Community Ambulance Service of Minot ALS Standing Orders Legend

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1 Legend Indicates General Information and Guidelines Indicates Procedures Indicates Medication Administration Indicates Referral to Other Protocol Indicates Referral to Online Medical Direction

2 Pediatric Airway Control tes - Calming approach to child - Avoid agitation - Only intubate patients when basic maneuvers are unsuccessful - Most proficient provider should attempt intubation - Use caution when intubating suspected epiglottitis patients - Use family to aid in assessment and treatment Trauma Head Tilt, Chin Lift Airway Obstruction Jaw Thrust Maneuver Airway Obstruction Protocol Gag Reflex Oropharyngeal Airway Nasopharyngeal Airway Oral-tracheal Intubation Pediatric Drug Assisted Intubation / RSI Protocol Unsuccessful Unsuccessful Pediatric Failed Airway Protocol

3 Standard Operating Guidelines Pediatric Drug Assisted Intubation / RSI Preoxygenate 100% 0 2 Sellick s maneuver Suspected head injury, increased Y ICP, or eye injury Atropine: 0.02 mg/kg IV minimum 0.1 mg, maximum 1 mg Defasciculation, Vecuronium: 0.01 mg/kg IV or Rocuronium: 0.01 mg/kg IV Etomidate: 0.3 mg/kg IV Succinylcholine: 1.5 mg/kg IV Oral-tracheal Intubation Placement verified? At least 4 methods. Vecuronium: 0.1 mg/kg IV or Rocuronium: 0.6 mg/kg IV as needed for paralysis Failed Airway Protocol Versed: 0.1 mg/kg IV

4 Pediatric Failed Airway Three failed intubation attempts by most proficient provider more than five attempts total Were failed intubations due to gag reflex and/or muscle non-flaccidity? Ventilate patient with BVM Consider Pediatric Drug Assisted Intubation (RSI) Protocol Signs of adequate ventilation Observe / Monitor Medical Direction: Consider Needle Cricothyrotomy

5 Pediatric Bradycardia Consider possible causes and treat appropriately -Hypovolemia -Hypoxia -Hydrogen Ion Acidosis -Hypo-Hyperkalemia -Hypoglycemia -Hypothermia -Toxins -Tamponade, Cardiac -Tension Pneumothorax -Thrombosis (coronary or pulmonary) -Trauma High flow 0 2, Assist respirations as needed Heart rate < 60 Bradycardia causing cardiorespiratory compromise Observe / Monitor Begin CPR Epinephrine: 0.01 mg/kg 1:10,000 IV/IO 0.1 mg/kg 1:1000 ET Medical Direction: Atropine: 0.02 mg/kg IV/IO, minimum 0.1 mg, maximum 1 mg Consider Transcutaneous Pacing

6 Pediatric Tachycardia tes - Children HR > Infant HR > Use of Broselow Tape is recommended - Use pediatric Quik combo on patients < 15 kg Consider possible causes and treat appropriately -Hypovolemia -Toxins -Hypoxia -Tamponade, Cardiac -Hydrogen Ion Acidosis -Tension Pneumothorax -Hypo/Hyperkalemia -Thrombosis (coronary or -Hypoglycemia pulmonary) -Hypothermia -Trauma Narrow QRS (< 0.08 sec) Wide QRS (> 0.08 sec) Unstable Supraventricular Stable Unstable Consider vagal maneuvers Medical Direction: Adenosine 0.1 mg/kg IV, max dose 6 mg, repeat at double dose one time up to 12 mg Observe / Monitor Medical Direction: Cardiovert J/kg, repeat at 2 J/kg Premedicate if no delay in treatment Versed: 0.1 mg/kg IV Medical Direction: Amiodarone 5 mg/kg IV over minutes

7 Withholding or Terminating Resuscitation Protocol V-fib/V-tach Community Ambulance Service of Minot Pediatric Pulseless Arrest Criteria for withholding or terminating resuscitation Shockable Rhythm Consider possible causes and treat appropriately -Hypovolemia -Hypoxia -Hydrogen Ion Acidosis -Hypo/Hyperkalemia -Hypoglycemia -Hypothermia -Toxins -Tamponade, Cardiac -Tension Pneumothorax -Thrombosis (coronary or pulmonary) -Trauma 2 J/kg Asystole/PEA Perform 5 cycles of CPR Perform Intubation Establish Vascular Access Confirm Asystole in 2 or more leads Epinephrine: 0.01 mg/kg 1:10,000 IV/IO 0.1 mg/kg 1:1000 ET, q 3-5 min Perform 5 cycles of CPR Perform Intubation Establish Vascular Access 4 J/kg Perform 5 cycles of CPR Amiodarone: 5 mg/kg IV/IO Epinephrine: 0.01 mg/kg 1:10,000 IV/IO 0.1 mg/kg 1:1000 ET q 3-5 minutes 4 J/kg Continue with 5 cycles of CPR and Defibrillation Regimen Continue with CPR and drug regimen Consider Magnesium Sulfate: mg/kg IV/IO for torsades de pointes If patient has return of spontaneous pulse or rhythm converts; refer to appropriate protocol.

8 Pediatric Respiratory Distress Inadequate respirations Pediatric Airway Protocol tes - Calming approach to child - Avoid agitation - Only intubate patients when basic maneuvers are unsuccessful - Use caution when intubating suspected epiglottitis patients - Administer 0 2 as tolerated, consider blow by Use family to aid in assessment and treatment Wheezes Albuterol: 2.5 mg nebulized repeat as necessary Support ABC s Observe / Monitor Medical Direction: Epinephrine: 0.01 mg/kg IM, up to 0.5 mg Solu-Medrol 1-2 mg/kg; Atrovent 0.5 mg Observe / Monitor

9 Pediatric Allergic Reaction / Anaphylaxis Hypotension / systolic BP < 70 mm/hg Pediatric Hypotension Protocol Epinephrine 1:1000: 0.01 mg/kg deep IM, repeat q 10 minutes as needed Maximum dose mg Severe reaction: Epinephrine 1:10, mg/kg Benadryl: 1 mg/kg IV Maximum dose 50 mg Albuterol: 2.5 mg nebulized Observe / Monitor Medical Direction: Solu-Medrol 1-2 mg/kg IV

10 Pediatric Hypoglycemia / Hyperglycemia Obtain blood glucose Blood glucose < 80 mg/dl Blood glucose > 300 mg/dl Oral Glucose if gag reflex is present Establish large bore IV, run wide open, up to 20 ml/kg Establish vascular access Glucagon: 0.5 mg IM Dextrose 25%: grams/kg IV Infant: Dextrose 12.5% Recheck blood glucose Medical Direction: Contact medical direction if patient refuses transport

11 Pediatric Hypotension Hypotensive / systolic BP < 70 mm/hg Dysrhythmia Bradycardia Protocol Tachycardia Protocol Assess for Pulmonary Edema, if present, contact medical direction Establish vascular access; administer fluid bolus 20 ml/kg, Infant 10 ml/kg Repeat twice as necessary Medical Direction: Dopamine: 5-20 mcg/kg/min, titrate to maintain systolic BP > 90 mm/hg

12 Pediatric Seizures Blood Glucose < 80 mg/dl Febrile Pediatric Hypoglycemia / Hyperglycemia Protocol Active seizures Cooling measures If unable to establish IV access, Midazolam may be given intranasal. 0.2 mg/kg. If seizure persists after 5 minutes, consider repeat dose of 0.1 mg/kg. Valium: 0.2 mg/kg IV, repeat q 10 minutes as necessary Or Midazolam: 0.1 mg/kg IV Control airway as necessary Consider possible causes and treat appropriately - Hypoxia - Head trauma - Environmental - Toxicologic - Psychiatric/ Behavioral - Substance Abuse - DT s Medical Direction - Unable to establish vascular access, consider IO - Refusal of transport with no history of seizures

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