyperkalemia, profound acidosis or prolonged down time with return of circulation

If Return of Spontaneous Circulation, see Symptomatic Bradycardia (A6), Shock (A10) if treatment indicated Key Treatment Considerations

• Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications.

• To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check)

• Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second. • If advanced airway placed, perform CPR continuously without pauses for ventilation • If available, ResQPOD impedance threshold device may be used • Place King Airway to utilize ResQPOD early in CPR • If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and

performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage.

• Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement and continuously monitor

• Prepare drugs before rhythm check and administer during CPR • Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) • Follow each drug with 20 ml NS flush • Sodium bicarbonate should only be given for listed indications, and should not be given if ventilation

ineffective


A5 ADULT PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3)

VENTILATION/AIRWAY • If ResQPOD available, utilize King Airway early • If no ResQPOD available, use BLS airway in first 2-3 cycles of CPR

o Defer advanced airway unless BLS airway inadequate IV or IO TKO

EPINEPHRINE 1:10,000 1 mg IV or IO every 3-5 minutes

ATROPINE Asystole or PEA with rate less than 60: 1 mg IV or IO. Repeat every 3-5 minutes to total dose of 3 mg

Consider treatable causes – treat if applicable: Consider FLUID BOLUS 500 ml NS IV or IO for hypovolemia

VENTILATION Ensure adequate ventilation (8-10 breaths per minute) for hypoxia. Consider SODIUM BICARBONATE

1 mEq/kg IV or IO for hydrogen ion (acidosis), tricyclic antidepressant or aspirin overdose, or hyperkalemia

Consider CALCIUM CHLORIDE

500 mg IV or IO – may repeat in 5-10 minutes for hyperkalemia or calcium channel blocker overdose

WARMING MEASURES For hypothermia

Consider NEEDLE THORACOSTOMY For tension pneumothorax

If Return of Spontaneous Circulation, see Symptomatic Bradycardia (A6), Shock (A10) if treatment indicated Key Treatment Considerations

• Uninterrupted CPR is the key to successful resuscitation. Its performance takes precedence over advanced airway management and administration of medications.

• Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second • If advanced airway placed, perform CPR continuously without pauses for ventilation

• If available, ResQPOD impedance threshold device may be used • Place King Airway to utilize ResQPOD early in CPR • If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and

performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage.

• Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement and continuously monitor

• Prepare drugs before rhythm check and administer during CPR • Follow each drug with 20 ml NS flush • Acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or if suspected

diabetic ketoacidosis


A6 ADULT SYMPTOMATIC BRADYCARDIA -

Heart rate less than 60 with signs or symptoms of poor perfusion (e.g., acute altered mental status, hypotension, other signs of shock) OXYGEN High flow. Be prepared to support ventilation as needed CARDIAC MONITOR 12-LEAD ECG Consider pre- and post-treatment if condition permits

IV TKO. If not promptly available, proceed to external cardiac pacing. Consider IO ACCESS if patient in extremis and unconscious or not responsive to painful stimuli.

TRANSCUTANEOUS PACING

Set rate at 80 Start at 10 mA, and increase in 10 mA increments until capture is achieved

Consider SEDATION

If pacing urgently needed, sedate after pacing initiated. • MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg increments

(maximum dose 5 mg), and/or • MORPHINE SULFATE 1-5 mg IV or IO in 1 mg increments for pain relief if BP

90 systolic or greater

Consider ATROPINE

• 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective • Consider repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3 mg Use with caution in patients with suspected ongoing cardiac ischemia. Atropine should not be used in wide-QRS second- and third-degree blocks.

TRANSPORT Consider FLUID BOLUS 250-500 ml NS if clear lung sounds and no respiratory distress

Consider DOPAMINE Begin infusion at 5 mcg/kg/min if not responsive to pacing or atropine (see table) Key Treatment Considerations

• Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor / observe) • Sedation prior to starting pacing is not required. Patients with urgent need should be paced first. • The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness.

Patients who are in need of pacing are unstable and sedation should be done with great caution. • Monitor respiratory status closely and support ventilation as needed • Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in these

patients) • Patients with wide-QRS second- and third-degree blocks will not have a response to atropine because

these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur.


A7 ADULT VENTRICULAR TACHYCARDIA WITH PULSES

Widened QRS Complex (greater than or equal to 0.12 sec) – generally regular rhythm INITIAL THERAPY

OXYGEN High flow. Be prepared to support ventilation as needed.

CARDIAC MONITOR

12-LEAD ECG Consider pre- and post treatment if condition permits IV TKO

STABLE VENTRICULAR TACHYCARDIA AMIODARONE 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min)

Consider repeat AMIODARONE If rhythm persists and patient remains stable, 150 mg IV over 10 minutes

UNSTABLE VENTRICULAR TACHYCARDIA Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF Consider SEDATION

Prepare for CARDIOVERSION: If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg)

SYNCHRONIZED CARDIOVERSION

100 joules (low energy setting – 75 W/S) 200 joules (low energy setting – 120 W/S) 300 joules (low energy setting – 150 W/S) 360 joules (low energy setting – 200 W/S) If VT recurs, use lowest energy level previously successful

Key Treatment Considerations • Document rhythm during treatment with continuous strip recording • Rhythm analysis should be based on recorded strip, not monitor screen

• Be prepared for previously stable patient to become unstable

• Give AMIODARONE via Infusion or slow IV push only • Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly. • AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should

be considered unstable and should not receive AMIODARONE.

• If sedation done for cardioversion, monitor respiratory status closely and support ventilations as needed


A8 ADULT SUPRAVENTRICULAR TACHYCARDIA

Heart rate greater than 150 beats per minute – regular rhythm usually with narrow QRS complex

INITIAL THERAPY OXYGEN High flow. Be prepared to support ventilation as needed.

CARDIAC MONITOR 12-LEAD ECG Consider pre- and post-treatment if condition permits

IV TKO

STABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) May have mild chest discomfort VALSALVA

Consider ADENOSINE

6 mg rapid IV - followed by 20 ml normal saline flush If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once.

UNSTABLE SVT

May need immediate synchronized cardioversion Signs of poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF If rhythm not regular, SVT unlikely If wide QRS complex, consider ventricular tachycardia

Consider ADENOSINE

6 mg rapid IV - followed by 20 ml normal saline flush. If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once.

Consider SEDATION

Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg)


50 joules (low energy setting – 50 W/S) 100 joules (low energy setting – 75 W/S) 200 joules (low energy setting – 120 W/S) 300 joules (low energy setting – 150 W/S) 360 joules (low energy setting – 200 W/S)

Key Treatment Considerations • Document rhythm during treatment with continuous strip recording • Rhythm analysis should be based on recorded strip, not monitor screen • Be prepared for previously stable patient to become unstable • Proceed to cardioversion if patient becomes unstable • Do not administer Adenosine if poison - or drug-induced tachycardia • If sedation done for cardioversion, monitor respiratory status closely and support ventilation as needed


A9

ADULT OTHER CARDIAC DYSRHYTHMIAS SINUS TACHYCARDIA – Heart rate 100-160, regular ATRIAL FIBRILLATION – Heart rate highly variable, irregular ATRIAL FLUTTER – Variable rate depending on block. Atrial rate 250-350, “saw-tooth” pattern

INITIAL THERAPY OXYGEN Low flow. High flow if unstable. CARDIAC MONITOR Consider 12-LEAD ECG 12-lead ECG pre- and post-treatment if patient symptomatic and condition permits

Consider IV TKO UNSTABLE ATRIAL FIBRILLATION OR ATRIAL FLUTTER

Ventricular rate greater than 150, and: BP less than 80, or unconsciousness / obtundation, or severe chest pain or dyspnea OXYGEN High flow. Be prepared to support ventilation. Consider SEDATION

Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) Atrial Flutter Only - Initial Level: 50 joules (low energy setting – 50 joules)


Atrial Flutter and Atrial Fibrillation: 100 joules (low energy setting – 75 joules) 200 joules (low energy setting – 120 joules) 300 joules (low energy setting – 150 joules) 360 joules (low energy setting – 200 joules)

Key Treatment Considerations • Sinus tachycardia commonly present because of pain, fever, hypovolemia

• Atrial fibrillation may be well-tolerated with moderately rapid rates (150-170) and often requires no specific treatment other than observation (oxygen, monitoring and transport)

• If sedation done for cardioversion, monitor respiratory status closely and support ventilation as needed

• Computerized rhythm analysis on 12-lead ECG is frequently incorrect and requires review of the ECG to verify rhythm

• Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI*** or ***Acute MI Suspected*** message encountered, the patient’s heart rate is important information to relate to the STEMI center at time of activation.


A10 ADULT SHOCK

HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with dry lungs, flat neck veins • May have poor skin turgor, history of GI bleeding, vomiting or diarrhea • May be warm and flushed, febrile • May have history of high fever (sepsis)

SHOCK (NOT CARDIOGENIC) OXYGEN High flow. Be prepared to support ventilations as needed.

Keep patient warm

CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline

EARLY TRANSPORT CODE 3

IV or IO

FLUID BOLUS 250-500 ml NS Recheck vitals every 250 ml to a maximum of 1 liter

BLOOD GLUCOSE Check and treat if indicated

Consider DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table)

Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12)

CARDIOGENIC SHOCK Signs and symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema

OXYGEN High flow. Be prepared to support ventilations as needed.

Keep patient warm

CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline


IV or IO TKO


Consider DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table)

12–LEAD ECG Perform if time and condition permits

Related guideline: Altered Level of Consciousness (G2)


G1 GENERAL ALLERGY / ANAPHYLAXIS

• Serious reactions involve upper or lower respiratory tract - dyspnea, stridor, wheezing, anxiety, tachycardia, tightness in chest

• Some reactions involve only skin (hives, itching) • Marked, sudden swelling of head, face neck and airway represents a serious systemic reaction

(angioedema) OXYGEN High flow. Be prepared to support ventilations.

EPI-PEN May assist with administration of patient’s auto-injector

CARDIAC MONITOR Treat dysrhythmias per specific treatment guidelines If upper or lower respiratory tract symptoms or hypotension: EPINEPHRINE 1:1000 IM

• Adult – 0.3-0.5 mg IM (use 0.3 mg in elderly, small patients or mild symptoms) Pediatric – 0.01 mg/kg IM – maximum dose 0.3 mg

ALBUTEROL Adult and pediatric - 5 mg/6 ml saline via nebulizer – may repeat as needed

IV TKO If itching or hives, consider:

DIPHENHYDRAMINE • Adult - 50 mg slow IV or IM

Consider 25 mg if patient has taken po diphenhydramine Pediatric – 1 mg/kg IV or IM (maximum dose 50 mg)

Consider 0.5 mg/kg dose if patient has taken po diphenhydramine MONITOR PATIENT Carefully monitor vital signs, respiratory status, and response to treatments If serious progression of symptoms after treatment with IM epinephrine: • Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis, severe

respiratory distress or respiratory arrest. In pediatric patients, hypotension is late sign of shock. Consider IO If IV access not immediately available

FLUID BOLUS • Adult - wide open NS. Recheck vitals after every 250 ml Pediatric - 20 ml/kg NS bolus, may repeat X 2

Consider EPINEPHRINE 1:10,000 IV

If patient not responsive to IM epinephrine treatment: Adult - titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg. Use extreme caution with patients with cardiac history, angina, hypertension.

Pediatric - titrate in up to 0.1 mg doses slow IV or IO to a maximum of 0.01 mg/kg

Key Treatment Considerations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.


G2 GENERAL ALTERED LEVEL OF CONSCIOUSNESS

Glasgow Coma Scale less than 15 – uncertain etiology. Consider AEIOU/TIPPS OXYGEN High flow. Be prepared to support ventilations as needed. SPINAL IMMOBILIZATION Consider need for spinal precautions

ORAL GLUCOSE Consider if known diabetic, conscious, able to sit upright, able to self-administer • Adult - 30 g po Pediatric – 15-30 g po

CARDIAC MONITOR

BLOOD GLUCOSE Check level

IV TKO

DEXTROSE If glucose 60 or less: • Adult – DEXTROSE 50% 25 g IV Pediatric – DEXTROSE 10% 0.5 g/kg IV (5 ml/kg)

GLUCAGON

If unable to establish IV: • Adult – 1 mg IM Pediatric - 24 kg or more – 1 mg IM Pediatric - Less than 24 kg – 0.5 mg IM

BLOOD GLUCOSE Recheck if symptoms not resolved

DEXTROSE Repeat initial IV dose if glucose remains 60 or less Related guideline: Respiratory Depression or Apnea (G12)

Key Treatment Considerations • Naloxone should not be given as treatment for altered level of consciousness in the absence of

respiratory depression (respiratory depression = rate of less than 12 breaths per minute) • Patients with hypoglycemia as a result of oral diabetic medications are at higher risk of recurrent

hypoglycemia and transport is highly recommended in these patients • With prolonged hypoglycemia and in many elderly patients, increase in level of consciousness after

dextrose given may not be as rapid as in others. Recheck glucose before considering repeat treatment.

• In patients with starvation, poor oral intake, or alcohol intoxication/alcoholism, glucagon may not be effective because of poor glycogen stores in liver

• Glucagon may take 10-20 minutes or longer to increase glucose level (peak effects in 45-60 minutes). Recheck glucose before considering additional treatment.

• Consider transport earlier in patients with poor vascular access who are not responding to glucagon or have reasons listed above for possible impaired response to glucagon

• Most patients with hypoglycemia have diabetes. Other causes of hypoglycemia include renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses and sulfa drugs. Hypoglycemia may also occur rarely following gastric surgery for weight loss.

Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.


G3 GENERAL BEHAVIORAL EMERGENCY

• A behavioral emergency is defined as combative or irrational behavior not caused by medical illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated states or other conditions

• Combative or irrational behavior may be caused by psychiatric or other behavioral disorder

• History of event and past history are important in patient evaluation

• Past history of psychiatric condition does not eliminate need to assess for other illnesses

SCENE SAFETY • Many patients merit a weapons search by law enforcement • Physical restraints may be needed if patient exhibits behavior that presents a

danger to him/herself or others

ASSESS PATIENT • Assess for evidence of hypoxia, hypoglycemia, trauma • Consider other medical causes for behavioral symptoms

VITAL SIGNS Obtain vital signs as possible

Consider OXYGEN Provide as possible if there is question of hypoxia or other medical condition

CARDIAC MONITOR Place as possible / safe

Consider BLOOD GLUCOSE Obtain as possible / safe

Consider CHEMICAL RESTRAINT

BASE ORDER REQUIRED Despite verbal de-escalation and physical restraint, if adult patient (15 years or older) remains extremely combative and struggling against restraints, consider: • MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small

patients (under 50 kg) • MIDAZOLAM 1-5 IV mg in 1 mg increments if IV established and patent

MONITOR PATIENT Monitor closely for respiratory compromise. Assess and document mental status, vital signs, and extremity exams (if restrained) at least every 15 minutes.

Related guidelines: Altered Level of Consciousness (G2), Trauma (G16)

Key Treatment Considerations • Calming measures may be effective and may preclude need for restraint in some circumstances • Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if

possible, but maintain contact with other personnel and ability to exit rapidly. • Avoid violating patient’s personal space, making direct eye contact or sudden movements. Frequent

reassurance and calm demeanor of personnel are important.

• Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position. • Assure adequate resources available to manage patient’s needs. Restraint may require up to five

persons to safely control patient. • Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior • In pediatric patients, consider child’s developmental level when providing care • Sedation with Midazolam intended for adult patients only (age 15 and over) • Not all patients will respond to Midazolam. Repeat dosage is not recommended.


G4 GENERAL BURNS

• Damage to the skin caused by contact with caustic material, electricity, or fire • Second or third degree burns involving 20% of the body surface area, or those associated with

respiratory involvement are considered major burns Move patient to safe area

Stop the burning process • Remove contact with agent, unless adhered to skin • Brush off chemical powders • Flush with water to stop burning process or to decontaminate

OXYGEN High flow. Be prepared to support ventilation as needed.

Protect the burned area Do not break blisters, cover with clean dressings or sheets. Remove restrictive clothing/jewelry if possible.

Assess for associated injuries

Consider IV or IO TKO

Consider MORPHINE SULFATE IV

For pain relief in the absence of hypotension (systolic BP less than 90), significant other trauma, altered level of consciousness: • Adult – 2-20 mg IV or IO, titrated in 2 - 4 mg increments Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart

Consider MORPHINE SULFATE IM

If IV or IO access not available: • Adult – 5-20 mg IM Pediatric – 0.1 mg/kg IM – See Pediatric drug chart

Key Treatment Considerations • Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or

edematous mucosa in mouth are clues)

• Transport to closest receiving facility for advanced airway management if time permits • Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia. • Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.


G5 GENERAL CHILDBIRTH – ROUTINE OR COMPLICATED

IMMINENT DELIVERY - Regular contractions, bloody show, low back pain, feels like bearing down, crowning Prepare for Delivery Reassure mother, instruct during delivery

Consider IV TKO if time allows

Deliver Infant

• As head is delivered, apply gentle pressure to prevent rapid delivery of the infant • Gently suction baby's mouth, then nose, keeping the head dependent • If cord is wrapped around neck and can't be slipped over the infant's head,

double-clamp and cut between clamps

Clamp/Cut Cord Immediately double-clamp cord 6-8 inches from baby and cut between clamps (if not done before delivery)

Warming Measures Dry baby and keep warm, placing baby on mother's abdomen or breast

Placenta Delivery If placenta delivers, save it and bring to the hospital with mother and child. DO NOT PULL ON UMBILICAL CORD TO DELIVER PLACENTA.

Post-Delivery Observation

Observe mother and infant frequently for complications. To decrease post-partum hemorrhage, perform firm fundal massage, put baby to mother's breast.

Transport Prepare mother and infant for transport. Neonatal care or resuscitation as indicated.

COMPLICATED DELIVERY BREECH DELIVERY – Presentation of buttocks or feet

Delivery

• Allow delivery to proceed passively until the baby's waist appears • Rotate baby to face down position (DO NOT PULL) • If the head does not readily deliver in 4-6 minutes, insert a gloved hand into the

vagina to create an air passage for the infant Transport Early transport if available – notify receiving hospital as soon as possible

PROLAPSED CORD - Cord presents first and is compressed, compromising infant circulation

Manage Cord • Insert gloved hand into vagina and gently push presenting part off of the cord • Do not attempt to reposition the cord • Cover cord with saline soaked gauze

Position Patient Place mother in trendelenburg position with hips elevated

Transport Early transport if available – notify receiving hospital as soon as possible


G6 GENERAL DYSTONIC REACTIONS

• History of ingestion of phenothiazine or related compounds, primarily anti-psychotic and anti-emetic medications (for nausea/vomiting). Symptoms include restlessness, muscle spasms of the neck, jaw, and back, oculogyric crisis.


IV TKO

DIPHENHYDRAMINE • Adult - 25-50 mg IV or 50 mg IM if unable to establish IV access Pediatric – 1 mg/kg IV or 1 mg/kg IM if unable to establish IV access

Key Treatment Considerations Common drugs implicated in dystonic reactions include many anti-emetics and anti-psychotic medications • Prochlorperazine (Compazine) • Haloperidol (Haldol) • Metoclopromide (Reglan) • Phenergan (Promethazine) • Fluphenazine (Prolixin) • Chlorpromazine (Thorazine) • Many other antipsychotic and anti-depressant drugs Rarely benzodiazepine drugs have been implicated as a cause of dystonic reaction



G7 GENERAL

ENVENOMATIONS Snake Bites, Insect Stings

SNAKE BITES • If the snake is positively identified as non-poisonous, treat with basic wound care INSECT STINGS • Symptoms of stings usually occur at the site of injury and have no specific treatment • Allergic reactions can be severe, and may cause anaphylactic shock

Keep patient calm

Address constricting items Remove rings, bracelets or other constricting items from affected extremity

WOUND MANAGEMENT

Snake bite: Splint extremity and keep at level of heart Insect Stings: Flick stinger off – do not squeeze stinger. Apply cold pack.

OXYGEN High flow If signs of shock or allergic reaction Be prepared to support ventilations

Monitor vital signs

Consider CARDIAC MONITOR Consider if patient potentially unstable

Consider IV TKO

Related Guidelines: Shock (A10, P8), Allergy / Anaphylaxis (G1)


G8 GENERAL HEAT ILLNESS / HYPERTHERMIA

HEAT EXHAUSTION • Presentation: Flu-like symptoms, cramps, normal mental status HEAT STROKE • Presentation: Altered level of consciousness, absence of sweating, tachycardia, and hypotension

OXYGEN Low flow for heat exhaustion High flow if altered level of consciousness / suspected heat stroke

COOLING MEASURES

• Move patient to cool environment • Promote cooling by fanning • Remove clothing and splash / sponge with water • Place cold packs on neck, in axillary and inguinal areas

IV TKO. Perform if heat stroke or marked symptoms with heat exhaustion.


If hypotensive or suspected heat stroke: • Adult – 500 ml NS bolus May repeat X 1 Pediatric – 20 ml/kg NS bolus. May repeat X 1

Consider BLOOD GLUCOSE Check level if altered level of consciousness, treat as indicated

Consider DOPAMINE

For adult patients only if hypotension persists despite fluid boluses Begin at 5 mcg/kg/min (see table)

Related guidelines: Altered Level of Consciousness (G2), Seizure (G14) Key Treatment Considerations

• Seizures may occur with heat stroke – treat as per treatment guideline for seizure • Increasing symptoms merit more aggressive cooling measures. With mild symptoms of heat

exhaustion, movement to cooler environment and fanning may suffice. • Conditions that may lead to or worsen hyperthermia include:

o Psychiatric Disorders o Heart Disease o Diabetes o Alcohol o Medications o Fever o Fatigue o Obesity o Pre-existent dehydration o Extremes of age (Elderly and pediatric)



G9 GENERAL HYPOTHERMIA

MODERATE HYPOTHERMIA • Conscious and shivering but lethargic, skin pale and cold SEVERE HYPOTHERMIA • Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations • Severe hypothermia patients may appear dead. When in doubt, begin resuscitation

OXYGEN Low flow. High flow if decreased level of consciousness (warm humidified oxygen if available). Be prepared to support ventilations.

SPINAL PRECAUTIONS For patients with possible trauma or submersion

WARMING MEASURES Gently move to sheltered area (warm environment) Minimize physical exertion or movement of the patient Cut away wet clothing and cover patient with warm, dry sheets or blankets

CARDIAC MONITOR Consider EARLY TRANSPORT Do not delay transport if patient unconscious

IV TKO BLOOD GLUCOSE Check and treat if indicated Consider NALOXONE If respiratory rate less than 12 and narcotic overdose suspected

Consider ADVANCED AIRWAY Only if unable to ventilate using BVM

Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12)

Key Treatment Considerations • Avoidance of excess stimuli important in severe hypothermia as the heart is sensitive and interventions

may induce arrhythmias. Needed interventions should be done as gently as possible. o Check for pulselessness for 30-45 seconds to avoid unnecessary chest compressions o Defer ACLS medications until patient warmed o If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, shock X 1 and defer

further shocks

• Patients with prolonged hypoglycemia often become hypothermic – blood glucose check essential

• Patients with narcotic overdose may develop hypothermia


G10 GENERAL

PAIN MANAGEMENT (NON-TRAUMATIC) • All patients expressing verbal or behavioral indicators of pain shall have an appropriate

assessment and management of pain • Morphine should be given in sufficient amount to manage pain but not necessarily to eliminate it Consider OXYGEN Low flow

IV TKO

ASSESS PAIN • Assess and document the intensity of the pain using the visual analog scale • Reassess and document the intensity of the pain after any intervention that

could affect pain intensity

PAIN RELIEF MEASURES

Psychologic measures and BLS measures, including cold packs, repositioning, splinting, elevation, and/or traction splints, are important considerations for patients with pain


See contraindications and cautions below: For pain relief: • Adult – 2-20 mg IV, titrated in 2-5 mg increments to pain relief Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart


If no IV access: • Adult - 5-10 mg IM Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart

Contraindications and Cautions for Morphine Sulfate Contraindications for Morphine:

• Closed head injury • Altered level of consciousness • Headache • Respiratory failure or worsening

respiratory status • Childbirth or suspected active labor

• Hypotension o Adults - Systolic BP less than 90 o Pediatric - Hypotension or impaired perfusion (e.g.

capillary refill > 2 seconds) • Infants 1mo-1yr systolic BP < 60 mmHg • Toddler 1-4 yrs systolic BP < 75 mmHg • School age 5-13 yrs systolic BP < 85 mmHg • Adolescent >13 yrs systolic BP < 90 mmHg

Cautions for Morphine: • Use with caution in patients with suspected drug or alcohol ingestion or with suspected hypovolemia

Key Treatment Considerations • Have Naloxone available to reverse respiratory depression should it occur

• Preferred route of administration for Morphine Sulfate is IV



G11 GENERAL POISONING - OVERDOSE

• If possible, determine substance, amount ingested, time of ingestion. Bring in container or label. • Be careful not to contaminate yourself and others

DECONTAMINATION Remove contaminated clothing, brush off powders, wash off liquids. Irrigate eyes if affected.

OXYGEN Low flow. Be prepared to support ventilations.

CARDIAC MONITOR

Consider IV TKO if unstable patient or suspected serious ingestion

Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2), Seizures (G14), Shock (A10, P8)

TRICYCLIC ANTIDEPRESSANT OVERDOSE

• Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes and associated ventricular arrhythmias are generally signs of a life-threatening ingestion.

SODIUM BICARBONATE For adults only: For life-threatening hemodynamically significant dysrhythmias, 1 mEq/kg slow IV or IO

ORGANOPHOSPHATE POISONING • Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness,

small/pinpoint pupils, muscle twitching, and/or seizures may occur

ATROPINE For adults only: 1-2 mg IV • Repeat every 3-5 minutes as necessary until relief of symptoms • Large doses of Atropine may be required

HYDROFLUORIC ACID EXPOSURE

CALCIUM CHLORIDE For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10% solution)


For adults only: In the absence of hypotension, significant other trauma or altered level of consciousness: 2-20 mg IV titrated in 2-5 mg increments to pain relief


For adults only: If no IV access, 5-10 mg IM

Key Treatment Considerations • Few overdoses have specific antidotes. Supportive care is the mainstay of treatment.

Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients

• Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium Channel Blocker overdose)

• Poison Control Center can offer information but cannot provide medical direction to EMS


G12 GENERAL RESPIRATORY DEPRESSION OR APNEA

• Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest

BVM VENTILATION Assist ventilation or provide ventilation if no spontaneous respirations OXYGEN High flow CARDIAC MONITOR

NALOXONE INTRANASAL or IM

• Adult not in shock: 2 mg IN (intranasal) if narcotic overdose suspected • Adult not in shock but unsuitable for IN (copious secretions): 1-2 mg IM Pediatric – 0.1 mg/kg IM – maximum dose 2 mg

Consider IV TKO if intravenous treatment indicated

NALOXONE IV

If patient in shock, if IN or IM routes ineffective (within 3 minutes), or if IV access already available for another reason: • Adult – 1-2 mg IV Pediatric – 0.1 mg/kg IV – maximum dose 2 mg

Repeat NALOXONE IV or IM if no response and narcotic overdose suspected – maximum dose 10 mg Titration of Diluted NALOXONE IV

Consider for patients with chronic narcotic use for terminal disease or chronic pain: Dilute 1:10 with normal saline and administer in 0.1 mg (1 ml) increments – titrate to increased respiratory rate

ADVANCED AIRWAY

Consider when indicated - only if naloxone ineffective and BVM ventilation not adequate

Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13)

Key Treatment Considerations

SAFETY WARNING! Naloxone will cause acute withdrawal symptoms in patients who are habituated users of narcotics (whether prescribed or from abuse)

• Use of diluted Naloxone IV and titration with small increments may help decrease adverse effects of naloxone in patients who have chronic narcotic usage for terminal disease or pain relief

• Naloxone treatment should only be given to patients with respiratory depression (rate less than 12)

• Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management

• Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%)

• Older patients are at higher risk for cardiovascular complications • Be prepared for patient agitation or combativeness after naloxone reversal of narcotic overdose



G13 GENERAL RESPIRATORY DISTRESS

• Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema • Rales may be present in pneumonia, pulmonary edema, and many other conditions

INITIAL THERAPY OXYGEN Low flow – increase as indicated. Be prepared to support ventilation. CARDIAC MONITOR Consider CPAP If respiratory rate greater than 25, accessory muscle use, pulse ox less than 94% Consider IV TKO. Do not delay transport for vascular access if in extremis.

ASTHMA ALBUTEROL Adult and Pediatric – 5 mg in 6 ml NS via nebulizer. Repeat as needed.

Consider EPINEPHRINE 1:1000 SC (subcutaneously)

For use in asthma only: Use only if respiratory status deteriorating despite repeat treatment with Albuterol and transport time more than 10 minutes. Do not use in patients with history of coronary artery disease or hypertension. • Adult - 0.3 mg SC Pediatric - 0.01 mg/kg SC - max dose 0.3 mg

Never give Epinephrine 1:1000 intravenously!

EPINEPHRINE 1:1000 IM

If respiratory arrest from asthma or bronchospasm: • Adult - 0.3 mg IM Pediatric - 0.01 mg/kg IM - max dose 0.3 mg

COPD EXACERBATIONALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed.

SUSPECTED PULMONARY EDEMA (ADULTS ONLY)

NITROGLYCERIN

0.4 mg sublingual if systolic BP between 90 and 149 0.8 mg sublingual if systolic BP 150 or greater Repeat every 5 minutes until symptoms improve Maximum dose 4.8 mg (12 - 0.4 mg doses) Discontinue if hypotension develops Caution: Do not administer if patient has taken erectile dysfunction medications Viagra or Levitra within prior 24 hours or Cialis within 36 hours

Consider MORPHINE SULFATE

2-5 mg IV in 1-2 mg increments for relief of anxiety. Do not administer if BP less than 90, if patient has altered mental status or decreased respiratory effort.

Related guidelines – Chest pain / Suspected ACS (A2), Shock (A10) Key Treatment Considerations

• CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of respiration will need assistance with BVM.

• Patients with potential respiratory failure should be transported emergently. • Patients requiring advanced airway management in these situations are best handled in the hospital

setting and CPAP may be a valuable “bridge” in care to potentially delay need for emergent intubation. • IV access should not delay transport. • For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If

blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg. • If cardiac ischemia suspected in addition to pulmonary edema, treat as per chest pain protocol (Aspirin,

12-lead ECG if possible). • Consider cardiac etiology for diabetic patients with respiratory distress Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.


G14

GENERAL SEIZURE / STATUS EPILEPTICUS • Tonic, clonic movements followed by a period of unconsciousness (post-ictal period) • A continuous or recurrent seizure is defined as seizure activity greater than 10 minutes or

recurrent seizures without patient regaining consciousness OXYGEN High flow. Be prepared to support ventilations. Protect patient Do not forcibly restrain but protect from injuring self CARDIAC MONITOR Consider IV TKO BLOOD GLUCOSE Check and treat if indicated

Consider MIDAZOLAM IV

For continuous or recurrent seizures: • Adult – initial dose 1 mg IV - titrate in 1-2 mg increments – max. dose 5 mg Pediatric – titrate in up to 1 mg IV increments – up to 0.1 mg/kg

Consider MIDAZOLAM IM

If IV access unavailable: • Adult – 0.2 mg/kg IM - maximum dose 10 mg Pediatric – 0.2 mg/kg IM - maximum dose 10 mg

MONITOR PATIENT Carefully observe vital signs, respiratory status – support ventilations as needed Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12)

SAFETY WARNING: • Use caution when treating with Midazolam in pediatric patients

previously treated by family or caretaker with rectal diazepam (Valium, Diastat) as a higher incidence of respiratory depression may occur.

• Wait five (5) minutes after last rectal dose to determine effect and need for treatment. Consider using reduced dosage of Midazolam.

Key Treatment Considerations • Most seizures are self-limiting and do not require prehospital medication • Seizures may appear frightening to observers. Provide reassurance to parents/family.

• Consider spinal immobilization if history of fall or trauma

• Febrile seizures in children are generally self-limiting • For febrile patients, remove or loosen clothing, remove blankets to address cooling measures



G15 GENERAL STROKE

• Sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit, may be associated with headache

• Determination of time of onset of symptoms is the most crucial historical information needed • If patient awoke with symptoms, time patient last seen normal is the time that should be noted


CARDIAC MONITOR

STROKE SCALE Note findings of stroke scale and time of onset of symptoms

TRANSPORT Minimize scene time


IV TKO. Perform enroute Consider FLUID BOLUS 250-500 ml if hypotensive or poor perfusion – reassess

CONTACT RECEIVING HOSPITAL

Report time of symptom onset (time last seen normal), ETA, physical exam and findings of Cincinnati Stroke Scale using SBAR format

Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12), Seizure (G14)

CINCINNATI STROKE SCALE If any one of the three tests are abnormal and is a new finding, the Stroke Scale is abnormal and may indicate an acute stroke

Finding Patient Activity Interpretation

Facial Droop Ask patient to smile and show teeth or grimace

Normal: Symmetrical smile or face

Abnormal: Asymmetry (one side droops or does not move)

Arm Weakness

Ask patient to close both eyes and extend both arms out straight for 10 seconds

Normal: Both arms move symmetrically or do not move

Abnormal: One arm drifts down or arms move asymmetrically

Testing with patient holding palms upward is most sensitive way to check. Patients with arm weakness will tend to pronate (turn from palms up to sideways or palms down).

Speech Abnormality

Have the patient say the words, “The sky is blue in Cincinnati”

Normal: The correct words are used and no slurring of words is noted

Abnormal: If the patient slurs words, uses the wrong words, or is unable to speak (aphasia)


G16

GENERAL TRAUMA SPINAL IMMOBILIZATION As indicated

OXYGEN High flow. Be prepared to support ventilations. EARLY TRANSPORT Limit scene time to less than 10 minutes when possible. Load and go if high risk. WOUND / GENERAL CARE

Place splints, cold packs, dressings and pressure on bleeding sites as needed. Keep patient warm – minimize exposure after assessment

Consider NEEDLE THORACOSTOMY Evaluate for and treat tension pneumothorax if indicated

IV TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS. Start two (2) large bore IV’s en route when possible. If stable, single IV acceptable.


If markedly hypotensive (absent peripheral pulses or BP less than 90), • Adult – 250-500 ml NS, recheck vitals. Titrate to presence of peripheral pulses Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2

BLOOD GLUCOSE Test if GCS less than 15. See Altered Level of Consciousness (G2). CARDIAC MONITOR

MORPHINE SULFATE IV

See indications and precautions below: • Adult – 2-20 mg IV in 2-5 mg increments. Titrate to pain relief and systolic BP

greater than 100. See precautions below. Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug chart

MORPHINE SULFATE IM

When IV access not available (non-critical patients only): • Adult – 5-10 mg IM Pediatric – 0.1 mg/kg IM – See Pediatric Drug chart

INDICATIONS AND PRECAUTIONS FOR MORPHINE USE

Morphine may be used for relief of extremity pain in the absence of head or torso trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in patients with drug or alcohol intoxication.

Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Considerations

• ALS procedures in the field (IV and advanced airway) do not improve outcome in critical patients. o IV starts should be done en route on these patients o Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers

• Repeated IV attempts in non-critical pediatric patients should be avoided Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

CRUSH INJURY SYNDROME (ADULTS ONLY) • Caused by muscle crush injury and cell death. Most patients have an extensive area of

involvement such as a large muscle mass in a lower extremity and/or pelvis. • May develop after one hour in severe crush, but usually requires at least 4 hours of compression • Hypovolemia and hyperkalemia may occur, particularly in extended entrapments • Hyperkalemia should be suspected if ECG monitor reveals peaked ‘T’ waves, absent ‘P’ waves or

widened QRS complexes FLUID BOLUS 20 ml/kg NS prior to release of compression

ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer CALCIUM CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after administration of calcium chloride to avoid precipitation with sodium bicarbonate.

IF ECG CHANGES SUGGEST HYPERKALEMIA: SODIUM BICARBONATE - 1 mEq/kg IV. Additionally, consider 1 mEq/kg added to

IV 1L NS - use second IV line as other medications may not be compatible


P1 PEDIATRIC PEDIATRIC PATIENT CARE

Pediatric patient is defined as age 14 or less. Neonate is 0-1 month These basic treatment concepts should be considered in all pediatric patients

Scene Safety Body Substance Isolation Use universal blood and body fluid precautions at all times

Systematic Assessment

• Management and support of ABC’s are a priority • Identify pre-arrest states • Assure open and adequate airway • Place in position of comfort unless condition mandates other position • Consider spinal immobilization if history or possibility of traumatic injury exists • Assess environment to consider possibility of intentional injury or maltreatment

Determine Primary Impression

• Apply appropriate field treatment guidelines • Explain procedures to family and patient as appropriate • Provide appropriate family support on scene

Base Contact • Contact base hospital if any questions arise concerning treatment or if additional

medication beyond dosages listed in treatment guidelines is considered • Use SBAR to communicate with base

Transport • Minimize scene time in pre-arrest patient, critical trauma, shock or respiratory failure • Transport patient medications or current list of patient medications to the hospital • Give report to receiving facility using SBAR

Document Document patient assessment and care per policy Key Treatment Considerations – Apparent Life-Threatening Event (ALTE)

An Apparent Life-Threatening Event (ALTE) Is an event that is frightening to the observer (may think the infant has died) and involves some combination of apnea, color change, marked change in muscle tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with symptoms described under 2 years of age may be considered an ALTE.

Most patients have a normal physical exam when assessed by responding personnel. Approximately half of the cases have no known cause, but the remainder of cases have a significant underlying cause such as infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS.

Because of the high incidence of problems and the normal assessment usually seen, there is potential for significant problems if the child's symptoms are not seriously addressed.

OBTAIN DETAILED HISTORY

Obtain history of event, including duration and severity, whether patient awake or asleep at time of episode, and what resuscitative measures were done by the parent or caretaker.

Obtain past medical history, including history of chronic diseases, seizure activity, current or recent infections, gastroesophageal reflux, recent trauma, medication history.

Obtain history with regard to mixing of formula if applicable.

ASSESSMENT Perform comprehensive exam, including general appearance, skin color, interaction with environment, or evidence of trauma

TREATMENT Treat identifiable cause if appropriate

TRANSPORT If treatment/transport is refused by parent or guardian, contact base hospital to consult prior to leaving patient. Document refusal of care.


P2 PEDIATRIC CARDIAC ARREST – INITIAL CARE AND CPR

AIRWAY Open airway and utilize BLS airway for initial management

VENTILATIONS Ventilations: • Give 2 breaths initially • Administer each breath over 1 second and observe for chest rise

COMPRESSIONS

Check pulse - If no pulse or if heart rate less than 60 with poor perfusion, begin CPR CPR • For 2 minutes or 5 cycles before rhythm analysis if unwitnessed arrest • Until monitor/defibrillator available for rhythm analysis if witnessed arrest Compressions: • Depth – one-third to one-half depth of chest – allow full recoil of chest • Rate - 100/minute • Compression/ventilation ratio - 30:2 for one rescuer, 15:2 for two rescuers • Rotate compressors every 2 minutes To minimize CPR interruptions: • Perform CPR during charging of defibrillator • Resume CPR immediately after shock (do not stop for pulse or rhythm check)

CARDIAC MONITOR Determine cardiac rhythm and follow specific treatment guideline IV / IO ACCESS If IV access not apparent or unsuccessful, use IO access

MEDICATIONS AND DEFIBRILLATION

• Use length-based tape to determine weight if not known o If child is obese and length-based tape used to determine weight, use

next highest color to determine appropriate equipment and drug dosing

• See Pediatric Drug Chart for medication dose and defibrillation energy levels

BLOOD GLUCOSE Treat if indicated. Glucose may be rapidly depleted in pediatric arrest.

PREVENT HYPOTHERMIA

Move to warm environment and avoid unnecessary exposure • Pediatric arrest victims are at risk for hypothermia due to their increased body

surface area, exposure and rapid administration of IV/IO fluids

TRANSPORT Consider rapid transport to definitive care


P3 PEDIATRIC

NEONATAL CARE AND RESUSCITATION

WARM PATIENT Provide warmth – move to warm environment immediately

CLEAR AIRWAY If needed, position airway or suction. Rapidly suction secretions from mouth or nares.

DRY AND STIMULATE Dry child thoroughly, stimulate, reposition if needed, place hat on infant

EVALUATE RESPIRATIONS, HEART RATE AND COLOR

• If breathing, heart rate above 100 and pink, observational care only

• If breathing, heart rate above 100 and central cyanosis – OXYGEN 100% by mask – reassess in 30 seconds o If cyanosis resolves (skin pink) – observational care only o If persistent central cyanosis after oxygen, initiate bag mask ventilation at rate

of 40-60/minute

• If apneic, gasping, or heart rate below 100 – initiate bag mask ventilation at a rate of 40-60/minute with OXYGEN 100% – reassess in 30 seconds o If heart rate increases to above 100 and patient ventilating adequately,

discontinue bag mask ventilation and continue close observation o If heart rate persists below 100 continue bag mask ventilation

REASSESS / BEGIN CPR IF INDICATED

If heart rate less than 60 despite ventilation with oxygen for 30 seconds, begin CPR (3:1 ratio – 90 compressions and 30 ventilations/minute). Reassess in 30 seconds.

If heart rate remains less than 60 despite adequate ventilation and chest compressions:

IV/IO TKO. 100-500 ml NS bag (use care to avoid inadvertent fluid administration). Do not delay transport for IV or IO access.

EPINEPHRINE 1:10,000, 0.01 mg/kg IV or IO. Repeat every 3-5 minutes if heart rate remains below 60.

Consider FLUID BOLUS 10 ml/kg NS IV or IO. May repeat once if needed.

Consider NALOXONE

0.1 mg/kg IV or IO if depressed respiratory status despite efforts. Avoid use if long term use of opioids during pregnancy known or suspected.

Key Treatment Considerations • For uncomplicated deliveries, treatment priorities are to warm, dry, and stimulate the infant

• Anticipate complex resuscitation if not term gestation, amniotic fluid not clear, if newborn is not breathing or crying or if newborn does not have good muscle tone



P4 PEDIATRIC

VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA

INITIAL CARE See Cardiac Arrest - Initial Care and CPR (P3)

DEFIBRILLATION

2 joules/kg • AED can be used if patient over 1 year and pediatric electrodes available (age

1-8) or if adult electrodes can be applied without touching each other • Use infant paddles and manual defibrillator up to 1 year of age or 10 kg

CPR For 2 minutes or 5 cycles between rhythm check and shock BVM VENTILATION Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate IV or IO TKO. Should not delay defibrillation or interrupt CPR DEFIBRILLATION 4 joules/kg EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes - See Pediatric Drug Chart CPR For 2 minutes or 5 cycles between rhythm check and shock DEFIBRILLATION 4 joules/kg AMIODARONE 5 mg/kg IV or IO (see Pediatric Drug Chart for dosage) CPR For 2 minutes or 5 cycles between rhythm check and shock TRANSPORT If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated

Key Treatment Considerations • Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance

takes precedence over advanced airway management and administration of medications. • To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock

administered (no pulse or rhythm check)

• Avoid hyperventilation with BLS airway management, which may cause gastric distention and limit chest expansion. Provide breaths over one second, with movement of chest wall as guide for volume needed.

• If advanced airway placed (40 kg and over), perform CPR continuously without pauses for ventilation • Prepare drugs before rhythm check and administer during CPR • Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) • Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in

adolescents).

Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for medication dose and defibrillation energy levels.


P5 PEDIATRIC PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (P3)

BVM VENTILATION Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate

IV or IO TKO

EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes Consider treatable causes – treat if applicable: Consider FLUID BOLUS 20 ml/kg NS – may repeat X 2 for hypovolemia

VENTILATION Ensure adequate ventilation (8-10 breaths per minute) for hypoxia

WARMING MEASURES For hypothermia

Consider NEEDLE THORACOSTOMY For tension pneumothorax

BASE CONTACT To determine treatment for other identified potentially treatable causes - Hydrogen Ion (Acidosis), Hyperkalemia, Toxins

Safety Warning: Unlike adult resuscitation, atropine is not used in treatment of asystole or PEA in the pediatric patient

If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated Key Treatment Considerations

• Uninterrupted CPR is key to successful resuscitation. This takes precedence over advanced airway management and administration of medications.

• If advanced airway placed in patients 40 kg and over, perform CPR continuously without pauses for ventilation

• Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second.

• Prepare drugs before rhythm check and administer during CPR • Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in

adolescents).



P6 PEDIATRIC SYMPTOMATIC BRADYCARDIA • 90% of pediatric bradycardias are related to respiratory depression and respond to support of

ventilation • Only unstable, severe bradycardia causing cardiorespiratory compromise will require further

treatment • Signs of severe cardiorespiratory compromise are poor perfusion, delayed capillary refill,

hypotension, respiratory difficulty, altered level of consciousness OXYGEN High flow. Be prepared to support ventilation.

IV or IO TKO. Use IO only if patient unstable and requires medication. Use 100-500 ml NS bag.

Consider CPR If heart rate remains less than 60 with poor perfusion despite oxygenation and ventilation, perform CPR.

EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO. Repeat every 3-5 minutes.

SAFETY WARNING: Atropine should be considered only

after adequate oxygenation/ventilation has been assured

Consider ATROPINE

0.02 mg/kg IV, IO (0.1 mg minimum dose) Child (1-8 years): Maximum single dose 0.5 mg. Maximum total dose 1 mg Adolescent (9-14 years): Maximum single dose 1 mg. Maximum total dose 2 mg. If continued heart rate less than 60, repeat 0.02 mg/kg IV or IO

Key Treatment Considerations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.


P7 PEDIATRIC TACHYCARDIA

Sinus tachycardia is by far the most common pediatric rhythm disturbance

UNSTABLE SINUS TACHYCARDIA (narrow QRS less than 0.08) • ‘P’ waves present/normal, variable R-R interval with constant P-R interval • Unstable sinus tachycardia is usually associated with shock and may be pre-arrest

UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less than 0.08) • ‘P’ waves absent/abnormal, heart rate not variable • History generally vague, non-specific and/or history of abrupt heart rate changes • Infants’ rate usually greater than 220 bpm, Children (ages 1 – 8) rate usually greater than 180 bpm

UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA - Wide QRS (greater than 0.08 sec) • In some cases, wide QRS can represent supraventricular rhythm

INITIAL THERAPY – ALL TACHYCARDIA RHYTHMS OXYGEN Low flow. If increased work of breathing – high flow. Be prepared to support

ventilation.

CHECK PULSE AND PERFUSION

Determine stability: • Stable - Normal perfusion: Palpable pulses, normal LOC, normal capillary

refill, and normal BP for age • Unstable - Poor perfusion: ALOC, abnormal pulses, delayed cap. refill,

difficult/unable to palpate BP. If unstable, transport early and treat as below. CARDIAC MONITOR Run strip to evaluate QRS Duration IV or IO TKO. Use 100-500 ml bag NS FLUID BOLUS 20 ml/kg NS if hypovolemia suspected. May repeat X 1.

UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (narrow QRS less than 0.08) VAGAL MANEUVERS Consider if will not result in treatment delays. ICE PACK to face of infant/child. BASE CONTACT ℡ For all treatments listed below:

ADENOSINE 0.1 mg/kg rapid IV push followed by 10-20 ml NS flush (maximum dose 6 mg) If not converted, 0.2 mg/kg rapid IV push followed by 10-20 ml NS flush (maximum dose 12 mg)


If unable to obtain IV access, prepare for Synchronized Cardioversion. Do NOT delay cardioversion to obtain IV or IO access or sedation.

Consider SEDATION Consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg)

SYNCHRONIZED CARDIOVERSION 0.5-1 joule/kg. If not effective, repeat at 2 joules/kg.

UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA ( Wide QRS greater than 0.08 sec) BASE CONTACT ℡ For all treatments listed below: SYNCHRONIZED CARDIOVERION

Prepare for CARDIOVERSION while attempting IV/IO access, but do not unduly delay care for IV access or medications

Consider SEDATION

If IV/IO access has been obtained, consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg)

SYNCHRONIZED CARDIOVERSION 0.5-1 joule/kg. If not effective, repeat at 2 joules/kg.

• Early transport appropriate in unstable patients Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.


P8 PEDIATRIC SHOCK

• Altered level of consciousness; cool, clammy, mottled skin; capillary refill greater than 2 seconds; tachycardia; blood pressure less than 70 systolic

• Listless infant or child with poor skin turgor, dry mucous membranes, history of fever may indicate sepsis, meningitis


Keep patient warm

CARDIAC MONITOR


IV or IO

FLUID BOLUS 20 ml/kg NS – may repeat X 2

BLOOD GLUCOSE Check and treat if indicated PREVENT HYPOTHERMIA Move to warm environment. Avoid unnecessary exposure.

Related guidelines: Altered level of consciousness (G2), Tachycardia (P7)

Key Treatment Considerations Successful pediatric resuscitation relies on early identification of the pre-arrest state • Normal blood pressure, delayed capillary refill, diminished peripheral pulses and tachycardia indicates

compensated shock in children

• Hypotension and delayed capillary refill > 4 seconds indicates impending circulatory failure

• Systolic blood pressure in children may not drop until the patient is 25-30% volume depleted. This may occur through dehydration, blood loss or an increase in vascular capacity (e.g. anaphylaxis).

• Decompensated shock (Hypotension with > 5 seconds capillary refill) may present as PEA in children • Sinus tachycardia is the most common cardiac rhythm encountered • Supraventricular tachycardia should be suspected if heart rate greater than 180 in children (ages 1-8) or

greater than 220 in infants Hypoglycemia may be found in pediatric shock, especially in infants

Pediatric shock victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids



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

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

• Anatomic deformity of spine

Blunt Injury (Regardless of mechanism)

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

tingling, priapism or neurogenic shock

Blunt Injury (When mechanism of injury is concerning)

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

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

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

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

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

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

VASCULAR ACCESS

Saline Lock Indicated for vascular access in upper extremity when medication alone is being administered or a potential need for medication is anticipated

Upper Extremity IV Indicated when fluids and / or medications are needed, and patient not in shock or arrest

Antecubital IV

• Indicated in arrest, shock or when adenosine (rapid IV bolus) is required o In arrest, use intraosseous access if rapid peripheral access cannot be obtained

within 30-60 seconds • Appropriate if other peripheral sites not available and medication or fluids indicated

Intraosseous Access (IO)

Indicated in cardiac arrest, profound shock, or unstable dysrhythmia when peripheral IV access cannot be accomplished or a suitable vein cannot be rapidly found • Should be done only when medication or fluid bolus is being administered, not for

prophylactic vascular access • Not indicated when other routes for medications available (IM, IN) • Not indicated in alert or stable patients • IO infusion is PAINFUL! In non-arrest patients, use lidocaine for pain control PRIOR

to giving fluid or medication

External Jugular IV

Indicated only when unstable patient requires vascular access for emergent intravenous medication or fluids, no peripheral site is available, and patient not appropriate for IO access (e.g., when patient is alert) • Use intraosseous access in arrest situations (IO does not disrupt CPR, higher

success rate) • Use alternative routes for medications when possible rather than EJ

o Patients requiring treatment of hypoglycemia should receive IM glucagon – monitoring for 10-15 minutes is appropriate before EJ considered

o Use intranasal or IM route for naloxone in respiratory depression


12-LEAD ACQUISITION AND LEAD PLACEMENT

Limb Lead Placement: Place limb leads on distal extremities if possible Confirm correct lead placement for each limb May be moved to proximal if needed (if motion artifact) Chest Lead Placement: To begin placement of chest leads, locate sternal angle (2nd ribs are adjacent) then count down to 4th interspace (below 4th rib) V1 – 4th intercostal space at the right sternal border V2 – 4th intercostal space at the left sternal border V4 – 5th intercostal space at left midclavicular line Note: Place V4 lead first to aid in correct placement of V3 V3 – Directly between V2 and V4 V5 – Level of V4 at left anterior axillary line V6 – Level of V4 at left mid-axillary line V4R – (to detect Right Ventricular Infarct) – mirrors V4 on right side of chest – move V4 lead across • Do V4R if Inferior MI noted (elevation in II, III, avF) • Label ECG for V4R Note: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG

LOCALIZING SITE OF INFARCT • Localization of an infarct pattern adds to the accuracy of ECG interpretation

• A STEMI will have 1 mm or more ST-segment elevation in two or more contiguous leads (which means findings noted in the same anatomical location of the infarct) o Contiguous leads for inferior infarction include II, III, and aVF o Contiguous leads for anterior infarction include V1-V4 (V1-V2 elevation also called septal infarction) o Contiguous leads for lateral myocardial infarction include Leads I, aVL, V5, and V6 o Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or inferolateral)

• In patients with an inferior infarct pattern (Leads II, III, aVF), a separate ECG with V4R should be obtained

• A 1 mm ST-segment elevation in V4R when inferior infarction noted indicates right ventricular infarct

I – LATERAL aVR V1 – SEPTAL or ANTERIOR

V4 – ANTERIOR (V4R – RVMI)

II - INFERIOR aVL – LATERAL V2 – SEPTAL or ANTERIOR

V5 – LATERAL

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

V4R

Sternal angle


STEMI RECOGNITION AND DESTINATION

STEMI Recognition

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

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

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

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

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

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

Destination Policy

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

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

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

emergency department

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

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

baseline artifact or other deficit before initiating a STEMI Alert

SITUATION

• Identify the call as a “STEMI Alert” • Estimated time of arrival (ETA) in minutes • Patient age and gender • Report ECG computer interpretation has a STEMI message (as listed above) • Report if subsequent ECG findings are variable or if ECG quality not optimal

(e.g., if no ***Acute MI*** findings noted in tracings without significant artifact)

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

ASSESSMENT

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

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


KEY PARAMEDIC PROCEDURES Skill Indication Contraindication Comment

External Cardiac Pacing

Symptomatic bradycardia • Cardiac arrest • Hypothermia • Pediatric Patients

Careful titration of midazolam or morphine if required for relief of discomfort

Continuous Positive Airway Pressure (CPAP)

Pt. has 2 of more findings:

• RR >25 • Pulse ox <94% • Use of accessory

muscles

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

• Unconscious or unable to follow commands

• Respiratory arrest / apnea

• Pneumothorax

• Vomiting

• Major head, facial or chest trauma

Increased pulse oximetry is not necessarily indicative of patient improvement – follow respiratory rate and level of distress

ResQPOD Cardiac Arrest

• Cardiac arrest from blunt chest trauma

• Any condition other than cardiac arrest

Optional equipment

Use King Airway early to facilitate use

Waveform Capnography (ETCO2)

All intubated patients

(King or Endotracheal Tube)

• None

Essential for ongoing verification of ET tube placement. Use as guide to ventilation rate in perfusing patients.

King Airway

• Cardiac arrest

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

• Presence of gag reflex • Caustic ingestion • Known esophageal

disease (e.g. cancer, varices, stricture)

• Laryngectomy with stoma (place ET tube in stoma)

• Height less than 4 feet

Ideal advanced airway device in cardiac arrest – less CPR interruption

Patients with perfusing pulses (e.g. trauma or respiratory insufficiency) should be managed with BLS airways unless unable to successfully ventilate

Endotracheal Intubation

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

• Patient with

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

• Pediatric patients under 40 kg

• Suspected hypoglycemia or narcotic overdose

• Maxillo-facial trauma with unrecognizable facial landmarks

• Seizures • Patients with an active gag

reflex

Patients with perfusing pulses (e.g. trauma or respiratory insufficiency) should be managed with BLS airways unless unable to successfully ventilate No more than 2 interruptions of ventilation lasting up to 30 seconds during laryngoscopy or intubation attempts


PEDIATRIC ASSESSMENT PEDIATRIC ASSESSMENT TRIANGLE - GENERAL VISUAL ASSESSMENT

Assessment Abnormal

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

Work of Breathing Assess effort Increased or decreased effort or abnormal

sounds Circulation Assess for skin color Abnormal skin color or external bleeding

PREHOSPITAL PRIMARY ASSESSMENT Assessment Signs of Life-Threatening Condition

Airway Assess patency Complete or severe airway obstruction

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

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

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

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

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

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

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

BEGIN INTERVENTIONS IMMEDIATELY AND TRANSPORT PROMPTLY IF LIFE-THREATENING CONDITIONS ARE IDENTIFIED IN GENERAL VISUAL ASSESSMENT OR PRIMARY ASSESSMENT

VITAL SIGNS / GLASGOW COMA SCALE IN CHILDREN Age Normal RR Normal HR Hypotension by systolic blood pressure

Term Neonate 30-60 100-205 Infant (<1 yr) 30-60 100-190 Toddler (1-3 yr) 24-40 90-150 Preschooler (4-5 yr) 22-34 80-140 School Age (6-12yr) 18-30 70-120 Adolescent (13-18 yr) 12-20 60-100

Neonate: Less than 60 mmHg or weak pulses Infant: Less than 70 mmHg or weak pulses 1-10 yrs: Less than 70 mmHg + (age in yrs x 2) Over 10: Less than 90 mmHg

Pediatric GCS Infant Score Child Score Spontaneous movements 6 Obeys commands 6

Withdraws to touch 5 Localizes 5 Withdraws to pain 4 Withdraws 4

Flexion 3 Flexion 3 Extension 2 Extension 2

Motor Response

No response 1 No response 1 Coos and babbles 5 Oriented 5

Irritable cry 4 Confused 4 Cries to pain 3 Inappropriate 3

Moans to pain 2 Incomprehensible 2

Verbal Response

No response 1 No response 1 Opens spontaneously 4 Opens spontaneously 4

Opens to speech 3 Opens to speech 3 Opens to pain 2 Opens to pain 2

Eye Response

No response 1 No response 1


ABC MANEUVERS FOR ADULTS, CHILDREN AND INFANTS

INTERVENTION ADULT CHILD 1 year -

adolescent INFANT

Under 1 year

AIRWAY Head tilt – chin lift. If trauma suspected, use jaw thrust. INITIAL BREATHS 2 effective breaths (make chest rise) - 1 second per breath RESCUE BREATHING - NO COMPRESSIONS

10 – 12 breaths/ minute 1 breath every 5-6 seconds

12-20 breaths / minute 1 breath every 3-5 seconds

BR

EATH

ING

WITH CPR AND ADVANCED AIRWAY

8-10 breaths/minute 1 breath every 6-8 seconds

Abdominal thrusts Up to 5 back slaps and 5 chest thrusts FOREIGN BODY

OBSTRUCTION Perform laryngoscopy and use Magill forceps if BLS efforts unsuccessful

PULSE CHECK (10 seconds or less) Carotid Brachial or femoral

LANDMARKS Lower half of the sternum between the nipples Just below nipple line

METHOD Heel of one hand, other hand on top

Heel of one hand, or same as adult

2 or 3 fingers, or 2 thumbs encircling (with two rescuers)

DEPTH 1.5 to 2 inches One-third to one-half depth of chest

RATE 100 per minute

CO

MPR

ESSI

ON

S

COMPRESSION / VENTILATION RATIO 30:2 30:2 (one rescuer) 2 minutes = 5 cycles

15:2 (two rescuers) 2 minutes = 8-10 cycles


Contra Costa County Base Hospital Hospital Base Phone ED Phone XCC EMS 2

Alert Code

John Muir Medical Center – Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA 94598

Taped:

(925) 939-5804

Receiving Facility Notification:

(925) 947-3379

ED: 939-5800

14524

Contra Costa County Hospitals (Receiving Facilities) Hospital Services ED Phone XCC EMS 2

Alert Code

Contra Costa Regional Medical Center 2500 Alhambra Avenue Martinez CA 94553

Basic ED OB/Neonatal

(925) 370-5971 14574

Doctor’s Medical Center – San Pablo 2000 Vale Road San Pablo CA 94806

Basic ED STEMI Center (510) 234-6010 13613

John Muir Medical Center – Concord Campus 2540 East Street Concord CA 94520

Basic ED STEMI Center (925) 689-0553 14214

John Muir Medical Center – Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA 94598

Basic ED OB/Neonatal Trauma Center STEMI Center

Receiving Facility Notification:

(925) 947-3379 ED: (925) 939-5800

14524

Kaiser Medical Center – Antioch 5001 Deer Valley Road Antioch CA 94531

Basic ED OB/Neonatal

(925) 813-6880 (switchboard)

14564

Kaiser Medical Center – Richmond 901 Nevin Avenue Richmond CA 94504

Basic ED (510) 307-1758 13653

Kaiser Medical Center – Walnut Creek 1425 South Main Street Walnut Creek CA 94596

Basic ED OB/Neonatal STEMI Center

(925) 939-1788 14284

San Ramon Regional Medical Center 6001 Norris Canyon Road San Ramon CA 94583


(925) 275-8338 13623

Sutter/Delta Medical Center 3901 Lone Tree Way Antioch CA 94509


(925) 779-7273 14294


DESTINATION DETERMINATION – BASIC PROCEDURE • Field personnel shall assess a patient to determine if the patient is unstable or stable • Patient stability must be considered along with a number of additional factors in making

destination and transport code decisions

FACTORS TO CONSIDER

• Patient or family’s choice of receiving hospital and ETA to that facility • Recommendations from a physician familiar with the patient’s current condition • Patient’s regular source of hospitalization or health care • Ability of field personnel to provide field stabilization or emergency intervention • ETA to the closest basic emergency department • Traffic conditions • Hospitals with special resources • Hospital diversion status

UNSTABLE PATIENTS

• Usually transported to the closest appropriate acute care hospital emergency department or specialized care centers if indicated

• If the patient or family requests, or if other factors exist which indicate that another facility be considered, field personnel are to contact the base hospital and present their findings, including ETAs to both facilities. Base personnel will assess the benefits of each destination and may direct field personnel to a facility other than the closest.

STABLE PATIENTS

• Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient’s/family preference

• If a patient does not express a preference, the hospital where the patient normally receives health care or the closest ED is to be considered

DESTINATION – 5150 and OBSTETRIC PATIENTS

Patients on 5150 Holds

A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable.

Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center Unstable patients on 5150 holds shall be transported to the closest acute care hospital: • A patient with a current history of overdose of medications is to be considered unstable • A patient with history of ingestion of alcohol / illicit street drugs is considered unstable if:

o Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or o Significantly abnormal vital signs; or o Any other history or physical findings that suggest instability (e.g. chest pain,

shortness of breath, hypotension, diaphoresis

Obstetric Patients

A patient is considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or more. Obstetric patients should be transported to hospitals with in-patient OB services in the following circumstances: • Patients in labor • Patients whose chief complaint appears to be related to the pregnancy, or who

potentially have complications related to the pregnancy • Injured patients who do not meet trauma criteria or guidelines

Obstetric patients with impending delivery or unstable conditions where imminent treatment appears necessary to preserve the mother’s life should be transported to the nearest basic emergency department

Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy


TRAUMA TRIAGE CRITERIA Unmanageable airway or arrest not meeting field determination of death

Closest receiving facility

The following meet high-risk criteria and merit direct transport to the trauma center: Physiologic Criteria • BP < 90 in adults

• GCS 13 or below if not pre-existing

Anatomic Criteria

• Penetrating injury to head, neck, torso, groin, pelvis or buttocks • Fracture of femur • Fracture of long bone(s) resulting from penetrating trauma • Traumatic Paralysis • Amputation above wrist or ankle • Major burns associated with trauma

Mechanism Criteria

• Motor vehicle crash with: o Extrication > 20 minutes o Fatalities in the same vehicle o Ejection

• Unrestrained motor vehicle crash with: o Head on mechanism > 40 mph o Extrication required

• Fall 15 feet or greater Combined Criteria

(combined mechanism and physical findings)

• Motorcycle crash with: o Abdominal or chest tenderness o Observed loss of consciousness

• Unrestrained motor vehicle crash with abdominal tenderness

TRAUMA – BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA)

Base Hospital Destination Decision Required Prior to Transport

• Evidence of high-energy dissipation or rapid deceleration which may include: o vehicle rollover with unrestrained occupant o intrusion of passenger space by 1 foot or greater o impact of 40 mph or greater (restrained) o persons requiring disentanglement from a vehicle

• Adult hit by vehicle traveling faster than 15 mph • Child (under 15) or elderly patient (65 years and over) struck by a vehicle • Persons ejected from a moving object (motorcycle, horse, etc.) • Significant blunt force to the head, neck, thorax (chest/back), abdomen or

pelvis • Penetrating injury to extremities (above knee or elbow) without apparent

fracture

Precaution with Elderly Patients

• Patients 65 years of age and older may sustain significant injuries with less forceful mechanisms, and may merit call-in for less significant mechanisms (e.g. ground level fall with new alteration of mental status)

Additional Considerations:

• Base contact should be made if a patient meets call-in criteria and it is believed trauma center services may be needed, even in the event that the trauma has occurred several hours prior to EMS response

• If no significant symptoms or physical findings noted despite above mechanism(s), call-in not required and patient may be transported to hospital of choice or to closest facility

Note: In the absence of significant symptoms or physical findings with these mechanisms, call base hospital for destination determination


HELICOPTER TRANSPORT CRITERIA USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET

Time Criteria

• Helicopter transport generally should be used only when it provides a time advantage. Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally 20-25 minutes in most cases

• Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter arrival

• Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when time criteria not met

Clinical Criteria

• Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except for: o Stable patients with isolated extremity trauma o Patients with mechanism but no significant physical exam findings

• Trauma patients who do not meet high-risk criteria but by evaluation of mechanism and physical exam findings, appear to have potential significant injuries that merit rapid transport

• Patients with specialized needs available only at a remote facility such as burn victims/critical pediatric

• Critically ill or injured patients whose conditions may be aggravated or endangered by ground transport (e.g. limited access via ground ambulance or unsafe roadway)

Use and Cancellation

The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not met, helicopter should be cancelled. Considerations for IC: • Patient need • Estimated ground transport time versus air response and transport • Proximity of a helispot or need for a helicopter/ambulance rendezvous site • ETA of the helicopter

RESTRAINTS

Restraint Types

• Leather or soft restraints may be used during transport • Handcuffs may only be used during transport if law enforcement accompanies the patient

in the ambulance. Patients may not be handcuffed to the gurney. • Chemical restraint requires a base hospital order

Restraint Issues

• Patients shall be placed in Fowler’s or Semi-Fowler’s position • Patients shall not be restrained in hogtied or prone position • Method of restraint should allow for monitoring of vital signs and respiratory effort and

should not restrict the patient or rescuer’s ability to protect the airway should vomiting occur

• Restrained extremities should be monitored for circulation, motor and sensory function every 15 minutes

Law Enforcement Role

• Law enforcement agencies are responsible for capture and/or restraint of assaultive or potentially assaultive patients

• Law enforcement agencies retain responsibility for safe transport of patients under arrest or on 5150 holds

• Patients under arrest or 5150 hold should undergo a weapons search by law enforcement personnel

• Patients under arrest must be accompanied by law enforcement personnel

Transport Issues

• If an unrestrained patient becomes assaultive during transport, ambulance personnel shall request law enforcement assistance, and make reasonable efforts to calm and reassure the patient

• If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. Ambulance personnel are to remain on scene until law enforcement arrives to take control of the situation.


RULE OF NINES – BURN SURFACE AREA

BURN PATIENT DESTINATION

General Destination Principles

• Burned patients with unmanageable airways should be transported to the closest basic ED

• Patients with minor burns and moderate burns can be cared for at any acute care hospital

• Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma center

Patient Selection for Initial Transport to Burn Center

The following patients may be appropriate for initial transport to a Burn Center: • Partial thickness (2nd degree) greater than 20% TBSA • Full thickness (3rd degree) greater than 10% • Significant burns to face, hands, feet, genitalia, perineum, or circumferential

burns of the torso or extremities • Chemical or high voltage electrical burns • Smoke inhalation with external burns

Procedure for Burn Center Destination

• Contact Burn Center prior to transport to confirm bed availability • Consult base hospital if any questions regarding destination decision

BURN CENTERS Hospital Services Phone

Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose CA

Adult and Pediatric Burn Center 408-885-6666

UC Davis Medical Center Regional Burn Center 2315 Stockton Blvd. Sacramento CA

Adult and Pediatric Burn Center 916-734-3636

St. Francis Burn Center 900 Hyde Street San Francisco CA

Adult and Pediatric Burn Center (No Helipad available) 415-353-6255


DECLINING MEDICAL CARE OR TRANSPORT (AMA) All qualified persons are permitted to make decisions affecting care, including the ability to decline care

Patient Any person encountered by EMS personnel who demonstrates any known or suspected illness or injury OR is involved in an event with significant mechanism that could cause illness or injury OR who requests care or evaluation

Competency The ability to understand and to demonstrate an understanding of the nature of the illness/injury and the consequence of declining medical care

Qualified Person

A competent person making decision for him/herself or another qualified by: • An adult patient defined as a person who is at least 18 years old; • A minor (under 18 years old) who qualifies based on one of the following conditions:

o A legally married minor; o A minor on active duty with the armed forces; o A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault; o A minor, 12 years of age or older, seeking treatment of contact with an infectious,

contagious or communicable disease or sexually transmitted disease; o A self-sufficient minor at least 15 years of age, living apart from parents and managing

his/her own financial affairs; o An emancipated minor (must show proof); OR

• The parent of a minor child or a legal representative of the patient (of any age). Spouses or relatives cannot consent to or decline care for the patient unless they are legally designated representatives.

Base Contact Requirements

• When, in the field personnel’s opinion, patient’s decision to decline care poses a threat to his/her well being

• If the patient’s competency status is unclear (neither competent nor clearly incompetent) and treatment or transport is felt to be appropriate

• Any other situation in which, in the field personnel’s opinion, that base contact would be beneficial in resolving treatment or transport issues

DETERMINATION OF DEATH

Obvious Death

Pulseless, non-breathing patients with any of the following: • Decapitation, Total incineration, Decomposition • Total destruction of the heart, lungs, or brain, or separation of these organs from the body • Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or

poisoning. In patients with rigor mortis or post-mortem lividity: o Attempt to open airway, assess for breathing for at least 30 seconds; assess pulse

for 15 seconds o Rigor, if present, should be noted in jaw and/or upper extremities o If any doubt exists, place cardiac monitor to document asystole in two leads for one

minute • Mass casualty situations

Medical Arrest

Definition: Cardiac arrest with total absence of observers or witness information; or cardiac arrest in which witness information states arrest occurred greater than 15 minutes prior to arrival of prehospital personnel and no resuscitative measures have been done Procedure: • BLS personnel – Follow Public Safety defibrillation guideline • ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no

heart tones/no carotid or femoral pulses), document asystole in two leads for one minute

Traumatic Arrest

Definition: Blunt or penetrating traumatic arrest Procedure: • BLS personnel – Follow Public Safety defibrillation guideline • ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no

heart tones/no carotid or femoral pulses), document asystole or wide-complex pulseless electrical activity (PEA) at rate of 40 or less

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