ADULT TREATMENT GUIDELINES - CARDIAC VENTRICULAR FIBRILLATION - PULSELESS VENTRICULAR TACHYCARDIA (SJ-AO1) effective 03/01/2002

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1 ADULT TREATMENT GUIDELINES - CARDIAC VENTRICULAR FIBRILLATION - PULSELESS VENTRICULAR TACHYCARDIA (SJ-AO1) effective 03/01/2002 Revision #5 01/11/02 Identify Dysrhythmia DEFIBRILLATE*: 200 J, 300 J, 360 J; Reassess as Indicated ( <200J if Biphasic technology ) INTUBATE: BV & 100% O2 IV ACCESS: rate as indicated EPINEPHRINE IVP: 1.0 mg 1:10,000 Repeat q 3-5 min., Double dose if via ET DEFIBRILLATE: at last highest Joules LIDOCAINE: 1.5 mg/kg IVP, repeat q 3-5 min x 1 Double dose if via ET (single dose, do not repeat) DEFIBRILLATE: at last highest Joules BRETYLIUM: 5.0 mg/kg IVP repeat q 5 min at 10 mg/kg (max 35 mg/kg) DEFIBRILLATE: at last highest Joules MgSO4: 1-2 gm in ml IVP over 1-2 min Airway, Pulse, ECG, throughout. If hyperkalemia suspected, give Sodium Bicarbonate early DEFIBRILLATE: at last highest Joules CONSIDER LIDOCAINE DRIP: 2-4 mg/min if Pt. converts (after bolus or defib) In the case of alternative waveforms (e.g., Biphasic), AHA guidelines will be followed or used after approval of the EMS medical director. 34

2 ADULT TREATMENT GUIDELINES - CARDIAC PULSELESS ELECTRICAL ACTIVITY (SJ-AO2) effective 05/01/02 Revision #4 04/19/02 Identify Dysrhythmia Auscultate Heart Sounds INTUBATE: BV & 100% O2 IV ACCESS: 2 Large bore at wide open EPINEPHRINE IVP: 1.0 mg 1:10,000; Repeat q 3-5 min., Double dose if via ET ATROPINE (for Bradycardia): 1.0 mg IVP, Repeat q 3-5 min. Max 3.0 mg (0.04 mg/kg), Double dose if via ET Airway, Pulse, ECG, throughout. DOPAMINE DRIP: 5-20 ug/kg/min for hypotensive patients refractory to IV fluids Titrate to SBP >90 (consider second IV) 35

3 ADULT TREATMENT GUIDELINES - CARDIAC ASYSTOLE (SJ-AO3) effective 05/01/02 Revision #5 04/19/02 Identify Dysrhythmia Define in two (2) leads minimum Consider Causes: Acidosis - adequate ventilation Hypoxia - provide ventilation Hypothermia - refer to guideline A62 Drug Overdose - refer to guidelines A51-A56 Hypokalemia - Hyperkalemia - Sodium Bicarbonate, 1 meq/kg IVP (after base contact) INTUBATE: BV & 100% O2 IV ACCESS: rate as indicated Consider TCP if patient was witnessed asystolic <8 minutes Simultaneous EPINEPHRINE IVP: 1.0 mg 1:10,000; Repeat q 3-5 min., Double dose if via ET ATROPINE: 1.0 mg IVP, Repeat q 3-5 min. to max 3.0 mg (0.04 mg/kg) Double dose if via ET Airway, Pulse, ECG, throughout. CONSIDER TERMINATION OF EFFORTS (PER BASE PHYSICIAN): if patient remains in Asystole after intubation and initial medications, if no reversible causes are identified. 36

4 ADULT TREATMENT GUIDELINES - CARDIAC BRADYCARDIA (SJ-AO4) effective 03/01/02 Revision # 4 Identify Dysrhythmia Type II second-degree heart block or Third-degree heart block IV ACCESS: rate as indicated ASSESS FOR SYMPTOMS RELATED TO HYPOTENSION: chest pain, dyspnea, decreased LOC, shock, pulmonary congestion, CHF ECG Rhythm Airway, Pulse, ECG, throughout. First-degree heart block or Type I second-degree heart block Unstable Stable Unstable Stable Atropine, 0.5 mg IVP, repeat q 3-5 min to max 3.0 mg (0.04 mg/kg) Simultaneous TCP If Available Observe Atropine 0.5 mg IVP, repeat q 3-5 min to max 3.0 mg (0.04 mg/kg) If no response Observe If no response Valium, 2-5 mg IV, titrate (if available) Versed 2-5 mg IV/IM to max of 10 mg TCP If Available DOPAMINE DRIP: 5-20 ug/kg/min for hypotensive patients refractory to IV fluids Titrate to SBP >90 (consider second IV) EPINEPHRINE DRIP: 2-10 ug/min Titrate to SBP >90 (consider second IV) Valium, 2-5 mg IV, titrate (if available) Versed 2-5 mg IV/IM to max of 10 mg 37

5 ADULT TREATMENT GUIDELINES - CARDIAC WIDE COMPLEX TACHYCARDIA OF UNCERTAIN TYPE WITH Revision# 3 PULSES (SJ-AO5) effective 03/01/02 Identify Dysrhythmia IV ACCESS: rate as indicated (proximal as possible) ASSESS FOR UNSTABLE vs. STABLE Airway, Pulse, ECG, throughout. UNSTABLE: chest pain, CHF, decreased LOC, dyspnea, hypotension, pulmonary congestion STABLE: no serious signs or symptoms FOR UNSTABLE PATIENTS FOR STABLE PATIENTS LIDOCAINE: mg/kg IVP Single Dose, if condition permits DIAZEPAM: (if available) 2-10 mg titrated for sedation if time allows Versed 2 mg IV/IM LIDOCAINE: mg/kg IVP Repeat q 5 min at 1/2 initial dose to total 3 mg/kg if no conversion CARDIOVERT: 100J, 200J, 300J, 360J Reduce by 1/2 for digitalized patient LIDOCAINE: mg/kg IVP Repeat q 5 min at 1/2 initial dose to total 3 mg/kg if no conversion ADENOSINE: 6 mg rapid IVP, repeat q 3 min with 12 mg rapid IVP x 2 if no conversion BRETYLIUM: 5 mg/kg IVP over 8-10 min. Repeat at 10 mg/kg to total dose of 35 mg/kg if no conversion Avoid in cyclic O.D. 38

6 ADULT TREATMENT GUIDELINES - CARDIAC VENTRICULAR TACHYCARDIA WITH PULSES (SJ-AO6) effective 03/01/02 Revision# 3 Identify Dysrhythmia IV ACCESS: rate as indicated ASSESS FOR UNSTABLE vs. STABLE UNSTABLE: chest pain, CHF, decreased LOC, dyspnea, hypotension, pulmonary congestion Airway, Pulse, ECG, throughout. STABLE: no serious signs or symptoms FOR UNSTABLE PATIENTS FOR STABLE PATIENTS LIDOCAINE: mg/kg IVP Single Dose, if condition permits DIAZEPAM: (if available) 2-10 mg titrated for sedation if time allows, or Versed 2 mg IV/IM LIDOCAINE: mg/kg IVP Repeat q 5 min at 1/2 initial dose to total 3 mg/kg if no conversion CARDIOVERT: 100J, 200J, 300J, 360J Reduce by 1/2 for digitalized patient LIDOCAINE: mg/kg IVP Repeat q 5 min at 1/2 initial dose to total 3 mg/kg if no conversion BRETYLIUM: 5 mg/kg IVP over 8-10 min. Repeat at 10 mg/kg to total dose of 35 mg/kg if no conversion Avoid in cyclic O.D. BRETYLIUM: 5 mg/kg IVP over 8-10 min. Repeat at 10 mg/kg to total dose of 35 mg/kg if no conversion Avoid in cyclic O.D. 39

7 ADULT TREATMENT GUIDELINES - CARDIAC PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (SJ-AO7) effective 03/01/02 Revision# 3 Identify Dysrhythmia IV ACCESS: rate as indicated (proximal as possible) ASSESS FOR UNSTABLE vs. STABLE UNSTABLE: chest pain, CHF, decreased LOC, dyspnea, hypotension, pulmonary congestion Airway, Pulse, ECG, throughout. STABLE: no serious signs or symptoms FOR UNSTABLE PATIENTS FOR STABLE PATIENTS DIAZEPAM: (if available) 2-10 mg titrated for sedation if time allows, or VERSED 2 mg IV/IM Valsalva's Maneuver CARDIOVERT: 100J, 200J, 300J, 360J Reduce by 1/2 for digitalized patient ADENOSINE: 6 mg rapid IVP, repeat q 3 min with 12 mg rapid IVP x 2 if no conversion ADENOSINE: 6 mg rapid IVP, repeat q 3 min with 12 mg rapid IVP x 2 if no conversion 40

8 ADULT TREATMENT GUIDELINES - CARDIAC Revision# 3 ATRIAL FIBRILLATION - ATRIAL FLUTTER* (SJ-AO8) effective 03/01/02 Identify Dysrhythmia IV ACCESS: rate as indicated ASSESS FOR UNSTABLE vs. STABLE Airway, Pulse, ECG, throughout. UNSTABLE: chest pain, CHF, decreased LOC, dyspnea, hypotension, pulmonary congestion STABLE: no serious signs or symptoms FOR UNSTABLE PATIENTS FOR STABLE PATIENTS DIAZEPAM: (if available) 2-10 mg titrated for sedation if time allows, or VERSED 2 mg IV/IM OBSERVE and REASSESS as appropriate CARDIOVERT: 100J, 200J, 300J, 360J Reduce by 1/2 for digitalized patient *Due to high incidence of chronic Atrial Fibrillation, cardiovert only if patient in extremis. 41

9 ADULT TREATMENT GUIDELINES - CARDIAC CORONARY ISCHEMIC CHEST DISCOMFORT (SJ-AO9) effective 09/01/00 Revision #7 04/17/2000 Identify Dysrhythmia APPLY OXYGEN TO PATIENT Consider the following treatments: Airway, Pulse, 3 Lead ECG, throughout. If available: 12 Lead ECG CONTACT WITH RECEIVING FACILITY MANDATORY NITROGLYCERINE: 1/150 gr. (0.4 MG) sublingual (if SBP >90) Repeat q 5 min ASPIRIN: 320mg P.O. (four 80 mg chewable tablets) if myocardial infarction suspected. Check for history of allergy. IV ACCESS: rate as indicated 1 Large Bore IV MORPHINE: 2-5 mg increments, slow IVP (if SBP > 90) Repeat as needed; max 20 mg CONSIDER LIDOCAINE: 1.0 mg/kg IVP for frequent, multifocal PVC's with hypotension 42

10 ADULT TREATMENT GUIDELINES - RESPIRATORY Revision #2 02/02/95 AIRWAY OBSTRUCTION - STRIDOR (SJ-A21) effective 09/01/95 Pulse Oximetry Determine degree of distress: Unstable Unstable vs. Stable Consider Causes Stable Foreign Body Croup/ Epiglottitis Trauma/ Burns Anaphylaxsis CONSIDER IV ACCESS: rate as indicated Position of Comfort Abdominal thrusts/finger sweeps Consider humidified oxygen Intubate and suction as appropriate Refer to allergic reaction guideline A43 ECG: treat dysrhythmia as appropriate Direct Laryngoscopy Avoid Visualization/ OPA OXYGEN: flow as indicated or tolerated Consider Intubation if ventilation inadequate NEEDLE CRICOTHYROTOMY: followed by 50 psi transtracheal oxygen ventilation 43

11 ADULT TREATMENT GUIDELINES - RESPIRATORY CHRONIC OBSTRUCTIVE PULMONARY DISEASE ASTHMA - BRONCHOSPASM (SJ-A22) effective 09/01/95 Revision #3 03/08/95 Pulse Oximetry Determine degree of distress OXYGEN: low flow via nasal cannula, increase as appropriate Consider Intubation ECG: treat dysrhythmia as appropriate ALBUTEROL: 2.5 mg via Hand Held Nebulizer (or inline) Repeat as needed CONSIDER IV ACCESS: rate as indicated Reassess frequently EPINEPHRINE: 0.01 mg/kg of 1:1,000 sub-q (max 0.5 mg) Repeat q 20 min. (Caution with history coronary artery disease, hypertension, age > 35) 44

12 ADULT TREATMENT GUIDELINES - RESPIRATORY ACUTE PULMONARY EDEMA (SJ-A23) effective 09/01/95 Revision #4 02/02/95 Pulse Oximetry Determine degree of distress ECG: treat dysrhythmia as appropriate NITROGLYCERINE: 1/150 gr. (0.4 mg) suglingual (if SBP >90) Repeat q 5 min IV ACCESS: rate as indicated MORPHINE: 2-5 mg increments, slow IVP (if SBP > 90) Repeat as needed; max 20 mg FUROSEMIDE: mg IV over 2-4 min. (if SBP > 90) CONSIDER INTUBATION DOPAMINE DRIP: 5-20 ug/kg/min for hypotension Titrate to SBP of 90 (consider second IV) 45

13 ADULT TREATMENT GUIDELINES - RESPIRATORY TENSION PNEUMOTHORAX (SJ-A24) effective 09/01/95 Revision #2 02/02/95 Determine degree of distress Pulse Oximetry NEEDLE THORACOSTOMY: on affected side(s) ECG: treat dysrhythmia as appropriate IV ACCESS: rate as indicated REASSESS and observe frequently 46

14 ADULT TREATMENT GUIDELINES - NEUROLOGIC ALTERED LEVEL OF CONSCIOUSNESS (SJ-A31) effective 09/01/95 Revision #6 09/15/95 Pulse Oximetry ECG: treat dysrhythmia as appropriate ORAL DEXTROSE: for suspected hypoglycemia with intact gag reflex IV ACCESS: rate as indicated Test for glucose DEXTROSE: 25 gm IVP if serum glucose < 75 Repeat x1 if needed NALOXONE: 2-4 mg IVP/IM or ET for depressed respirations or altered level of consciousness. Repeat as needed. 47

15 ADULT TREATMENT GUIDELINES - NEUROLOGIC ACUTE CEREBROVASCULAR ACCIDENT (SJ-A32) effective 09/01/95 Revision #7 09/15/95 Identify and document neurologic deficits - progressive vs. non-progressive Pulse Oximetry Prevent Aspiration ECG: treat dysrhythmia as appropriate IV ACCESS: rate as indicated Test for glucose DEXTROSE: 25 gm IVP if serum glucose < 75 Repeat x1 if needed REASSESS neurologic findings TRANSPORT: code 3 if progressive neurologic deficit evident CONSIDER FUROSEMIDE: mg slow IVP if SBP > 190 and DBP > 110 mmhg 48

16 ADULT TREATMENT GUIDELINES - NEUROLOGIC Revision# 6 SEIZURES (SJ-A33) effective 03/01/02 Prevent injury ECG: treat dysrhythmia as appropriate CONSIDER IV ACCESS: rate as indicated Test for glucose DEXTROSE: 25 gm IVP if serum glucose < 75 Repeat x1 if needed DIAZEPAM: (if available) 2-10 mg slow IVP Titrate in 2 mg increments to max 20 mg or VERSED: 1-2 mg IV/IM, max 10 mg, for active seizure control 49

17 ADULT TREATMENT GUIDELINES - NEUROLOGIC ALTERED LEVEL OF CONSCIOUSNESS (SJ-A31) effective 09/01/95 Revision #6 09/15/95 Pulse Oximetry ECG: treat dysrhythmia as appropriate ORAL DEXTROSE: for suspected hypoglycemia with intact gag reflex IV ACCESS: rate as indicated Test for glucose DEXTROSE: 25 gm IVP if serum glucose < 75 Repeat x1 if needed NALOXONE: 2-4 mg IVP/IM or ET for depressed respirations or altered level of consciousness. Repeat as needed. 47

18 ADULT TREATMENT GUIDELINES - MEDICAL SHOCK, NON-TRAUMATIC (SJ-A41) effective 09/01/95 Revision #4 02/02/95 Attempt to determine cause of shock Pulse Oximetry ECG: treat dysrhythmia as appropriate IV ACCESS: 2 - large bore 250cc fluid challenges to SBP of 90 If no signs/symptoms of pulmonary edema REASSESS as indicated DOPAMINE DRIP: 5-20 ug/kg/min for hypotension Titrate to SBP of 90 (consider second IV) 51

19 ADULT TREATMENT GUIDELINES - MEDICAL DIABETIC KETOACIDOSIS (SJ-A42) effective 09/01/95 Revision #4 02/02/95 Pulse Oximetry ECG: treat dysrhythmia as appropriate IV ACCESS: 250cc boluses, max 2 liters Test for glucose 52

20 ADULT TREATMENT GUIDELINES - MEDICAL ALLERGIC REACTION (SJ-A43) effective 09/01/95 Revision #5 03/08/95 Determine type of allergen if possible Determine severity of reaction Pulse Oximetry Severe Severe vs. Mild/Mod REMOVE ALLERGEN: if possible Mild/ Moderate REMOVE ALLERGEN: if possible EPINEPHRINE: 0.01 mg/kg sub-q of 1:1,000 Max dose 0.5 mg. Caution with age > 35, hx: HTN IV ACCESS: 2 - large bore. 250cc fluid challenges as indicated DIPHENHYDRAMINE: mg IVP or IM CONSIDER DIPHENHYDRAMINE: mg IVP or IM CONSIDER ALBUTEROL: 2.5 mg via Hand Held Nebulizer (or inline) for persistent respiratory distress CONSIDER ALBUTEROL: 2.5 mg via Hand Held Nebulizer CONSIDER INTUBATION CONSIDER EPINEPHRINE: 0.01 mg/kg sub-q of 1:1,000. Max dose 0.5 mg. Caution with age > 35, hx: HTN EPINEPHRINE: 0.1 mg of 1:10,000 slow IVP if SBP < 80. Repeat every 1-2 min. (OR) CONSIDER IV ACCESS: rate as indicated EPINEPHRINE DRIP: 2-10 ug/min Titrate to SBP >90 (consider second IV) DOPAMINE DRIP: 5-20 ug/kg/min for hypotensive patients refractory to IV fluids Titrate to SBP >90 (consider second IV) 53

21 ADULT TREATMENT GUIDELINES - MEDICAL HYPERTENSION (SJ-A44) effective 09/01/95 Revision #3 02/02/95 ECG: treat dysrhythmia as appropriate CONSIDER IV ACCESS: rate as indicated TREAT ASSOCIATED SYNDROMES Acute Cerebrovascular Accident - refer to guideline A32 Coronary Ischemic Chest Discomfort - refer to guideline A09 Pregnancy - if seizing, refer to guideline A75 Pulmonary Edema - refer to guideline A23 54

22 ADULT TREATMENT GUIDELINES - POISONINGS BETA BLOCKER OVERDOSE (SJ-A51) effective 09/01/95 Revision #5 09/15/95 Determine type, amount, and when ingestion occurred Severity of distress ECG: treat dysrhythmia as appropriate IV ACCESS: rate as indicated ATROPINE: 0.5 mg IVP every 3-5 min to max 3 mg (0.04 mg/kg). For symptomatic bradycardia. Test for glucose DEXTROSE: 25 gm IVP if serum glucose < 75 Repeat x1 if needed DIAZEPAM: 2-10 mg slow IVP. Titrate in 2 mg increments to max. 20 mg for active seizure control. ALBUTEROL: 2.5 mg via Hand Held Nebulizer (or inline). Repeat as needed. ACTIVATED CHARCOAL: gm P.O. DOPAMINE DRIP: 5-20 ug/kg/min for hypotensive patients refractory to IV fluids. Titrate to SBP >90 (consider second IV) EPINEPHRINE DRIP: 2-10 ug/min. Titrate to SBP >90 (consider second IV) 55

23 ADULT TREATMENT GUIDELINES - POISONINGS CALCIUM CHANNEL BLOCKER OVERDOSE (SJ-A52) effective 09/01/95 Revision #3 02/02/95 Determine type, amount, and when ingestion occurred ECG: treat dysrhythmia as appropriate IV ACCESS: rate as indicated ATROPINE: 0.5 mg IVP every 3-5 min to max 3 mg (0.04 mg/kg). For symptomatic bradycardia. ACTIVATED CHARCOAL: gm P.O. DOPAMINE DRIP: 5-20 ug/kg/min for hypotensive patients refractory to IV fluids. Titrate to SBP >90 (consider second IV) EPINEPHRINE DRIP: 2-10 ug/min. Titrate to SBP >90 (consider second IV) 56

24 ADULT TREATMENT GUIDELINES - POISONINGS CAUSTICS - CORROSIVES (SJ-A53) effective 09/01/95 Revision #4 02/02/95 Scene Safety - HAZMAT Determine type, amount, and when exposure occurred REMOVE AGENT: brush then flush DO NOT INDUCE VOMITING: if ingestion occurred CONSIDER: early intubation if respiratory burn likely ECG: treat dysrhythmia as appropriate IV ACCESS: rate as indicated BURN or SHOCK GUIDELINES: as indicated Burn = A81 Shock = A41 WATER or MILK: p.o. if ingestion occurred 57

25 ADULT TREATMENT GUIDELINES - POISONINGS Revision# 6 CYCLIC ANTIDEPRESSANTS (SJ-A54) effective 03/01/02 Determine type, amount, and when ingestion occurred Pulse Oximetry ECG IV ACCESS: rate as indicated. Caution with fluid boluses due to high incidence of pulmonary edema SODIUM BICARBONATE: 1 meq/kg slow IVP for dysrhythmias, altered mental status, or QRS > 0.10 sec. Max dose 2 meq/kg. Treatment of choice for cardio-respiratory and neurologic dysfunction. MgSO4: 1-2 gm in ml IVP over 1-2 min For Torsades de Pointes refractory to Sodium Bicarbonate ECG: treat dysrhythmia as appropriate if refractory to Sodium Bicarbonate DIAZEPAM: (if available) 2-10 mg slow IVP Titrate in 2 mg increments to max 20 mg or VERSED: 2-5 mg,iv/im max of 10mg ACTIVATED CHARCOAL: gms via NG Tube after intubation. Early administration encouraged. SODIUM BICARBONATE DRIP: 100 meq/1000ml for dysrhythmias or QRS > 0.10 sec. (consider second IV) EPINEPHRINE DRIP: 2-10 ug/min. Titrate to SBP >90 (consider second IV) 58

26 ADULT TREATMENT GUIDELINES - POISONINGS PHENOTHIAZINE REACTIONS (SJ-A55) effective 09/01/95 (DYSTONIC REACTIONS) Revision #3 02/02/95 Determine type, amount, and when ingestion occurred CONSIDER IV ACCESS: rate as indicated DIPHENHYDRAMINE: mg IVP or IM May repeat x1. 59

27 ADULT TREATMENT GUIDELINES - POISONINGS NARCOTICS - SEDATIVES (SJ-A56) effective 09/01/95 Revision #3 02/02/95 Determine type, amount, and Time taken CONSIDER IV ACCESS: rate as indicated NALOXONE: 2-4 mg IVP/IM or ET for depressed respirations or L.O.C. Repeat as needed ECG: treat dysrhythmia as appropriate ACTIVATED CHARCOAL: gms for history of oral ingestion. 60

28 ADULT TREATMENT GUIDELINES - POISONINGS Revision# 5 ORGANOPHOSPHATES (SJ-A57) effective 03/01/02 Scene Safety - HAZMAT Determine type, amount, and time of exposure REMOVE AGENT: brush then flush ECG: treat dysrhythmia as appropriate IV ACCESS: rate as indicated ATROPINE: mg slow IVP, or 2.0 mg IM, or 4.0 mg ET Repeat q 5 min as needed to control secretions, bronchorrhea, or dysrhythmias. NOTE: large amounts may be needed. DIAZEPAM: (if available) 2-10 mg slow IVP Titrate in 2 mg increments to max 20 mg or VERSED: 2-5 mg IV/IM, max of 10mg ACTIVATED CHARCOAL: gms p.o. for oral ingestion Early Notification for Hospital Preparation 61

29 ADULT TREATMENT GUIDELINES - POISONINGS PETROLEUM DISTILLATES (SJ-A58) effective 09/01/95 Revision #3 02/02/95 Determine type, amount, and time of exposure REMOVE AGENT: brush then flush DO NOT INDUCE VOMITING: if ingestion occurred Monitor for Aspiration CONSIDER EARLY INTUBATION ECG: treat dysrhythmia as appropriate CONSIDER IV ACCESS: rate as indicated 62

30 ADULT TREATMENT GUIDELINES - ENVIRONMENTAL ENVENOMATION (SJ-A61) effective 09/01/95 Revision #5 09/15/95 Determine type and time of exposure ECG: treat dysrhythmia as appropriate CONSIDER IV ACCESS: rate as indicated Identify Cause Bee/Wasp Spider/ Scorpion Snake Scrape stinger away Scrape stinger away Avoid movement Keep extremity below heart Cold packs for pain Cold packs for pain Circle swelling and note time Measure proximal circumference and note time Apply loose restricting band Refer to Allergic Reaction Guideline A43 63

31 ADULT TREATMENT GUIDELINES - ENVIRONMENTAL HYPOTHERMIA - FROSTBITE (SJ-A62) effective 09/01/95 Revision #5 09/15/95 Determine time and duration of exposure Determine severity of exposure Severe Hypothermia Mild/Moderate Hypothermia Frostbite PREVENT FURTHER HEAT LOSS: remove wet clothing and cover with dry blankets (move gently) PREVENT FURTHER HEAT LOSS: remove wet clothing and cover with dry blankets (move gently) PREVENT FURTHER HEAT LOSS: remove wet clothing and cover with dry blankets (move gently) ECG: observe rhythm/pulse for one minute for organized rhythm. Treat dysrhythmia as appropriate IV ACCESS: rate as indicated with warm fluids IV ACCESS: rate as indicated with warm fluids Test for glucose DEXTROSE: 25 gms IVP for serum glucose < 75 Repeat x1 if needed NALOXONE: 2-4 mg IVP/IM or ET for suspected narcotic O.D. Repeat as needed IV ACCESS: rate as indicated with warm fluids MORPHINE: 2-5 mg increments, slow IVP (if SBP > 90). Repeat as needed. Max 20 mg. 64

32 ADULT TREATMENT GUIDELINES - ENVIRONMENTAL Revision# 6 HEAT ILLNESS (SJ-A63) effective 03/01/02 Determine severity of distress Heat Stroke Heat Cramps/ Heat Exhaustion COOLING MEASURES COOLING MEASURES IV ACCESS: 250cc fluid challenges to SBP of 90 CONSIDER IV ACCESS: rate as indicated CONSIDER Test for glucose DEXTROSE: 25 gms IVP if serum glucose < 75 Repeat x1 if needed DIAZEPAM: (if available) 2-10 mg slow IVP Titrate in 2 mg increments to max 20 mg or VERSED: 2-5 mg IV/IM, max of 10mg 65

33 ADULT TREATMENT GUIDELINES - OBSTETRICS VAGINAL HEMORRHAGE WITH SHOCK (SJ-A71) effective 09/01/95 Revision #3 02/02/95 Determine trimester of pregnancy Estimate blood loss (EBL) Early transport IV ACCESS: two large bore, 250cc fluid challenges as needed to SBP of 90 POSITION: left lateral decubitus if 3rd trimester pregnancy 66

34 ADULT TREATMENT GUIDELINES - OBSTETRICS VAGINAL HEMORRHAGE WITHOUT SHOCK (SJ-A72) effective 09/01/95 Revision #3 02/02/95 Determine trimester of pregnancy Estimate blood loss (EBL) Early transport CONSIDER IV ACCESS: rate as indicated POSITION: left lateral decubitus if 3rd trimester pregnancy 67

35 ADULT TREATMENT GUIDELINES - OBSTETRICS IMMINENT DELIVERY - NORMAL (SJ-A73) effective 09/01/95 Revision #3 02/02/95 Determine trimester of pregnancy Estimate blood loss (EBL) IV ACCESS: consider if time allows, rate as indicated DELIVER HEAD: suction mouth/nose CHECK NECK: for wrapped cord; if present - loosen and slip over infants head, if unable - double clamp and cut between clamps PROCEED WITH DELIVERY: DRY INFANT WRAP: in warm, dry, cloth or place on mom and cover CUT & CLAMP: six (6) inches from baby APGAR's: at one (1) & five (5) min. NEONATAL RESUSCITATION FORMAT: per guideline N01 ALLOW DELIVERY OF PLACENTA 68

36 ADULT TREATMENT GUIDELINES - OBSTETRICS IMMINENT DELIVERY - COMPLICATED (SJ-A74) effective 09/01/95 Revision #3 02/02/95 Determine trimester of pregnancy Estimate blood loss (EBL) IV ACCESS: if time allows, rate as indicated Transport according to specialty triage criteria Type of abnormal presentation Breech or Footling Prolapsed cord Early Transport Insert gloved hand into vagina, gently push presenting part off cord Allow delivery to proceed to waist Place mom into Trendelenburg position with hips elevated Transport ROTATE: infant to face-down If head does not deliver, insert gloved hand into vaginal opening and create air passage for infant Early if possible Early if possible 69

37 ADULT TREATMENT GUIDELINES - OBSTETRICS PRE-ECLAMPSIA, ECLAMPSIA (SJ-A75) effective 09/01/95 Revision #4 03/08/95 Determine trimester of pregnancy Early transport Determine degree of distress POSITION: left lateral decubitus if 3rd trimester pregnancy Transport according to specialty triage criteria EARLY TRANSPORT: quiet, non-stimulating environment IV ACCESS: rate as indicated MgSO4: 2-4 gm in ml slow IVP over 1-2 min. for active seizure control. FOR SEIZURES: refractory to MgSO4, proceed to Guideline A33 70

38 ADULT TREATMENT GUIDELINES - TRAUMA BURNS (SJ-A81) effective 09/01/95 Revision #3 02/02/95 Determine time, type, and severity of burn MOVE PATIENT: to safe environment STOP THE BURNING PROCESS: brush then flush airway frequently CONSIDER: early intubation if respiratory burn likely IV ACCESS: large bore, wide open for 2nd & 3rd Degree Burns CONSIDER: second IV, large bore ECG: treat dysrhythmia as appropriate DRESS BURNS: with sterile drapes MORPHINE: 2-5 mg increments, slow IVP (SBP > 90) Repeat as needed. Max 20 mg. 71

39 ADULT TREATMENT GUIDELINES - TRAUMA TRAUMATIC SHOCK (SJ-A82) effective 09/01/95 Revision #3 02/02/95 Determine mechanism of injury Load and Go: to appropriate facility by best method available Early base notification for surgical mobilization frequently C-SPINE: as indicated BLEEDING CONTROL: as indicated IV ACCESS: 2 large bore, 250 cc fluid challenges as needed until SBP of 100 DRESS & SPLINT: as needed. Return extremities to anatomical position. Reassess neurovascular frequently. CONSIDER NEEDLE THORACOSTOMY: for tension pneumothorax on affected side(s) 72

40 ADULT TREATMENT GUIDELINES - TRAUMA TRAUMATIC ARREST (SJ-A83) effective 09/01/95 Revision #4 03/08/95 Determine mechanism of injury Load and Go: to appropriate facility by best method available Early base notification for surgical mobilization ECG: treat dysrhythmia as appropriate INTUBATE: BV & 100% O2 airway, rhythm and pulse frequently C-SPINE: as indicated BLEEDING CONTROL: as indicated IV ACCESS: 2 large bore, 250 cc fluid challenges as needed until SBP of 100 DRESS & SPLINT: as needed. Return extremities to anatomical position. Reassess neurovascular frequently. CONSIDER NEEDLE THORACOSTOMY: for tension pneumothorax on affected side(s) CONSIDER TERMINATION OF EFFORTS (PER BASE PHYSICIAN): if patient remains in Asystole after intubation and initial medications, if no reversible causes are identified 73

41 ADULT TREATMENT GUIDELINES - TRAUMA HEAD - NECK - FACIAL TRAUMA (SJ-A84) effective 09/01/95 Revision #4 09/15/95 Determine mechanism of injury Consider Load and Go: to appropriate facility by best method available Early base notification for surgical mobilization Hyperventilate via ET to decrease ICP NOTE: medicate head injured patients with Lidocaine 1.5 mg/kg IV prior to intubation as time allows C-SPINE: as indicated airway frequently Transport according to specialty triage criteria BLEEDING CONTROL: as indicated POSITION: head injured patients with head of board elevated degrees (if normotensive) IV ACCESS: rate as indicated DRESS & SPLINT: as needed CONSIDER MORPHINE: 2-5 mg increments, slow IVP (if SBP > 90) for severe pain. Repeat as needed. Max dose 20 mg LASIX: 40 mg slow IVP if SBP > 90 74

42 ADULT TREATMENT GUIDELINES - TRAUMA CHEST TRAUMA (SJ-A85) effective 09/01/95 Revision #4 09/15/95 Determine mechanism of injury Load and Go: to appropriate facility by best method available Early base notification for surgical mobilization C-SPINE: as indicated airway frequently BLEEDING CONTROL: as indicated ECG: treat dysrhythmia as appropriate IV ACCESS: 2 large bore, 250 cc fluid challenges as needed until SBP of 100 DRESS & SPLINT: as needed. Return extremities to anatomical position. Reassess neurovascular frequently. MORPHINE: 2-5 mg increments, slow IVP (if SBP > 90) for severe pain. Repeat as needed. Max dose 20 mg NEEDLE THORACOSTOMY: for tension pneumothorax on affected side(s) 75

43 ADULT TREATMENT GUIDELINES - TRAUMA ABDOMINAL TRAUMA (SJ-A86) effective 09/01/95 Revision #3 02/02/95 Determine mechanism of injury Load and Go: to appropriate facility by best method available Early base notification for surgical mobilization frequently C-SPINE: as indicated BLEEDING CONTROL: as indicated IV ACCESS: 2 large bore, 250 cc fluid challenges as needed until SBP of 100 DRESS & SPLINT: as needed. Return extremities to anatomical position. Reassess neurovascular frequently. MORPHINE: 2-5 mg increments, slow IVP (if SBP > 90) for severe pain. Repeat as needed. Max dose 20 mg 76

44 ADULT TREATMENT GUIDELINES - TRAUMA EXTREMITY TRAUMA (SJ-A87) effective 09/01/95 Revision #4 03/08/95 Determine mechanism of injury Consider Load and Go: to appropriate facility by best method available Early base notification for surgical mobilization C-SPINE: as indicated frequently BLEEDING CONTROL: as indicated IV ACCESS: 2 large bore, 250 cc fluid challenges as needed until SBP of 100 DRESS & SPLINT: as needed. Return extremities to anatomical position. Reassess neurovascular frequently. Cover exposed bone with saline soaked gauze. MORPHINE: 2-5 mg increments, slow IVP (if SBP > 90) for severe pain. Repeat as needed. Max dose 20 mg AMPUTATIONS: partial, dress and splint in anatomical position; complete, place part in sterile container and place container on ice 77