Sumner County EMS. Medical Protocols with added Ebola Protocols

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1 Sumner County EMS Medical Protocols with added Ebola Protocols The following protocols in this manual are written for the use of Sumner County personnel while attending to patients whose care originates in Sumner County. They are to be used to expedite patient care within our medical response area. Individuals may use these protocols only as allowed by his/her level of licensure. These are only guidelines and do not prohibit the use of sound medical judgment by the pre-hospital provider; however, deviation from these protocols requires consultation of medical control. Ray Pinkston, M.D. Medical Director, Sumner County EMS 1

2 PROTOCOL GUIDELINES Emergency Services are composed of personnel from many different backgrounds. This difference extends into training and experience. The protocols show which procedures and medications can be used under standing orders and provide a guideline for patient care. The following guidelines are to help use the protocols. ITEMS IN BOLD REFLECT CHANGES FOR

3 TABLE OF CONTENTS Procedures 12 Lead ECG application 4 Auto Pulse 9 Induced Hypothermia 10 Adult Cardiac Protocols General guidelines 11 Pediatric Cardiac Protocols General guidelines 12 3

4 General BLS Adult and Pediatric Protocols Abdominal Pain 13 Alcohol Emergency 14 Altered Mental Status / Coma 15 Amputated Parts 16 Anaphylaxis / Allergic Reaction 17 Burns 18 Chest Pain, non-traumatic 19 Chest Pain, traumatic 20 Childbirth 21 CVA / Stroke 22 Dehydration 23 Diabetic Emergencies (Hypo-Hyperglycemia) 24 Dyspnea Eye Injury 27 Fractures 28 Head Injury 29 Hypertensive Emergency 30 Hyperthermia 31 Hypothermia 32 Nausea / Vomiting 33 Near-Drowning 34 Poisoning / Overdose 35 Psychiatric Emergencies 36 Seizure 37 Sexual Assault 38 Spinal Immobilization 39 Shock 40 Snake Bite 41 Spinal Injury 42 Syncope 43 Field Determination of Death 44 4

5 Medication Formulary General Information 45 Albuterol 46 Aspirin 47 Atrovent 48 Dextrose 50%, 25% and 10% 49 Epinephrine 1:1, Glucagon 51 Nitroglycerin 52 Oxygen 53 Ebola Protocol 54 5

6 12-LEAD ECG ***Transmit all ECG s that are concerning for possible MI*** ***Upload ALL 12-Lead ECG s to PCR*** Out of hospital 12-Lead ECG s and advance notification to the receiving facility speeds the diagnosis, shortens the time to fibrinolysis or catheterization, and may be associated with decreased mortality rates. Providers shall complete training for 12-Lead ECG s acquisition prior to utilizing this protocol and ECG machines. INDICATIONS If greater than 5 minutes away from the hospital 12-Lead ECG s should be obtained on all the following: o Non-traumatic chest pain greater than 25 years of age. o Symptomatic tachyarrhythmias such as wide-complex tachycardias, atrial fibrillation, SVT or frequent ectopy. o Symptomatic bradycardias or heart blocks (Type I, II and AV dissociation). o Congestive Heart Failure / Pulmonary edema. o CVA / Stroke. PRECAUTIONS Ideally, 12-Lead ECG acquisition and treatment should occur concurrently but ultimately should not delay treatment of any life threatening conditions. o Lethal dysrhythmias. o Respiratory emergencies. o Treatments such as O2, aspirin and NTG. o Request for advanced life support. Scene time should not be prolonged by acquisition of ECG. Factors that can reduce quality of tracing include dirt, oil, sweat and other material on the skin and patient/vehicle movement. 6

7 12-LEAD ECG PROCEDURE 1. Prepare all the equipment and ensure the cable is in good repair. Check to make sure there are adequate leads and materials for prepping the skin. 2. Prep the skin by first drying sweat or water. Lightly buff the electrode placement areas with an alcohol prep if skin is dirty. 3. Place the four limb leads in accordance with manufacturer s recommendations. Limb lead electrodes are typically placed on the deltoid area and the lower leg or thigh. Avoid placing limb leads over bony prominences. 4. Place the precordial leads (chest or V leads) in accordance with manufacturer s recommendations. Proper placement is important for accurate diagnosis. Leads locations are identified as V1 through V6. a. Locating the V1 position is critically important because it is the reference point for locating the placement of the remaining V leads. To locate the V1 position: I. Place your finger at the notch in the top of the sternum. II. Move your finger slowly downward about 1.5 inches until you feel a slight horizontal ridge of elevation. This is the Angle of Louis where the manubrium joins the body of the sternum. III. Locate the second intercostals space on the patient s right side, lateral to and just below the Angle of Louis. IV. Move your finger down two more intercostals spaces to the fourth intercostals space which is the V1 position. b. Place V2 by attaching the positive electrode to the left of the sternum at the further intercostal space. c. Place V4 by attaching the positive electrode at the midclavicular line at the fifth intercostal space. Note: V4 must be placed prior to V3. d. Place V3 by attaching the positive electrode in the line midway between lead V2 and V4. e. Place V5 by attaching the positive electrode at the anterior axillary line as the same level as V4. f. Place V6 by attaching the positive electrode to the midaxillary line at the same level as V4. CAUTION Never use the nipples as reference points for locating the electrodes for male or female patients because nipple locations may vary widely. When placing electrodes on female patients, always place leads V3 through V6 under the breast rather than on the breast. 5. Ensure that all leads are attached. 6. Turn on the machine. 7. Record the tracing by following the machines specific acquisition procedure and function. 7

8 8. Document on the tracing, the patient s name, date and time the tracing was obtained. 9. Refer to the ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) TRIAGE as indicated. CONSIDERATIONS Acquire an additional 12-Lead ECG every 15 minutes or if the patient s clinical condition changes. 8

9 AUTOPULSE CONTRAINDICATIONS Age < 18 Maximum patient weight is 300 lbs. Trauma APPLICATION 1. Remove all clothing from torso front and back. 2. Align armpits onto yellow line on platform. 3. Do not twist bands and maintain bands at 90 degrees to platform. 4. Power on Autopulse. 5. Close chest bands. 6. Press continue (green button). 7. Press start (green button) to begin compressions. 8. To pause or stop operation, press STOP (orange button). REMOVAL OF LIFEBAND 1. Place Autopulse face down. 2. Lift hinged skirts, pinch 4 locked tabs and remove cover plate. 3. Grasp band with the thumb and index finger of both hands. Push in the middle fingers and pull up the band to remove clip from the shaft. INSTALL NEW LIFEBAND 1. Match arrow on the cover plate with arrow on platform. 2. Insert head end of band clip into slot. 3. Press tail end of band clip into guide plate slot and feel for click. 4. Rotate shaft in either direction to verify band clip is seated in slot. 5. Snap cover plate in place and flip down hinged skirts. 6. IMPORTANT: power on Autopulse. If a fault/user advisory is displayed, check installation of the band clip into the drive shaft slot. 9

10 INDUCED HYPOTHERMIA Begin cold fluids on all patients in which CPR is initiated!!!! Initiate on all arrest patients with the exception of trauma. CAB s. IV access, cardiac monitor, pulse oximetry. INCLUSION CRITERIA Age greater than 18 years old. Initial temperature greater than 34 degrees Celcius (93.2 degrees F). No purposeful pain response. Intubated. More than 5 minutes or less than 30 minutes of no circulation. EXCLUSION CRITERIA Trauma. Obviously pregnant. PREPARATION FOR INDUCTION 1. Conduct a NEURO assessment: o Pupils (size, reactivity, equality). o Motor response to pain. 2. Remove clothing, protect modesty. 3. Apply cold packs axilla and groin areas. 4. Obtain second IV access, if not already in place. 5. Begin cold normal saline infusion of 30 ml/kg to a maximum of 2 liters. 6. Give Versed 2-5 mg IV for sedation, repeat as necessary, titrate to desired effect. 7. Give Vecuronium (Norcuron) 0.1 mg/kg IV to a maximum of 10 mg as necessary to reduce shivering. 8. Start Dopamine at mcg/kg/min IV as needed to maintain a MAP of ***REMEMBER*** DO NOT INITIATE INDUCED HYPOTHERMIA PROTOCOL IF THE PATIENT IS NOT INTUBATED. METABOLIC ALKALOSIS IS COMMON IN COOLING, SO AVOID HYPERVENTILATION (8-10 breaths/minute or 1 breath every 6-8 seconds). DO NOT DELAY TRANSPORT TO INITIATE HYPOTHERMIA. 10

11 ADULT CARDIAC GUIDELINES Always treat the patient and not the monitor. Cardiac arrest caused by trauma is treated by correcting the underlying problem. Protocols for cardiac arrest situations, presumes that the condition under discussion continually persists, the patient on a cardiac monitor remains in cardiac arrest, and CPR is being performed. Chest compressions and defibrillation are more important than the administration of medications or establishment of an advanced airway. All attempts should be made to minimize interruptions in compressions which include allowing no more than 10 seconds for pulse check or no more than 5 seconds to deliver breaths. If an advanced airway is in place, CPR is not stopped to deliver breaths. IV or IO access is the preferred method of delivery of drugs. If an IV cannot be started in an arrest patient quickly, consider starting an IO line. There is a standing protocol for intraosseous lines in arrest patients. Lidocaine, Atropine, Narcan and Epinephrine (LANE) can be administered via the endotracheal tube at 2 to 2 ½ times their regular doses if an IV or IO line cannot be established. This should be followed by 10cc of NS, along with hyperventilation of the patient after each drug. After each IV medication, give a 20 to 30 ml bolus of IV fluid and elevate the extremity. The fluid of choice for the patient in cardiac arrest is Normal Saline. If greater than 5 minutes from the hospital, 12-lead ECG s should be obtained on all the following cardiac problems: o Non-traumatic chest pain greater than 25 years of age. o Symptomatic tachyarrhythmias such as wide-complex tachycardias, atrial fibrillations, SVT or frequent ectopy. o Symptomatic bradycardias or heart blocks (Type I and II and AV dissociation). o Congestive Heart Failure / Pulmonary edema. Initiate Induced Hypothermia Protocol if applicable. Consider 5-H s and 5 T s as underlying causes for PEA / Asystole H T Hypoxia Toxins Hypovolemia Tamponade (cardiac) Hydrogen ion (acidosis) Tension Pneumothorax Hypo- / Hyperkalemia Thrombosis (coronary, pulmonary) Hypothermia Trauma For example: If possible pre-existing acidosis, give Sodium Bicarbonate. If renal failure with possible increased potassium, give Calcium Chloride. If tension pneumothorax, needle decompression. If hypovolemia, give normal saline wide open. If tricyclic overdose, give Sodium Bicarbonate. If narcotic overdose, give Narcan. 11

12 GENERAL PEDIATRIC CARE GUIDELINES The key to quality pediatric care lies in the realization that children are not small adults. Scaled down equipment and smaller drug dosages are only the beginning. Pediatrics requires a different approach to patient care. The following guidelines should be kept in mind when treating pediatrics. The age range in pediatrics can make obtaining a history difficult but you should never dismiss the child s history. A rapid cardiopulmonary assessment should be performed on all patients on initial contact and after each intervention. Cardiac arrest is seldom a sudden event. It is most often the results of a progressive deterioration of the circulatory (shock) and respiratory (hypoxia) systems. Hypoxia produces a reflex bradycardia in children. Any change in respiratory rate should be evaluated for a corresponding change in heart rate and vice-versa. Aggressive airway control and ventilation should always be a top priority. Pediatric IO s are the preferred route of access for all arrest victims. IO s may also be placed in a pediatric patient that is critically ill and needs immediate life-saving intervention. For example, such a patient may be displaying signs and symptoms of inadequate tissue perfusion (pale, cool, cyanotic or diaphoretic skin), altered level consciousness (lethargy), or profound hypotension defined as a systolic blood pressure less than (70 + (age in years x 2)). Note: Any medication directed to be given IV may also be given IO. Never forget you actually have two patients, the child and the parents. Try to involve the parents as much as possible without compromising that care. In a case of obvious death, CPR should be performed if it is the parent s wishes. Never leave the parent with the impression that something else could have been done. 12

13 ABDOMINAL PAIN 1. CAB s. 2. Pulse oximetry. 3. O2 as indicated. 4. Obtain IV access as indicated. Severe pain. Abnormal vital signs. Needed for administration of analgesia or antiemetics ****NO STANDING ORDERS FOR ANALGESICS**** 5. Consider ALS assistance. 6. Treat for shock with NS 500 ml bolus, repeat as necessary and titrate to effect (use with caution in CHF and renal failure patients). 7. Place in position of comfort. 8. Transport as indicated. 13

14 ALCOHOL EMERGENCIES 1. CAB s. 2. Pulse oximetry. 3. O2 as indicated. 4. Consider ALS assistance. 5. Obtain IV access as indicated. Significant altered mental status. Unstable vital signs. 6. Determine glucose level If glucose is less than 70, go to appropriate hypoglycemia protocol. 7. Transport as indicated. 14

15 ALTERED MENTAL STATUS / COMA 1. CAB s. 2. Pulse oximetry. 3. O2 as indicated. 4. Consider ALS assistance. 5. Obtain IV access. 6. Determine glucose level. If glucose is < 70, go to appropriate Hypoglycemia protocol. 7. Transport as indicated. 15

16 AMPUTATIONS 1. CAB s. 2. Control bleeding. Direct pressure. Tourniquet (Document time of application). 3. Pulse oximetry. 4. O2 as indicated. 5. Consider ALS assistance for pain management. 6. Obtain IV access (LARGE BORE PREFERRED). 7. Manage hypovolemic shock if present with NS 500 ml bolus. Repeat as necessary and titrate to effect. Use caution in patients with a history of CHF or renal failure. 8. Rinse amputated part, DO NOT SCRUB!!!!!!!! 9. Wrap part in moistened gauze and place in a plastic bag. 10. Place sealed bag in a container filled with ice water if available. 11. Label container with name, date and time. 12. Transport as indicated. 13. Reassure patient without providing false hopes. 16

17 ANAPHYLAXIS / ALLERGIC REACTION 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen via NRB. 4. Consider ALS assistance. 5. Administer Epinephrine (1:1,000) 0.01 mg/kg IM, maximum dose 0.3 mg. May repeat once after 15 minutes. Use caution with known cardiac history or age over Obtain IV access. 7. If hypotensive or inadequate tissue perfusion, treat with a 500 ml bolus of Normal Saline (NS); repeat as necessary and titrate to effect. For pediatrics, administer Normal Saline 20 ml/kg. 8. Give Albuterol 2.5 mg in 3 ml of NS nebulized, if wheezing or dyspnea is present. 9. Transport as indicated. 17

18 BURNS 1. Stop the burning. Remove burned or smoldering clothes. Cool with cool (not cold), moist, sterile towels if available. Remove dry chemicals by brushing off the substance, and remove liquid chemicals by flushing with large amounts of water. 2. Assure CAB s. 3. Oxygen via NRB and control airway as indicated. 4. Consider ALS assistance. 5. Obtain IV access if applicable (Large bore preferred) with NS bolus of 20 ml/kg. 6. Transport as indicated. 18

19 CHEST PAIN / ANGINA *PRECAUTIONS* Levitra (vardinafil), Cialis (tadalafil), Viagra (sildenafil) and Revatio are the class of drugs that interact with Nitroglycerin (NTG) that can cause life-threatening hypotension. Do Not Give NTG if the patient has had Viagra, Levitra or Revatio within 24 hours of your interview / assessment, or if Cialis (a longer lasting medication) within 48 hours. 1. Assure CAB s obtain a good history of the events leading up to you being there will help figure out if this is a possible angina case or more severe cardiac problem. 2. Obtain vital sign (baseline) with a manual cuff. 3. Pulse oximetry. 4. Apply Oxygen 4 LPM nasal cannula, unless the patient is short of breath give Oxygen at 15 LPM via NRB. 5. Obtain IV access. 6. Administer 4 chewable 81 mg Aspirin. Withhold Aspirin if the patient is on Coumadin (warfarin), Levonox, Heparin, Arixtra, Pradaxa and Xarelto. 7. If systolic blood pressure is greater than 100, then give 1 NTG tablet or spray sublingual every 5 minutes until a maximum of 3 doses, pain is relieved or blood pressure falls less than a 100 systolic. 8. Treat the patient, not the monitor. 19

20 CHEST TRAUMA 1. Assure CAB s. 2. Pulse oximetry. 3. Give Oxygen NRB at LPM. 4. Consider ALS assistance. 5. Obtain IV access Large bore preferred. 6. If open pneumothorax: Place occlusive dressing over the wound and seal on three sides. Monitor for the development of tension pneumothorax. 7. If a tension pneumothorax develops or discovered, remove the dressing and let the pressure equal in the chest, and then replace the dressing. 8. If the patient has a suspected tension pneumothorax with decreased breath sounds, hypotension and hypoxia: Position of comfort. Reduce anxiety. Get ALS. 9. If a flail segment is found, then stabilize it with a bulky dressing. 10. Intubate and ventilate as indicated. 11. Transport as indicated. 20

21 CHILD BIRTH 1. Assure CAB s. 2. Pulse oximetry 3. Consider ALS assistance. 4. Apply Oxygen 100% via NRB. 5. Begin transport immediately. 6. Best position for a patient, not actively delivering, is on the left side. 7. Obtain IV access at least an 18 gauge between wrist and AC preferred. 8. Obtain pertinent history: Number of pregnancies and deliveries. History of problems with pregnancy. Last menstrual period and due date. Current complaints. Past medical history. 9. Perineal examination (DO NOT perform an internal vaginal exam): If in active labor with no bleeding or crowning, transport as indicated. If vaginal bleeding and/or signs of shock, transport emergency. 10. If delivery is imminent: Prepare area for delivery. Prepare mother for delivery. Assist delivery. Protect infant from fall and temperature loss. Clamp cord in 2 places and cut between clamps. Suction, warm, dry and stimulate the infant. Check infant vital signs. Assist with the delivery of the afterbirth. 11. If prolapsed cord: Place mother in a supine position with hips elevated. Place gloved index and middle fingers of one hand into the vagina and push the infant up to relieve the pressure. Check umbilical cord for a pulse and place the cord in a warm, moist dressing level with vagina. Transport in a supine position with her hips elevated. 12. If abnormal presentation, place patient in best possible position and transport emergency: Contact medical control. 21

22 CVA / STROKE 1. Assure CAB s. 2. Begin emergency transport ASAP. *NOTE: If known time since onset of signs/symptoms of CVA is greater than 4.5 hours, then transport non-emergent, if stable. 3. Consider ALS assistance. 4. Pulse oximetry. 5. Apply Oxygen 4 LPM via nasal cannula. If the patient is hypoxic, apply 100% via NRB. 6. Elevate the head no higher than 30 degrees. 7. Obtain IV access. 8. Check glucose: If glucose is less than 70, go to the hypoglycemia protocol. 9. Obtain history from the family if the patient is unable to provide: Onset of symptoms. Seizure at onset of symptoms. Previous CVA. Previous neurologic surgery. On Coumadin (warfarin). Any recent trauma, bleeding or surgery. 10. Perform Cincinnati Prehospital Stroke Scale: Facial droop. Arm drift. Abnormal speech. 11. DO NOT TREAT HYPERTENSION without consultation of medical control. 12. When calling report, include onset of symptoms. 13. Be prepared to go directly to CT scan when arriving at the ED. 14. Notify closest facility of patient report for approval to bypass!!!! **STROKE CENTER TRANSPORT GUIDELINES** 22

23 DEHYDRATION 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen as indicated. 4. Consider ALS assistance. 5. Obtain IV access: Adults Administer NS 500 ml bolus repeat as necessary and titrate to effect. o Use caution in patients with a history of CHF or renal failure. Pediatrics Administer NS 20 ml/kg bolus. 6. Transport as indicated. 23

24 DIABETIC EMERGENCY / HYPERGLYCEMIA 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen as indicated. 4. Consider ALS assistance. 5. Obtain IV access. 6. Determine glucose level: If > 70 and < 400, transport as indicated. If > 400 and patient is STABLE, transport non-emergency. If > 400 and patient is UNSTABLE, transport emergency. 7. Transport as indicated. DIABETIC EMERGENCY / HYPOGLYCEMIA 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen as indicated. 4. Consider ALS assistance. 5. Obtain IV access. 6. Determine glucose level: If < 70 administer Dextrose 50% 25 grams IVP slowly. If patient is awake, alert, cooperative, and blood glucose is > 50 or an IV cannot be obtained, then oral glucose may be given instead of IV Dextrose. If unable to start IV after 3 attempts and patient is not awake, alert, and cooperative, give Glucagon 1 mg IM. Repeat in 20 minutes if glucose level stays < 70. If glucose is > 70, transport as indicated. 7. If IV Dextrose is given, repeat glucose level check in 5 minutes (not sooner). If glucose level is still < 70, repeat Dextrose 50% 25 grams and recheck in 5 minutes. 8. If IV is established after Glucagon administration, then go to step 6 (above) and treat as indicated. 9. Transport as indicated: If the patient s blood glucose and mental status has returned to normal, it is acceptable for EMT s to attend transport non-emergency. If unable to give Dextrose 50% and the patient s mental status is abnormal, then transport emergency. 24

25 DYSPNEA (ADULT) 1. Assure CAB s. 2. Pulse oximetry. 3. Consider ALS assistance. 4. Oxygen to keep O2 sats > 90%. 5. Obtain IV access (may give one nebulizer treatment without IV access). 6. If patient has a history of Asthma or COPD with wheezing or poor air movement, then give: Albuterol 2.5 mg in 3 ml s via nebulizer and Atrovent 0.5 mg in 2.5 ml s. Repeat Albuterol only in 10 minutes if an IV is successfully placed. Otherwise contact medical control for orders to give second Albuterol treatment if needed without IV access. (NOTE: If allergy to Albuterol or heart rate is greater than 130, then administer nebulized Atrovent alone). 7. If the patient has rales and known history of CHF: Consider CPAP, if patient can tolerate. 8. IF NO RESPONSE, Intubate and/or ventilate as needed. 9. If allergen exposure, go to the anaphylaxis protocol. 10. Transport as indicated. 25

26 DYSPNEA (PEDIATRIC) 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen to keep O2 sats > 90%. 4. Consider ALS assistance. 5. Obtain IV access (may give one nebulized treatment without IV access). 6. If history of Asthma: Albuterol 2.5 mg in 3 ml s via nebulizer. Repeat Albuterol in 10 minutes if an IV is successfully placed. Otherwise contact medical control for orders to give a second Albuterol treatment if needed. 7. If allergen exposure, then go to the anaphylaxis protocol. 8. Transport as indicated. 26

27 EYE INJURIES 1. Assure CAB s. 2. Secondary survey for additional injuries. 3. If a chemical injury, flush with large amounts of sterile water and continue flushing en route. 4. Treat and cover the eye (s) without placing pressure on the globe, as indicated by injury. 5. Calm the patient. 6. Transport as indicated. 27

28 FRACTURES (GENERAL CARE) 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen as indicated. 4. Consider ALS assistance for pain management. 5. Secondary survey. 6. Obtain IV access (large bore preferred). 7. Treat for shock, if signs and symptoms are present. 8. Immobilize the fracture by securing both fractured ends and the distal and proximal joints: Femur fracture apply a traction splint or device as needed. Pelvic fracture Stabilize the hip if possible (XP1, KED, sheet wrap, padding, etc.). o Document pulse, motor and sensation before, during and after splinting. 9. Transport as indicated. NOTE: Never delay transport to apply splints to a critical patient. 28

29 HEAD INJURY 1. Assure CAB s. 2. Maintain C-spine precautions. 3. Pulse oximetry. 4. Ventilate with 100% oxygen, if needed. 5. Consider ALS assistance. 6. Obtain IV access. 7. Incline head of spineboard 15 degrees. 8. Restrain as needed to LSB for the combative patient (DO NOT restrain the patient to the cot). 9. Transport as indicated. 29

30 HYPERTENSIVE EMERGENCY 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen via Nasal Cannula at 4 lpm, unless dyspnea/hypoxia exists then apply Non-rebreather mask at 15 lpm. 4. Consider ALS assistance. 5. Obtain IV access. 6. If the patient has CVA or AMS symptoms, DO NOT treat hypertension (refer to CVA/Stroke protocol) and transport as indicated. 7. Try and keep the patient calm and relaxed. 8. Transport as indicated. 30

31 HYPERTHERMIA 1. Immediately cooling has been proven to be more beneficial if done prior to transport from sporting events. If the athletic trainers have cooling capabilities, allow them to cool the patient prior to transport. 2. Assure CAB s. 3. If history is suggestive of heat exhaustion or heat stroke: Remove to cooler environment. Cool with moist sheets slowly so that the patient will not start to shiver. 4. Pulse oximetry. 5. Administer oxygen in indicated. 6. Consider ALS assistance. 7. Obtain IV access and administer Normal Saline from the chill core (1 liter for adults if no history of cardiac disease and 20 ml/kg for pediatrics). 8. If seizures are present, protect the patient from injury. 9. Transport as indicated. 31

32 HYPOTHERMIA 1. Assure CAB s. 2. Actions for all patients: Remove all wet clothing. Protect against heat loss and wind chill. Avoid rough and excessive movement. Consider ALS assistance. Treat only life-threatening arrhythmias. Administer oxygen and begin external warming. Obtain IV access with Normal Saline from the fluid warmers: o Adult dose: Maximum of 1 liter. o Pediatric dose: 20 ml/kg. 3. If no pulse or breathing: Start CPR. 4. Transport as indicated. 32

33 NAUSEA / VOMITING 1. Assure CAB s. 2. Control airway and be prepared to suction. 3. Pulse oximetry. 4. Oxygen as indicated. 5. Consider ALS assistance. 6. Obtain IV access. 7. Transport as indicated. 33

34 NEAR DROWNING 1. Assure CAB s with attention to C-spine. 2. Pulse oximetry. 3. Oxygen via Non-Rebreather or BVM as necessary. 4. Consider ALS assistance. 5. Obtain IV access. 6. If in cardiac arrest, begin CPR. 7. Use aggressive airway control and suction as needed. 8. Transport emergency. 34

35 POISONING / OVERDOSE 1. If inhaled poison, remove patient from the source using appropriate PPE. 2. Assure CAB s. 3. Pulse oximetry. 4. Oxygen via NRB. 5. Consider ALS assistance. 6. Obtain IV access. 7. Check blood glucose, if < 70, go to the hypoglycemia protocol. 8. Obtain history: Type and amount of poison, if possible then bring the container with the patient. Route of intake. Time of intake. History of drug or alcohol usage. 9. Aggressive airway control with ventilation if needed. 10. Suction as needed. 11. If the patient is seizing, then protect from further injury. 12. If involving a chemical, then irrigate it off of the patient. 13. If the chemical is a dry substance, then brush off the chemical before irrigating. 14. Any hypotension, then give a fluid bolus of Normal Saline 1 liter for adults and 20 ml/kg in pediatrics. WHEN IN DOUBT, THEN HAVE DISPATCH CALL POISON CONTROL!!!!!! 35

36 PSYCHIATRIC EMERGENCIES 1. Assure personal safety and involve law enforcement when needed. 2. Approach the patient slowly. 3. Talk in a calm and reassuring tone. 4. Assure CAB s. 5. Apply oxygen as tolerated. 6. Obtain IV access. 7. Determine glucose level and treat as indicated. 8. Restrain the patient as needed for patient care and safety. 9. If restraining and securing is needed, then restrain the patient to a long spine board and not the cot. 10. Transport as indicated. 36

37 SEIZURES 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen via NRB. 4. Consider ALS assistance. 5. Obtain IV access. 6. Determine glucose level: If < 70, go to the appropriate Hypoglycemia protocol. 7. If the patient is actively seizing: Protect the patient from injury. Suction as needed. Consider a nasal trumpet for airway control. 8. If the patient is not seizing: Open and control the airway. Suction as needed. 9. Transport as indicated. 37

38 SEXUAL ASSAULT 1. Assure CAB s. 2. Reassure the patient and provide emotional support. 3. Treat all injuries accordingly. 4. Protect the scene and preserve evidence. 5. Do not allow the patient to bathe, change clothes, or go to the bathroom or douche. 6. Notify the police, if it has not already been done. 7. Place the patient on an open sheet and save the sheet for possible evidence. 8. Transport to the hospital with a same sex crew member as attendant, if possible. 38

39 SPINAL IMMOBILIZATION 1. Spinal immobilization should be performed on the basis of mechanism of injury and the patient s symptoms. If the patient has major mechanism of injury (MOI) or MOI cannot be ruled out, then always immobilize. 2. Do not immobilize if all of the following are present: The patient s mental status is not impaired by drugs, alcohol or head injury. There is no pain to spinal palpation or movement (check palpation first). A brief neurological exam is normal. There is no severe distracting injury. 3. If the patient refuses immobilization, all risks are to be explained to the patient and documented in the narrative along with a witness signature. 4. Any deviation from this protocol requires contact with Medical Control. 5. When in doubt, immobilize. 39

40 SHOCK 1. Assure CAB s. 2. Pulse oximetry. 3. Oxygen via NRB. 4. Consider ALS assistance. 5. Place in supine position as tolerated. 6. Obtain IV access (2 large bore is preferred). 7. Give Normal Saline 500 ml bolus may be repeated PRN (check lung sounds after each bolus). Pediatrics: Give 20 ml/kg bolus. 8. Attempt to determine etiology of shock by history and exam. If hypovolemic / hemorrhagic shock, then continue with IV fluid bolus as necessary and titrate to effect. If anaphylactic shock, then continue with fluid bolus and go to Anaphylaxis / Allergic Reaction protocol. 9. Transport emergency. 40

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