UH EMS PROTOCOLS INTRODUCTION

Transcription

1 UH EMS PROTOCOLS INTRODUCTION Chapter 1: Admin Ops Chapter 2: Airway Breathing Protocol Chapter 3: Shock Circulation Chapter 4: ACLS Protocols Chapter 5: Medical Emergencies Protocol Chapter 6: Pediatric Protocols Chapter 7: Trauma Protocols Chapter 8: Obstetrics Protocols Chapter 9: Pharmacology Protocol Chapter 10: RSI Protocol Chapter 11: Protocol Appendix

2 ADMINISTRATION/OPERATIONS EMS Levels of Certification EMS Recertification Requirements / Scope of Practice Aeromedical Transport Advanced Directives - Do Not Resuscitate (DNR) Orders Child Abuse/ Neglect Concealed Weapons Guidelines Consent and Refusal of Care Guidelines EMS Communications EMS Documentation Dead On Arrival (DOA) Domestic Violence/ Sexual Assault/ Rape/ Elder Abuse Health Insurance Portability and Accountability Act (HIPAA) Newborn Abandonment Obese Patients On Scene EMT/Nurse/ Physician Intervener Transports, Inter-Facility & Non-Hospital Patient Drug Exchange (Box Exchange) 1-28 UH Protocols Chapter 1 Administration/Operations 1

3 ADMINISTRATION/OPERATIONS EMS LEVELS OF CERTIFICATION / SCOPE OF PRACTICE These protocols recognize that there is a role for all levels of Emergency Medical Technician Certification. Not every function defined by the State of Ohio is approved under specific hospital Medical Directors. Patient care should always be delivered at the highest level of EMS available. All Provider levels must function within the State Of Ohio EMS Scope Of Practice for their particular Provider level. Every EMS Provider must be aware of the State of Ohio requirements for recertification, and each individual is responsible for personally fulfilling these requirements. Those seeking to fulfill National Registry of Emergency Medical Technician (NREMT) requirements may do so under their own individual responsibility. Continuing Education certifications must be received through an approved Continuing Education site with a valid accreditation # noted, and must be filed properly. Each EMS Provider must maintain his / her own personal records, and be responsible for his / her own Continuing Education status. UH Protocols Chapter 1 Administration/Operations 3

4 ADMINISTRATION/OPERATIONS EMS RECERTIFICATION REQUIREMENTS EMT ADVANCED PARAMEDIC 40 hours of CE which includes: 6 hours of pediatric education 2 hours of geriatric education 8 hours of trauma training 2 hours of local trauma time protocol/issues training (2 of the 8 hours must be dedicated to local protocol/issues training) OR State approved EMT Refresher Course (including pediatric, geriatric and trauma requirements) Current NREMT Renewal Requirements Current registration as an EMT Basic with the NREMT on the expiration date of your Ohio certification will be recognized as having met the CE requirements for renewal If opting for National Registry Renewal, all that is required is: 2 hours of local trauma/triage/issues training OR Exam in Lieu of CE (for all levels) This exam is similar to the exam for initial certification and can be taken during the last six months of your certification cycle. Contact the Division of EMS to obtain information on registering for this exam 60 hours of CE which includes: 8 hours of pediatric education 4 hours of geriatric education 8 hours of trauma training 2 hours of local trauma triage protocol/issues training (2 of the 8 hrs must be dedicated to local/issues training) OR Current NREMT Renewal Requirements Current registration as an EMT intermediate with the NREMT on the expiration date of your Ohio certification will be recognized as having met the CE requirements for renewal OR Forty-eight (40) hours Advanced Refresher Course PLUS 20 additional hours of CE OR If opting for National Registry Renewal, all that is required is: 2 hours of local trauma/triage issues training 86 hours of CE which includes: 12 hours of pediatric education 4 hours of geriatric education 8 hours of trauma training 2 hours of local trauma triage protocol/issues training (2 of the 8 hrs must be dedicated to local protocols/issues training) PLUS 6 hours on emergency cardiac care, ACLS certification or equivalent course approved by EMS Board OR Forty-eight (48) hours Paramedic Refresher Course PLUS Thirty Eight (38) additional hours of CE PLUS ACLS certification or equivalent course approved by the EMS Board OR Current NREMT-P Renewal Requirements Current registration as a Paramedic with the NREMT on the expiration date of your Ohio certification will be recognized as having met the CE requirements for renewal If opting for National Registry Renewal, all that is required is: 2 hours of local trauma/triage/ issues training UH Protocols Chapter 1 Administration/Operations 4

5 ADMINISTRATION/OPERATIONS AEROMEDICAL TRANSPORT Helicopter/Hospital Intercepts If the patient requires specialized care, i.e. level 1 trauma center, and conditions allow for rapid transport to the nearest facility, a helicopter/hospital intercept can be initiated. When a helicopter/hospital intercept is initiated, the receiving hospital medical control will be contacted, advised of request for helicopter intercept and minimum patient information of nature of call/chief complaint, and then medical control will direct the appropriate personnel to call for the helicopter. Scene Flights Scene flights will be organized with the cooperation of the responding EMS, fire, and law enforcement agencies. The following defines how the on-scene Incident Command (IC) should request an Air Ambulance to the scene of an emergency incident due to the mixture of public fire, EMS and private EMS systems. KEY POINTS Recognize that it is safer to transport a patient from a well-lit, specially designed helipad than it is from an accident scene. EMS must be aware of the potential danger presented by poor lighting and potential scene hazards such as electrical wires or fire. Limit helicopter scene loading to the few cases where it is essential. Patient transportation via ground ambulance will not be delayed to wait for helicopter transportation. If the patient is packaged and ready for transport and the helicopter is not on the ground, or within a reasonable distance, the transportation will be initiated by ground ambulance. Aeromedical transport should be requested to the ground ambulance destination when appropriate, after conferring with medical control, to ensure the patient is transported to the most appropriate facility. Time estimation should be made from the time the patient is ready for transport to arrival at the medical facility/the most appropriate trauma center. This should include aircraft response to the scene. A flight physician on the scene assumes care of the patient. If a physician on the scene asks a squad member to perform beyond the squad member s level of authorization, the squad member should inform the physician that he/she is unable to do so. EMS should request aeromedical transport of the patient to the closest most appropriate hospital, based upon location, patient or family request, and the capabilities of the hospitals (i.e. Trauma Center, OB Unit, etc.). UH Protocols Chapter 1 Administration/Operations 5

6 ADMINISTRATION/OPERATIONS ADVANCED DIRECTIVES - DO NOT RESUSCITATE (DNR) ORDERS PURPOSE Ideally, any patient presenting to the EMS system with a valid DNR form shall have the form honored and CPR and ALS therapy withheld in the event of cardiac arrest. To honor the end of life wishes of the patient To prevent the initiation of unwanted resuscitation PROCEDURE Ohio s DNR Comfort Care is the only law encompassing EMS. For any other type of DNR documents, you must contact Medical Control and describe your circumstances to a Physician. The Physician will then decide if EMS should honor the DNR document, or begin resuscitation of the patient. This includes the Ohio Living Will or any other document to this effect. A DNR order for a patient of a healthcare facility shall be considered current in accordance with the facility s policy. A DNR order for a patient outside a healthcare facility shall be considered current unless discontinued by the patient s attending physician/cnp/cns, or revoked by the patient. EMS personnel are not required to research whether a DNR order that appears to be current has been discontinued. *** If you are presented with any in hospital Limitation of Life Treatment Orders (DNAR form) or any end of life care document other then the standard Ohio DNR Comfort Care form. Contact Medical Control for guidance. *** STATE OF OHIO DNR COMFORT CARE GUIDELINES Under its DNR Comfort Care Protocol, the Ohio Department of Health has established two standardized DNR order forms: DNR Comfort Care Terminally ill condition and in effect at all times. DNR Comfort Care Arrest In effect in the event of a cardiac or respiratory arrest. When completed by a doctor (or certified nurse practitioner or clinical nurse specialist, as appropriate), these standardized DNR orders allow patients to choose the extent of the treatment they wish to receive at the end of life. Ohio DNR Comfort Care can be identified by the original/copy of the State of Ohio DNR Comfort Care Form with official DNR logo, a DNR Comfort Care necklace, bracelet, or card with official DNR Comfort Care logo. The form must be completed with effective date and signed by the patient s physician. To enact the DNR Comfort Care, the patient must be experiencing a terminal event. EMS is not required to search for a DNR identification but should make a reasonable attempt to identify that the patient is the person named on the DNR Comfort Care form. Only the patient may request reversal of the DNR Comfort Care order. UH Protocols Chapter 1 Administration/Operations 6

7 ADMINISTRATION/OPERATIONS ADVANCED DIRECTIVES - DO NOT RESUSCITATE (DNR) ORDERS Care to be provided by EMS: Suction the airway Administer oxygen Position for comfort Splint or immobilize Control bleeding Provide pain medication Provide emotional support Contact other appropriate health care providers (hospice, home health, attending physician or certified nurse) Care NOT to be provided by EMS: Administer chest compressions Insert artificial airway Administer resuscitative drugs Defibrillate or cardiovert Provide respiratory assistance (other than described above) Initiate resuscitative IV Initiate cardiac monitoring UH Protocols Chapter 1 Administration/Operations 7

8 ADMINISTRATION/OPERATIONS ADVANCED DIRECTIVES - DO NOT RESUSCITATE (DNR) ORDERS KEY POINTS The DNR order addresses a patient s current state of health and the kind of medical treatment he/she and their physician decide is appropriate under the current circumstances. A DNR order for a patient of a healthcare facility shall be considered current in accordance with the facility policy. A DNR order for a patient outside a healthcare facility shall be considered current unless discontinued by the patient s attending physician/cnp/cns, or revoked by the patient. EMS personnel are not required to research whether a DNR order that appears to be current has been discontinued. It is imperative that a copy of or the original DNR / Comfort Care orders and identification accompany the patient wherever the patient goes. This will help to alleviate any confusion between healthcare givers at multiple sites. Be careful to check the patient s DNR order or DNR identification to determine if DNR-CC or DNR-CC Arrest. EMS is not required to search a person to see if they have DNR identification. If any of the DNR identifiers are in the possession of the patient, EMS must make a reasonable attempt to identify the patient by patient s name given by patient, family, caregiver, friend, or healthcare worker who knows the patient; ID band from healthcare institution; drivers license or other picture I.D. The patient may request resuscitation even if he/she is a DNR Comfort Care or DNR Comfort Care- Arrest Patient and/or the DNR Comfort Care Protocol has already been activated. The patient s request for resuscitation amounts to a revocation of any or all DNR Comfort Care Status and resuscitative efforts must be activated. If EMS has responded to an emergency situation by initiating any of the will not perform actions prior to confirming that the DNR Comfort Care Protocol must be activated, discontinue them when you activate the protocol. You may continue respiratory assistance, IV medications, etc, that have been part of the patient s ongoing course of treatment for their underlying condition or disease. If the patient s family or bystanders request or demand resuscitation for a patient for whom the DNR Comfort Care Protocol has been activated, do not proceed with resuscitation. Provide will perform actions as outlined above and try to help them understand the dying process and the patient s initial choice not to be resuscitated. For EMS - The Ohio DNR Comfort Care law is the only one you (EMS) can honor on your own. For any other types of DNR documents, you must contact Medical Control and describe your circumstances to a Physician. The Physician will decide if you should honor the DNR document, or begin resuscitation of the patient. A living will document specifies in advance the kind of medical treatment a patient would want if and when he/she has a terminal illness or are in a permanently unconscious state and are no longer able to state their own wishes. It may not protect him/her from receiving CPR or other heroics. It only takes effect if they are in a certifiably terminal or permanently unconscious state. A Health Care Power of Attorney is a document that names another person (usually a spouse, child, or other relative, and preferably someone who can understand a patients health status and make hard decisions on their behalf, if necessary) to make healthcare decisions for them whenever they are unable to do so. It is not a DNR order, though it ordinarily would permit the person they appoint to agree to a DNR order for them if they are unable to express their wishes at the time. The General Power of Attorney usually does not address healthcare issues and ends if he/she becomes disabled. They may have given their general power of attorney to someone to manage their financial affairs while you were on vacation or in the hospital. If you want a general power of attorney to continue, even if you become disabled, the document must state that it is a durable, or continuing, power of attorney. A healthcare power of attorney is a durable power; it continues even after they become disabled and appoints someone to carry out their healthcare wishes. UH Protocols Chapter 1 Administration/Operations 8

9 ADMINISTRATION/OPERATIONS CHILD ABUSE / NEGLECT Child abuse is a physical and mental injury, sexual abuse, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the child s welfare. The recognition of abuse and the proper reporting is a critical step to improving the safety of children and preventing child abuse. PURPOSE Assessment of a child abuse case based upon the following principles: Protect the life of the child from harm, as well as that of the EMS team from liability. Suspect that the child may be a victim of abuse, especially if the injury/illness is not consistent with the reported history. Respect the privacy of the child and family. Collect as much evidence as possible, especially information. PROCEDURE 1. With all children, assess for and document psychological characteristics of abuse, including excessive passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive crying, fussy behavior, hyperactivity, or other behavioral disorders. 2. With all children, assess for and document physical signs of abuse, including any injuries that are inconsistent with the reported mechanism of injury. The back, buttocks, genitals, and face are common sites for abusive injuries. 3. With all children, assess for and document signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition. 4. With all children, assess for and document signs of sexual abuse, including torn, stained, or bloody underclothing, unexplained injuries, pregnancy, or sexually transmitted diseases. 5. Immediately report any suspicious findings to the receiving hospital (if transported) or Law Enforcement if there is no transport. 6. EMS should not accuse or challenge the suspected abuser. This is a legal requirement to report, not an accusation. In the event of a child fatality, law enforcement must also be notified. UH Protocols Chapter 1 Administration/Operations 9

10 ADMINISTRATION/OPERATIONS CHILD ABUSE / NEGLECT KEY POINTS Child abuse/neglect is widespread enough that nearly all EMS Providers will see these problems at some time. The first step in recognizing abuse or neglect is to accept that they exist and to learn the signs and symptoms. Initiate treatment as necessary for any situation using established protocols. If possible remove child from scene, transporting them to the hospital even if there is no medical reason for transport. If parents refuse permission to transport, notify law enforcement for appropriate disposition. If the patient is in immediate danger, let law enforcement handle scene. Advise parents to go to the hospital. AVOID ACCUSATIONS as this may delay transport. The adult with the child may not be the abuser. RED FLAGS TO CHILD ABUSE: The presence of a red flag does not necessarily mean maltreatment. The suspicion of maltreatment is also based upon the EMS provider s observations and assessment. Signs that parents may display include (not all inclusive): Parent apathy Parent over reaction A story that changes or that is different when told by two different witnesses Story does not match the injury Injuries not appropriate for child s age Unexplained injuries Signs that the child may display include (not all inclusive): Pattern burns (donuts, stocking, glove, etc ) Multiple bruises in various stages of healing Not age appropriate when approached by strangers Not age appropriate when approached by parent Blood in undergarments UH Protocols Chapter 1 Administration/Operations 10

11 ADMINISTRATION/OPERATIONS CONCEALED WEAPONS GUIDELINES While the possibility of finding a dangerous weapon on a scene has always existed, EMS personnel must be aware of current issues which impose unique hazards upon them while performing their duties. These dangers present in many different ways regardless of jurisdiction or call volume. Although all accidents can not be prevented, awareness must be made regarding the State of Ohio Concealed-Carry Law. Ohio's Concealed - Carry Law permits individuals to obtain a license to carry a concealed handgun in Ohio, including into private businesses, if the licensee also carries a valid license and valid identification when carrying the concealed handgun. This law has been in effect since April 8th, Be aware that all patients may be carrying a dangerous weapon at all times, regardless of whether a permit has or has not been issued. GUIDELINES Upon arrival at the scene, EMS personnel should directly ask patients if they are carrying a weapon prior to performing a physical assessment. If the patient is unable to answer, please proceed with caution. If a weapon is present on scene or with a patient, it is recommended that a Law Enforcement Official be present to secure the weapon. Caution is advised due to the many types of weapons and the handler s ability to modify them. When transporting a patient to the hospital, please inform the receiving facility that a weapon has been found on the patient. This will allow enough time for Security to safely secure the weapon and maintain possession of it until Law Enforcement arrives. UH Protocols Chapter 1 Administration/Operations 11

12 ADMINISTRATION/OPERATIONS CONSENT AND REFUSAL OF CARE GUIDELINES PURPOSE To provide: Rapid emergency EMS transport when needed. Protection of patients, EMS personnel, and citizens from undue risk when possible. Method to document patient refusal of care. PROCEDURES - ADULT Consent: Express Consent: Where a conscious, oriented (to person, place and time) competent adult (over 18 years old) gives the EMS provider permission to care for him/her. This may be in the form of a nod, verbal consent or gesture after the intended treatment has been explained. Implied Consent: Occurs when a person is incapable of giving permission for treatment due to being unconscious or incompetent. It is assumed that permission would be given for any life saving treatments. Refusal of Treatment An EMS Patient Refusal or Transport sign-off sheet must be completed for all refusals prior to Medical Control contact. Competent Adult: ***For the purposes of this Protocol, Competent will be defined as Lucid and capable of making an informed decision, alert to Person, Place, Time, and Event. This definition is consistent with approved EMT, Advanced EMT, and Paramedic textbooks*** A competent adult may refuse treatment even after calling for help. The person must be informed that they may suffer loss of life, limb or severe disability if they refuse care and transport, and sign a Release indicating that they understand this. If the patient refuses to sign, a witness at the scene, preferably a relative should sign. Documentation of the events must be clearly made. It also must be documented on the run sheet that the person is oriented to person place time and event, and a set of vital signs should be obtained if at all possible. An offer to return and transport them at a later time should be made by EMS. Contact with Medical Control should be made. If the need for treatment is obvious, speaking directly to the Nurse or Physician may assist in convincing the patient to be transported. Incompetent patient: While an adult may refuse treatment, in some situations, their refusal may not be competent. In the following situations, the refusal of treatment may be incompetent: Patients showing altered mental status due to head trauma, drugs, alcohol, psychiatric illness, hypotension, hypoxia, or severe metabolic disturbances. Violent patients. Uncooperative minors. UH Protocols Chapter 1 Administration/Operations 12

13 ADMINISTRATION/OPERATIONS CONSENT AND REFUSAL OF CARE GUIDELINES PROCEDURES MINOR Consent to treat: (under the age of 18 years in Ohio) Must be obtained from the parent or guardian with two exceptions: There is need for life saving immediate treatment which should be given to the point of it being considered elective. The Minor is emancipated (i.e. married, living on their own, or in the armed forces and may give permission themselves). Refusal of Treatment: A minor might refuse to cooperate with the EMS crew, or the minor s parent or guardian may refuse to consent to necessary treatment of the minor. A minor under the age of 18 years may not refuse treatment in Ohio. Transport should be initiated unless the parent or legal guardian refuses treatment on behalf of the minor. A circumstance may occasionally arise where the patient is a minor and there is no illness or injury, yet EMS has been called to the scene. Medical Control must be contacted and agree that there is no illness or injury. If the responsible person is not able to be at the scene, it is acceptable for contact to be made by telephone. If care and transport is refused by the parent or guardian, TWO witnesses should verify this, and this shall be documented and signed by both witnesses on the run sheet. It is also acceptable for the minor to be left in the care of a responsible adult that is not the parent or legal guardian. The responsible adult may be a family friend, neighbor, school bus driver, teacher, school official, police officer, social worker, or other person at the discretion of Medical Control and the EMT. A second circumstance may occur when the minor patient really needs to be transported and the parent or guardian is refusing transport. In this case, action must be taken in the minor s best interest. This is described in the following section, Incompetent Refusal. Incompetent Refusal Parent/guardian refuse to give consent for treating their child when the child s life or limb appears to be at risk. Parent/guardian refuse to give consent where child abuse is suspected. Suicidal patients any age. In all such cases, contact with Medical Control and a Physician is mandatory, as the patient may have a life-threatening problem and is in need of medical care. The involvement of the police in these situations is often necessary and crucial. They may assist the EMS crew with transport as ordered by the On-line Physician. This is described in the Ohio Revised Code, Section Non-Transports In the event of a patient assist call and no Emergency Medical Services are rendered, a report should be made but Medical Control need not be contacted. If the patient is requesting transport and the EMT in charge does not feel it is necessary to transport the patient, Medical Control must be contacted and approve the EMS refusal. This includes any case that might be transported by car or another ambulance service. UH Protocols Chapter 1 Administration/Operations 13

14 ADMINISTRATION/OPERATIONS EMS COMMUNICATIONS Direct communication by EMS with the receiving hospital is required to insure continuity of care and the accurate reporting of the incoming patient s condition, history, and treatment. A member of the prehospital care team must contact the receiving hospital at the earliest time that is conducive to good patient care. If patient treatment advice is needed or if Medical Command orders are required per the protocol, Medical Command should be contacted. Medical Command will provide advice and any protocol orders deemed necessary in the care of the patient. If transporting the patient to a Non-UH facility, EMS will then contact the receiving hospital as stated above. PURPOSE To provide the receiving hospital an accurate, updated report of the patient(s) presentation and condition throughout prehospital care and transport. To allow the receiving hospital the opportunity to prepare for receiving the patient and continue necessary medical treatment. PROCEDURE Contact the receiving facility and provide the following information: Type of Squad: EMT, Advanced, Paramedic Age and Sex of Patient Type of Situation: Injury and/or Illness Specific Complaint: Short and to the point (i.e., chest pain, head injury) Mechanism: MVA / MCA / Fall Vital Signs: B/P / Pulse / Resp. / LOC / EKG Patient Care: Airway Management, Circulatory Support, Drug Therapy General Impression: Stable / Unstable Destination ETA KEY POINTS When calling in a report it should begin by identification of the squad calling, and the level of care that can be provided to the patient (EMT, Advanced, Paramedic), and the nature of the call (who you need to talk with, physician or nurse). Whenever possible, the EMT responsible for direct patient care should call in the report. Although all EMS Providers have been trained to give a full, complete report, this is often not necessary and may interfere with the physician's duties in the Emergency Department. Reports should be as complete but concise as possible to allow the physician to understand the patient's condition. It is not an insult for the physician to ask questions after the report is given. This is often more efficient than giving a thorough report consisting mostly of irrelevant information. If multiple victims are present on the scene, it is advisable to contact receiving hospital with a preliminary report. This should be an overview of the scene, including the number of victims; seriousness of the injuries, estimated on-scene and transport times to the control hospital or possible other nearby facilities. This allows preparation for receiving the victims and facilitates good patient care. UH Protocols Chapter 1 Administration/Operations 14

15 ADMINISTRATION/OPERATIONS EMS DOCUMENTATION An EMS patient care report form (PCR) will be completed accurately and legibly to reflect the patient assessment, patient care and interaction between EMS and the patient for each patient contact which results in some assessment component. Every patient encounter by EMS will be documented. Vital signs are a key component in the evaluation of any patient and a complete set of vital signs is to be documented for any patient who receives some assessment component. EMS providers are to leave a short, hand-written Patient Information Form (PIF) at the patient s bedside in the emergency department until the official electronic form is turned in. This will ensure patient care continuity between prehospital and emergency department staff. PURPOSE To document total patient care provided including: Care provided prior to EMS arrival. Exam of the patient as required by each specific complaint based protocol. Past medical history, medications, allergies, living will / DNR, and personal MD. All times related to the event. All procedures / medications administered and their associated time and patient response. Notation of treatment authorization if any deviation from protocol / narcotic use. Reason for inability to complete or document any above item. A complete set of vital signs. PROCEDURE 1. The patient care report should be completed as soon as possible after the time of the patient encounter. 2. All patient interactions are to be recorded on the patient care report form or the disposition form (if refusing care). 3. The patient care report form must be completed with the above information. 4. A copy of the patient care report form should be provided to the receiving medical facility. 5. A copy of the patient care report form is to be maintained by the EMS entity. UH Protocols Chapter 1 Administration/Operations 15

16 ADMINISTRATION/OPERATIONS EMS DOCUMENTATION KEY POINTS Document the contact and any on-line medical direction that is given. If you are not able to reach Medical Control, document attempts and cause for failure. Always describe the circumstances of the call. The times that vitals are taken must be noted. Vitals should be repeated a minimum of every five minutes for unstable patients and every 15 minutes for stable patients, or following any medical treatments. Vitals should be completely recorded. If a part of the set of vitals is omitted, the reason should be clearly given. ("Unable to obtain B/P due to clothing" is clear; "unable" written under the B/P space is not clear). Use accepted medical abbreviations and terminology. Do not make them up. Make an effort to spell correctly. Become familiar with the correct spelling of commonly used words. The name, dose, route, time and effect should be documented for all medications. When standards are followed, such as in a full arrest, every step should be documented. To write "ACLS protocols followed" is NOT SATISFACTORY. When providing copies of the run report for the Emergency Department and the Medical Director, be sure to include the EKG strips and second sheets. A complete set of times must be recorded on every report. If the patient refuses treatment/transport, the reason for refusal must be documented, along with 3 offers to treat/transport and an offer to return and transport. Medical Control contact should be noted. It is very important to document the mental status and assessment or the reason for lack of an assessment of the patient who refuses treatment/transport. Documentation of Vital Signs 1. An initial complete set of vital signs includes: Pulse rate Systolic AND diastolic blood pressure Respiratory rate Pain / severity (when appropriate to patient complaint) Pulse Oximetry 2. When no ALS treatment is provided, palpated blood pressures are acceptable for repeat vital signs. 3. Document situations that preclude the evaluation of a complete set of vital signs. 4. Record the time vital signs were obtained. 5. Any abnormal vital sign should be repeated and monitored closely. UH Protocols Chapter 1 Administration/Operations 16

17 ADMINISTRATION/OPERATIONS FIELD TERMINATION OF RESUSCITATION EFFORTS INDICATIONS When a patient that is in cardiac arrest has failed to respond to Advanced Life Support, it may be decided to terminate the effort and not transport the patient to the hospital. When the paramedic determines that this option is appropriate, the following criteria must be met: a. The victims is 18 years or older b. The victim must be in asystole in two leads and have the absence of a pulse confirmed. c. The victim must not be in arrest due to hypothermia, or apparent drug overdose. d. The victim must have a properly placed advanced airway. e. The patient must have a patent IV / IO access. f. At least three rounds of ACLS drugs have been administered. g. Medical control must be contacted - the physician must speak directly with the paramedic. Then the physician and paramedic must agree on the termination of efforts. The physician must give consent for the resuscitation effort to cease. Until the coroner releases the body, or a physician has agreed to sign the death certificate, do not remove endotracheal tubes, IV S, etc. If for any reason, the body will not be released (i.e. it will be Coroner s case.) Do not remove any equipment. EACH PATIENT SHOULD BE EVALUATED ON A CASE-BY-CASE BASIS WHEN IN DOUBT, CONTACT MEDICAL DIRECTION UH Protocols Chapter 1 Administration/Operations 17

18 ADMINISTRATION/OPERATIONS DEAD ON ARRIVAL (DOA) PURPOSE EMS should not begin to resuscitate if any of the following criteria for death in the field are met for a patient who presents pulseless, apneic and with any one of the following: Injury incompatible with life (i.e. decapitated, burned beyond recognition). Cardiac arrest, secondary to massive blunt trauma without signs of exsanguinating hemorrhage. Signs of decomposition, rigor mortis, extreme dependent lividity. Adult: Unwitnessed cardiac arrest >20 minutes, history of absence of vitals signs >20 minutes with asystole on the EKG, not secondary to hypothermia or cold water drowning. Ohio DNR Comfort Care Order. Other DNR as validated by On-line Physician. PROCEDURE If any of the above criteria is met, follow your local County Coroner s procedures. Once this is done, the police and/or Coroner s Office should assume control of the scene. KEY POINTS If a bystander or first responder has initiated CPR or AED prior to EMS arrival and any of the above criteria (signs of obvious death) are present, a Paramedic may discontinue CPR and ALS therapy. All other EMS personnel levels must communicate with medical control prior to discontinuation of the resuscitative efforts. If doubt exists, start resuscitation immediately. Once resuscitation is initiated, continue until either the Criteria for implementing Termination of Resuscitative efforts protocol have been met or Patient care responsibilities are transferred to the ED staff. When a DOA is encountered, EMS should avoid distributing the scene or the body as much as possible, unless it is necessary to do in order to care for other victims. Once it is determined that the victim is dead, EMS should move as rapidly as possible to transfer responsibility/management of the scene to the police and or Coroner per your local Counties procedures.. Pregnant patients estimated to be 20 weeks or later in gestation should have standard resuscitation initiated and rapid transport to a facility capable of providing as emergency C- section. Victims of lightning strike, drowning, or a mechanism of injury that suggested a non-traumatic cause for cardiac arrest should have standard resuscitation initiated. If a patient is pronounced at the scene, leave the ETT, IV, and other interventions in place. UH Protocols Chapter 1 Administration/Operations 18

19 ADMINISTRATION/OPERATIONS DOMESTIC VIOLENCE / SEXUAL ASSAULT / RAPE / ELDER ABUSE Domestic violence is physical, sexual, or psychological abuse and/or intimidation, which attempts to control another person in a current or former family, dating, or household relationship. The recognition, appropriate reporting, and referral of abuse is a critical step to improving patient safety, providing quality healthcare, and preventing further abuse. Elder abuse is the physical and/or mental injury, sexual abuse, negligent treatment, or maltreatment of a senior citizen by another person. Abuse may be at the hand of a caregiver, spouse, neighbor, or adult child of the patient. The recognition of abuse and the proper reporting is a critical step to improve the health and well - being of senior citizens. PURPOSE Assessment of an abuse case is based upon the following principles: Protect the patient from harm, as well as protecting the EMS team from harm and liability. Suspect that the patient may be a victim of abuse, especially if the injury/illness is not consistent with the reported history. Respect the privacy of the patient and family. Collect as much information and evidence as possible and preserve physical evidence. PROCEDURE 1. Assess the patient(s) for any psychological characteristics of abuse, including excessive passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive crying, behavioral disorders, substance abuse, medical non-compliance, or repeated EMS requests. This is typically best done in private with the patient. 2. Assess the patient (s) for any physical signs of abuse, especially any injuries that are inconsistent with the reported mechanism of injury. The back, chest, abdomen, genitals, arms, legs, face, and scalp are common sites for abusive injuries. Defensive injuries (e.g. to forearms), and injuries during pregnancy are also suggestive of abuse. Injuries in different stages of healing may indicate repeated episodes of violence. 3. Assess the patient(s) for signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition. 4. Assess the patient(s) for signs of sexual abuse, including torn, stained, or bloody underclothing, unexplained injuries, pregnancy, or sexually transmitted diseases. 5. Immediately report any suspicious findings to the receiving hospital (if transported). If an elder or disabled adult is involved, also contact the Department of Social Services (DSS). After office hours, the adult social services worker on call can be contacted by the 911 communications center. UH Protocols Chapter 1 Administration/Operations 19

20 ADMINISTRATION/OPERATIONS DOMESTIC VIOLENCE / SEXUAL ASSAULT / RAPE / ELDER ABUSE KEY POINTS SEXUAL ASSAULT: A victim of a sexual assault has experienced an emotionally traumatic event. It is imperative to be compassionate and non-judgmental. Be sensitive to the victim. Expect a wide range of responses to such an assault, depending upon social, cultural, and religious backgrounds. An abbreviated assessment may be indicated based on the patient s mental state. Your responsibility is patient care and not detective work. Questioning of the patient should be limited as there is no need for the EMS provider to attempt to get a detailed description of the assault. That type of questioning by EMS can harm the investigation, and should be left up to professional investigators. However, carefully document verbatim anything the patient says about the attack. DO NOT paraphrase. Based upon the patient s mental state, the following questions may be asked and documented: What happened? (A brief description is acceptable) When did the attack occur? Did the patient bathe or clean up after the attack? If the patient changed his/her clothes, attempt to bring the clothes in a brown paper bag. DO NOT use a plastic bag. If the patient did not change his/her clothes, have the patient bring a change of clothes to the hospital (if possible). Transport the patient to an appropriate medical facility. Some hospitals are capable of providing additional sexual assault care. UH Protocols Chapter 1 Administration/Operations 20

21 ADMINISTRATION/OPERATIONS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) What does HIPAA stand for? The Health Insurance Portability and Accountability Act. Enacted in 1996, this federal law regulates health insurance and insurance benefit programs. What is HIPAA s Privacy Rule? The privacy rule is a set of laws created to protect the privacy of a patient s health information, including medical records. Why was HIPAA created? Before this rule was created, it was possible for patient information to be easily accessible without the patient s authorization and for reasons that had nothing to do with medical treatment. For example, a patient s medical information might be passed to a bank or lender who might deny or approve a loan requested by the patient. Who has to follow the rule? The privacy rule directly relates to healthcare providers (such as ambulance services, hospitals, physicians, and home health agencies), health plans and insurance companies, and healthcare clearing houses (such as companies that bill for healthcare services). What if you don t comply? The penalty for one violation is $100, with a limit of $25,000 per year for any single organization that fails to comply with multiple requirements. The authority to impose penalties is carried out by the Department of Health and Human Services. In cases involving grossly flagrant and intentional misuse of patient information, violators may be socked with criminal penalties up to $250,000, ten years in jail, or both, depending on the circumstances. What should I do at the scene? Exercise confidentiality on the scene. Do not share information with bystanders. Limit radio transmissions that identify patients. Avoid disclosure of unnecessary information to police (appropriate info includes patient s name, DOB, and destination hospital). Protect patient s privacy whenever possible. Don t volunteer patient medical information with people at the scene. UH Protocols Chapter 1 Administration/Operations 21

22 ADMINISTRATION/OPERATIONS HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) Hospital Contact and EMS The relationship of the hospital and EMS are not really affected by HIPAA. The process of Performance Improvement is an important element of patient care that is worked on at each department under Medical Control and then the issues are addressed by the Medical Director during Run Reviews at each station. Information about the patient may be given to the Emergency Department by radio, phone, fax, or electronically. The information is needed for treatment of the patient and becomes part of the medical record. Following the privacy policy along with common sense regarding your patient s right will assure that no HIPAA rules are violated. UH Protocols Chapter 1 Administration/Operations 22

23 ADMINISTRATION/OPERATIONS NEWBORN ABANDONMENT SAFE HAVEN LAW Ohio law provides that a parent may drop off a newborn baby within the first 30 Days after birth at any law enforcement agency, hospital, or emergency medical service. Should this occur, the first priority is to care for the infant s health and safety. Notification should then be made to the Public Children s Services agency for that county. If possible, obtain any medical information that may be available. If it appears that the infant has suffered any type of physical harm, attempts should be made to detain the person who delivered the child. PURPOSE To provide: Protection to infants that are placed into the custody of EMS under this law Protection to EMS systems and personnel when confronted with this issue PROCEDURE 1. Initiate the Pediatric Assessment Procedure. 2. Initiate other treatment protocols as appropriate. 3. Keep infant warm. 4. Contact Medical Control as soon as infant is stabilized. 5. Transport infant to medical facility as per local protocol. 6. Assure infant is secured in appropriate child restraint device for transport. 7. Document protocols, procedures, and agency notifications. UH Protocols Chapter 1 Administration/Operations 23

24 ADMINISTRATION/OPERATIONS OBESE PATIENTS All individuals served by the EMS system will be evaluated, furnished transportation (if indicated) in the most timely and appropriate manner for each individual situation. PURPOSE To provide: Rapid emergency EMS transport when needed. Appropriate medical stabilization and treatment at the scene when necessary. Protection of patients, EMS personnel, and citizens from undue risk when possible. PROCEDURE 1. Each situation may dictate its own procedure for the transport of obese patients. 2. It is the responsibility of EMS personnel at the scene to provide the most appropriate medical care, including the protection of the patient, EMS personnel, and bystanders, while transporting morbidly obese patients. 3. Utilization of additional resources may be required, at the discretion of the on scene EMS personnel. KEY POINTS Less than one percent of the population has a weight in excess of 300 lbs. This means that in any community there may be one or more individuals who fall into this extreme. As patients, these individuals are frequently classed as high risk because of the increased medical complications associated with their excess weight. In the EMS system they present the additional problem of movement and transportation. These individuals have the right to expect prompt and expert emergency medical care. Therefore, in order to facilitate the care of these individuals without risking the health of EMS workers, the following protocol is established. In managing a patient with weight greater than 300 lbs., at no time should the patient be moved without sufficient manpower to assist. At the scene, as many EMS personnel as can be mobilized may be supplemented by police or other safety personnel as appropriate. If sufficient manpower is not available, mutual aid may be required. It may be necessary to remove doors, walls or windows. The situation is no different than extrication from a vehicle, although property damage may be higher. At all times the patient's life must be the first priority. The patient is to be placed on at least 2 (double) backboards or other adequate transfer device for support. The patient is to be loaded on a cot that is in the down position, and the cot is to be kept in the down position at all times. Be aware of the cot weight limitations. It is necessary to notify the hospital well in advance of arrival so that preparations can be completed in a timely fashion. If individuals in the community are known to fall within this special category it is appropriate to inform them in advance of the type of assistance they can expect from the EMS system, and help them make plans well in advance to assist you. When calling for the squad, and if they identify themselves and their special needs, it will promote the timeliness of your efforts. Truly obese people often live a very private life. Please do not forget to treat these people with the same dignity and respect your other patients receive. UH Protocols Chapter 1 Administration/Operations 24

25 ADMINISTRATION/OPERATIONS ON SCENE EMT / NURSE / PHYSICIAN INTERVENER The medical direction of prehospital care at the scene of an emergency is the responsibility of those most appropriately trained in providing such care. PURPOSE To identify a chain of command to allow field personnel to adequately care for the patient. To assure the patient receives the maximum benefit from prehospital care To minimize the liability of the EMS system as well as the on-scene intervener. PROCEDURE - PHYSICIAN 1. When a non medical-control physician offers assistance to EMS or the patient is being attended by a physician with whom they do not have an ongoing patient relationship, EMS personnel must contact On-line Medical Control and the physician must be approved by On-line Medical Control. 2. When the patient is being attended by a physician with whom they have an ongoing patient relationship, EMS personnel may follow orders given by the physician if the orders conform to current EMS guidelines, and if the physician signs the PCR. Notify Medical Control at the earliest opportunity. Any deviation from local EMS protocols requires the physician to accompany the patient to the hospital. 3. EMS personnel may accept orders from the patient s physician over the phone with the approval of Medical Control. The paramedic should obtain the specific order and the physician s phone number for relay to Medical Control so that Medical Control can discuss any concerns with the physician directly. PROCEDURE EMT 1. Ideally, if no further assistance is needed, the offer should be declined. 2. If the intervener s assistance is required or may significantly contribute to the care of the patient, obtain proper identification and note intervener name/address/certification number on the patient care report. UH Protocols Chapter 1 Administration/Operations 25

26 ADMINISTRATION/OPERATIONS ON SCENE EMT / NURSE / PHYSICIAN INTERVENER EMT / Nurse / Healthcare Intervener KEY POINTS On an EMS run where an unknown EMT / Nurse/ Healthcare - Intervener from outside the responding EMS agency wishes to intervene in the care of patients, the following steps should be initiated: Ideally, if no further assistance is needed, the offer should be declined. If the intervener's assistance is needed or may contribute to the care of the patient: An attempt should be made to obtain proper identification of a valid license/certification. Notation of intervener name, address and certification numbers must be documented on the run report. Medical control should be contacted and permission given. On Scene Physician This is a physician with no previous relationship to the patient who is not the patient's private physician, but is offering assistance in caring for the patient. The following criteria must be met for this physician to assume any responsibility for the care of the patient: Ideally, if no further assistance is needed, the offer should be declined. Medical Control must be informed and give approval. Encourage physician to physician contact. The physician must have proof they are a physician. They should be able to show you their medical license. Notation of physician name, address and certification numbers must be documented on the run report. The physician should have expertise in the medical field for which the patient is being treated. The physician must be willing to assume responsibility for the patient until relieved by another physician, usually at the emergency department. The physician must not require the EMT to perform any procedures or institute any treatment that would vary from protocol and/or procedure. If the physician is not willing or able to comply with all the above requirements, his / her assistance must be declined. On Scene Personal Care Physician This is a physician with a current relationship to the patient, who is offering assistance in caring for the patient. The following criteria must be met for this physician to assume further responsibility for the care of the patient: EMS should perform its duties as usual under the supervision of Medical Control or by protocol. Physician to Medical Control Physician contact is optimal. The physician may elect to treat the patient in his office. EMS should not provide any treatment under the physician's direction that varies from protocol. If asked, EMS should decline until contact is made with Medical Control. Once the patient has been transferred into the squad, the patient's care comes under Medical Control. UH Protocols Chapter 1 Administration/Operations 26

27 ADMINISTRATION/OPERATIONS Transports, Inter-Facility and Non-Hospital Patient EMS Providers might be called upon to transport patients from one healthcare facility to another healthcare facility or a non-healthcare facility to another non-healthcare facility or a combination thereof. Procedure The provider(s) will follow the written or pre-existing orders of the transferring physician unless acting as the agent of the receiving facility with superseding medical control, or if a physician accompanies the patient. Regardless of origin or destination, patients remain the responsibility of the transferring physician until received by the accepting physician or his/her agent. The decision regarding the level and scope of practice of the transporting agency and the individual providers should be made in consultation with the receiving physician and must be appropriate to the stability of the patient and their medical and equipment needs. The transfer papers and accompanying record must document the reason for the transfer as well as the time of contact and name of the receiving facility, physician, and/or accepting agent in accordance with nationally recognized standards and federal regulations. If unanticipated problems arise during transport, direct, on line medical control will be obtained. If for technical or logistical reasons this is not possible, the transporting agent should follow written protocols or standing orders until the transferring, receiving, or nearest diversionary facility can be contacted on-line. KEY POINTS Any questions or concerns regarding orders, including but not limited to Do Not Resuscitate orders, medication, or treatments must be answered or clarified prior to departure. UH Protocols Chapter 1 Administration/Operations 27

28 ADMINISTRATION/OPERATIONS Drug Exchange (Box Exchange) The exchange of drugs use by the EMS services under the University Hospitals Medical Control is done using a drug box system. These drug boxes are stocked and inventoried by the Pharmacy Departments at each of the University Hospitals Health Systems Medical Centers. An explanation and Procedure for the exchange of drugs / drug boxes is as follows: The Pharmacy will stock, inventory and seal the drug box with the appropriate drugs and amounts needed as per the University Hospitals Pre-Hospital Protocol. Note: All drug boxes are numbered and have a sticker on them indicating the date filled and the earliest expiration date of the drugs in the box. The Box is sealed by the Pharmacy Department with a numbered Green zip tie tag. This Green zip tie tag indicates that the box is fully stocked and ready for use. Once the Green tag is broken and drugs are used in the treatment of a patient, the EMS Provider that is responsible for the care of the patient must follow the following procedure: Fill out an account of the drugs used on the drug inventory sheet that can be found inside the box. This sheet should be filled out completely. For Controlled substances a separate inventory form found inside the box must be filled out completely. The amounts of the drugs used and wasted must be signed for and witnessed as per the information found on the sheet. The EMS Services official Patient Care Report (if using EMS Charts, EMS Charts is the official PCR) Will be completed, and signed (in wet ink) by all Providers that were present on the run and placed inside the box with the completed inventory sheets. If controlled substances were used the box is to be sealed with a numbered Red zip line tag found inside the drug box and exchanged for a new drug box immediately as the box is out of service. If no controlled substances were used and the box still has an adequate supply of drugs (enough of a supply to properly treat another patient per the protocol). The EMS Provider has the option to seal the drug box with a numbered Yellow zip tie tag found inside the box. The Yellow zip tie tag indicates that non controlled drugs were used from the box. The box is still in service and ready to treat any patient to the fullest extent of the protocol. All signed run sheets and inventory sheets from the previous patient must be in the Yellow zip tie tag sealed box. Any box that is being turned into pharmacy for exchange must be sealed and have all appropriate paperwork inside. 28 UH Protocols Chapter 1 Administration/Operations

29 All drug boxes should be exchanges at the University Hospital Medical Center Pharmacy from which it was originally stocked, inventoried, and sealed. If a drug box is missing, or suspected stolen from your EMS Service you must immediately notify the Director of the University Hospitals EMS Training and Disaster Preparedness Institute. This should be done via to establish a time line for your services reporting of the situation. The that should be used is [email protected]. and carbon copied to [email protected] and [email protected] If any drug is found to be missing from any drug box you must immediately notify the Director of the University Hospitals EMS Training and Disaster Preparedness Institute. This should be done via to establish a time line for your services reporting of the situation. The that should be used is [email protected] and carbon copied to EMS Coordinators [email protected] and [email protected] UH Protocols Chapter 1 Administration/Operations 29

30 AIRWAY / BREATHING PROTOCOLS Airway / Breathing Guidelines Airway Adjuncts Adult Airway Adult Foreign Body Airway Obstruction (FBAO) Adult Respiratory Distress Asthma & COPD Congestive Heart Failure (CHF) & Pulmonary Edema CPAP Traumatic Breathing UH Protocols Chapter 2 Airway / Breathing 1

31 AIRWAY / BREATHING AIRWAY / BREATHING GUIDELINES GUIDELINES OF AIRWAY ASSESSMENT PARTIAL OBSTRUCTION May include coughing with some air movement. Give 100% Oxygen and encourage the patient to cough. Monitor for changes. Transport immediately. FOREIGN BODY AIRWAY OBSTRUCTIONS (FBAO) Should be removed immediately if able. Visualize airway and either suction or sweep out liquids and other materials. Solids must be hooked with finger or instrument. A laryngoscope may be used for direct visualization of the airway. If unable to clear airway by these methods, use Heimlich maneuver if conscious and begin CPR if unconscious as appropriate. GUIDELINES OF BREATHING ASSESSMENT STRIDOR High pitched crowing sound caused by obstruction of the upper airway. WHEEZING A whistling or sighing sound, usually lower airway and found upon expiration. (e.g. pneumonia) RALES Fine to coarse crackle representing fluid in the lower airway indicative of CHF/Pulmonary Edema and also a secondary infection (eg. Pneumonia). RHONCHI Coarse upper airway sound representing mucus blocking the larger bronchioles. COPD Pulmonary disease (emphysema / chronic bronchitis) that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation CROUP Inflammation of the larynx and upper airway leading to airway narrowing especially in infants and young children (3 months to 3 years) that is typically caused by a virus and is marked by episodes of difficulty breathing and hoarse barky cough. EPIGLOTTITIS Inflammation of the epiglottis usually caused by HIB microbes, now uncommon in children. KEY POINTS Airway Assessment If you don t have an airway you don t have anything! C-Spine precautions must be considered prior to the insertion of airway adjuncts. Provide manual stabilization prior to insertion. See PEDIATRIC Section for pediatric airway management. Breathing Assessment Be sure that the airway is open before assessing breathing. When assessing breathing, observe rate, quality, depth, and equality of chest movement. COPD patients maintain on low flow oxygen (usually <2 L which keeps their O2 Sat in the low 90 s%). Some may stop breathing on high flow due to diminished respiratory drive. However - if the COPD patient needs high flow oxygen - it should be given. Be prepared to support breathing with BVM if needed. Always record vital signs when treating breathing problems. UH Protocols Chapter 2 Airway / Breathing 2

32 Suction ADJUNCT INDICATIONS CONTRAINDICATIONS COMMENTS Indispensable for all patients No more than 15 with fluid or particulate debris NONE seconds per attempt in airway Modified jaw thrust Hyperextension of neck Nasal airway Initial airway maneuver for all trauma patients Opening airway of nontrauma patient Obstruction by tongue with gag reflex present NONE Potential cervical spine injury Potential mid-face injury Does not protect against aspiration in a patient with a depressed level of consciousness Same as above Same as above Oral airway Obstruction of tongue Positive gag reflex Same as above Orotracheal intubation Failure of above; provides airway protection NONE Difficult in patients with severe maxillofacial injuries King LT/LTSD Airway Failure to place ETT successfully Positive gag reflex Known esophageal disease Ingestion of caustic substance Remove dentures and use caution if trauma with broken teeth may tear balloon Needle Cricothyrotomy Tracheostomy device High obstructed airway Unable to clear; Unable to establish any other airway; Unable to ventilate; Unable to oxygenate; Maxillo facial trauma Must be able to identify cricoid ring; Not best for anterior neck trauma Must have training in procedure UH Protocols Chapter 2 Airway / Breathing 3

33 AIRWAY / BREATHING AIRWAY (ADULT) Assess ABC s Respiratory Rate, Effort, and Adequacy B EMT B A Advanced A M MED CONTROL M Adequate Supplemental OXYGEN Inadequate Basic maneuvers first --- Open airway Nasal / Oral Airway Bag-Valve-Mask King Airway Obstruction See Foreign Body Airway Obstruction Protocol Orotracheal Intubation Limit 2 attempts Needle Cricothyrotomy if Trained BVM TRANSPORT UH Protocols Chapter 2 Airway / Breathing 4

34 KEY POINTS For this protocol, adult is defined as post start of puberty. When intubation is performed, 4 confirmation methods need to be used and documented including electronic capnometry if available. Examples of confirmation methods: EZ-cap. breath sounds, chest rise, Capnography, no gastric sounds. Maintain C-spine immobilization for patients with suspected spinal injury. Do not assume hyperventilation is psychogenic -- use oxygen, not a paper bag. Sellick's maneuver should be used to assist with intubations to reduce risk of aspiration. Paramedics should consider using a King Airway when they are unable to intubate a patient. Consider c-collar to maintain ETT placement for all intubated patients in addition to commercial tube securing device (REMOVE COLLAR upon patient TRANSFER). EMT s are only able to use King Airway if the patient is pulseless AND apneic. Advanced EMT s are only able to use King Airways and orothracheal intubation if the patient is apneic. Paramedic s are able to use King Airways and orothracheal intubation as necessary per the appropriate protocol. UH Protocols Chapter 2 Airway / Breathing 5

35 AIRWAY / BREATHING FOREIGN BODY AIRWAY OBSTRUCTION (FBAO) - ADULT B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Head Tilt / Chin Lift/ Jaw Thrust Airway Maneuvers Coughing Complete Obstruction Complete Obstruction Conscious Conscious Unconscious Encourage patient to cough OXYGEN L NRB Abdominal Thrusts Visualize / Finger Sweep (No Blind Finger Sweep) Open Airway / Rescue Breathing If unable to ventilate, reposition and attempt again Chest Compressions 30:2 If unable to ventilate, Continue sequence Visualize airway with laryngoscope; use magill forceps to remove foreign body CONTACT MEDICAL CONTROL If unable to remove foreign body, consider needle cricothyrotomy if trained TRANSPORT UH Protocols Chapter 2 Airway / Breathing 6

36 AIRWAY / BREATHING FOREIGN BODY AIRWAY OBSTRUCTION (FBAO) - ADULT INDICATIONS Coughing Choking Inability to speak Unresponsive SIGNS AND SYMPTOMS Witnessed Aspiration Sudden Episode of Choking Gagging Audible Stridor Change in Skin Color Decreased LOC Increased or Decreased Respiratory Rate Labored Breathing Unproductive Cough DIFFERENTIAL DIAGNOSIS Cardiac Arrest Respiratory Arrest Anaphylaxis KEY POINTS With complete obstruction, positive-pressure ventilation may be successful. Chest thrust should be used in place of abdominal thrust on pregnant or obese patients. If airway can not be cleared in 60 seconds, transport should be immediate. Cardiac Monitor and IV Protocol shall not delay transport. UH Protocols Chapter 2 Airway / Breathing 7

37 AIRWAY / BREATHING ASTHMA / COPD UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Administer Oxygen / Apply Cardiac Monitor IV/IO PROTOCOL :CPAP Assist with patients prescribed inhaler, if available Mild Slight wheezing and SOB: Treat with DuoNeb aerosol & Oxygen as needed Moderate Tachypnea & Wheezing: Treat with DuoNeb aerosol & Oxygen Follow up pulse-ox; Repeat DuoNeb aerosol Severe Tachypnea, wheezing accessory muscle use, difficulty speaking: Treat with DuoNeb aerosol & Oxygen Follow up pulse-ox; Repeat aerosol Consider CPAP with aerosol treatment for severe hypoxia not responding to treatment Administer Solumedrol 125 mg slow IV/IO Administer Solumedrol 125 mg slow IV/IO Administer Magnesium Sulfate 45 mg/kg to a total of 75 mg/kg SLOW IV/IO (Approx 2 grams adult) Administer Magnesium Sulfate 45 mg/kg to a total of 75 mg/kg SLOW IV/IO (Approx. 2 grams Adult) Consider Nebulized Epinephrine 1:1000 2mg (2ml) mixed in 1ml NS Epinephrine 1:1000 IM ONLY mg CONTACT MEDICAL CONTROL Consider Intubation or BIAD TRANSPORT UH Protocols Chapter 2 Airway / Breathing 8

38 HISTORY Asthma; Congestive heart failure; COPD -- chronic bronchitis, emphysema, Home treatment (oxygen, nebulizer, inhaler) Medications (theophylline, steroids, inhalers) Toxic exposure, smoke inhalation AIRWAY / BREATHING Asthma / COPD SIGNS AND SYMPTOMS Shortness of breath Pursed lip breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi Use of accessory muscles Fever, cough Tachycardia Retractions DIFFERENTIAL DIAGNOSIS Asthma Anaphylaxis Aspiration COPD (Emphysema, Bronchitis) Pleural effusion Pneumonia Pulmonary embolus Pneumothorax Cardiac (MI or CHF) Pericardial tamponade Hyperventilation Inhaled toxin (Carbon monoxide, etc.) KEY POINTS Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro Status asthmaticus -- severe prolonged asthma attack unresponsive to therapy -- life threatening! A silent chest in respiratory distress is a pre-respiratory arrest sign. Be alert for respiratory depression in COPD patients on prolonged high flow oxygen administration. DO NOT withhold oxygen from hypoxic patients. If DuoNeb is given, monitor the patient s cardiac rhythm and consider IV. If assisting with patient s prescribed bronchial dilator inhaler, you shall: assure medication is prescribed for patient, check medication expiration date/administration method, contact medical control prior to administration if possible, record patient reaction to medication including vital signs and relay to medical control. Administer medication by having the patient exhale, then activate spray during inhalation, and have patient hold their breath for ten seconds so medication can be absorbed. Use patient s spacer if available. UH Protocols Chapter 2 Airway / Breathing 9

39 AIRWAY / BREATHING CONGESTIVE HEART FAILURE (CHF)/PULMONARY EDEMA Mild OXYGEN 100% L NRB Administer CPAP UNIVERSAL PATIENT CARE PROTOCOL Cardiac Monitor IV/IO PROTOCOL Moderate/Severe OXYGEN 100% NRB or BVM if needed B EMT B I Advanced I M MED CONTROL M Cardiogenic Shock OXYGEN 100% Bag Valve Mask NITROGLYCERIN 0.4 mg SL (If B/P >110 Systolic) Monitor and Reassess NITROGLYCERIN 0.4 mg SL (If B/P >100 Systolic may repeat q5 minutes if B/P >110) Administer CPAP Consider Intubation or BIAD Pale, cool, clammy, hypotensive; Acute MI in progress, severe pulmonary edema DOPAMINE 5 mcg/kg/min IV/IO (max 20 mcg/kg/min) Titrate to effect Furosemide 1 mg/kg IV/IO or Double daily dose to 100mg Monitor and Reassess Monitor and Reassess Cardiac Wheezing? Cardiac Asthma: Consider DuoNeb aerosol treatment CONTACT MEDICAL CONTROL CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 2 Airway / Breathing 10

40 Heart Rate Normal Range AIRWAY / BREATHING CONGESTIVE HEART FAILURE (CHF)/PULMONARY EDEMA I MILD II MODERATE III SEVERE Blood Pressure Normal or slightly elevated Breath Sounds Bilateral Rales Wheezing possible Some difficulty breathing Heart Rate Tachycardia Blood Pressure Hypertension Breath Sounds Bilateral Diffuse Rales Wheezing possible Diminished Working hard to breath Frothy sputum may occur Heart Rate Tachycardia then drops to Bradycardia Blood Pressure Hypertension then drops to Hypotension Breath Sounds May be ominously quiet Fatigued from work of breathing HISTORY Congestive heart failure Past medical history Medications (digoxin, lasix) Viagra, etc. Cardiac history --past myocardial infarction SIGNS AND SYMPTOMS Respiratory distress, bilateral rales Apprehension, orthopnea Jugular vein distention Pink, frothy sputum Peripheral edema, diaphoresis Hypotension, shock Chest pain Positive Hepato-jugular reflex DIFFERENTIAL DIAGNOSIS Myocardial infarction Congestive heart failure Asthma Anaphylaxis Aspiration COPD Pleural effusion Pneumonia Pulmonary embolus Pericardial tamponade KEY POINTS Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro Obtain 12-lead EKG to evaluate for AMI. If the patient has taken their own nitroglycerin without relief, consider potency of the medication and repeat per protocol as needed. Monitor for hypotension after administration of nitroglycerin and morphine. Be suspicious of a Silent MI in the elderly, diabetics, and women. DO NOT administer Nitroglycerin to a patient who took an erectile dysfunction medication (Viagra, Cialis, Levitra, etc.) within the last hours. Nitroglycerin can be administered to a patient by EMS if the patient has already taken 3 of their own prior to your arrival. Document if the patient had any changes in their symptoms or a headache after taking their own Nitroglycerin. Check and document the expiration date of the patient s prescribed nitroglycerin. Nitroglycerin can be administered without an IV as long as the patient takes Nitroglycerin at home and has a BP greater than 120 mmhg or (BP greater than 150 mmhg if over 70 years old). Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is =15 drops per min (approx 5 mcg/kg/min) UH Protocols Chapter 2 Airway / Breathing 11

41 AIRWAY / BREATHING PROTOCOL Continuous Positive Airway Pressure (CPAP) UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Breathing patient whose condition is not improving with O2 therapy and/or medication Respiratory distress or failure due to pulmonary edema, asthma, pneumonia, bronchitis, CHF, or COPD/emphysema SpO2 < 94% Patient spontaneously breathing without altered level of consciousness You may use an Aerosol Treatment with CPAP in Asthma YES NO Administer CPAP Start 5cm H2O then titrate to 10 cm H2O as needed Continue Asthma / COPD or CHF / Pulmonary Edema Protocol without CPAP Patient Improving? NO Remove from CPAP Apply BVM Ventilation YES Continue CPAP, reassess every 5 minutes CONTACT MEDICAL CONTROL ASAP to allow Emergency Department to prepare for continuation of CPAP TRANSPORT UH Protocols Chapter 2 Airway / Breathing 12

42 KEY POINTS Indications: Breathing patient whose condition is not improving with O2 therapy, respiratory distress or failure due to pulmonary edema, asthma, pneumonia, bronchitis, CHF, or COPD/emphysema. Associated Signs and Symptoms: Dyspnea, tachypnea, chest pain, hypertension, tachycardia, anxiety, altered LOC, rales and/or wheezes, frothy sputum, accessory muscle use and/or retractions, pulse ox <94%. Patient must be adequately and spontaneous breathing. Contraindications: BP <90 systolic, respiratory arrest, agonal respirations, unconscious, shock associated with cardiac insufficiency, pneumothorax, penetrating chest trauma, persistent nausea and vomiting, facial anomalies, facial trauma, known blebs, unable to follow commands, apnea, hypercarbia, airway compromise, respiratory compromise, open stoma or tracheostomy. UH Protocols Chapter 2 Airway / Breathing 13

43 AIRWAY / BREATHING Traumatic Breathing UNIVERSAL PATIENT CARE PROTOCOL Evidence of Trauma Blunt or Penetrating Abnormal breath sounds, Inadequate Respiratory rate, Unequal symmetry, Diminished chest excursion, Cyanosis B EMT B A Advanced A M MED CONTROL M Jaw Thrust Airway Maneuver Give High Flow Oxygen Suspect Sucking Chest Wound? Apply 3-sided Occlusive Dressing or Chest Seal Suspect Flail Chest? Splint with bulky dressing Assist with ventilation gentle positive pressure Suspect Penetrating Object? Immobilize Object Apply sterile saline dressing Suspect Tension Pneumothorax? Confirm and Decompress Chest by Needle Decompression if trained CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 2 Airway / Breathing 14

44 KEY POINTS These injuries involve the airway and are life-threatening. Do not become distracted by non life-threatening injuries that appear terrible. A sucking chest wound is when the thorax is open to the outside. The occlusive dressing may be anything such as petroleum gauze, plastic, or a defibrillator pad. Tape only 3 sides down so that excess intrathoracic pressure can escape, preventing a tension pneumothorax. It may help respirations to place patient on the injured side, allowing the unaffected lung to expand easier. A flail chest is when there are extensive rib fractures present, causing a loose segment of the chest wall resulting in paradoxical and ineffective air movement. This movement must be stopped by applying a bulky pad to inhibit the outward excursion of the segment. Positive pressure breathing via BVM will help push the segment and the normal chest wall out with inhalation and to move inward together with exhalation, getting them working together again. Do not use too much pressure to prevent additional damage or pneumothorax. A penetrating object must be immobilized by any means possible. If it is very large, cutting may be possible, with care taken to not move it when making the cut. Place an occlusive & bulky dressing over the entry wound. A tension pneumothorax is life threatening. Look for unequal breath sounds, JVD, increasing respiratory distress, decreased mental status, and lastly, tracheal displacement. The pleura must be decompressed with a needle to provide relief. Use either the midclavicular (2 nd or 3 rd intercostal space) or the midaxillary (5 th or 6 th space) landmarks, going in on the top side of the rib. Once the catheter is placed, watch closely for reocclusion. Repeat if needed. You may attach the finger of a glove to the outside end of the catheter to assist in watching air movement. UH Protocols Chapter 2 Airway / Breathing 15

45 MEDICATIONS DOPAMINE (Intropine) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE Alpha and beta adrenergic receptor stimulator Dopaminergic receptor stimulator Dilates renal and mesenteric blood vessels Vasoconstriction Arterial resistance Increases cardiac output Increases preload Cardiogenic shock Distributive Shock Cyanide poisoning (contact Medical Control) Known hypersensitivity /Allergy Hypovolemic hypotension VF or VT Do not mix with bicarbonate, dopamine may be inactivated by alkaline solutions Extravasation may cause tissue necrosis Ectopic beats, palpitations Tachycardia, angina Nausea/vomiting VF or VT Dyspnea Headache 2-20mcg/kg/min IV drip. Start 5 micrograms/kg/minute IV/IO infusion, titrate to effect Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is =15 drops per min (approx 5 mcg/kg/min) 16

46 MEDICATIONS DuoNeb A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS (Albuterol) Parasympatholytic bronchodilator Dries respiratory tract secritations (Ipratropium Atrovent) B2 selective bronchodilator Increases HR Asthma exacerbation COPD exacerbation Patients that have used their prescribed inhaler more than once Pulmonary edema with wheezing Known hypersensitivity /Allergy Allergy to peanuts Acute myocardial infarction Arrhythmias Cardiovascular disease Hypertension history CHF Palpitations Anxiety Nausea Dissiness ADULT/PEDS DOSAGE Unit dose inhaled via nebulizer. May repeat as needed 17

47 ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE MEDICATIONS EPINEPHRINE (Adrenaline) Alpha and Beta adrenergic agonist Bronchodilation Increases heart rate and automaticity Increases cardiac contractility Increases myocardial electrical activity Increases systemic vascular resistance Increases blood pressure Cardiac arrest Allergic reaction/anaphylaxis Respiratory distress Acute Asthma Pediatric Bradycardia A Advanced A Hypersensitivity, Tachycardia, Hypertension, Hypothyroidism Angina / Chest pain, Coronary artery disease Pregnancy Blood pressure, pulse, and EKG must be routinely monitored Palpitations, ectopic beats, tachycardia Anxiety / Tremors Hypertension VF / VT Angina Asthma and Anaphylaxis Mild / Moderate Reaction (1-1,000) mg IM ONLY Consider 1:1000 2mg mixed with 1ml NS in nebulizer for Asthma Severe Anaphylaxis (1:10,000) 0.5 mg slow IV/IO over 5 minutes - EMT-P Only Cardiac Arrest 1:10,000 1 mg IV/IO every 3-5 minutes EMT-P Only 18

48 MEDICATIONS FUROSEMIDE (Lasix) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Potent diuretic Decreases preload Vasodilator Acute pulmonary edema Congestive heart failure Acute pulmonary edema secondary to hypertension Hypokalemia Dehydration Pneumonia Allergy to Lasix Hypokalemia Dehydration Depletion of potassium Hypotension 1.0mg/kg SLOW IV/IO or double the daily oral dose. 100mg maximum dose 1 mg/kg slow IVP CONTACT MEDICAL COMMAND 19

49 MEDICATIONS MAGNESIUM SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Anticonvulsant Antiarrhythmic CNS depressant Seizures secondary to eclampsia Ventricular ectopy refractory to Amiodarone Torsades Adjunct to alleviate acute asthma attack Renal disease Heart blocks Respiratory depression CNS depression Hypotension Cardiac arrest ADULT DOSAGE Torsades grams SLOW IVP over 5 minutes (Max dose 4 grams) Eclampsia grams over 2-3 minutes PEDIATRIC DOSAGE KEY POINTS Asthma dose 45mg/kg IV to a total of 75mg/kg (approx 2 grams in adult Not recommended for pediatric use 20

50 MEDICATIONS METHYLPREDNISOLONE (Solumedrol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Anti-inflammatory steroid Anaphylaxis Asthma COPD NONE in emergency setting GI bleeding Prolonged wound healing Suppression of natural steroids 125 mg IV/IO 1-2 mg/kg IV/IO KEY POINTS 21

51 MEDICATIONS NITROGLYCERIN A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Decreases preload and afterlead Increases coronary blood flow Cardiac chest discomfort, angina STEMI Pulmonary edema Known hypersensitivity Hypotension (systolic BP <110, diastolic BP <60 Increased intracranial pressure Glaucoma CVA Erectile dysfunction drugs (contact med control) Headache Hypotension Dizziness, weakness Syncope Dilated pupils Cardiac Chest Discomfort 0.4 mg SL or spray May repeat every 5 minutes up to 3 doses if B/P systolic > 100mmHg PEDIATRIC DOSAGE KEY POINTS Not recommended in the prehospital setting 22

52 CIRCULATION / SHOCK PROTOCOLS Shock Guidelines Shock Key Points..3-3 Anaphylactic Shock Cardiogenic Shock Non-Traumatic Hypovolemic Shock / Neurogenic Shock Septic Shock UH Protocols Chapter 3 Circulation / Shock 1

53 CIRCULATION / SHOCK SHOCK GUIDELINES TYPES OF SHOCK ANAPHYLACTIC SHOCK CARDIOGENIC SHOCK HYPOVOLEMIC SHOCK NEUROGENIC SHOCK SEPTIC SHOCK SIGNS AND SYMPTOMS Warm Burning Feeling Itching Rhinorrhea Hoarseness / Stridor Wheezing Shock Severe Respiratory Distress Altered LOC / Coma Cyanosis Pulmonary Edema Facial / Airway Edema Urticaria / Hives Dyspnea Cool, Clammy Skin Mottled Altered Mental Status Anxiety / Restlessness Weakness Difficulty Breathing Hypotension JVD Decreased Urine Output Tachycardia Weak, Thready Pulse Hypotension with Narrow Pulse Pressure Hypotension or Falling Systolic B/P Pale Skin Clammy or Dry Skin Dyspnea Altered LOC/ Coma Decreased Urine Output Restlessness Irritability Evidence of Trauma (lacerations, bruising, swelling, deformity) Normal or Bradycardic HR Hypotension with a Narrow Pulse Pressure Compromise in Neurological Function Normal or Flush Skin Color Warm, Dry Extremities Peripheral Vasodilation Tachycardia Hypovolemia Hypotension with a Narrow Pulse Pressure Dehydration Altered LOC / Coma Dyspnea Febrile Signs of Infection Hx of Infection (UTI, Pneumonia, etc.) UH Protocols Chapter 3 Circulation / Shock 2

54 CIRCULATION / SHOCK SHOCK / KEY POINTS HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Blood loss - vaginal or Restlessness, confusion Shock gastrointestinal bleeding, Weakness, dizziness Hypovolemic AAA, Trauma Weak, rapid pulse Cardiogenic Fluid loss - vomiting, Pale, cool, clammy skin Septic diarrhea, fever Delayed capillary refill Neurogenic Infection Hypotension Anaphylactic Cardiac ischemia (MI, Coffee-ground emesis Ectopic pregnancy /AAA CHF) Tarry stools Dysrhythmia Medications Pulmonary embolus Allergic reaction Tension pneumothorax Pregnancy Medication effect /overdose Vasovagal Physiologic (pregnancy) KEY POINTS Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro Hypotension can be defined as a systolic blood pressure of less than 90. Consider performing orthostatic vital signs on patients in nontrauma situations if suspected blood or fluid loss. Consider all possible causes of shock and treat per appropriate protocol. Anaphylactic Shock Sudden, severe allergic reaction characterized by sharp drop in B/P, urticaria and breathing difficulty caused by exposure to a foreign substance. Routine assessment and supportive care of the patient s respiratory and cardiovascular systems is required. DO NOT confuse epinephrine 1:10,000 IV/IO with 1:1,000 IM ONLY Treat patients with a history of anaphylaxis aggressively. If bee sting, remove stinger (scrape, don t squeeze it). Cardiogenic Shock Circulatory failure is due to inadequate cardiac function. Be aware of patients with congenital defects. Cardiogenic shock exists in the prehospital setting when an MI is suspected and there is no specific indication of volume related shock. Pulmonary Edema, CHF, AMI, PE may cause cardiogenic shock. Marked, symptomatic tachycardia and bradycardia can also cause cardiogenic shock. Hypovolemic Shock Shock caused by decreased blood volume Patients suffering from hemorrhagic shock secondary to trauma, should be treated under the Trauma Criteria and should be rapidly transported to the nearest appropriate facility. Initiate a second large bore IV for all patients in hypovolemic shock. Neurogenic Shock Caused by sudden loss of the sympathetic nervous system signals to smooth muscle in vessel walls leading to a decrease in peripheral vascular resistance and decreased B/P To be considered in spinal cord and head trauma. Cushing s Reflex is a sign of increased ICP. Cushing s Reflex is a hypertension, bradycardia, and irregular respirations. Septic Shock Be alert for septic shock in the elderly. Caused by overwhelming infection UH Protocols Chapter 3 Circulation / Shock 3

55 CIRCULATION / SHOCK ANAPHYLACTIC SHOCK UNIVERSAL PATIENT CARE PROTOCOL Apply Cardiac Monitor and Assess Vitals IV/IO PROTOCOL B EMT B A Advanced A M MED CONTROL M ****DO NOT CONFUSE**** Epi 1:10,000 IV/IO vs. 1:1,000 IM ONLY Mild Moderate Severe Adult Any Age Rash, itching, No difficulty breathing or throat tightening, B/P normal limits Treatment Rash, Itching, Wheezing, Throat tightening, Swelling (face/lips), B/P normal limits Treatment Rash, itching, Airway compromise Wheezing Swelling Hypotension Treatment Impending Arrest Severe hypotension No response to Epi Decreased level of consciousness Airway compromise Treatment Oxygen per cannula Consider Benadryl 50 mg IV or IM Oxygen per NRB Assist with Epi-pen Consider DuoNeb aerosol Benadryl 50 mg IV/IO/ IM Administer solumedrol 125 mg slow IV/IO Epinephrine 1: ml IM ONLY CONTACT MEDICAL CONTROL Oxygen per NRB Assist with Epi-pen Epinephrine 1: ml IM ONLY Benadryl 50 mg IV/IO/IM DuoNeb Aerosol watch airway & breathing may repeat Administer solumedrol 125 mg slow IV/IO If HTN, CAD, CVA, Pregnant: Consider Glucagon 1mg IM/IV/IO/IN instead of Epi Epinephrine 1:10,000 Up tp 0.5mg SLOW IV/IO NS Bolus 20 ml/kg IV/IO Administer solumedrol 125 mg slow IV/IO Control airway by whatever means possible Follow ACLS TRANSPORT Epinephrine 1:10,000 Up to 0.5mg SLOW IV/IO for Hypotension UH Protocols Chapter 3 Circulation / Shock 4

56 CIRCULATION / SHOCK CARDIOGENIC SHOCK UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Airway Protocol Use NRB 100% O2 Monitor Lung Sounds for Fluid Overload Apply Cardiac Monitor and Assess Vitals IV/IO PROTOCOL - TKO Pale, cool, clammy, hypotensive Acute MI in progress Suspicion of Pulmonary Edema, CHF, PE Dopamine 5 mcg/kg/min IV/IO Titrate for increase B/P >90 systolic or to Maintain MAP >70 (if NIBP is available) MAX 20 mcg/kg/min ***NOTE*** 2x Diastolic + systolic Divided by 3 = MAP Monitor and Reassess B/P CONTACT MEDICAL CONTROL TRANSPORT Dopamine Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is = 15 drops per min (approx 5 mcg/kg/min) UH Protocols Chapter 3 Circulation / Shock 5

57 CIRCULATION / SHOCK NON-TRAUMATIC HYPOVOLEMIC AND NEUROGENIC UNIVERSAL PATIENT CARE PROTOCOL Airway Protocol Monitor Lung Sounds for Fluid Overload B EMT B A Advanced A M MED CONTROL M Apply Cardiac Monitor and Assess Vitals Apply Oxygen via NRB or use ResQGard IV/IO PROTOCOL Non - traumatic Hypovolemic Shock If hypotensive and breathing adequately Apply the ResQGard NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic or MAP >70 (if NIBP is available) Neurogenic Shock Consider Spinal Immobilization procedure if necessary NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic or MAP >70 (if NIBP is available) If hypotensive and breathing adequately Apply the ResQGard Check Glucose Level Monitor and Reassess B/P Treatment per Trauma Protocol if Appropriate ***NOTE*** 2x Diastolic + systolic Divided by 3 = MAP Check Glucose Level B/P < 100 Systolic NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic or MAP >70 (if NIBP is available) Monitor and Reassess B/P CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 3 Circulation / Shock 6

58 UNIVERSAL PATIENT CARE PROTOCOL CIRCULATION / SHOCK SEPTIC SHOCK B EMT B A Advanced A M MED CONTROL M Airway Protocol Monitor Lung Sounds for Fluid Overload Apply Cardiac Monitor and Assess Vitals Apply Oxygen via NRB or use ResQGard if Hypotensive IV/IO PROTOCOL Identify if the patient has SIRS (**) If Yes: Does Patient have a prior history of any of the following: Pneumonia, Urinary Tract Infection, Cellulitis, Septic Arthritis, Diarrhea, ABD pain, Wound Infection, Decubitus ulcer, Meningitis, Indwelling Device, Fever Are any of the following present and new to the patient? ***NOTE*** 2x Diastolic + systolic Divided by 3 = MAP **SIRS Systemic Inflamatory Response System Patient has 2 or more of the following: Temp >38 C (100.4) F or <36 C (96.8 F) Heart Rate >90 Respiratory Rate >20 BPM or PaCO 2 <32mmHg If Yes, Patient has Sepsis DOES THE PATIENT HAVE SEVERE SEPSIS? If Yes - Patient has Severe Sepsis Begin Resuscitation YES BP < 90 Oxygen Sat < 90 No urine output in the last 8 hours Prolong Bleeding from the gums Lactate levels >4 NO APPLY ResQGard for hypotension if not already done IV/IO FLUID RESUSCITATION AT LEAST 20cc/kg No Organ Dysfunction Sepsis is likely, but severe sepsis is unlikely Continue Current Treatment Still Hypotensive?? Dopamine 5 mcg/kg/min IV/IO Titrate to maintain SBP >90 or to a MAP >70( if NIBP is available) MAX 20 mcg/kg/min CONTACT MEDICAL CONTROL CONTACT MEDICAL CONTROL Advise that you have a patient with severe sepsis UH Protocols Chapter 3 Circulation / Shock TRANSPORT 7

59 MEDICATIONS DOPAMINE (Intropine) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE Alpha and beta adrenergic receptor stimulator Dopaminergic receptor stimulator Dilates renal and mesenteric blood vessels Vasoconstriction Arterial resistance Increases cardiac output Increases preload Cardiogenic shock Distributive Shock Cyanide poisoning (contact Medical Control) Known hypersensitivity /Allergy Hypovolemic hypotension VF or VT Do not mix with bicarbonate, dopamine may be inactivated by alkaline solutions Extravasation may cause tissue necrosis Ectopic beats, palpitations Tachycardia, angina Nausea/vomiting VF or VT Dyspnea Headache 2-20mcg/kg/min IV drip. Start 5 micrograms/kg/minute IV/IO infusion, titrate to effect Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is =15 drops per min (approx 5 mcg/kg/min) 8

60 MEDICATIONS DuoNeb A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS (Albuterol) Parasympatholytic bronchodilator Dries respiratory tract secritations (Ipratropium Atrovent) B2 selective bronchodilator Increases HR Asthma exacerbation COPD exacerbation Patients that have used their prescribed inhaler more than once Pulmonary edema with wheezing Known hypersensitivity /Allergy Allergy to peanuts Acute myocardial infarction Arrhythmias Cardiovascular disease Hypertension history CHF Palpitations Anxiety Nausea Dissiness ADULT/PEDS DOSAGE Unit dose inhaled via nebulizer. May repeat as needed 9

61 ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE MEDICATIONS EPINEPHRINE (Adrenaline) Alpha and Beta adrenergic agonist Bronchodilation Increases heart rate and automaticity Increases cardiac contractility Increases myocardial electrical activity Increases systemic vascular resistance Increases blood pressure Cardiac arrest Allergic reaction/anaphylaxis Respiratory distress Acute Asthma Pediatric Bradycardia A Advanced A Hypersensitivity, Tachycardia, Hypertension, Hypothyroidism Angina / Chest pain, Coronary artery disease Pregnancy Blood pressure, pulse, and EKG must be routinely monitored Palpitations, ectopic beats, tachycardia Anxiety / Tremors Hypertension VF / VT Angina Asthma and Anaphylaxis Mild / Moderate Reaction (1-1,000) mg IM ONLY Consider 1:1000 2mg mixed with 1ml NS in nebulizer for Asthma Severe Anaphylaxis (1:10,000) 0.5 mg slow IV/IO over 5 minutes - EMT-P Only Cardiac Arrest 1:10,000 1 mg IV/IO every 3-5 minutes EMT-P Only 10

62 MEDICATIONS GLUCAGON A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose level Relaxes smooth muscle of GI tract Hypoglycemia when IV/IO is not able to be established and oral glucose is contraindicated Esophageal obstruction Beta Blocker overdose Known hypersensitivity Pheochromocytoma Glucagon is only effective in patients with sufficient stores of glycogen Use caution in patients with renal or cardiovascular disease Glucagon can be administered on scene, but do not wait for it to take effect Nausea/Vomiting 1mg IM/IN for Hypoglycemia 2mg IV/IO/IM/IN in esophageal foreign body obstruction 2 mg IV/IO/IM/IN for hypotension / bradycardia in Betablocker overdose and Calcium Channel overdose <20kg give 0.5mg IM / IN >20kg give 1mg IM / IN Response is usually noticed in 5-20 minutes Glucagon is NOT a substitute for D25, or D12.5. IV must be attempted prior to administering Glucagon 11

63 MEDICATIONS METHYLPREDNISOLONE (Solumedrol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Anti-inflammatory steroid Anaphylaxis Asthma COPD NONE in emergency setting GI bleeding Prolonged wound healing Suppression of natural steroids 125 mg IV/IO 1-2 mg/kg IV/IO KEY POINTS 12

64 MEDICATIONS DIPHENHYDRAMINE HCL (Benadryl) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Antihistamine Sedative Inhibits motion sickness (antiemetic) Anaphylactic shock and severe allergic reaction Acute dystonia Nausea/vomiting (contact Medical Control) Extrapyramidal reaction (Parkinson-like movement disorders) Known hypersensitivity / Allergy Pregnancy or lactating Avoid the use of Diphenhydramine in nursing mothers May induce vomiting Carefully monitor patient while awaiting for medication to take effect (effect of medication begins 15 minutes after administration) Drowsiness, confusion Blurring of vision Dry mouth Wheezing; thickening of bronchial secretions Hypotension ADULT DOSAGE PEDIATRIC DOSAGE Allergic Reaction or Anaphylaxis mg IV/IO/IM Behavioral Psychiatric Emergencies 50 mg IM Allergic Reaction or Anaphylaxis 1 mg/kg (without hypotension) IV/IO/IM Max 50mg 13

65 ACLS PROTOCOLS CHEST PAIN / ACLS Chest Pain / Acute Coronary Syndrome ARRHYTHMIAS / ACLS Sinus Bradycardia Narrow - Complex Tachycardia Wide - Complex Tachycardia CARDIAC ARREST / ACLS Cardiac Arrest Asystole / Pulseless Electrical Activity (PEA) Ventricular Fibrillation (V-FIB) / Pulseless Ventricular Tachycardia (V-Tach) Post - Resuscitation Cardiac Care Induced Hypothermia Left Ventricular Assist Device (LVAD) UH Protocols Chapter 4 ACLS Protocols 1

66 UNIVERSAL PATIENT CARE PROTOCOL CHEST PAIN / ACLS CHEST PAIN / ACUTE CORONARY SYNDROME Patient has Chest Pain that is possibly cardiac in nature / Hx OXYGEN to maintain SpO2 >94 >95% = 4 L NC, <95% = 15 L NRB Obtain 12 lead and transmit B EMT B A Advanced A M MED CONTROL M If arrhythmia exists go to appropriate Arrhythmia Protocol Evaluate 12 Lead EKG (If Positive for ST Elevation Activate Cath Lab) (If Left Bundle Branch Block with symptoms Activate Cath Lab) IV/IO PROTOCOL ASPIRIN 324 mg/ 325 mg PO NITROGLYCERIN 0.4 mg SL/Spray (If BP > 100 Systolic with IV - may give total of 3 1 q 5 min) (EMT, Pt Assisted with Med Control) If ST segment changes are found in Leads ll, lll and AVF (inferior wall) conduct a right side 12 lead EKG. Move V4 to right side of chest on the midclavicular line <same location as on the left> and run 12 lead again. Label 12 lead as "right side" look to V4 in the right side 12 lead for ST segment changes and notify ER. Do not delay transport while obtaining RV4 12 Lead (If there is ST Elevation in RV4 DO NOT give Nitroglycerin, Beta Blocker, or Morphine) DO NOT give Nitroglycerin if patient has taken a Phosphodiesterase Inhibitors (ED enhancement drugs within hours) MORPHINE SULFATE 2 4 mg Slow IV/IO/IM/IN q5 min (Max = 10 mg if no relief with a total of 3 NTG) Give Zofran 4mg IV/IO/IM for nausea Zofran Oral Disolving Tabs 8 mg Oral Confirmed STEMI on 12 Lead Brilinta 180 mg PO **If Brilinta is not available - Plavix 600 mg PO** Heparin 60units/kg max dose of 4000units IV Reassess and Monitor CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 4 ACLS Protocols Consider Transport to a Facility With PCI Capabilities if Patient is Showing Signs of a ST Elevation MI 2

67 CHEST PAIN / ACLS CHEST PAIN / ACUTE CORONARY SYNDROME HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Age Medications Past medical history (MI, Angina, Diabetes) Allergies Recent physical exertion Onset Palliation / Provocation Quality (crampy, constant, sharp, dull, etc.) Region / Radiation / Referred Severity (0-10) Time (duration / repetition) CP (pain, pressure, aching, vice like tightness) Location (substernal, epigastric, arm, jaw, neck, shoulder) Radiation of pain Pale, diaphoresis Shortness of breath Nausea, vomiting, dizziness Trauma vs. Medical Angina vs. Myocardial infarction Pericarditis Pulmonary embolism Asthma / COPD Pneumothorax Aortic dissection or aneurysm GE reflux or hiatal hernia Esophageal spasm Chest wall injury or pain Pleural pain KEY POINTS All cardiac chest pain patients must have an IV, O2 and monitor. Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro. If patient has taken nitroglycerin without relief, consider potency of the medication. If positive ECG changes, establish a second IV while en route to the hospital. Monitor for hypotension after administration of nitroglycerin and morphine. Nitroglycerin and Morphine may be repeated per dosing guidelines in Appendix 1:Medications. Diabetics, women and geriatric patients often have atypical pain, or generalized complaints. Refer to the Sinus Bradycardia Protocol if indicated (HR < 60 bpm) or Wide & Narrow Complex Tachycardia Protocol (HR > 150 bpm) and hypotension. If the patient becomes hypotensive from Nitroglycerin administration, place the patient in the Trendelenburg position and administer a 250 ml Normal Saline bolus. Be prepared to administer Naloxone (Narcan) if the patient experiences respiratory depression or hypotension due to Morphine administration. If pulmonary edema is present, refer to the PULMONARY EDEMA/CHF PROTOCOL. Be suspicious of a Silent MI in the elderly, diabetics, and women. Consider other causes of chest pain such as aortic aneurysm, pericarditis, and pulmonary embolism. Aspirin can be administered to a patient on Coumadin unless the patient s physician has advised them otherwise. If the patient took a dose of Aspirin that was less than 325 mg in the last 24 hours, then additional Aspirin can be administered to achieve a therapeutic dose of 325 mg. DO NOT administer Nitroglycerin to a patient who took an erectile dysfunction medication (Viagra, Cialis, Levitra, etc) within the last hours due to potential for severe hypotension. Nitroglycerin can be administered to a patient by EMS if the patient has already taken 3 of their own prior to your arrival. Document it if the patient had any changes in their symptoms or a headache after taking their own Nitroglycerin. Check and document the expiration date of the patient s prescribed Nitroglycerin. Nitroglycerin can be administered to a hypertensive patient complaining of chest discomfort without Medical Direction permission. Nitroglycerin can be administered without an IV as long as the patient takes Nitroglycerin at home and has a BP greater than120 mmhg. All patients complaining chest discomfort must be administered at least 4 lpm of oxygen by nasal cannula. Administer oxygen by non-rebreather or assist the patient s ventilations as indicated. UH Protocols Chapter 4 ACLS Protocols 3

68 ARRHYTHMIAS / ACLS SINUS BRADYCARDIA UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Apply Cardiac Monitor / Obtain 12 lead EKG and transmit IV/IO PROTOCOL Evaluate 12 Lead EKG (Look for ST Elevation) Hypotension, AMS, Chest Pain, Shock Blood Pressure < 90 Systolic No Monitor and Reassess Yes ATROPINE IV/IO 0.5 mg (max 3mg) Repeat every 3-5 minutes Use with Coution if type II 2 nd or 3 rd degree heart block EXTERNAL TRANSCUTANEOUS PACING Start at 10 over the intrinsic rate and adjust for BP > 90 Consider DOPAMINE 2-10 mcg/kg/min Iv/IO Titrate to HR > 60 & BP > 90 systolic Dopamine Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is = 15 drops per min (approx 5 mcg/kg/min) CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 4 ACLS Protocols 4

69 ARRHYTHMIAS / ACLS SINUS BRADYCARDIA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Medications Beta-Blockers Calcium channel blockers Clonidine Digitalis Pacemaker HR < 60/min Chest pain Respiratory distress Hypotension or Shock Altered mental status Syncope Acute myocardial infarction Hypoxia Hypothermia Sinus bradycardia Head injury (elevated ICP) or Stroke Spinal cord lesion Sick sinus syndrome AV blocks (1, 2, or 3 ) KEY POINTS Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro. Pharmacological treatment of bradycardia is based upon the presence or absence of hypotension. If hypotension exists, treat. If blood pressure is adequate, monitor only. Use Atropine with caution, if the patient s rhythm is a Type II second-degree heart block or a third degree heart block. Transcutaneous pacing is the treatment of choice for Type II second-degree heart blocks and third degree heart blocks. If the patient is critical and an IV is not established, initiate pacing with Medical Direction permission. If the patient converts to another rhythm, refer to the appropriate protocol and treat accordingly. UH Protocols Chapter 4 ACLS Protocols 5

70 ARRHYTHMIAS / ACLS NARROW COMPLEX TACHYCARDIA If <150 bpm Consider Sinus Tachycardia Look for and treat reversible causes H s & T s UNIVERSAL PATIENT CARE PROTOCOL Cardiac Monitor IV/IO PROTOCOL >150 bpm Stable B EMT B A Advanced A M MED CONTROL M Unstable Vagal Maneuvers Attempt Stable Procedures or you may go directly to Cardioversion ADENOSINE 6 mg IV/IO followed by 20mL N/S flush Consider Sedation with Cardioversion Ativan 1-2 mg IV/IO/IN or Versed 2 mg IV/IO/IN if Ativan is unavailable No Response ADENOSINE 12 mg IV/IO followed by 20 ml N/S flush CARDIOVERSION Synchronized Biphasic: 100J 200J 300J 360J Or manufacturer s recommendations No response No Response Repeat CARDIOVERSION Synchronized Monitor and Reassess Metoprolol 5 mg IV/IO if HR> 60 and B/P > 110 systolic May Repeat in 3 minutes if B/P>110 + HR>60 If rhythm changes, Go to Appropriate Protocol CONTACT MEDICAL CONTROL UH Protocols Chapter 4 ACLS Protocols TRANSPORT 6

71 ARRHYTHMIAS / ACLS NARROW COMPLEX TACHYCARDIA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Medications (Aminophylline, diet pills, thyroid supplements, decongestants, Digoxin) Diet (caffeine, chocolate) Drugs (nicotine, cocaine) Past medical history History of palpitations / heart racing Syncope / near syncope HR > 150/Min QRS < 0.12 Sec Dizziness, CP, SOB Potential presenting rhythm Sinus tachycardia PSVT Atrial fibrillation / flutter Multifocal atrial tachycardia Heart disease (WPW, Valvular) Sick sinus syndrome Myocardial infarction Electrolyte imbalance Exertion, Pain, Emotional stress Fever Hypoxia Hypovolemia or anemia Drug effect / Overdose Hyperthyroidism Pulmonary embolus KEY POINTS Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro Adenosine may not be effective in identifiable atrial flutter/fibrillation, but is not harmful. Monitor for respiratory depression and hypotension associated with Versed. Continuous pulse oximetry is required for all patients. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. If the patient converts to another rhythm, refer to the appropriate protocol and treat accordingly. Examples of vagal maneuvers include bearing down, coughing, or blowing into a syringe. DO NOT perform a carotid massage. If possible, the IV should be initiated in either the left or right AC. When administering Adenosine follow the bolus with 20 ml rapid bolus of normal saline. Record EKG strips during Adenosine administration. Perform a 12-Lead EKG prior to and after Adenosine conversion or cardioversion of SVT. If the patient converts into ventricular fibrillation or pulseless ventricular tachycardia immediately DEFIBRILLATE the patient and refer to the appropriate protocol and treat accordingly. Give a copy of the EKGs and code summaries to the receiving facility upon arrival. UH Protocols Chapter 4 ACLS Protocols 7

72 ARRHYTHMIAS / ACLS WIDE COMPLEX TACHYCARDIA V-Fib Pulseless V-Tach Protocol UNIVERSAL PATIENT CARE PROTOCOL No Palpate Pulse Yes B EMT B A Advanced A M MED CONTROL M Apply Cardiac Monitor IV/IO PROTOCOL Stable Polymorphic Unstable Versed 2 mg IV/IO Regular / Monomorphic Consider Adenosine 6mg IV/IO May Consider additional Adenosine 12mg IV/IO Prepare for immediate Cardioversion If V-Tach or uncertain rhythm AMIODARONE 150 mg IV/IO (Over 10 minutes) Consider Sedation with Cardioversion Ativan 1-2 mg IV/IO/IN or Versed 2 mg IV/IO/IN if Ativan is unavailable Monitor and obtain 12-lead EKG Transmit to ED Paramedics Reassess for underlying rhythm Consider Synchronized Cardioversion with sedation If (Polymorphic VT) torsades de pointes Consider Magnesium grams IV/IO Over 5 min Synchronized CARDIOVERSION Biphasic: 100J 200J 300J 360J Or manufacturer s recommendations (If Polymorphic 200J) AMIODARONE 150 mg IV/IO (Over 10 minutes) For Polymorphic Consider Magnesium Sulfate If V-Tach or uncertain rhythm AMIODARONE 150 mg IV/IO (Over 10 minutes) CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 4 ACLS Protocols 8

73 ARRHYTHMIAS / ACLS WIDE COMPLEX TACHYCARDIA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Medications, diet, drugs Syncope / near-syncope Palpitations Pacemaker Allergies Ventricular tachycardia on ECG (Runs or sustained) Conscious Rapid pulse Chest pain Shortness of breath Dizziness Rate usually bpm for sustained V-Tach Artifact / device failure Cardiac Endocrine / Metabolic Drugs Pulmonary KEY POINTS Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro. For witnessed / monitored ventricular tachycardia, try having patient cough or deliver a precordial thump. Polymorphic V-Tach (Torsades de Pointes) may benefit from the administration of magnesium sulfate and may require non-sync cardioversion. If the patient converts to another rhythm, refer to the appropriate protocol and treat accordingly. If the patient relapses back into wide complex tachycardia / ventricular tachycardia, initiate synchronized cardioversion with the joules setting that previously cardioverted the patient. Record EKG strips during Amiodarone administration. Perform a Code Summary and attach it to the patient run report. Be sure to treat the patient and not the monitor. UH Protocols Chapter 4 ACLS Protocols 9

74 CARDIAC ARREST / ACLS CARDIAC ARREST Withhold Resuscitation Follow Local County Coroner Procedures Yes UNIVERSAL PATIENT CARE PROTOCOL Criteria for Death Criteria for DNR Start CPR B EMT B A Advanced A M MED CONTROL M Yes Review DNR Comfort Care Guidelines CONTACT MEDICAL CONTROL Attach Cardiac Monitor Defibrillator/ AED Go to Appropriate Protocol Follow AED Prompts (if applicable) If V-Fib is witnessed by EMS Immediately Dfibrillate CPR x 5 cycles / 2 minutes Airway Protocol Consider: Termination of Resuscitation Efforts Protocol Follow AED Prompts (if applicable) Maintain CPR / Airway IV/IO PROTOCOL CONTACT MEDICAL CONTROL TRANSPORT AT ANY TIME Return of Spontaneous Circulation GO TO POST RESUSCITATION CARDIAC CARE PROTOCOL UH Protocols Chapter 4 ACLS Protocols 10

75 CARDIAC ARREST / ACLS CARDIAC ARREST HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Events leading to arrest Estimated down time Past medical history Medications Existence of terminal illness DNR or Living Will Unresponsive Apneic Pulseless Signs of lividity, rigor mortis Medical vs Trauma V-fib vs Pulseless V-tach Asystole Pulseless electrical activity (PEA) KEY POINTS Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro. Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. If witnessed arrest consider a precordial thump. Reassess airway frequently and with every patient move. Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transport. If the patient converts to another rhythm, refer to the appropriate protocol and treat accordingly. Attempt to obtain patient history from family members or bystanders. Estimated down time Medical history Complaints prior to arrest Bystander CPR prior to EMS arrival AED use prior to EMS arrival Administer Dextrose only if the patient has a Glucose Level < 70 mg/dl. Dextrose should be administered as soon a hypoglycemia is determined. DO NOT administer Narcan until the patient has been resuscitated and is known or suspected to have used narcotics. Reassess the patient if the interventions do not produce any changes. If indicated, refer to the Termination of Resuscitative Efforts Protocol. UH Protocols Chapter 4 ACLS Protocols 11

76 CARDIAC ARREST / ACLS ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) Withhold Resuscitation Follow Local County Coroner Procedures Yes UNIVERSAL PATIENT CARE PROTOCOL Criteria for Death Criteria for DNR Start CPR B EMT B A Advanced A M MED CONTROL M Yes Review DNR Comfort Care Guidelines CONTACT MEDICAL CONTROL Airway Protocol IV/ IO PROTOCOL Apply Cardiac Monitor (AED) ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA) Resume CPR for 5 cycles End Stage Renal Pt. Consider: Calcium Chloride 1 gram (10cc) slow IVP & Sodium Bicarbonate 50mEq or 1mEq/kg IVP DO NOT MIX IN SAME IV LINE EPINEPHRINE 1 mg IV / IO 1:10,000 Solution Repeat every 3-5 minutes Or VASOPRESSIN 40 U IV / IO Give ONE Dose AT ANY TIME Consider: Termination of Resuscitation Efforts CONTACT MEDICAL CONTROL TRANSPORT Return of Spontaneous Circulation GO TO POST RESUSCITATION CARDIAC CARE PROTOCOL UH Protocols Chapter 4 ACLS Protocols 12

77 CARDIAC ARREST / ACLS ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Medications Tricyclics Digitalis Beta blockers Calcium channel blockers Events leading to arrest End stage renal disease Estimated down time Suspected hypothermia Suspected overdose DNR or Living Will Pulseless Apneic No electrical activity on ECG Cyanosis Medical or Trauma Hypoxia Potassium (hypo / hyper) Acidosis Hypothermia Device (lead) error Death Hypovolemia Cardiac tamponade Drug overdose (Tricyclics, Digitalis, Beta blockers, Calcium channel blockers) Massive Myocardial infarction Tension pneumothorax Pulmonary embolus Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-hyperkalemia Hypoglycemia Hypothermia CONSIDER TREATABLE CAUSES Tamponade, cardiac Tension Pneumothorax Thrombosis (coronary or pulmonary ACS or PE) Trauma Toxins KEY POINTS Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro. Always confirm asystole in more than one lead. Consider each possible cause listed in the differential: Survival is based on identifying and correcting the cause! Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options. Early identification and treatment of reversible causes of PEA increases the chance of a successful outcome. If the patient converts to another rhythm, refer to the appropriate protocol and treat accordingly. Consider volume infusion for all patients in PEA. Be alert for fluid overload. Vasopressin is not repeated. If given, Epinephrine may be used 5 minutes after Vasopressin if still in arrest, 1mg of Epinephrine 1:10,000 would then be administered every 3-5 minutes. Treat as ventricular fibrillation if you cannot differentiate between asystole and fine ventricular fibrillation. Medical Direction must be contacted prior to administering antidotes for all poisonings/overdoses except for narcotic overdoses. Dextrose 50% should only be administered to a patient with a confirmed blood glucose level less that 70 mg/dl. UH Protocols Chapter 4 ACLS Protocols 13

78 CARDIAC ARREST / ACLS VENTRICULAR FIBRILLATION (V FIB) PULSELESS VENTRICULAR TACHYCARDIA (V TACH) Withhold Resuscitation UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A Follow Local County Coroner Procedures Yes Criteria for Death Criteria for DNR M MED CONTROL M Review DNR Comfort Care Guidelines Start CPR X 5 cycles / 2 minutes If V-Fib is Witnessed by EMS immediately 200J CONTACT MEDICAL CONTROL Apply Cardiac Monitor Defibrillator / AED Defibrillate Biphasic: 200J or Monophasic 360J Resume effective CPR / 2 minutes, then check rhythm AIRWAY PROTOCOL IV/IO PROTOCOL IO PROTOCOL Continue effective CPR / 2 minutes, then check rhythm EPINEPHRINE 1 mg IV / IO 1:10,000 Solution Repeat every 3-5 minutes OR VASOPRESSIN 40 u. IV / IO Max 1 Dose Defibrillate Biphasic: 300J or Monophasic 360J Return of Spontaneous Circulation GO TO POST RESUSCITATION INDUCED HYPOTHERMIA CARDIAC CARE PROTOCOL Continue effective CPR / 2 minutes, then check rhythm Give Antiarrhythmic during CPR AMIODARONE 300 mg IV/IO May 150 mg IV in 3-5 minutes Defibrillate Biphasic: 360J or Monophasic 360J Continue effective CPR / 2 minutes, then check rhythm TRANSPORT UH Protocols Chapter 4 ACLS Protocols CONTACT MEDICAL CONTROL Consider: Termination of Resuscitation Efforts 14

79 CARDIAC ARREST / ACLS VENTRICULAR FIBRILLATION (V FIB) PULSELESS VENTRICULAR TACHYCARDIA (V TACH) HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Estimated down time Past medical history Medications Events leading to arrest Renal failure / dialysis DNR or living will Unresponsive Apneic Pulseless Ventricular fibrillation or ventricular tachycardia on EKG/monitor Asystole Artifact / device failure Cardiac Endocrine / Metabolic Drugs Pulmonary KEY POINTS Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro. Effective CPR should be as continuous as possible with a minimum of 5 cycles or 2 minutes. Reassess and document endotracheal tube placement and ET CO2 frequently: after every move, and at transfer. Polymorphic V-Tach (Torsades de Pointes) may benefit from administration of magnesium sulfate. If the patient converts to another rhythm, or has a return of circulation, refer to the appropriate protocol and treat accordingly. If the patient converts back to ventricular fibrillation or pulseless ventricular tachycardia after being converted to ANY other rhythm, defibrillate at the previous setting used. Defibrillation following effective CPR is the definitive therapy for ventricular fibrillation and pulseless ventricular tachycardia. Vasopressin is not repeated and may be administered in place of the first or second dose of epinephrine only. If given, Epinephrine may be used 5 minutes after Vasopressin if still in arrest, 1mg of Epinephrine 1:10,000 would then be administered every 3-5 minutes. UH Protocols Chapter 4 ACLS Protocols 15

80 CARDIAC ARREST / ACLS POST RESUSCITATION CARDIAC CARE B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Begin Induced Hypothermia Protocol Continue Ventilatory Support with 100% OXYGEN IV/IO PROTOCOL Apply Cardiac Monitor Obtain 12 Lead Vital Signs Hypotension Ventricular Ectopy Bradycardia NS bolus 20 ml/kg IV/IO DOPAMINE 5 20 mcg/kg/min IV/IO Titrate to effect AMIODARONE 150 mg IV/IO in 100 ml bag over 10 minutes Treat per Bradycardia Protocol if Hypotensive Dopamine Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is = 15 drops per min (approx 5 mcg/kg/min) If arrest reoccurs, revert to appropriate protocol and/or initial successful treatment CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 4 ACLS Protocols 16

81 CARDIAC ARREST/ ACLS POST RESUSCITATION CARDIAC CARE HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Respiratory arrest Cardiac arrest Return of pulse Continue to address specific differentials associated with the original Arrythmia KEY POINTS Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro. Most patients immediately post resuscitation will require ventilator assistance. The condition of post-resuscitation patients fluctuates rapidly and continuously, and they require close monitoring. Appropriate post-resuscitation management can best be planned in consultation with Medical Control. This is the period of time between restoration of spontaneous circulation and the transfer of care at the emergency department. The focus is aimed at optimizing oxygenation and perfusion. Adequate oxygenation is the key to a good outcome. UH Protocols Chapter 4 ACLS Protocols 17

82 CARDIAC ARREST / ACLS INDUCED HYPOTHERMIA Return of Spontaneous Circulation Patient is still unresponsive / Comatose B EMT B A Advanced A M MED CONTROL M Airway Protocol NO Advanced Airway in place (ET or King Airway) With ET CO 2 >20 mmhg? Expose patient apply ice packs to axilla and groin Apply Cooling Collar if available Cold Saline Bolus 20 ml/kg to max 2 liters Dopamine mcg/kg/min Target BP 90 Discontinue Cooling Measures <33 C Reassess >33C Temperature Continue to monitor temperature and go to post resuscitation protocol Post Resuscitation Protocol Dopamine Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is = 15 drops per min (approx 5 mcg/kg/min) UH Protocols Chapter 4 ACLS Protocols 18

83 CARDIAC ARREST/ ACLS INDUCED HYPOTHERMIA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Non-traumatic cardiac arrest (drowning and hanging are permissible in this protocol Return of pulse Continue to address specific differentials associated with the original Arrythmia KEY POINTS Criteria for Induced Hypothermia ROSC not related to blunt/penetrating trauma or hemorrhage Age 12 or older with adult body habitus Advanced airway in place (ET or King Airway) with no purposeful response to pain If no advanced airway can be obtained, cooling may only be initiated on order from online medical control Take care to protect patient modesty. Undergarments may remain in place during cooling. Do not delay transport to cool Frequently monitor airway, especially after each patient move Patients may develop metabolic alkalosis with cooling. Do not hyperventilate UH Protocols Chapter 4 ACLS Protocols 19

84 CARDIAC ARREST/ ACLS Left Ventricular Assist Device (LVAD) Ventricular assist device patients (VAD) are special care situations. Unless these patients are in cardiac arrest they need to be transported to their VAD implantation center. Local or regional hospitals are not equipped to handle these patients. B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Determine if VAD is functioning Auscultate chest and upper abdominal quadrants Continuous Humming sound = pump is working Many pumps are non-pulsatile; patient may not have palpable pulses, measurable BP, or Pulse Oximetery. Use other indicators of perfusion such as skin signs, mental status, and Capnography. Contact Appropriate VAD team Cleveland Clinic Pager University Hospital Pager The Patient should have a companion (Family member, friend, caretaker, etc) who is knowledgeable in the function of the VAD. Utilize this resource regarding specifics of each type of VAD system. Keep the companion with the patient Keep all equipment with the patient Not Functioning / Alarming Find Accompanying Instructions for Device 1. Page / call VAD team 2. Check that all Wires / Leads Connected to Controller / Power 3. Check Power Sources 4. Change Power Sources (Only change 1 battery at a time) 5. Attempt Re-start or Start in Backup Mode 6. Switch to Back-Up Controller (If Instructed by VAD Coordinator) IF unable to Maintain Pump Operation Follow VAD team instructions Treat for Cardiogenic Shock Rapid Transport Patient Unstable Treat Per Standard ACLS Protocols Pacing OK Defibrillation OK ACLS drugs OK Chest Compressions only as ABSOLUTE last resort Functioning Do not ever shut off Patient Stable Treat Per Standard Medical Protocols TRANSPORT to appropriate facility (Air Transport OK for VAD Patients) CONTACT receiving facility CONSULT Medical Direction where indicated UH Protocols Chapter 4 ACLS Protocols 20

85 MEDICATIONS ADENOSINE (Adenocard) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Slows conduction time and can interrupt re-entrant pathways through the AV node Slows the sinus rate Supra Ventricular Tachycardia (SVT) Consider in Regular Wide Complex Tachycardia Paroxysmal Supra Ventricular Tachycardia (PSVT) Wolf Parkinson White (WPW) Second or third degree AV block, sick sinus syndrome Ventricular tachycardia Hypersensitivity to Adenosine It is helpful to inform the patient of likely side effects prior to medication administration Facial flushing Shortness of breath Chest pain Palpitations Brief period of sinus arrest /Transient Dysrhythmias Headache Lightheadedness Hypotension Nausea Initial Dose 6 mg rapid IVP (over 1-3 sec) immediately followed with a 20 ml saline flush Repeat Dose If no response is observed after 1 min., administer 12 mg rapid IVP (over 1-3 sec) immediately followed with a 20 ml saline flush. Max dose 30 mg Initial Dose 0.1 mg/kg rapid IVP followed with a 10 ml saline flush Repeat Dose If no response is observed after 1-2 min., administer 0.2 mg/kg rapid IVP followed with a 10 ml saline flush. Max dose 0.5 mg/kg up to 6mg Adenosine has a short half life, and should be administered rapidly followed by a rapid IV/IO flush Reassess after each medication administration, refer to the appropriate protocol and treat accordingly. Perform a 12 Lead EKG prior to the administration of Adenosine and after the rhythm converts Record rhythm during and post administration

86 MEDICATIONS AMIODARONE (Cordarone) ACTIONS INDICATIONS CONTRAINDICATIONS Prolongs the refractory period and action potential duration Ventricular Fibrillation (refractory to shock treatment) Pulseless Ventricular Tachycardia (refractory to shock treatment) Polymorphic VT and wide complex tachycardia Hypersensitivity (including iodine) Cardiogenic shock Second and Third degree AV block Severe sinus bradycardia Severe sinus node dysfunction SIDE EFFECTS ADULT DOSAGE Tremors, Paresthesia, Ataxia Headache, Fatigue Abdominal pain, Nausea/Vomiting, Hepatic failure Arrhythmia, Bradycardia, Sinus arrest, Heart block (Prolonged QT), Heart failure Acute Respiratory Distress Syndrome, Severe pulmonary edema Blue-Gray skin Ventricular Fibrillation and Pulseless Ventricular Tachycardia 300 mg IV/IO bolus Repeat Dose: 150 mg IV/IO in 3-5 minutes, Max 2.2 g IV/24hrs PEDIATRIC DOSAGE KEY POINTS Wide Complex Tachycardia 150 mg IV/IO over 10 minutes (15 mg/min) Repeat Dose: 150 mg IV/IO every 10 minutes prn, Max 2.2 g IV/24hrs Ventricular Fibrillation and Pulseless Ventricular Tachycardia 5 mg/kg IV/IO bolus Ventricular Arrhythmias Loading dose 5 mg/kg IV/IO over mins Avoid excessive movement and shaking of the medication

87 MEDICATIONS ASPIRIN B EMT B A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE PEDIATRIC DOSE Blocks platelet aggregation Chest pain suggestive of a MI 12-Lead EKG indicating a possible MI Hypersensitivity Active ulcer disease Impaired renal function Upset stomach GI bleeding Mucosal lesions Bronchial spasm in some asthma patients 325 mg tablet or 81 mg chewable tablet 325 mg tablet or 324 mg (81 mg x 4 tablets) PO Not Recommended for Pediatric Use

88 MEDICATIONS ATIVAN (LORAZEPAM) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSE Sedative Anticonvulsant Amnestic (induces amnesia) Status epilepticus Sedation prior to transcutaneous pacing and synchronized cardioversion in the conscious patient Known hypersensitivity Altered mental status of unknown origin Head injury Respiratory insufficiency May cause respiratory depression, respiratory effort must be continuously monitored with Capnography Should be used with caution with hypotensive patients and patients with altered mental status Lorazepam (Ativan) potentiates alcohol or other CNS depression Respiratory depression Hypotension Lightheadedness Confusion Slurred speech Amnesia 1 2 mg IV / IO / IM / IN Not Recommended for Pediatric Use

89 MEDICATIONS ATROPINE SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE PEDIATRIC DOSAGE Increases sinus node firing Increases conduction through the AV node by blocking vagal activity Increases cardiac output Decreases ectopic beats or fibrillation of the ventricles Symptomatic sinus bradycardia Organophosphate poisoning/nerve agent exposure Known hypersensitivity Atrial flutter/fibrillation where there is a rapid ventricular response Glaucoma narrow angle 2 nd and 3 rd degree AV Block with wide QRS complex Use with extreme caution in myocardial infarction May increase myocardial oxygen demand May trigger tachy-dysrhythmias Patient needs to be warned about side effects Doses smaller than 0.5 mg or administered too slowly may slow rather than speed up the heart rate Excessive doses in adults may precipitate ventricular tachycardia or fibrillation Dry mouth, thirst, urinary retention Blurred vision, pupillary dilation, headache Flushed skin Tachycardia Prefilled syringes containing 1 mg in 10 ml Auto-Injector containing 2 mg (nerve agent exposure only) Bradycardia 0.5 mg IV/IO (1.0 mg ETT) every 5 minutes Max dose 0.04 mg/kg or 3 mg Organophosphate Poisoning 2 5mg IVP, IM, or IO every 5 min Bradycardia 0.02 mg/kg IV/IO, repeated X 1, 5 minutes (minimum dose 0.1 mg), Max single dose 0.5 mg CHILD / 1.0 mg ADOLESCENT, Max total dose 1.0 mg CHILD / 2.0 mg ADOLESCENT Organophosphate Poisoning 0.2 mg/kg IV/IO, repeat every 3-5 minutes / Max dose 0.5mg Child Max dose 1.0mg Adolescent.

90 MEDICATIONS BiCarbonate (Sodium BiCarbonate) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDS DOSAGE Buffers metabolic acidosis Enhances the urinary excretion of tricyclics Metabolic Acidosis from cardiac arrest Tricyclic Overdose Hyperkalemia Post Crushing Entrapment Heart Failure Seizures Tissue necrosis if infiltration Can precipitate with Calcium 50mEq IVP for tricyclic overdose 50mEq or 1mEq/kg IVP for cardiac arrest asystole or PEA 50 meq IVP for cardiac arrest with prolonged down time(10 minutes) 50mEq to 100mEq Post Crushing Entrapment 1mEq/kg IV/IO Diluted in 1:1 NS or as advised By Med Command

91 MEDICATIONS BRILINTA (ticagrelor) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE A P2Y12 platelet inhibitor indicated to reduce the rate of thrombotic cardiovascular events in patients with acute coronary syndrome, Acute Coronary Syndrome / STEMI 12-Lead EKG indicating a ST elevation MI History of intracranial hemorrhage Active pathological bleeding Severe hepatic impairment Increased risk of bleeding Dyspnea Bleeding Dyspnea 180mg PO (2 90mg Tablets) NOT RECOMMENDED FOR PEDIATRIC USE

92 MEDICATIONS CALCIUM CHLORIDE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Reverses overdose with magnesium sulfate or calcium channel blockers (such as verapamil) Antidote magnesium sulfate and calcium channel blocker toxicity Hyperkalemia Beta Blocker overdose Known dialysis patient in cardiac arrest Hypersensitivity to calcium chloride Do not infuse with sodium bicarbonate will combine to form an insoluble precipitate Can cause ventricular fibrillation when pushed too fast or given to a patient who has been taking digitalis 1 gram (10cc) slow IVP NOT RECOMMENDED FOR PEDIATRIC USE Previously, calcium was used in resuscitation because it was believed to stimulate the heart to beat in asystole and to strengthen cardiac contractions in electromechanical dissociation careful recent studies have failed to show any benefit from using calcium in cardiac arrest, and indeed the effects of calcium may be harmful in that situation

93 MEDICATIONS DOPAMINE (Intropine) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE Alpha and beta adrenergic receptor stimulator Dopaminergic receptor stimulator Dilates renal and mesenteric blood vessels Vasoconstriction Arterial resistance Increases cardiac output Increases preload Cardiogenic shock Distributive Shock Cyanide poisoning (contact Medical Control) Known hypersensitivity /Allergy Hypovolemic hypotension VF or VT Do not mix with bicarbonate, dopamine may be inactivated by alkaline solutions Extravasation may cause tissue necrosis Ectopic beats, palpitations Tachycardia, angina Nausea/vomiting VF or VT Dyspnea Headache 2-20mcg/kg/min IV drip. Start 5 micrograms/kg/minute IV/IO infusion, titrate to effect Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is =15 drops per min (approx 5 mcg/kg/min)

94 MEDICATIONS HEPARIN ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Anticoagulant Acute Coronary Syndrome LVAD malfunction Hypersensitivity to Heparin Active bleeding Trauma Severe hypertension Aortic dissection Pregnancy Major surgery within the last 14 days Symptoms of CVA Bleeding 60 units/kg IV Maximum dose (4000 units) KEY POINTS

95 MEDICATIONS KETOROLAC (Toradol) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE NSAID analgesic Reduces pain Moderate pain Pain associated with kidney and gall stones >65 Years Old Hypersensitivity including aspirin or other NSAIDS Advanced renal impairment Suspected cerebrovascular bleeding Recent GI bleeding Nursing mothers Labor and delivery Asthma Edema Hypertension Rash Nausea Dizziness 30 mg IV, 60 mg IM (If <65 Year Old Only) 0.15 mg/kg IV or 0.3 mg/kg IM

96 MEDICATIONS MORPHINE SULFATE A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Narcotic Analgesic Causes peripheral vasodilation Pulmonary edema MI pain unrelieved with nitro Pain management Pain secondary to burns Known hypersensitivity / Allergy Head injury or head trauma Hypotension Altered LOC Undiagnosed abdominal pain(consult Med Command) COPD Bradycardia Multiple trauma patients If the patient responds with respiratory depression or hypotension, administer Narcan to reverse the effects Routinely monitor the patient s respiratory effort and SpO2 Respiratory depression Altered LOC, constricted pupils Bradycardia Nausea/Vomiting Hypotension 2-4 mg slow IV/IO/IM/IN (If no relief, may repeat at 2 to 4 mg) For further doses over 10mg of Morphine, contact medical direction. Follow with Zofran Pain Management: mg/kg slow IV/IO/IM/IN KEY POINTS

97 MEDICATIONS NITROGLYCERIN A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Decreases preload and afterlead Increases coronary blood flow Cardiac chest discomfort, angina STEMI Pulmonary edema Known hypersensitivity Hypotension (systolic BP <110, diastolic BP <60 Increased intracranial pressure Glaucoma CVA Erectile dysfunction drugs (contact med control) Headache Hypotension Dizziness, weakness Syncope Dilated pupils Cardiac Chest Discomfort 0.4 mg SL or spray May repeat every 5 minutes up to 3 doses if B/P systolic > 100mmHg PEDIATRIC DOSAGE KEY POINTS Not recommended in the prehospital setting

98 MEDICATIONS ONDANSETRON (Zofran) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Antiemetic Nausea & vomiting Hypersensitivity Drowsiness, vertigo Blurred vision, headache Hypotension 4 mg slow IV/IO/IM - 8 mg Oral Dissolving Tabs Contact Medical Control

99 MEDICATIONS LOPRESSOR (Metoprolol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Beta Blocker Decreases HR Decreases systolic BP Convert or slow ventricular response in SVT (adenosine preferred) Rate Control in SVT that will not convert Bronchial asthma CHF Second or third degree heart block Bradycardia Cardiogenic shock Cocaine use Bradycardia Heart block CHF Bronchospasm Hypotension ADULT DOSAGE PEDIATRIC DOSAGE 5 mg IV/IO over 1 minute. May repeat 5 mg after 3 minutes if inadequate response and B/P>110 and HR>60 Not recommended for Pediatric use

100 MEDICATIONS VERSED (Midazolam) A Advanced A ACTION INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Sedative and hypnotic benzodiazepine Induces amnesia Conscious sedation Seizure Facilitate intubation Facilitate pacing / cardioversion Intolerance to benzodiazepines Narrow-angle glaucoma Shock Coma CNS amnesia, headache, dizziness, euphoria, comfusion, agitation, anxiety, delirium, drowsiness, muscle tremor, ataxia, dysphoria, slurred speech, and paresthesia. Cardiovascular hypotension, PVC s, tachycardia, vasocagel episode Eye blurred vision, diplopia, nystagmus, pinpoint pupils Respiratory coughing, bronchospasms, laryngospasm, apnea, hypoventilation, wheezing, airway, obstruction, tachypnea ADULT DOSAGE PEDIATRIC DOSAGE NOTE Skin swelling, burning, pain at the site of injection 2mg IV/IO max initial dose for sedation (may repeat as necessary) 5mg IV/IO max initial dose for seizures (may repeat as necessary) 5mg IV/IO for RSI and Violent Patients Versed may be administered IM or IN in actively seizing or violent patients whenever IV access is not achieved. Seizures 0.1mg/kg IV/IO/IM/IN to a max dose of 5mg 0.2mg/kg IN to a max dose of 10mg For adult patients use only if Ativan is unavailable 44

101 MEDICATIONS MAGNESIUM SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Anticonvulsant Antiarrhythmic CNS depressant Seizures secondary to eclampsia Ventricular ectopy refractory to Amiodarone Torsades Adjunct to alleviate acute asthma attack Renal disease Heart blocks Respiratory depression CNS depression Hypotension Cardiac arrest ADULT DOSAGE Torsades grams SLOW IVP over 5 minutes (Max dose 4 grams) Eclampsia grams over 2-3 minutes PEDIATRIC DOSAGE KEY POINTS Asthma dose 45mg/kg IV to a total of 75mg/kg (approx 2 grams in adult Not recommended for pediatric use 27

102 MEDICATIONS VASOPRESSIN (Pitressin) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE Alpha agonist Causes vasoconstriction Increases smooth muscle activity Ventricular Fibrillation Pulseless Ventricular Tachycardia Known hypersensitivity Nephritis (inflammation of the kidney) Not recommended for responsive patients with CAD May provoke cardiac ischemia and angina Nausea/Vomiting Diarrhea Confusion Pain at IV site 20 Units / ml in a vial Cardiac Arrest / Ventricular Fibrillation / Pulseless Ventricular Tachycardia 40 Units IV/IO push (administered in place of the first or second dose of Epinephrine) PEDIATRIC DOSAGE Not recommended for pediatric use KEY POINTS The half-life of Vasopressin is approximately minutes 43

103 ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE MEDICATIONS EPINEPHRINE (Adrenaline) Alpha and Beta adrenergic agonist Bronchodilation Increases heart rate and automaticity Increases cardiac contractility Increases myocardial electrical activity Increases systemic vascular resistance Increases blood pressure Cardiac arrest Allergic reaction/anaphylaxis Respiratory distress Acute Asthma Pediatric Bradycardia A Advanced A Hypersensitivity, Tachycardia, Hypertension, Hypothyroidism Angina / Chest pain, Coronary artery disease Pregnancy Blood pressure, pulse, and EKG must be routinely monitored Palpitations, ectopic beats, tachycardia Anxiety / Tremors Hypertension VF / VT Angina Asthma and Anaphylaxis Mild / Moderate Reaction (1-1,000) mg IM ONLY Consider 1:1000 2mg mixed with 1ml NS in nebulizer for Asthma Severe Anaphylaxis (1:10,000) 0.5 mg slow IV/IO over 5 minutes - EMT-P Only Cardiac Arrest 1:10,000 1 mg IV/IO every 3-5 minutes EMT-P Only 18

104 MEDICAL EMERGENCIES PROTOCOLS Abdominal Pain Allergic Reaction / Anaphylaxis Altered Level of Consciousness Behavioral / Psychiatric Emergencies Chest Pain... ACLS/Chest pain Protocol Diabetic Emergencies Dialysis / Renal Patient Esophageal Foreign Body Obstruction 5-14 Heat Exposure Hypertensive Emergencies Hypothermia / Frostbite Pain Management Seizure Stroke/ CVA Toxic Ingestion / Exposure / Overdose UH Protocols Chapter 5 Medical Emergencies 1

105 MEDICAL EMERGENCIES ABDOMINAL PAIN B EMT B A Advanced A M MEDCONTROL M UNIVERSAL PATIENT CARE PROTOCOL Yes Evidence of Dehydration / Vomiting YES IV/IO PROTOCOL Normal Saline 20ml/kg Bolus (If B/P < 100 Systolic) No Consider Pain Management Protocol Severe Nausea/Vomiting: Zofran 4 8 mg IV/IO/IM Zofran Oral Disolving Tabs 8 mg Oral Contact Medical Control TRANSPORT UH Protocols Chapter 5 Medical Emergencies 2

106 MEDICAL EMERGENCIES ABDOMINAL PAIN HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Age Past medical / surgical history Medications Onset Palliation / Provocation Quality (crampy, constant, sharp, dull, etc.) Region / Radiation / Referred Severity (1-10) Time (duration / repetition) Fever Last meal eaten Last bowel movement / emesis Menstrual history (pregnancy) Pain (location / migration) Tenderness Nausea Vomiting Diarrhea Dysuria Constipation Vaginal bleeding / discharge Pregnancy Associated symptoms: (Helpful to localize source) Fever, headache, weakness, malaise, myalgias, cough, headache, mental status changes, rash Pneumonia or pulmonary embolus Liver (hepatitis, CHF) Peptic ulcer disease / gastritis Gallbladder Myocardial infarction Pancreatitis Kidney stone Abdominal aortic aneurysm Appendicitis Bladder / Prostate disorder Pelvic (PID, Ectopic pregnancy, Ovarian cyst) Spleen enlargement Diverticulitis Bowel obstruction Gastroenteritis (infectious) DKA KEY POINTS Exam: Mental Status, Skin, HEENT, Neck, Heart, Lung, Abdomen, Back, Extremities, Neuro. Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise. The diagnosis of acute abdominal aneurysm should be considered with abdominal pain and hypotension in patients over 50. DKA may present with abdominal pain and vomiting. Check blood glucose level. It is important to remember that abdominal pain can be caused by a large number of different disease processes. The organ systems that may be involved in abdominal pain include esophagus, stomach, intestinal tract, liver, pancreas, spleen, kidneys, male and female genital organs, bladder, as well as referred pain from the chest that can involve the heart, lungs or pleura. Abdominal pain may also be caused by muscular and skeletal problems Abdominal pain emergencies are likely to lead to death due to blood or fluid loss with resultant shock. There may also be severe electrolyte abnormalities that can cause arrhythmias. In some patients, cardiac chest pain may manifest as abdominal pain. Consider this in all patients with abdominal pain, especially patients with diabetes and in women. If the abdominal pain may be of cardiac origin, perform cardiac monitoring and a 12-Lead EKG. UH Protocols Chapter 5 Medical Emergencies 3

107 MEDICAL EMERGENCIES ALLERGIC REACTION / ANAPHYLAXIS UNIVERSAL PATIENT CARE PROTOCOL Apply Cardiac Monitor and Assess Vitals IV/IO PROTOCOL B EMT B A Advanced A P EMT P P M MED CONTROL M DO NOT CONFUSE Epi 1:10,000 IV vs. 1:1,000 IM ONLY Mild Moderate Severe Adult Any Age Rash, itching, No difficulty breathing or throat tightening, B/P normal limits Treatment Rash, Itching, Wheezing, Throat tightening, Swelling (face/lips), B/P normal limits Treatment Rash, itching, Airway compromise Wheezing Swelling Hypotension Treatment Impending Arrest Severe hypotension No response to Epi Decreased level of consciousness Airway compromise Treatment Oxygen per cannula Oxygen per NRB Oxygen per NRB Epinephrine 1:10,000 Consider Benadryl 50 mg IV/IO/IM Epi-pen Consider DuoNeb aerosol Epi-pen Epinephrine 1: ml IM ONLY Benadryl 50 mg IV/IO/ IM Up to 0.5mg SLOW IV/IO NS Bolus 20 ml/kg IV/IO Administer Solumedrol 125 mg slow IV/IO CONTACT MEDICAL CONTROL TRANSPORT Benadryl 50 mg IV/IO/ IM Administer solumedrol 125 mg slow IVP Epinephrine 1: ml IM ONLY DuoNeb Aerosol watch airway & breathing may repeat Administer solumedrol 125 mg slow IVP If HTN, CAD, CVA, Pregnant: Consider Glucagon 1mg IV/IO/IM/IN instead of Epi Epinephrine 1:10,000 Up to 0.5mg SLOW IV/IO for Hypotension Control airway by whatever means possible Follow ACLS UH Protocols Chapter 5 Medical Emergencies 4

108 HISTORY Onset and location Insect sting or bite Food allergy / exposure Medication allergy / exposure New clothing, soap, detergent Past history of reactions Past medical history Medication history MEDICAL EMERGENCIES ALLERGIC REACTION SIGNS AND SYMPTOMS Itching or hives Coughing / wheezing or respiratory distress Chest or throat constriction Difficulty swallowing Hypotension or shock Edema DIFFERENTIAL DIAGNOSIS Urticaria (rash only) Anaphylaxis (systemic effect) Shock (vascular effect) Angioedema (drug induced) Aspiration / airway obstruction Vasovagal event Asthma or COPD CHF KEY POINTS Exam: Mental Status, Skin, Heart, Lungs. Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine. The shorter the onset from symptoms to contact, the more severe the reaction. Routine assessment and supportive care of the patient s respiratory and cardiovascular systems is required. DO NOT Confuse Epinephrine 1:10,000 IV with 1:1,000 IM ONLY Treat patients with a history of anaphylaxis aggressively. When possible, remove any stingers. UH Protocols Chapter 5 Medical Emergencies 5

109 MEDICAL EMERGENCIES ALTERED LEVEL OF CONSCIOUSNESS UNIVERSAL PATIENT CARE PROTOCOL Spinal Immobilization Protocol If suspected trauma B EMT B A Advanced A M MED CONTROL M Assess Vital signs / Cardiac Monitor Obtain 12 lead and transmit IV/IO PROTOCOL Glucose Glucose < 70 and Symptomatic Glucose > 200 (Signs of Dehydration) Consider Other Causes: Head Injury Overdose Stroke Hypoxia See Diabetic Protocol See Diabetic Protocol NARCAN mg IV/IO/IM/IN May repeat if needed EMT NARCAN 2 mg IN (Intranasal) Thiamine 100 mg IV/IO/IM for malnourished or alcohol dependent adults Return to Baseline CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 5 Medical Emergencies 6

110 MEDICAL EMERGENCIES ALTERED LEVEL OF CONSCIOUSNESS HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Known diabetic, medic alert tag Drugs, drug paraphernalia Report of illicit drug use or toxic ingestion Past medical history Medications History of trauma Decreased mental status Change in baseline mental status Bizarre behavior Hypoglycemia (cool, diaphoretic skin) Hyperglycemia (warm, dry skin; fruity breath; Kussmal resps; signs of dehydration) Head trauma CNS (stroke, tumor, seizure, infection) Cardiac (MI, CHF) Infection Thyroid (hyper / hypo) Shock (septic, metabolic, traumatic) Diabetes (hyper / hypoglycemia) Toxicologic Acidosis / Alkalosis Environmental exposure Pulmonary (Hypoxia) Electrolyte abnormality Psychiatric disorder KEY POINTS Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia and need Thiamine before glucose. Low glucose (< 70), normal glucose (70-120), high glucose (> 200). Protect the patient airway and support ABCs. Document the patient s initial Glasgow Coma Score. Narcan administration may cause the patient to go into acute opiate withdrawal, which includes vomiting, agitation, and/or combative behavior. Always be prepared for combative behavior. Naloxone (Narcan) may wear off in as little as 20 minutes causing the patient to become more sedate and possibly hypoventilate. All patients receiving Naloxone (Narcan) MUST be transported. RESTRAINT MAY BE NEEDED TO PROTECT THE PATIENT AND EMS PERSONNEL SEE RESTRAINT POLICY UH Protocols Chapter 5 Medical Emergencies 7

111 MEDICAL EMERGENCIES BEHAVIORAL / PSYCHIATRIC EMERGENCIES B EMT B A Advanced A M MED CONTROL M SCENE SAFETY UNIVERSAL PATIENT CARE PROTOCOL Remove patient from stressful environment Treat suspected medical or trauma Causes first Per appropriate protocol Altered Mental Status Overdose Head Trauma Diabetic RESTRAINED PATIENT ON COT OVERHEAD VIEW Verbal techniques (Reassurance, calm, establish rapport) Restraint Procedure Consider: Haldol 5 mg IM; Benadryl 50mg IM; Ativan 1-2 mg IV/IO/IM/IN or Versed 5mg IM/IN if Ativan is not available Secure Cot Straps nips, hips, knees Tie to Bottom Rail Tie to Bottom Rail Use Oxygen Mask or PPE Mask Tie to Bottom Rail Use Kerlix or Kling to tie arms and legs CONTACT MEDICAL CONTROL Note: Benadryl is used for the treatment of (EPS) extrapyramidal symptoms (tremors, stuffness) secondary to Haldol. Note: If patient is Hyperthermic begin cooling with ice packs in groin and axcilla. Can also use a cooling collar if available. TRANSPORT UH Protocols Chapter 5 Medical Emergencies 8

112 MEDICAL EMERGENCIES BEHAVIORAL / PSYCHIATRIC EMERGENCIES ALL RESPONDERS SHOULD HAVE A HEIGHTENED AWARENESS OF SCENE SAFETY HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Situational crisis Psychiatric illness/medications Injury to self or threats to others Medic alert tag Substance abuse / overdose Diabetes Anxiety, agitation, confusion Affect change, hallucinations Delusional thoughts, bizarre behavior Combative violent Expression of suicidal / homicidal thoughts Criteria for Restraint Use: 1. Patient out of control and may cause harm to self or others 2. Necessary force required for patient control without causing harm 3. Position of patient must not impede airway or breathing 4. Restraints must not impede circulation 5. Place mask on patient for body secretion protection. May use TB mask, or Non-rebreather if patient needs oxygen 6. Use supine or lateral positioning ONLY 7. Frequent distal neurovascular checks are required 8. DOCUMENT methods used See Altered LOC differential Alcohol intoxication Toxin / substance abuse Medication effect / overdose Withdrawal syndromes Depression Bipolar (manic-depressive) Schizophrenia Anxiety KEY POINTS Your safety first!! Exam: Mental Status, Skin, Heart, Lungs, Neuro. All psychiatric patients must have medical clearance at a hospital ED before transport to a mental health facility. Be sure to consider all possible medical/trauma causes for acute psychosis (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) Also treat hyperthermia with cooling measures. Do not irritate the patient with a prolonged exam. Do not overlook the possibility of associated domestic violence or child abuse. The safety of on scene personnel is the first priority. Protect yourself and others by summoning Law Enforcement to assure everyone s safety and if necessary, to enable you to render care. Do not approach the patient if he/ she is armed with a weapon. Suicidal ideation or attempts must be transported for evaluation. Be alert for rapidly changing behaviors. Limit patient stimulation and use de-escalation techniques. If the patient has been placed in handcuffs by a law enforcement agency, then a member from that agency MUST be immediately available to adjust restraints as necessary for the patient s safety. UH Protocols Chapter 5 Medical Emergencies 9

113 MEDICAL EMERGENCIES DIABETIC EMERGENCIES UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M IV/IO PROTOCOL Blood Sugar Analysis Glucose < 70 Glucose Glucose >200 Symptomatic ORAL GLUCOSE 1 TUBE (If Alert with no IV Access) Monitor and Transport NORMAL SALINE BOLUS 20ml/kg IV/IO DEXTROSE 50% 25g IV Thiamine 100 mg IV/IO for malnourished or alcohol dependant adults GLUCAGON 1mg IM/IN (if no IV Access) Recheck Blood Glucose May Repeat DEXTROSE Monitor and Reassess Apply Cardiac Monitor CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 5 Medical Emergencies 10

114 MEDICAL EMERGENCIES DIABETIC EMERGENCIES HYPOGLYCEMIA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Known diabetic, medic alert tag Past medical history Medications Last meal Recent Blood Sugar Analysis Altered level of consciousness Dizziness Irritability Diaphoresis Convulsions Hunger Confusion HYPERGLYCEMIA ETOH Toxic Overdose Trauma Seizure Syncope CNS disorder Stroke Pre-existing condition HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Known diabetic, medic alert tag Past medical history Medications Last meal Recent Blood Sugar Analysis Altered level of consciousness / coma Abdominal pain Nausea / vomiting Dehydration Frequent thirst Frequent urination General weakness Malaise Hypovolemic shock Hyperventilation Deep / rapid respirations ETOH Toxic Overdose Trauma Seizure Syncope CNS disorder Stroke Diabetic ketoacidoss KEY POINTS Hyperglycemia: Diabetic Ketoacidosis(DKA) is a complication of diabetes mellitus. It can occur when insulin levels become inadequate to meet the metabolic demands of the body for a prolonged amount of time (onset can be within hours). Without enough insulin the blood glucose increases and cellular glucose depletes. The body removes excess blood glucose by dumping it into the urine. Pediatric patients in DKA should be treated as hyperglycemic under the Pediatric Diabetic Emergency Protocol. Patients can have Hyperglycemia without having DKA. Hypoglycemia: Always suspect Hypoglycemia in patients with an altered mental status. If a blood glucose analysis is not available, a patient with altered mental status and signs and symptoms consistent with hypoglycemia should receive Dextrose or Glucagon. Dextrose is used to elevate BGL but it will not maintain it. The patient will need to follow up with a meal, if not transported to a hospital. Miscellaneous: If IV access is successful after Glucagon IM/IN and the patient is still symptomatic, Dextrose 50% 25g IV/IO can be administered. Consider the need for the malnourished or alcohol dependant to receive thiamine before giving glucose to avoid Wernicke s encephalopathy UH Protocols Chapter 5 Medical Emergencies 11

115 MEDICAL EMERGENCIES DIALYSIS / RENAL PATIENT B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Airway Protocol Apply Cardiac Monitor, Assess Vitals, and Perform 12-lead EKG IV/IO PROTOCOL Breathing Difficulty Chest Pain Pulmonary Edema Abnormal EKG Bleeding Catheter Assess Breath Sounds See Asthma/ COPD Protocol Treat with Appropria te ACLS Protocol See CHF/Pulmonary Edema Protocol If signs of hyperkalemia present e.g., peaked T- waves Albuterol Treatment Via Nebulizer If no improvment Consider Calcium Chloride 1 gram IV/IO If sinusoidal wave form administer Calcium Chloride 1 gram (10cc) slow IVP & Sodium Bicarbonate 50mEq or 1mEq/kg IVP DO NOT ADMINISTER IN THE SAME IV LINE Apply pressure over site and/or pressure points Consider application of tourniquet proximal to catheter. DO NOT PLACE TOURNIQUET DIRECTLY OVER CATHETER. UH Protocols Chapter 5 Medical Emergencies CONTACT MEDICAL CONTROL TRANSPORT Consider application of hemostatic gauze over large catheters in groin. DO NOT PLACE HEMOSTATIC GAUZE OVER ARM SHUNT

116 MEDICAL EMERGENCIES DIALYSIS / RENAL PATIENT HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Renal failure Hypotension Congestive Heart Failure Dialysis treatment Bleeding Pericarditis Anemia Fever Diabetic Problem Dialysis treatment schedule Electrolyte imbalances Previous implications Nausea Long term catheter access Vomiting Shunt access Altered mental status Hyperkalemia Seizure Arrhythmias KEY POINTS The chronic renal dialysis patient has numerous medical problems. The kidneys help maintain electrolyte balance, acid-base balance and rid the body of metabolic waste. Kidney failure results in a build-up of toxins within the body, which can cause many problems. Dialysis is a process which filters out the toxins, excess fluids and restores electrolyte balance. The process may be done in two ways: 1. Peritoneal Dialysis Toxins are absorbed by osmosis through a solution infused into the peritoneal cavity; and then drained out. The solution is placed into the abdomen by means of a catheter, which is placed below the navel. This process must be done frequently, as much as every 12 hours for a period of 1-2 hours. 2. Hemodialysis Removes toxins by directly filtering the blood using equipment that functions like an electric kidney, circulating the blood through a shunt that is connected to a vein and an artery. A permanent shunt can be surgically formed as a fistula. This process usually needs to be done every 2-3 days for a period of 3-5 hours. POSSIBLE COMPLICATIONS OF DIALYSIS TREATMENT 1. Hypotension (15-30%) May result in angina, MI, dysrhythmia, altered mental status, and seizure 2. Removal of therapeutic medications Example: Tegretol 3. Disequilibrium syndrome Cause: shift of urea and / or electrolytes Signs and symptoms: Nausea and / or vomiting, altered mentation, or seizure 4. Bleeding These patients are often treated with heparin and they may have a low platelet count Bleeding may be at the catheter site, retroperitoneal, gastrointestinal, or subdural 5. Equipment malfunctions Possible air embolus Possible fever or endotoxin 6. Infection Do not take blood pressure in arm that has the shunt. Use shunt for IV access ONLY if full arrest. Notify Medical Control A dialysis patient may not respond to drug therapy. A renal patient in full cardiac arrest should be treated according to current ACLS guidelines. Also consider concurrent treatment as above for hyperkalemia. Peaked T Wave Sinusoidal Wave Form UH Protocols Chapter 5 Medical Emergencies 13

117 MEDICAL EMERGENCIES ESOPHAGEAL FOREIGN BODY OBSTRUCTION UNIVERSAL PATIENT CARE PROTOCOL Airway Obstruction Difficulty Breathing Coughing Difficulty / Unable to Talk Esophageal Obstruction Salivation Unable to Swallow Secretions AIRWAY PROTOCOL Patient is in Distress Evaluate Level of Obstruction LOW (Neck Down) HIGH (Neck Up) IV/IO Protocol Position and Protect Airway GLUCAGON 1 mg IV PROBLEM RESOLVED? May take up to 20 min YES NO NITROGLYCERINE 0.4 mg SL CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 5 Medical Emergencies 14

118 MEDICAL EMERGENCIES ESOPHAGEAL FOREIGN BODY OBSTRUCTION HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Onset during eating or swallowing pills, etc. Salivation Unable to swallow secretions Distressed patient Able to breathe but may feel impaired Airway obstruction coughing, unable to speak, difficulty breathing KEY POINTS Rule out airway obstruction first. Patient may be helpful in identifying location of bolus obstruction as they can feel it, point to it. If bolus is located in neck area, Glucagon (Glucagen) will not work, just monitor and transport. If bolus located from neck down, proceed with Glucagon (Glucagen) treatment. Glucagon (Glucagen) affect will take from 5-20 minutes. Administer Nitroglycerine (Nitro-Stat) for its smooth muscle relaxant properties to help pass the bolus if Glucagon (Glucagen) fails. UH Protocols Chapter 5 Medical Emergencies 15

119 MEDICAL EMERGENCIES HEAT EXPOSURE UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Document Patient Temperature apply high flow O 2 Remove Patient from Heat Source Remove Patient Clothing Apply Room Temperature Water to Patient Skin and Increase Air Flow around Patient Apply cold packs to body IV/IO PROTOCOL 20ml/kg Bolus NS IV/IO May Repeat Monitor and Reassess Appropriate Protocol Based on Patient Symptoms CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 5 Medical Emergencies 16

120 MEDICAL EMERGENCIES HEAT EXPOSURE HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Age Exposure to increased temperatures and humidity Past medical history / medications Extreme exertion Time and length of exposure Poor PO intake Fatigue and / or muscle cramping Altered mental status or unconsciousness Hot, dry or sweaty skin Hypotension or shock Seizures Nausea Fever (Infection) Dehydration Medications Hyperthyroidism Delirium tremens (DT's) Heat cramps Heat exhaustion Heat stroke CNS lesions or tumors Heat Exhaustion: Dehydration Muscular / abdominal cramping General weakness Diaphoresis Febrile Confusion Dry mouth/ thirsty Tachycardia BP normal or orthostatic Heat Stroke: Cerebral Edema Confusion Bizarre behavior Skin hot dry, febrile Tachycardia Hypotensive Seizure Coma KEY POINTS Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro. Extremes of age are more prone to heat emergencies (i.e. young and old). Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications and alcohol. Cocaine, Amphetamines, and Salicylates may elevate body temperatures. Sweating generally disappears as body temperature rises above 104 F (40 C). Intense shivering may occur as patient is cooled. Heat Cramps consists of benign muscle cramping secondary to dehydration and is not associated with an elevated temperature. Heat Exhaustion consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, normotension, and an elevated temperature. Heat Stroke consists of dehydration, tachycardia, hypotension, temperature >104 F (40 C), and an altered mental status. Patients at risk for heat emergencies include neonates, infants, geriatric patients, and patients with mental illness. Other contributory factors may include heart medications, diuretics, cold medications and/or psychiatric medications. Heat exposure can occur either due to increased environmental temperatures or prolonged exercise or a combination of both. Environments with temperature > 90 F and humidity > 60% present the most risk. Heat stroke occurs when the cooling mechanism of the body (sweating) ceases due to temperature overload and/or electrolyte imbalances. Be alert for cardiac arrhythmias for the patient with heat stroke. UH Protocols Chapter 5 Medical Emergencies 17

121 MEDICAL EMERGENCIES HYPERTENSIVE EMERGENCIES UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M IV/IO PROTOCOL Apply Cardiac Monitor Assess Neuro Status Via Cincinnati Stroke Scale NITROGLYCERIN 0.4 mg SL (If B/P > 120 Diastolic Repeat B/P x2) and the patient has signs and symptoms of CHF or Cardiac Chest Pain Consult Medical Direction if CVA suspected Monitor and Reassess CONTACT MEDICAL CONTROL TRANSPORT Head Up > 30 Degrees Position UH Protocols Chapter 5 Medical Emergencies 18

122 MEDICAL EMERGENCIES HYPERTENSIVE EMERGENCIES HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Documented hypertension Related diseases: diabetes, CVA renal failure, cardiac Medications (compliance?) Viagra Pregnancy One of these: Systolic BP 200 or greater Diastolic BP 120 or greater AND at least one of these: Headache Nosebleed Blurred vision Dizziness Hypertensive encephalopathy Primary CNS Injury (Cushing's response = bradycardia with hypertension) Myocardial infarction Aortic dissection Pre-eclampsia / Eclampsia KEY POINTS Prehospital treatment of hypertension is very conservative because a CVA in progress may be made worse by a drop in B/P following aggressive hypertension treatment. Consider treatment ONLY if Diastolic is >120 mm/hg (repeat B/P x2), and patient has signs and symptoms of CHF or Cardiac Chest Pain! Hypertensive emergencies are life threatening emergencies characterized by an acute elevation in blood pressure AND end-organ damage to the cardiac, CNS or renal systems. These crisis situations may occur when patients have poorly controlled chronic hypertension. Avoid Nitroglycerin in any patient who has used Viagra or similar drug in the past hours due to potential severe hypotension. All symptomatic patients with hypertension should be transported with their head elevated. Evidence of neurological deficit includes: confusion, slurred speech, facial asymmetry, focal weakness, coma, lethargy and seizure activity. Evidence of cardiac impairment includes: angina, jugular vein distention, chest discomfort and pulmonary edema. If the patient becomes hypotensive from Nitroglycerin administration, place the patient in the Trendelenburg position and administer a 250 ml Normal Saline bolus. Toxic ingestion such as cocaine may present with a hypertensive emergency. Hypertension can be a neuroprotective reflex in patients with increased intracranial pressure. UH Protocols Chapter 5 Medical Emergencies 19

123 MEDICAL EMERGENCIES HYPOTHERMIA / FROSTBITE B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Remove Wet Clothing Evidence of Decreased Core Temperature? Yes No Handle Patient Gently Indirectly Apply Hot Packs and/or Blankets and Turn Up Vehicle Heat IV/IO PROTOCOL Appropriate Protocol Based on Patient s Signs and Symptoms CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 5 Medical Emergencies 20

124 MEDICAL EMERGENCIES HYPOTHERMIA / FROSTBITE HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Medications Exposure to environment even in normal temperatures Exposure to extreme cold Extremes of age Drug use: alcohol, barbituates Infections / Sepsis Length of exposure / wetness Cold, clammy Shivering Mental status changes Extremity pain or sensory abnormality Bradycardia Hypotension or shock Sepsis Environmental exposure Hypoglycemia CNS dysfunction Stroke Head injury Spinal cord injury KEY POINTS Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro. Hypothermic/drowning/near -drowning patients that appear cold and dead are NOT dead until they are warm and dead, or have other signs of obvious death (putrification, traumatic injury unsustainable to life). Defined as core temperature < 35 C (95 F). Extremes of age are more susceptible (i.e. young and old). Patients with low core temperatures will not respond to ALS drug interventions. Maintain warming procedure and supportive care. Warming procedures includes removing wet clothing, limiting exposure, and covering the patient with warm blankets if available. Do not allow patients with frozen extremities to ambulate. Superficial frostbite can be treated by using the patient s own body heat. Do not attempt to rewarm deep frostbite unless there is an extreme delay in transport, and there is no risk that the affected body part will be refrozen. Contact Medical Control prior to rewarming a deep frostbite injury. With temperature less than 31 C (88 F) ventricular fibrillation is common cause of death (rarely responds to defibrillation). Handling patients gently may prevent this. The most common mechanism of death in hypothermia is ventricular fibrillation. If the hypothermia victim is in ventricular fibrillation, CPR should be initiated. If V fib is not present, then all treatment and transport decisions should be tempered by the fact that V fib can be caused by rough handling, noxious stimuli or even minor mechanical disturbances. This means that respiratory support with 100% oxygen should be done gently, including intubation, avoiding hyperventilation. If the temperature is unable to be measured, treat the patient based on the suspected temperature. Hypothermia may produce severe bradycardia. Shivering stops below 32 C (90 F). Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly against the patient's skin. Consider withholding CPR if patient has organized rhythm. Discuss with Medical Control. All hypothermic patients should have resuscitation performed until care is transferred. If there are signs of obvious death (putrification, traumatic injury unsustainable to life), DOA Protocol should be followed. UH Protocols Chapter 5 Medical Emergencies 21

125 MEDICAL EMERGENCIES PAIN MANAGEMENT UNIVERSAL PATIENT CARE PROTOCOL Treat per Appropriate Trauma Protocol B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Treat per Appropriate Trauma Protocol NITROUS OXIDE Self Administered with Mask Not for Abdominal Trauma, Altered Mentation, Suspected Pneumothorax, Head Injury, COPD, SBO, Psychiatric, Respiratory Distress IV/IO PROTOCOL MORPHINE SULFATE 2 4 mg IV/IO/IM/IN Not for Altered Mentation, Head Trauma, Hypotension, Sever Respiratory Distress May repeat to a total of 10 mg - contact med control for further dose OR Follow Morphine Sulfate with Zofran 4 mg slow IV/IO/IM/PO Zofran Oral Disolving Tabs 8 mg Oral Toradol (NSAID) 30mg IV/IO, 60mg IM x1 (If <65 Years Old Only) Not for :Altered Mentation, Abdominal Pain, Head Trauma, Hypovolemia, Multiple Trauma, Use With or Hypersensitivity to Aspirin, Active or History of Peptic Ulcer Disease, GI Bleeding, Cerebrovascular Bleeding, Risk of Any Bleeding, Prior to Surgery, Possible Pregnancy OR Fentanyl mcg IV/IO/IM/IN slow over at least 1-2 minutes, every minutes PRN, titrated to Systolic BP of > 90 mm/hg or for proper analgesic effect. Monitor and Reassess CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 5 Medical Emergencies 22

126 MEDICAL EMERGENCIES PAIN MANAGEMENT HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Age Severity (pain scale) Musculoskeletal Location Quality (sharp, dull, etc.) Visceral (abdominal) Duration Radiation Cardiac Severity (0-10) Relation to movement, Pleural / Respiratory Past medical history respiration Neurogenic Medications Increased with palpation Renal (colic) Drug allergies of area KEY POINTS Exam: Mental Status, Area of Pain, Neuro, Lungs. Pain severity (0-10) is a vital sign to be recorded pre and post IV/IO/IM/IN medication delivery and at disposition. Vital signs should be obtained pre, 15 minutes post, and at disposition with all pain medications. Contraindications to pain management include hypotension, head injury or severe respiratory distress. All patients should have drug allergies documented prior to administering pain medications. All patients who receive IV/IO/IM/IN medications must be observed 15 minutes for drug reaction. All patients who receive medication for pain must have continuous ECG monitoring, pulse oximetry, and oxygen administration. The patient s vital signs must be routinely reassessed. The routine reassessments must be documented on the run report. Have Narcan on hand if the patient has respiratory depression or hypotension after narcotic administration (Dose-Narcan 0.4mg-2.0mg IV/IO/IM/PO). When in doubt, contact medical control UH Protocols Chapter 5 Medical Emergencies 23

127 MEDICAL EMERGENCIES SEIZURES UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Airway Protocol Consider Spinal Immobilization Protocol Loosen Patient s Clothing / Protect Patient IV/IO PROTOCOL Glucose < 70 Blood Glucose Analysis See Diabetic Protocol Seizure/ Status Epilepticus Ativan 1-2 mg IV/IM/IO/IN or Versed 2mg IV/IO or 5mg IM/IN If Ativan is unavailable Postictal Monitor and Reassess Monitor and Reassess CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 5 Medical Emergencies 24

128 HISTORY Reported / witnessed seizure activity Previous seizure history Medical alert tag information Seizure medications History of trauma History of diabetes History of pregnancy MEDICAL EMERGENCIES SEIZURES SIGNS AND SYMPTOMS Decreased mental status Sleepiness Incontinence Observed seizure activity Evidence of trauma DIFFERENTIAL DIAGNOSIS CNS (Head) trauma Tumor Metabolic, hepatic, or renal failure Hypoxia Electrolyte abnormality Drugs, medications, noncompliance Infection / Fever Alcohol withdrawal Eclampsia Stroke Hyperthermia KEY POINTS Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro. Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport. Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness Be prepared for airway problems and continued seizures. Assess possibility of occult trauma and substance abuse. Be prepared to assist ventilations especially if Versed is used. For any seizure in a pregnant patient, follow the OB Emergencies Protocol. The seizure has usually stopped by the time the EMS personnel arrive and the patient will be found in the postictal state. There are many causes for seizures including: epilepsy, head trauma, tumor, overdose, infection, hypoglycemia, and withdrawal. Be sure to consider these when doing your assessment. Routinely assess the patient s airway. If the patient is combative and postictal, DO NOT refer to the Restraint Procedure before assessing for/treating hypoglycemia and hypoxia. If the patient is actively seizing, move any objects that may injure the patient. Protect, but do not try to restrain them. UH Protocols Chapter 5 Medical Emergencies 25

129 MEDICAL EMERGENCIES STROKE / CVA B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Airway Protocol Consider other protocols as indicated Altered LOC Protocol Seizure Protocol IV/IO PROTOCOL Glucose <70 See Diabetic Protocol Blood Glucose Analysis Prehospital Stroke Screen / establish time last seen normal Cincinnati Pre-Hospital Stroke Assessment Facial Droop Have patient smile Normal both sides equal Abnormal one side does not move as well Arm Drift Patient closes eyes and holds both arms out straight for 10 seconds Normal both arms move or don t move equally Abnormal one arm doesn t move or drifts down compared to the other Speech Have patient say you can t teach an old dog a new trick Normal patient says correctly with no slurring Abnormal patient slurs words, uses wrong words or is unable to speak CONTACT MEDICAL CONTROL TRANSPORT Consider Transport to Stroke Center UH Protocols Chapter 5 Medical Emergencies 26

130 MEDICAL EMERGENCIES STROKE / CVA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Previous CVA, TIA's Previous cardiac / vascular surgery Associated diseases: diabetes, hypertension, CAD, atrial fibrillation Medications (blood thinners) History of trauma Altered mental status Weakness / Paralysis Blindness or other sensory loss Aphasia / Dysarthria Syncope Vertigo / Dizziness Vomiting Headache Seizures Respiratory pattern change Hypertension / hypotension See Altered LOC TIA (Transient ischemic attack) Seizure Hypoglycemia Stroke Thrombotic Embolic Hemorrhagic Tumor Trauma Bell s Palsy KEY POINTS Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro. Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke symptoms would be defined as an onset time of the previous night when patient was symptom free). Elevated blood pressure is commonly present with stroke. Be alert for airway problems (swallowing difficulty, vomiting). Hypoglycemia can present as a localized neurological deficit, especially in the elderly. Patients who experience transient ischemic attack (TIA) develop most of the same signs and symptoms as those who are experiencing a stroke. The signs and symptoms of TIA s can last from minutes up to one day. Thus the patient may initially present with typical signs and symptoms of a stroke, but those findings may progressively resolve. The patient needs to be transported, without delay, to the most appropriate hospital for further evaluation. Hypertension in stroke patients routinely should not be treated in the prehospital setting. It is not uncommon for blood pressures to be as high as 220/140 and not require intervention. Nitroglycerin should not be used unless signs and symptoms consistent with AMI or Acute Pulmonary Edema are present. Document the time of onset for the symptoms, or the last time the patient was seen normal for them. Reassess neurological deficit every 10 minutes and document the findings. UH Protocols Chapter 5 Medical Emergencies 27

131 MEDICAL EMERGENCIES TOXIC INGESTION / EXPOSURE / OVERDOSE Hypotension, Seizures, Ventricular Arrhythmias, Mental Status Changes, or Nerve Agent Exposure Appropriate Protocol UNIVERSAL PATIENT CARE PROTOCOL Airway Protocol IV/IO PROTOCOL Blood Glucose Analysis B EMT B B I EMT I I P EMT P P M MEDCONTROL M Carbon Monoxide: O2 NRM 15 LPM Beta Blocker or Calcium Channel Organophosphates Tricyclic Ingestion Overdose (bradycardia) (SLUDGE symptoms) (Wide QRS) Yes Yes Yes Immediate Transcutaneous Pacing for Severe Cases Hypotension / AMS NORMAL SALINE Bolus to Maintain SBP 90 or Radial Pulses Glucagon 2 mg IV/IO/IM/IN Calcium 1g slow IVP If Glucagon is unsuccessful ATROPINE 2-5 mg IV/IO/IM Repeat every 3-5 minutes Atropine is: To improve respirations Dry secretions Unlike ACLS is not being given for bradycardia Patient noted to be on any TRICYCLIC listed below and QRS complex wider than.12 msc Brand Name Adapin Anafranil Elavil Endep Ludiomil Norpramin Pamelor Pertofrane Sinequan Surmontil Tofranil Vivactil Generic Name doxepin clomipramine amitriptyline amitriptyline maprotine desipramine nortryptyline desipramine doxepin trimipramine imipramine protriptyline DOPAMINE 2 20 mcg / kg / min IV Drip For Severe Cases or Not Responding to Treatment CONTACT MEDICAL CONTROL TRANSPORT Sodium BiCarb 50mEq IV/IO (until the QRS complex narrows to less than.12msec and the patient condition improves) UH Protocols Chapter 5 Medical Emergencies 28

132 MEDICAL EMERGENCIES TOXIC INGESTION / EXPOSURE / OVERDOSE HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Ingestion or suspected ingestion of a potentially toxic substance Substance ingested, route, quantity Time of ingestion Reason (suicidal, accidental, criminal) Available medications in home Past medical history, medications Mental status changes Hypo / Hypertension Decreased respiratory rate Tachycardia, arrhythmias Seizures Tricyclic antidepressants (TCAs) Acetaminophen (Tylenol) Depressants Stimulants Anticholinergic Cardiac medications Solvents, alcohols, cleaning agents Insecticides (organophosphates) Carbamates Carbon Monoxide poisoning KEY POINTS Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro. Do not rely on patient history of ingestion, especially in suicide attempts. Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert mental status to death. Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure Depressants: decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes Cardiac Meds: dysrhythmias and mental status changes Solvents: nausea, vomiting, and mental status changes Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Protocol. MARK 1 kits contain 2 mg of Atropine and 600 mg of pralidoxime in an autoinjector for self-administration or patient care. These kits may be available as part of the domestic preparedness for Weapons of Mass Destruction. They are for the use of first responders only. If it can be done safely, take whatever container the substance came from to the hospital along with readily obtainable samples of medication unless this results in an unreasonable delay of transport If applicable, DO NOT transport a patient to the hospital until properly decontaminated. Carbon monoxide poisoning patients that show signs and symptoms at lower CO levels include: pregnant females, infants, children and the elderly. Patients that demonstrate altered mental status may NOT sign refusals for treatment or transport. UH Protocols Chapter 5 Medical Emergencies 29

133 MEDICATIONS ALBUTEROL (Proventil / Ventolin) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Acts directly on beta 2 adrenergic receptors to relax bronchial smooth muscle, resulting in reduced airway resistance and relief of bronchospasm Shortness of breath caused by bronchoconstriction Peaked T-Waves with symptoms in Renal Patients Known hypersensitivity Use precaution when administering to pregnant women or patients with cardiac history Nervousness Weakness Tremor Tachycardia 2.5 mg in 3 ml via unit dose nebulizer and 6 lpm oxygen 2.5 mg in 3 ml via unit dose nebulizer and 6 lpm oxygen May repeat treatment if partial relief is obtained 6

134 MEDICATIONS ATIVAN (LORAZEPAM) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSE Sedative Anticonvulsant Amnestic (induces amnesia) Status epilepticus Sedation prior to transcutaneous pacing and synchronized cardioversion in the conscious patient Known hypersensitivity Altered mental status of unknown origin Head injury Respiratory insufficiency May cause respiratory depression, respiratory effort must be continuously monitored with Capnography Should be used with caution with hypotensive patients and patients with altered mental status Lorazepam (Ativan) potentiates alcohol or other CNS depression Respiratory depression Hypotension Lightheadedness Confusion Slurred speech Amnesia 1 2 mg IV / IO / IM / IN Not Recommended for Pediatric Use

135 MEDICATIONS ATROPINE SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE PEDIATRIC DOSAGE Increases sinus node firing Increases conduction through the AV node by blocking vagal activity Increases cardiac output Decreases ectopic beats or fibrillation of the ventricles Symptomatic sinus bradycardia Organophosphate poisoning/nerve agent exposure Known hypersensitivity Atrial flutter/fibrillation where there is a rapid ventricular response Glaucoma narrow angle 2 nd and 3 rd degree AV Block with wide QRS complex Use with extreme caution in myocardial infarction May increase myocardial oxygen demand May trigger tachy-dysrhythmias Patient needs to be warned about side effects Doses smaller than 0.5 mg or administered too slowly may slow rather than speed up the heart rate Excessive doses in adults may precipitate ventricular tachycardia or fibrillation Dry mouth, thirst, urinary retention Blurred vision, pupillary dilation, headache Flushed skin Tachycardia Prefilled syringes containing 1 mg in 10 ml Auto-Injector containing 2 mg (nerve agent exposure only) Bradycardia 0.5 mg IV/IO (1.0 mg ETT) every 5 minutes Max dose 0.04 mg/kg or 3 mg Organophosphate Poisoning 2 5mg IVP, IM, or IO every 5 min Bradycardia 0.02 mg/kg IV/IO, repeated X 1, 5 minutes (minimum dose 0.1 mg), Max single dose 0.5 mg CHILD / 1.0 mg ADOLESCENT, Max total dose 1.0 mg CHILD / 2.0 mg ADOLESCENT Organophosphate Poisoning 0.2 mg/kg IV/IO, repeat every 3-5 minutes / Max dose 0.5mg Child Max dose 1.0mg Adolescent.

136 MEDICATIONS BiCarbonate (Sodium BiCarbonate) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDS DOSAGE Buffers metabolic acidosis Enhances the urinary excretion of tricyclics Metabolic Acidosis from cardiac arrest Tricyclic Overdose Hyperkalemia Post Crushing Entrapment Heart Failure Seizures Tissue necrosis if infiltration Can precipitate with Calcium 50mEq IVP for tricyclic overdose 50mEq or 1mEq/kg IVP for cardiac arrest asystole or PEA 50 meq IVP for cardiac arrest with prolonged down time(10 minutes) 50mEq to 100mEq Post Crushing Entrapment 1mEq/kg IV/IO Diluted in 1:1 NS or as advised By Med Command

137 MEDICATIONS CALCIUM CHLORIDE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Reverses overdose with magnesium sulfate or calcium channel blockers (such as verapamil) Antidote magnesium sulfate and calcium channel blocker toxicity Hyperkalemia Beta Blocker overdose Known dialysis patient in cardiac arrest Hypersensitivity to calcium chloride Do not infuse with sodium bicarbonate will combine to form an insoluble precipitate Can cause ventricular fibrillation when pushed too fast or given to a patient who has been taking digitalis 1 gram (10cc) slow IVP NOT RECOMMENDED FOR PEDIATRIC USE Previously, calcium was used in resuscitation because it was believed to stimulate the heart to beat in asystole and to strengthen cardiac contractions in electromechanical dissociation careful recent studies have failed to show any benefit from using calcium in cardiac arrest, and indeed the effects of calcium may be harmful in that situation

138 MEDICATIONS DEXTROSE 50 % (D50) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Restores circulating blood sugar Hypoglycemia Altered mental status of unknown origin Coma of unknown origin Seizures of unknown origin Known hyperglycemia. Head trauma unless confirmed hypoglycemia Caution with chronic renal failure Intracranial hemorrhage Use with caution for stroke patients Use a large vein to administer D50 Treat known alcoholics, renal failure patients, or malnourished patients with Thiamine prior to administering glucose Extravasation of D50 may cause necrosis Hyperglycemia May precipitate severe neurologic symptoms in alcoholics Dextrose 50% (D50) 25 g IV/IO 2 ml/kg D25 IV/IO

139 MEDICATIONS DIPHENHYDRAMINE HCL (Benadryl) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Antihistamine Sedative Inhibits motion sickness (antiemetic) Anaphylactic shock and severe allergic reaction Acute dystonia Nausea/vomiting (contact Medical Control) Extrapyramidal reaction (Parkinson-like movement disorders) Known hypersensitivity / Allergy Pregnancy or lactating Avoid the use of Diphenhydramine in nursing mothers May induce vomiting Carefully monitor patient while awaiting for medication to take effect (effect of medication begins 15 minutes after administration) Drowsiness, confusion Blurring of vision Dry mouth Wheezing; thickening of bronchial secretions Hypotension ADULT DOSAGE PEDIATRIC DOSAGE Allergic Reaction or Anaphylaxis mg IV/IO/IM Behavioral Psychiatric Emergencies 50 mg IM Allergic Reaction or Anaphylaxis 1 mg/kg (without hypotension) IV/IO/IM Max 50mg

140 MEDICATIONS DOPAMINE (Intropine) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE Alpha and beta adrenergic receptor stimulator Dopaminergic receptor stimulator Dilates renal and mesenteric blood vessels Vasoconstriction Arterial resistance Increases cardiac output Increases preload Cardiogenic shock Distributive Shock Cyanide poisoning (contact Medical Control) Known hypersensitivity /Allergy Hypovolemic hypotension VF or VT Do not mix with bicarbonate, dopamine may be inactivated by alkaline solutions Extravasation may cause tissue necrosis Ectopic beats, palpitations Tachycardia, angina Nausea/vomiting VF or VT Dyspnea Headache 2-20mcg/kg/min IV drip. Start 5 micrograms/kg/minute IV/IO infusion, titrate to effect Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is =15 drops per min (approx 5 mcg/kg/min)

141 MEDICATIONS DuoNeb A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS (Albuterol) Parasympatholytic bronchodilator Dries respiratory tract secritations (Ipratropium Atrovent) B2 selective bronchodilator Increases HR Asthma exacerbation COPD exacerbation Patients that have used their prescribed inhaler more than once Pulmonary edema with wheezing Known hypersensitivity /Allergy Allergy to peanuts Acute myocardial infarction Arrhythmias Cardiovascular disease Hypertension history CHF Palpitations Anxiety Nausea Dissiness ADULT/PEDS DOSAGE Unit dose inhaled via nebulizer. May repeat as needed

142 ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE MEDICATIONS EPINEPHRINE (Adrenaline) Alpha and Beta adrenergic agonist Bronchodilation Increases heart rate and automaticity Increases cardiac contractility Increases myocardial electrical activity Increases systemic vascular resistance Increases blood pressure Cardiac arrest Allergic reaction/anaphylaxis Respiratory distress Acute Asthma Pediatric Bradycardia A Advanced A Hypersensitivity, Tachycardia, Hypertension, Hypothyroidism Angina / Chest pain, Coronary artery disease Pregnancy Blood pressure, pulse, and EKG must be routinely monitored Palpitations, ectopic beats, tachycardia Anxiety / Tremors Hypertension VF / VT Angina Asthma and Anaphylaxis Mild / Moderate Reaction (1-1,000) mg IM ONLY Consider 1:1000 2mg mixed with 1ml NS in nebulizer for Asthma Severe Anaphylaxis (1:10,000) 0.5 mg slow IV/IO over 5 minutes - EMT-P Only Cardiac Arrest 1:10,000 1 mg IV/IO every 3-5 minutes EMT-P Only PEDIATRIC DOSAGE Asthma and Anaphylaxis Mild Reaction Ages yrs (1:1,000) 0.03 mg/kg IM Under 10 yrs (1:1,000) 0.01mg/kg IM May use 1:1000 2mg mixed with 1ml NS in nebulizer aerosolized Severe Anaphylaxis Pending Arrest Ages yrs (1:10,000) 0.01mg/kg IV/IO over 5 minutes EMT-P Only Cardiac Arrest 1:10, mg/kg IV/IO push 0.1ml/kg EMT-P Only or 0.1 mg/kg 1:1000 ETT 0.1ml/kg EMT-P Only 18

143 MEDICATIONS Fentanyl (Sublimaze) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Pediatric Dose Analgesic anesthetic narcotic Pain Management Acute Coronary Syndrome STEMI Hypersensitivity Hemorrhage Shock Decreases in Respiratory Apnea Bradycardia Muscle Rigidity 25-50mcg IV, IM, or IN (May repeat in minutes) Children 2-12 years of age 1mcg/kg IV, IO, IM, or IN

144 MEDICATIONS GLUCAGON A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose level Relaxes smooth muscle of GI tract Hypoglycemia when IV/IO is not able to be established and oral glucose is contraindicated Esophageal obstruction Beta Blocker overdose Known hypersensitivity Pheochromocytoma Glucagon is only effective in patients with sufficient stores of glycogen Use caution in patients with renal or cardiovascular disease Glucagon can be administered on scene, but do not wait for it to take effect Nausea/Vomiting 1mg IM/IN for Hypoglycemia 2mg IV/IO/IM/IN in esophageal foreign body obstruction 2 mg IV/IO/IM/IN for hypotension / bradycardia in Betablocker overdose and Calcium Channel overdose <20kg give 0.5mg IM / IN >20kg give 1mg IM / IN Response is usually noticed in 5-20 minutes Glucagon is NOT a substitute for D25, or D12.5. IV must be attempted prior to administering Glucagon

145 MEDICATIONS HALDOL (Haloperidol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE KEY POINTS Antipsychotic Major tranquilizer Combative patient Acute psychotic episodes Known hypersensitivity Head injury or head trauma Seizure or history of seizure Children less than 16 years old Altered LOC/ Coma Nausea/Vomiting Hypotension Tremors Known Hypersensitivity 5 mg IM Call Medical Direction for orders of repeat single dose after 5 minutes The patient MUST be routinely Monitored for respiratory depression and or hypotension. The run documentation MUST clearly support the use of this medication.

146 MEDICATIONS KETOROLAC (Toradol) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE NSAID analgesic Reduces pain Moderate pain Pain associated with kidney and gall stones >65 Years Old Hypersensitivity including aspirin or other NSAIDS Advanced renal impairment Suspected cerebrovascular bleeding Recent GI bleeding Nursing mothers Labor and delivery Asthma Edema Hypertension Rash Nausea Dizziness 30 mg IV, 60 mg IM (If <65 Year Old Only) 0.15 mg/kg IV or 0.3 mg/kg IM

147 MEDICATIONS METHYLPREDNISOLONE (Solumedrol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Anti-inflammatory steroid Anaphylaxis Asthma COPD NONE in emergency setting GI bleeding Prolonged wound healing Suppression of natural steroids 125 mg IV/IO 1-2 mg/kg IV/IO KEY POINTS

148 MEDICATIONS MORPHINE SULFATE A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Narcotic Analgesic Causes peripheral vasodilation Pulmonary edema MI pain unrelieved with nitro Pain management Pain secondary to burns Known hypersensitivity / Allergy Head injury or head trauma Hypotension Altered LOC Undiagnosed abdominal pain(consult Med Command) COPD Bradycardia Multiple trauma patients If the patient responds with respiratory depression or hypotension, administer Narcan to reverse the effects Routinely monitor the patient s respiratory effort and SpO2 Respiratory depression Altered LOC, constricted pupils Bradycardia Nausea/Vomiting Hypotension 2-4 mg slow IV/IO/IM/IN (If no relief, may repeat at 2 to 4 mg) For further doses over 10mg of Morphine, contact medical direction. Follow with Zofran Pain Management: mg/kg slow IV/IO/IM/IN KEY POINTS

149 MEDICATIONS NALOXONE (Narcan) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Reverses all effects from opioid agents such as respiratory depression and all central and peripheral nervous system effects Narcotics overdoses Altered mental status of unknown origin None Withdrawal syndrome in addiction Ventricular dysrhythmias Cerbral edema mg IV/IO/IM/IN. Administer in small doses. May repeat the initial dose if the patient becomes symptomatic again EMT 2 mg IN 0.1 mg/kg IV,IO,IM,IN. May be repeated at 0.1 mg/kg

150 MEDICATIONS NITROGLYCERIN A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Decreases preload and afterlead Increases coronary blood flow Cardiac chest discomfort, angina STEMI Pulmonary edema Known hypersensitivity Hypotension (systolic BP <110, diastolic BP <60 Increased intracranial pressure Glaucoma CVA Erectile dysfunction drugs (contact med control) Headache Hypotension Dizziness, weakness Syncope Dilated pupils Cardiac Chest Discomfort 0.4 mg SL or spray May repeat every 5 minutes up to 3 doses if B/P systolic > 100mmHg PEDIATRIC DOSAGE KEY POINTS Not recommended in the prehospital setting

151 MEDICATIONS NITROUS OXIDE A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS Provides rapid, easily reversible relief of pain Abdominal pain Chest pain secondary to infarction or angina Acute urinary retention Fractures Severe exterior burns Kidney stones Musculoskeletal trauma Patients under 12 years of age Severe COPD Head injury ABD pain or trauma Intoxication or drug ingestion Shortness of breath Chest trauma with a possible pneumothorax (during prolonged transport) SIDE EFFECTS SUPPLIED ADULT DOSAGE Discontinue if any of the following arise Apnea, cyanosis Nausea/vomiting Deteriorating vital signs (administer O2 100%) Ambulance crew may experience giddiness if the vehicle is not properly vented Nitronox, a set containing an oxygen cylinder and a nitrous oxide cylinder joined by a valve that regulates flow to provide a 50:50 mixture of the two gases - the mixture is piped to a demand valve apparatus Invert cylinder several times before use; instruct the patient to inhale deeply though a patient-held demand valve mouthpiece PEDIATRIC DOSAGE KEY POINTS Self-administered by mask: a good seal around the mouth and nose is important; the gas is breathed deeply and may give relief after about two minutes; the patient should stop when relief is obtained The paramedic should not hold the face mask in place for the patient 33

152 MEDICATIONS ONDANSETRON (Zofran) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Antiemetic Nausea & vomiting Hypersensitivity Drowsiness, vertigo Blurred vision, headache Hypotension 4 mg slow IV/IO/IM - 8 mg Oral Dissolving Tabs Contact Medical Control

153 MEDICATIONS Thiamine / Vitamin B1 ACTIONS INDICATIONS Allows normal breakdown of glucose Indicated for use in adult patients only Altered mental status. Given prior to D50 to avoid Wernicke Karsakoff Syndrome. (alcoholic, renal failure patients, or malnourished patients may have a Thiamine deficiency) CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Alcohol abuse None None 100 mg IVP prior to administering D50 Not recommended for pediatric use

154 MEDICATIONS VERSED (Midazolam) A Advanced A ACTION INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Sedative and hypnotic benzodiazepine Induces amnesia Conscious sedation Seizure Facilitate intubation Facilitate pacing / cardioversion Intolerance to benzodiazepines Narrow-angle glaucoma Shock Coma CNS amnesia, headache, dizziness, euphoria, comfusion, agitation, anxiety, delirium, drowsiness, muscle tremor, ataxia, dysphoria, slurred speech, and paresthesia. Cardiovascular hypotension, PVC s, tachycardia, vasocagel episode Eye blurred vision, diplopia, nystagmus, pinpoint pupils Respiratory coughing, bronchospasms, laryngospasm, apnea, hypoventilation, wheezing, airway, obstruction, tachypnea ADULT DOSAGE PEDIATRIC DOSAGE NOTE Skin swelling, burning, pain at the site of injection 2mg IV/IO max initial dose for sedation (may repeat as necessary) 2mg IV/IO or 5mg IM/IN max initial dose for seizures (may repeat as necessary) 5mg IV/IO for RSI and Violent Patients Versed may be administered IM or IN in actively seizing or violent patients whenever IV access is not achieved. Always be ready to assist ventilations Seizures 0.1mg/kg IV/IO/IM/IN to a max dose of 5mg 0.2mg/kg IN to a max dose of 10mg For adult patients use only if Ativan is unavailable 44

155 PEDIATRIC PROTOCOLS EMS and Children with Special Healthcare Needs AIRWAY / BREATHING PROTOCOLS Pediatric Airway Pediatric Foreign Body Airway Obstruction (FBAO) Pediatric Respiratory Distress Lower Airway ARRYTHMIAS / PALS Pediatric Sinus Bradycardia Pediatric Narrow Complex Tachycardia (SVT) CARDIAC ARREST / PALS Pediatric Asystole / Pulseless Electrical Activity (PEA) Pediatric Ventricular Fibrillation (V-FIB) and Pulseless Ventricular Tachycardia MEDICAL PROTOCOLS Pediatric Altered Level of Consciousness Pediatric Diabetic Emergencies Pediatric Heat Illness Pediatric Hypothermia Pediatric Neonatal Resuscitation Pediatric Esophageal Foreign Body Pediatric Seizure Pediatric Shock Non Trauma Pediatric Toxic Ingestion / Exposure PEDIATRIC TRAUMA Pediatric Head Trauma Pediatric Multiple Trauma PEDIATRIC ASSESSMENT CHARTS Glascow Coma Scale Normal Vital Sign APGAR Scoring Chart UH Protocols Chapter 6 Pediatric Protocols 1

156 MEDICAL PROTOCOLS PEDIATRIC EMERGENCIES IN CHILDREN WITH SPECIAL HEALTHCARE NEEDS GENERAL CONSIDERATIONS 1. Treat the ABC s first. Treat the child, not the equipment. If the emergency is due to an equipment malfunction, manage the child appropriately using your own equipment. 2. Children formerly cared for in hospitals or chronic care facilities are often cared for in homes by parents or other caretakers. These children may have self-limiting or chronic diseases. There are multitudes of underlying medical conditions that may categorize children as having special needs. Many are often unstable and may frequently involve the EMS system for evaluation, stabilization, and transport. Special needs children include technology-assisted children such as those with tracheostomy tubes with or without assisted ventilation, children with gastrostomy tubes, and children with indwelling central lines. The most serious complications are related to tracheostomy problems. 3. Children with Special Healthcare Needs (CSHCN) have many allergies. It is important to ask the caregiver, who knows the child best, what allergies the child has. This is particularly important since they may not be accompanying the child on transport. For example, children with spina bifida often have latex allergies. It is important to stock latex free equipment such as; gloves, oxygen masks, IV tubing, BVM, blood pressure cuffs, IV catheters, ect. 4. Knowing which children in a given area have special needs and keeping a logbook is encouraged. Such a book could include; major medical diagnosis, allergies, tracheostomy size, ventilator settings ect. 5. Parents and caretakers are usually trained in emergency management and can be of assistance to EMS personnel. Listen carefully to the caregiver and follow his/her guidance regarding the child s treatment. 6. Children with chronic illnesses often have different physical development from well children. Therefore, their baseline vital signs may differ from normal standards. The size and developmental level may be different from age-based norms and length based tapes used to calculate drug dosages. Ask the caregiver if the child normally has abnormal vital signs (i.e. a fast heart rate or a low pulse oximeter reading). 7. Some CSHCN may have sensory deficits (i.e. they may be hearing impaired or blind) yet may have age-appropriate cognitive abilities. Follow the caregivers lead in talking to and comforting a child during treatment and transport. Do not assume that a CSHCN is developmentally delayed. 8. When moving a special needs child, a slow careful transfer with two or more people is preferable. Do not try to straighten or unnecessarily manipulate contracted extremities as it may cause injury or pain to the child. Certain medical conditions will require special care. Again, consult the child s caregiver. 9. Caregivers of CSHCN often carry go bags or diaper bags that contain supplies to use with the child s medical technologies and additional equipment such as extra tracheostomy tubes, adapters for feeding tubes, suction catheters, etc. Before leaving the scene, ask the caregivers if they have a go bag and carry it with you. 10. Caregivers may also carry a brief medical information form or card. The child may be enrolled in a medical alert program whereby emergency personnel can get quick access to the child s medical history. Ask the caregivers if they have an emergency information form or some other form of medical information for their child. 11. Caregivers of CSHCN often prefer that their child be transported to the hospital where the child is regularly followed or the home hospital. When making the decision as to where to transport a CSHCN, take into account: local protocols, the child s condition, capabilities of the local hospital, caregivers request, ability to transport to certain locations. UH Protocols Chapter 6 Pediatric Protocols 2

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158 AIRWAY / BREATHING PEDIATRIC AIRWAY Supplemental OXYGEN Adequate Assess ABC s Respiratory Rate, Effort, and Adequacy B EMT B A Advanced A M MED CONTROL M Inadequate Positive Respirations Positive Gag Reflex Oxygenate Ventilate Position Reassess Basic maneuvers first --- Open airway Nasal / Oral Airway Bag-Valve-Mask (BVM) Apneic No Gag Reflex Obstruction See Pediatric Foreign Body Airway Obstruction Protocol Orotracheal Intubation limit 2 attempts Direct Laryngoscopy Unsuccessful Continue Bag BVM Ventilations CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 4

159 AIRWAY / BREATHING PEDIATRIC AIRWAY KEY POINTS Capnometry is mandatory with all methods of intubation. Document results of SpO2. Limit intubation attempts to 2 per patient. If unable to intubate, continue BVM ventilations, transport rapidly, and notify receiving hospital early Maintain C-spine immobilization for patients with suspected spinal injury. Do not assume hyperventilation is psychogenic -- use oxygen, not a paper bag. Sellick's maneuver (Cricoid Pressure) should be used to assist with difficult intubations. Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function. Consider c-collar to help maintain ETT placement for all intubated patients. UH Protocols Chapter 6 Pediatric Protocols 5

160 AIRWAY / BREATHING PEDIATRIC FOREIGN BODY AIRWAY OBSTRUCTION (FBAO) Infant (0 12 months) Coughing Complete Obstruction Complete Obstruction Conscious Conscious Unconscious Encourage patient to cough OXYGEN L Pediatric Mask, as tolerated Head Tilt / Chin Lift/ Jaw Thrust / Airway Maneuvers 5 Back Blows / 5 Chest Thrusts B EMT B A Advanced A M MED CONTROL M Visualize Finger Sweep (Only if visualized / attainable) Consider use of Laryngoscope/ Magill Forceps Open airway / ventilate (May reposition and repeat if necessary) Start CPR Check for Object Prior to Ventilation Attempts Child (1 8 years) Head Tilt / Chin Lift/ Jaw Thrust / Airway Maneuvers Coughing Complete Obstruction Complete Obstruction Conscious Conscious Unconscious Encourage patient to cough OXYGEN L Pediatric Mask, as tolerated Abdominal Thrusts Visualize Finger Sweep (Only if visualized / attainable) Consider use of Laryngoscope/ Magill Forceps Open airway / ventilate (May reposition and repeat if necessary) CONTACT MEDICAL CONTROL TRANSPORT If unable to ventilate, Consider Needle Cricothyrotomy UH Protocols Chapter 6 Pediatric Protocols 6

161 AIRWAY / BREATHING PEDIATRIC FOREIGN BODY AIRWAY OBSTRUCTION (FBAO) HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Coughing Witnessed aspiration Cardiac Arrest Choking Sudden episode of choking Respiratory Arrest Inablity to speak Audible stridor Anaphylaxis Unresponsive Change in skin color Decreased LOC Increased / Decreased respiratory rate Labored breathing Unproductive cough KEY POINTS Infants 0-12 months DO NOT receive abdominal thrusts. Use chest thrusts. NEVER perform blind finger sweeps in infants or children. Attempt to clear the airway should only be made if foreign body aspiration is witnessed or very strongly suspected and there is complete airway obstruction. Even with a complete airway obstruction, positive-pressure ventilation is often successful. Keep child and parent (or caregiver) CALM. Do not agitate child. UH Protocols Chapter 6 Pediatric Protocols 7

162 AIRWAY/BREATHING PEDIATRIC RESPIRATORY DISTRESS LOWER AIRWAY UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Respiratory Insufficiency Yes Pediatric Airway Protocol No Position to Patient Comfort Wheezing No Yes ASSIST PATIENT WITH PERSONAL INHALER ALBUTEROL or DuoNeb AEROSOL Nebulized Epinephrine 1:1000 2mg (2ml) mixed with 1ml Normal Saline CONTACT MEDICAL CONTROL TRANSPORT IV/IO PROTOCOL Attempt if Severe Respiratory Distress or Arrest DO NOT Agitate Child UH Protocols Chapter 6 Pediatric Protocols 8

163 AIRWAY / BREATHING PROTOCOLS PEDIATRIC RESPIRATORY DISTRESS - LOWER AIRWAY HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL Time of onset Possibility of foreign body Medical history Medications Fever or respiratory infection Other sick siblings History of trauma Wheezing or stridor Respiratory retractions Increased heart rate Altered level of consciousness Anxious appearance Asthma Aspiration Foreign body Infection Pneumonia Croup Epiglottitis Congenital heart disease Medication or toxin Trauma UH Protocols Chapter 6 Pediatric Protocols 9

164 ARRYTHMIAS / PALS PEDIATRIC SINUS BRADYCARDIA UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Pediatric Airway Protocol Poor Perfusion Decreased B/P Respiratory Insufficiency No Yes IV PROTOCOL Heart Rate < 60 Initiate CPR Monitor and Reassess IV/IO PROTOCOL EPINEPHRINE 0.01 mg/kg IV/IO 1:10,000 Solution (0.1 ml/kg) or 0.1 mg/kg ETT (0.1ml/kg) 1:1000 Solution Repeat every 3-5 minutes ATROPINE 0.02 mg/kg IV/IO Minimum 0.1 mg Maximum 0.5 mg Pulse Reassess Consider External Transcutaneous Pacing No Pulse CONTACT MEDICAL CONTROL Pulseless Arrest Protocol TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 10

165 ARRYTHMIAS / PALS PEDIATRIC SINUS BRADYCARDIA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Foreign body exposure Respiratory distress or arrest Apnea Possible toxin or poison exposure Congenital disease Medication (maternal or infant) Hypoxia Decreased heart rate Delayed capillary refill or cyanosis Mottled, cool skin Hypotension or arrest Altered level of consciousness Poor perfusion Shock Short of breath Pulmonary fluid Respiratory effort Respiratory obstruction Foreign body / secretions Croup / epigolotitis Hypovolemia Hypothermia Infection / sepsis Medication or toxin Hypoglycemia Trauma KEY POINTS Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. Heart Rate < 100 (Neonates) Heart Rate < 80 (Infants) Heart Rate <60 (Children > 2 years) In older children who may be athletes a Heart Rate <60 may be normal (Are they Symptomatic?) Infant = < 1 year of age Most maternal medications pass through breast milk to the infant. The majority of pediatric arrests are due to airway problems. Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia. Pediatric patients requiring external transcutaneous pacing require the use of pads appropriate for pediatric patients per the manufacturers guidelines. Identify and treat possible causes for pediatric bradycardia: Hypoxia Hypothermia Head injury Heart block Toxic ingestion/exposure Refer to Broselow Pediatric Tape when unsure about patient weight, age and/or drug dosage. The minimum dose of Atropine that should be administered to a pediatric patient is 0.1 mg. The maximum single dose of Atropine is 0.5mg in a child and 1 mg in an adolescent. If the rhythm changes, follow the appropriate protocol. UH Protocols Chapter 6 Pediatric Protocols 11

166 ARRYTHMIAS / PALS PEDIATRIC TACHYCARDIA UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Continuous Cardiac Monitor Attempt to Identify Cause IV/IO PROTOCOL Narrow Evaluate QRS wide or narrow? Wide Evaluate rhythm Possible Ventricular Tachycardia Probable Sinus Tachycardia Infant <220 bpm Child < 180 bpm Search for and treat cause Probable Supreventricular Tachycardia Infant >220 bpm Child > 180 bpm Cardiopulmonary Compromise? Hypotension, AMS, Shock? Yes Yes No May Attempt Vagal Maneuvers SyncronizedCardioversion Biphasic: 0.5 to 1 J/KG ADENOSINE 0.1 mg/kg IV/IO RapidPush - max of 6mg If not effective, increase to 2 j/kg No response TRANSPORT ADENOSINE 0.2 mg/kg IV/IO Rapid Push - max 12 mg CONTACT MEDICAL CONTROL Consider Adenosine if rhythm is regular and QRS is monomorphic or Consider Amiodarone 5mg/kg over minutes UH Protocols Chapter 6 Pediatric Protocols 12

167 HISTORY Past medical history Medications or toxic ingestion (Aminophylline, diet pills, thyroid supplements, decongestants, Digoxin) Drugs (nicotine, cocaine) Congenital Heart Disease Respiratory Distress Syncope or Near-Syncope ARRYTHMIAS / PALS PEDIATRIC TACHYCARDIA SIGNS AND SYMPTOMS HR: Child > 180/bpm Infant > 220/bpm Pale or Cyanosis Diaphoresis Tachypnea Vomiting Hypotension Altered level of consciousness Pulmonary congestion Syncope DIFFERENTIAL DIAGNOSIS Heart disease (congenital) Hypo / Hyperthermia Hypovolemia or anemia Electrolyte imbalance Anxiety / Pain / Emotional stress Fever / Infection / Sepsis Hypoxia Hypoglycemia Medication / Toxin / Drugs Pulmonary embolus Trauma Tension pneumothorax KEY POINTS Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro. Carefully evaluate the rhythm to distinguish Sinus Tachycardia, Supraventricular Tachycardia, and Ventricular Tachycardia Separating the child from the caregiver may worsen the child's clinical condition. Pediatric paddles should be used in children < 10 kg or Broselow Tape color purple Monitor for respiratory depression and hypotension associated if Versed is used. Continuous pulse oximetry is required for all patients if available. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Possible causes of tachycardia: hypoxia, hypovolemia, fear, and pain. A complete medical history must be obtained. Do not delay cardioversion to gain vascular access for the unstable patient. If you are unable to get the monitor to select low enough joules, then rapid transport to the nearest appropriate facility is indicated. If the patient is stable, do not cardiovert. Record EKG strips during Adenosine administration. Perform a 12-Lead EKG prior to and after Adenosine conversion or cardioversion of SVT. If the rhythm changes, follow the appropriate protocol. UH Protocols Chapter 6 Pediatric Protocols 13

168 CARDIAC ARREST / PALS PEDIATRIC ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Continuous CPR Pediatric Airway Protocol Confirm Asystole in 2 Leads AT ANY TIME Return of Spontaneous Circulation GO TO POST RESUSCITATION PROTOCOL Apply Cardiac Monitor Confirm Asystole / PEA IV/IO PROTOCOL EPINEPHRINE 0.01 mg/kg IV/IO 1:10,000 Solution (0.1 ml/kg) or 0.1 mg/kg ETT (0.1ml/kg) 1:1000 Solution Repeat every 3-5 minutes NORMAL SALINE IV, BOLUS 20 ml/kg Repeat as needed Identify Possible Causes: 5 H 5 T Blood Glucose Analysis Continuous CPR CONTACT MEDICAL CONTROL Glucose < 60 DEXTROSE 25% 2 ml/kg, IV/IO TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 14

169 CARDIAC ARREST / PALS PEDIATRIC ASYSTOLE / PULSELESS ELECTRICAL ACTIVITY (PEA) HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Time of arrest Medical history Medications Possibility of foreign body Hypothermia Pulseless Apneic or agonal respirations Cyanosis Ventricular Fibrillation Pulseless Ventricular Tachycardia CONSIDER TREATABLE CAUSES Hypovolemia Cardiac Tamponade Tension Pneumothorax Pulmonary Embolism Myocardial Infarction Tricyclic Overdose Drug Overdose Hypoxia Hypothermia Hypoglycemia Acidosis Hyperkalemia / Hypokalemia KEY POINTS Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro. Always confirm asystole in more than one lead. Cardiac arrest in children is primarily due to lack of an adequate airway, resulting in hypoxia If the patient converts to another rhythm or has a return of circulation, refer to the appropriate protocol and treat accordingly. When assessing for a pulse palpate the brachial or femoral arteries for infants and the carotid or femoral artery for children. Continue BLS procedures throughout the resuscitation. If the patient is intubated, be sure to routinely reassess tube placement. If the patient has an IO, routinely reassess for patency. When there is an established ETT, DO NOT delay administration of medications for IV/IO attempts. Administer the appropriate medications down the tube. UH Protocols Chapter 6 Pediatric Protocols 15

170 CARDIAC ARREST / PALS PEDIATRIC VENTRICULAR FIBRILLATION (V-FIB) PULSELESS VENTRICULAR TACHYCARDIA (V-TACH) If V-Fib/V-Tach is Witnessed by EMS immediately 2J/kg UNIVERSAL PATIENT CARE PROTOCOL CPR X 5 cycles / 2 minutes Apply Cardiac Monitor / AED B EMT B A Advanced A M MED CONTROL M Defibrillate 2 J/kg AT ANY TIME Pediatric Airway Protocol Return of Spontaneous Circulation Resume CPR X 5 cycles / 2 minutes IV/IO PROTOCOL GO TO POST RESUSCITATION PROTOCOL EPINEPHRINE 0.01 mg/kg IV/IO 1:10,000 Solution (0.1 ml/kg) or 0.1 mg/kg ETT (0.1ml/kg) 1:1000 Solution Repeat every 3-5 minutes Identify Possible Causes: 5 H 5 T CPR X 5 cycles / 2 minutes Defibrillate 4 J/kg Give Antiarrhythmic during CPR CPR X 5 cycles / 2 minutes AMIODARONE 5 mg/kg IV/IO Push May repeat once Defibrillate 4 J/kg TRANSPORT CONTACT MEDICAL CONTROL UH Protocols Chapter 6 Pediatric Protocols 16

171 CARDIAC ARREST / PALS PEDIATRIC VENTRICULAR FIBRILLATION (V-FIB) PULSELESS VENTRICULAR TACHYCARDIA HISTORY Time of arrest Medical history Medications Possibility of foreign body Hypothermia SIGNS AND SYMPTOMS Unresponsive Cardiac arrest DIFFERENTIAL DIAGNOSIS Respiratory failure Foreign body Secretions Infection (croup, epiglotitis) Hypovolemia (dehydration) Congenital heart disease Trauma Tension pneumothorax Hypothermia Toxin or medication Hypoglycemia Acidosis KEY POINTS Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro. Monophasic and Biphasic waveform defibrillators should use the same energy levels noted. In order to be successful in pediatric arrests, a cause must be identified and corrected. Airway is the most important intervention. This should be accomplished immediately. Patient survival is often dependent on airway management success. You should only attempt intubation once. If the patient converts to another rhythm, follow the appropriate protocol and treat accordingly. If the patient converts back to ventricular fibrillation or pulseless ventricular tachycardia, defibrillate at the previously used setting. Defibrillation is the definitive therapy for ventricular fibrillation and pulseless ventricular tachycardia. Do not delay transport for IV/IO access. UH Protocols Chapter 6 Pediatric Protocols 17

172 MEDICAL PROTOCOLS PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Pediatric Airway Protocol Spinal Immobilization Protocol If suspected trauma IV/IO PROTOCOL Blood Glucose Analysis Glucose < 60 Glucose ORAL GLUCOSE (If Alert With No IV Access and No Airway Compromise) (Signs of Dehydration) Check for Hypotension, Tachycardia, Poor Cap Refill Dextrose D25% - 2mL/kg IV/IO May repeat in 10 min if BGL remains <60 If no IV Glucagon IM or IN 0.5mg if < 20kg 1.0mg if >20kg NORMAL SALINE IV/IO BOLUS 20 ml/kg may repeat CONTACT MEDICAL CONTROL NARCAN 0.1 mg/kg IV/IO/IM/IN TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 18

173 MEDICAL PROTOCOLS PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Known diabetic, medic alert tag Drugs, drug paraphernalia Report of illicit drug use or toxic ingestion Past medical history Medications History of trauma Unresponsive Decreased Responsiveness Inadequate Respirations Confusion Agitation Decreased mental status Change in baseline mental status Hypoglycemia (cool, diaphoretic skin) Head trauma CNS (stroke, tumor, seizure, infection) Infection Shock (septic, metabolic, traumatic) Diabetes (hyper / hypoglycemia) Toxicologic Acidosis / Alkalosis Environmental exposure Pulmonary (Hypoxia) Electrolyte abnormality Psychiatric disorder KEY POINTS Protect the patient s airway and support ABCs. Document the patient s initial Glasgow Coma Score. Naloxone (Narcan) administration may cause acute opiate withdrawal, which includes vomiting, agitation, or combative behavior. Be prepared for the possibility of combative behavior to ensure crew safety. Naloxone (Narcan) may wear off in as little as 20 minutes causing the patient to become more sedate and possibly hypoventilate. All patients receiving Naloxone (Narcan) MUST be transported. ONLY A FEW CAUSES CAN BE TREATED IN THE FIELD. CARE SHOULD FOCUS ON MAINTAINING AIRWAY AND RAPID TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 19

174 MEDICAL PROTOCOLS PEDIATRIC DIABETIC EMERGENCIES UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M IV/IO PROTOCOL Blood Sugar Analysis Glucose < 60 Glucose Glucose > 400 ORAL GLUCOSE (If Alert with no IV Access and no airway compromise) Dextrose D25% - 2mL/kg IV/IO May repeat in 10 min if BGL remains <60 If no IV Glucagon IM or IN 0.5mg if < 20kg 1.0mg if >20kg Check for Hypotension, Tachycardia, Poor Cap Refill NORMAL SALINE IV/IO BOLUS 20 ml/kg may repeat Recheck Blood Glucose CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 20

175 MEDICAL PROTOCOLS PEDIATRIC DIABETIC EMERGENCIES HISTORY HISTORY Known diabetic, medic alert tag Past medical history Medications Recent Blood Sugar Analysis Known diabetic, medic alert tag Past medical history Medications Recent Blood Sugar Analysis HYPOGLYCEMIA SIGNS AND SYMPTOMS Altered level of consciousness Dizziness Irritability Diaphoresis Convulsions Hunger Confusion HYPERGLYCEMIA SIGNS AND SYMPTOMS Altered level of consciousness / coma Abdominal pain Nausea / Vomiting Dehydration Frequent thirst Frequent urination General weakness Malaise Hypovolemic shock Hyperventilation Deep / Rapid respirations DIFFERENTIAL DIAGNOSIS ETOH Toxic overdose Trauma Seizure Syncope CNS disorder Stroke Tumor Pre-existing condition DIFFERENTIAL DIAGNOSIS ETOH Toxic overdose Trauma Seizure Syncope CNS disorder Stroke Diabetic Ketoacidosis KEY POINTS Hyperglycemia: Diabetic Ketoacidosis (DKA) is a complication of Diabetes Mellitus. It can occur when insulin levels become inadequate to meet the metabolic demands of the body for a prolonged amount of time (onset can be within hours). Without enough insulin, the blood glucose increases and cellular glucose depletes. The body removes excess blood glucose by dumping it into the urine. Pediatric patients in DKA should be treated as hyperglycemic under the Pediatric Diabetic Emergency Protocol. Patients can have hyperglycemia without having DKA. Hypoglycemia: Always suspect hypoglycemia in patients with an altered mental status. If a blood glucose analysis is not available, a patient with altered mental status and signs and symptoms consistent with hypoglycemia should receive Dextrose or Glucagon. o Dextrose is used to elevate BGL but it will not maintain it. The patient will need to follow up with a meal if not transported to a hospital. If the patient is alert and has the ability to swallow, consider administering oral glucose, have patient drink orange juice with sugar or a sugar containing beverage, or have the patient eat a candy bar or meal. Check the patient s BGL after the administration of Dextrose or after any attempt to raise the patient s BGL. UH Protocols Chapter 6 Pediatric Protocols 21

176 MEDICAL PROTOCOLS PEDIATRIC HEAT ILLNESS UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Document Patient Temperature Remove Patient from Heat Source Remove Patient Clothing Apply Room Temperature Water to Patient Skin and Increase Air Flow Around Patient IV/IO PROTOCOL Fever 20 cc/kg, NS Bolus Heat Exhaustion: IV NS Wide Open Heat Stroke: IV NS TKO Monitor and Reassess Appropriate Protocol Based on Patient Symptoms CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 22

177 MEDICAL PROTOCOLS PEDIATRIC HEAT ILLNESS HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Age Exposure to increased temperatures and humidity Past medical history/medications Extreme exertion Time and length of exposure Poor PO intake Fatigue and/or muscle cramping Altered mental status or unconsciousness Hot, dry or sweaty skin Hypotension or shock Seizures Nausea Fever (infection) Dehydration Medications Hyperthyroidism Delirium tremens Heat cramps Heat exhaustion Heat stroke CNS lesions or tumors Heat Exhaustion: Dehydration Muscular/abdominal cramping General weakness Diaphoresis Febrile Confusion Dry mouth/thirsty Tachycardia BP normal or orthostatic Heat Stroke: Cerebral Edema Confusion Bizarre behavior Skin hot, dry, febrile Tachycardia Hypotensive Seizure Coma KEY POINTS Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro. Extremes of age are more prone to heat emergencies (i.e. young and old). Patients at risk for heat emergencies include neonates, infants, geriatric patients, and patients with mental illness. Other contributory factors may include heart medications, diuretics, cold medications and/or psychiatric medications. Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. Cocaine, Amphetamines, and Salicylates may elevate body temperatures. Sweating generally disappears as body temperature rises above 104 F (40 C). Intensive shivering may occur as patient is cooled. Heat cramps consists of benign muscle cramping 2nd to dehydration and is not associated with an elevated temperature. Heat exhaustion consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, and an elevated temperature. Heat stroke consists of dehydration, tachycardia, hypotension, temperature >104 F (40 C), and altered mental status. Heat exposure can occur either due to increased environmental temperatures or prolonged exercise or a combination of both. Environments with temperature >90 F and humidity >60% present the most risk. Heat stroke occurs when the cooling mechanism of the body (sweating) ceases due to temperature overload and/or electrolyte imbalances. Be alert for cardiac dysrhythmias for the patient with heat stroke. UH Protocols Chapter 6 Pediatric Protocols 23

178 MEDICAL EMERGENCIES PEDIATRIC HYPOTHERMIA / FROSTBITE B EMT B A Advanced A M MEDCONTROL M UNIVERSAL PATIENT CARE PROTOCOL Remove Wet Clothing Evidence or decreased core temperature? Yes No Handle Patient Gently Apply Hot Packs Indirectly to Skin and/or Blankets and Turn Up Vehicle Heat IV/IO PROTOCOL Appropriate Protocol Based on Patient s Signs and Symptoms CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 24

179 MEDICAL PROTOCOLS PEDIATRIC HYPOTHERMIA/FROSTBITE HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Medications Exposure to environment even in normal temperatures Exposure to extreme cold Extremes of age Drug use: alcohol, barbiturates Infection / Sepsis Length of exposure / Wetness Cold, clammy Shivering Mental status changes Extremity pain or sensory abnormality Bradycardia Hypotension or shock KEY POINTS Sepsis Environmental exposure Hypoglycemia CNS dysfunction Stroke Head injury Spinal cord injury Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro. Hypothermic/drowning/near drowning patients that appear cold and dead are NOT dead until they are warm and dead, or have other signs of obvious death (putrification, traumatic injury unsustainable to life). All hypothermic patients should have resuscitation performed until care is transferred. Defined as core temperature < 35 C (95 F). Extremes of age are more susceptible (i.e. young and old). Patients with low core temperatures will not respond to ALS drug interventions. Maintain warming procedure and supportive care. Warming procedures includes removing wet clothing, limiting exposure, and covering the patient with warm blankets if available. Do not allow patients with frozen extremities to ambulate. Superficial frostbite can be treated by using the patient s own body heat. Do not attempt to rewarm deep frostbite unless there is an extreme delay in transport, and there is no risk that the affected body part will be refrozen. Contact Medical Control prior to rewarming a deep frostbite injury. If the temperature is unable to be measured, treat the patient based on the suspected temperature. Hypothermia may produce severe bradycardia. Shivering stops below 32 C (90 F). Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly against the patient's skin. Consider withholding CPR if patient has organized rhythm. Discuss with Medical Control. The most common mechanism of death in hypothermia is ventricular fibrillation. If the hypothermia victim is in ventricular fibrillation, CPR should be initiated. If V fib is not present, then all treatment and transport decisions should be tempered by the fact that V fib can be caused by rough handling, noxious stimuli or even minor mechanical disturbances, this means that respiratory support with 100% oxygen should be done gently, including intubation, avoiding hyperventilation. UH Protocols Chapter 6 Pediatric Protocols 25

180 MEDICAL PROTOCOLS PEDIATRIC NEONATAL RESUSCITATION (Newborns Immediately After Delivery) UNIVERSAL PATIENT CARE PROTOCOL (For Mother) B EMT B A Advanced A M MED CONTROL M Meconium in Amniotic Fluid? Yes Suction Airway No Dry Infant and Keep Warm Bulb Syringe Suction Mouth & Nose Stimulate Infant and Note APGAR Score Normal Respirations? No Yes Reassess Heart Rate and APGAR Score / Check Glucose BVM 30 Seconds at Breaths Per Minute with 100% OXYGEN HR < 60 HR HR > 100 Pediatric Airway Protocol PPV With BVM Begin CPR IV/IO PROTOCOL HR < 60 Pediatric Airway Protocol PPV With BVM Reassess HR Monitor and Reassess Appropriate Dysrhythmia Protocol Consider NORMAL SALINE BOLUS 10mL/kg IV/IO NARCAN 0.1mg/kg every 3 min HR HR > 100 IV/IO PROTOCOL CONTACT MEDICAL CONTROL TRANSPORT OXYGEN Blow - By UH Protocols Chapter 6 Pediatric Protocols 26

181 MEDICAL PROTOCOLS PEDIATRIC NEONATAL RESUSCITATION HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Due date and gestational age Multiple gestation (twins etc.) Meconium Delivery difficulties Congenital disease Medications (maternal) Maternal risk factors substance abuse smoking Respiratory distress Peripheral cyanosis or mottling (normal) Central cyanosis (abnormal) Altered level of responsiveness Bradycardia Airway failure Secretions Respiratory drive Infection Maternal medication effect Hypovolemia Hypoglycemia Congenital heart disease Hypothermia SIGN KEY POINTS Exam: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Extremities, Neuro. Maternal sedation or narcotics will sedate infant (Naloxone effective). Consider hypoglycemia in infant. Document 1 and 5 minute APGAR scores (see Appendix) If the patient is in distress, consider hypovolemia. Administer a 10 ml/kg fluid bolus of normal saline. If the BGL is less than 40 mg/dl go to the Pediatric Diabetic Protocol. Hypothermia is a common complication of home and field deliveries. Keep the baby warm and dry. If there is a history of recent maternal narcotic use, consider Naloxone (Narcan) 0.1 mg/kg every 3 minutes until patient responds. Meconium may need to be suctioned several times to clear the airway. It may also be necessary to visualize the trachea and suction the lower airway. Lower airway suction is achieved by intubating the infant and suctioning directly through the ET tube. Each time his suctioning is done, the infant will have to be reintubated with a new tube. This lower airway suction is only done when the infant is NOT vigorous. If drying and suction has not provided enough stimulation, try rubbing the infant s back or flicking their feet. If the infant still has poor respiratory effort, poor tone, or central cyanosis, consider them to be distressed, Most distressed infants will respond quickly to BVM. Use caution not to allow newborns to slip from grasp. PEDIATRIC ASSESSMENT CHARTS PEDIATRIC APGAR SCORING Blue / Pale Pink Body, Blue Completely Pink COLOR Extremities HEART RATE Absent Below 100 Above 100 IRRITABILITY No Response Grimace Cries (Response to Stimulation) MUSCLE TONE Limp Flexion of Extremities Active Motion RESPIRATORY EFFORT Absent Slow and Regular Strong Cry UH Protocols Chapter 6 Pediatric Protocols 27

182 MEDICAL PROTOCOLS PEDIATRIC ESOPHAGEAL FOREIGN BODY OBSTRUCTION UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MEDCONTROL M Airway Obstruction Difficulty Breathing Coughing Difficulty/Unable to Talk Esophageal Obstruction Salivation Unable to Swallow Secretions Airway Protocol Patient is in Distress Evaluate Level of Obstruction LOW (Neck Down) HIGH (Neck Up) IV/IO PROTOCOL Support and Protect Airway CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 28

183 MEDICAL PROTOCOLS PEDIATRIC ESOPHAGEAL FOREIGN BODY OBSTRUCTION HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Onset during eating or swallowing pills, etc. Salivation Unable to swallow secretions Distressed patient Able to breathe but may feel impaired Airway obstruction KEY POINTS Rule out airway obstruction first. Patient may be helpful in identifying location of bolus obstruction as they can feel it, point to it. If bolus is located in neck area, glucagon will not work, just monitor and transport. If bolus located from neck down, proceed with glucagon treatment. Treat patients <16 years with ½ mg dose of glucagon. UH Protocols Chapter 6 Pediatric Protocols 29

184 MEDICAL PROTOCOLS PEDIATRIC SEIZURE UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Position on Side to Prevent Aspiration Cooling Measures Tylenol (oral liquid) (If not already administered in the last 4 hours) Glucose < 60 Yes mg/kg oral liquid Febrile? No Blood Glucose Analysis IV/IO PROTOCOL Evidence of Shock or Trauma? Active Seizure? See Appropriate Protocol ORAL GLUCOSE 5-10 g (1/2 Tube) Alert with No IV Access And No Airway Compromise DEXTROSE 25% - 2mL/kg IV/IO Yes VERSED 0.1mg/kg IV/IO/IM to max dose of 5mg OR 0.2mg/kg Intranasal to a max dose of 10mg For a Repeat Dose CONTACT MEDICAL CONTROL CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 30

185 HISTORY Fever Prior history of seizures Seizure medications Reported seizure activity History of recent head trauma Congenital abnormality MEDICAL PROTOCOLS PEDIATRIC SEIZURE SIGNS AND SYMPTOMS Observed seizure activity Altered mental status Hot, dry skin or elevated body temperature DIFFERENTIAL DIAGNOSIS Fever Infection Head trauma Medication or Toxin Hypoxia or Respiratory failure Hypoglycemia Metabolic abnormality / acidosis Tumor Categories of Seizures Complex Unconscious Simple Conscious Complex Focal Complex Generalized Focal Partial, Localized Generalized All Body Simple Focal Simple Generalized KEY POINTS Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro. Status Epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport. Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness. Jacksonian seizures are seizures, which start as a focal seizure and become generalized. Be prepared to assist ventilations especially if a benzodiazipine is used. If evidence or suspicion of trauma, spine should be immobilized. If febrile, remove clothing and sponge with room temperature water. In an infant, a seizure may be the only evidence of a closed head injury. UH Protocols Chapter 6 Pediatric Protocols 31

186 MEDICAL PROTOCOLS PEDIATRIC SHOCK (NON TRAUMATIC) B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Pediatric Trauma Protocol Yes Evidence or history of trauma No IV/IO PROTOCOL Anaphylaxis Hypovolemic / Septic / Neurogenic ASSIST PATIENT WITH PERSONAL EPI PEN NORMAL SALINE BOLUS 20 ml/kg IV/IO May be Repeated Respiratory Distress EPINEPHRINE 0.01 mg/kg IM 1:1000 Solution Max Dose 0.5 mg BENADRYL 1 mg/kg slow IV/IM/IO Allergic Reaction Hives EPINEPHRINE 0.01 mg/kg IM 1:1000 Solution Max Dose 0.5 mg BENADRYL 1 mg/kg slow IV/IM/IO Monitor and Reassess Blood Glucose Analysis Glucose < 60 ORAL GLUCOSE 5-10 g (1/2 Tube) If Alert with No IV Access and No Airway Compromise Wheezes ALBUTEROL Or DuoNeb Aerosol Impending Full Arrest & Hypotensive EPINEPHRINE 0.01 mg/kg IV/IO 1:10,000 Solution (0.1 ml/kg) or 0.1 mg/kg ETT (0.1ml/kg) 1:1000 Solution Repeat every 3-5 minutes DEXTROSE 25% - 2mL/kg IV/IO CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 32

187 MEDICAL PROTOCOLS PEDIATRIC SHOCK (NON TRAUMATIC) HYPOVOLEMIC / SEPTIC / NEUROGENIC HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Blood loss Fluid loss Vomiting Diarrhea Fever Infection Restlessness, confusion, weakness Dizziness Increased HR Decreased BP Pale, cool, clammy skin Delayed capillary refill Trauma Infection Dehydration Vomiting Diarrhea Fever Congenital heart disease Medication or toxin ALLERGIC REACTION / ANAPHYLAXIS HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Onset and location Warm burning feeling Urticaria (rash only) Insect sting or bite Itching Anaphylaxis (systemic Food allergy / exposure Rhinorrhea effect) Medication allergy / Hoarseness Shock (vascular effect) exposure Stridor Angioedema (drug New clothing, soap, Wheezing induced) detergent Respiratory distress Aspiration / Airway Past history of reactions Altered LOC / Coma obstruction Past medical history Cyanosis Vasovagal event Medication history Pulmonary edema Asthma Facial / Airway edema Urticaria / Hives Dyspnea KEY POINTS Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro. Consider all possible causes of shock and treat per appropriate protocol. Decreasing heart rate is a sign of impending collapse. Be sure to use the appropriate sized BP cuff. Findings in the primary assessment should alert you that the patient is in shock. Pay particular attention to the patient s mental status, tachycardia, skin color, and capillary refill. Shock is not only caused by blood loss. The EMT must evaluate for fluid loss from other causes such as excessive vomiting and/or diarrhea, heat exposure and malnutrition. Do not use only the patient s blood pressure in evaluating shock; also look for lower body temperature, poor capillary refill, decreased LOC, increased heart rate and/or poor skin color or turgor Routinely reassess the patient and provide supportive care. Use caution when using Epinephrine for patients with a cardiac history. Use caution when using Epinephrine for patients with a heart rate greater than 150 bpm. Blood pressure is a late and unrealable indication of pediatric shock. UH Protocols Chapter 6 Pediatric Protocols 33

188 MEDICAL PROTOCOLS PEDIATRIC TOXIC INGESTION / EXPOSURE / OVERDOSE B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Pediatric Airway Protocol IV/IO PROTOCOL Blood Glucose Analysis Tricyclic Ingestion? SODIUM BICARBONATE 1 meq/kg IV/IO Diluted in 1:1 NS or as advised Respiratory Organophosphates Carbon Other Depression Carbamates Monoxide NARCAN 0.1 mg/kg IV/IM/IO/IN ATROPINE 0.02 mg/kg IV/IO repeat every 3-5 minutes Minimum dose 0.1mg Max dose 0.5mg Child Max dose 1.0mg Adolescent Oxygen 100% NRB Hypotension, Seizures, Ventricular Dysrythmias, or Mental Status Changes Appropriate Protocol CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 34

189 MEDICAL PROTOCOLS PEDIATRIC TOXIC INGESTION / EXPOSURE / OVERDOSE HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Ingestion or suspected ingestion of a potentially toxic substance Substance ingested, route, quantity, dose Time of ingestion Reason (suicidal, accidental, criminal) Available medications in home Past medical history, medications Mental status changes Hypo / Hypertension Decreased respiratory rate Tachycardia, dysrhythmias Seizures Tricyclic antidepressants (TCAs) Acetaminophen (Tylenol) Asprin Depressants Stimulants Anticholinergic Cardiac medications Solvents, alcohols, cleaning agents Insecticides (organophosphates) / Carbamates KEY POINTS Routinely assess and document the patient s cardiopulmonary status. Determine what the patient was exposed to, how much, and when. If it is safe to do so, bring a sample with you to the hospital. Be sure to find out what interventions were administered prior to EMS arrival and document. If the patient ingested bleach, monitor the airway and remove contaminated clothing. Medical Control may order antidotes for specific ingestions. DO NOT use syrup of ipecac. Reference: Greater Cleveland Poison Control Center UH Protocols Chapter 6 Pediatric Protocols 35

190 TRAUMA PROTOCOLS PEDIATRIC HEAD TRAUMA Pediatric Multiple Trauma Protocol No UNIVERSAL PATIENT CARE PROTOCOL Isolated Head Trauma? Yes B EMT B A Advanced A M MED CONTROL M Spinal Immobilization Protocol IV/IO PROTOCOL Does patient respond to verbal? No None or Extension Response to Pain? Intubate No Localizes, Flexes, or Withdraws Pupils Equal and Reactive? Yes Yes Repeat Every 5 Maintain Pulse Oximetry > 90% Minutes Pediatric Seizure Protocol DEXTROSE 25% - 2mL/kg IV/IO Yes Seizure? No Blood Glucose Analysis Glucose < 60 Glucose > 60 Monitor and Reassess CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 36

191 TRAUMA PROTOCOLS PEDIATRIC HEAD TRAUMA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Time of injury Mechanism: blunt or penetrating Loss of consciousness Bleeding Past medical history Medications Evidence for multi-trauma History of Vomiting Pain, swelling, bleeding Altered mental status Unconscious Respiratory distress / Failure Vomiting Major traumatic mechanism of injury Seizure Skull fracture Brain injury (Concussion, Contusion, Hemorrhage or Laceration) Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Spinal injury Abuse KEY POINTS Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro. If GCS < 12 consider air / rapid transport and if GCS < 8 intubation should be anticipated. Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Hypotension usually indicates injury or shock unrelated to the head injury. The most important item to monitor and document is a change in the level of consciousness. Concussions are periods of confusion or LOC associated with trauma, which may have resolved by the time EMS arrives. A physician should evaluate any prolonged confusion or mental status abnormality, which does not return to normal within 15 minutes or any documented loss of consciousness. Consider Zofran for nausea/vomiting. Consult with medical control. UH Protocols Chapter 6 Pediatric Protocols 37

192 TRAUMA PROTOCOLS PEDIATRIC MULTIPLE TRAUMA B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Rapid Trauma Assessment Pediatric Airway Protocol Spinal Immobilization Protocol Rapid Transport to Most Appropriate Facility; Consider Transport to Trauma Center Abnormal Determine Load and Go Situation IV/IO PROTOCOL Assess Vital Signs / Perfusion? Normal Consider Air Transport Consider Medication for Pain Management NORMAL SALINE IV/IO BOLUS 20 ml/kg Repeat as needed Ongoing Assessment Appropriate Protocol Reassess Airway Protocol Check Tube Placement CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 6 Pediatric Protocols 38

193 HISTORY TRAUMA PROTOCOLS PEDIATRIC MULTIPLE TRAUMA SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Time and mechanism of Pain, swelling Chest tension pneumothorax injury Deformity, lesions, bleeding Flail chest Damage to structure or Altered mental status Pericardial tamponade vehicle Unconscious Open chest wound Location in structure or Hypotension or shock Hemothorax vehicle Arrest Intra-abdominal bleeding Others injured or dead Pelvis / Femur fracture Speed and details of Trauma Spine fracture / Cord injury Restraints / Protective Head injury (see Head equipment Trauma) Car seat Extremity fracture / Helmet dislocation Pads Airway obstruction Ejection Hypothermia Past medical history Medications A Pediatric Trauma Victim is a person < 16 years of age exhibiting one or more of the following physiologic or anatomic conditions Physiologic Conditions Glasgow Coma Scale < 13 Loss of consciousness > 5 minutes Deterioration in level of consciousness at the scene or during transport Failure to localize to pain Evidence of poor perfusion, or evidence of respiratory distress or failure Anatomic Conditions Penetrating trauma to the head, neck, or torso Significant, penetrating trauma to extremities proximal to the knee or elbow with evidence of neurovascular compromise Injuries to the head, neck, or torso where the following physical findings are present: o Visible crush injury o Abdominal tenderness, distention, or seatbelt sign o Pelvic fracture o Flail chest Injuries to the extremities where the following physical findings are present: o Amputations proximal to the wrist or ankle o Visible crush injury o Fractures of two or more proximal long bones o Evidence of neurovascular compromise Signs or symptoms of spinal cord injury 2 nd or 3 rd Degree burns > 10% total BSA, or other significant burns involving the face, feet, hands, genitalia, or airway KEY POINTS Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro. Examine all restraints / protective equipment for damage. In prolonged extrications or serious trauma consider air transportation for transport times and the ability to give blood. Do not overlook the possibility for child abuse. A trauma victim is considered to be a pediatric patient if they are younger that 16 years old. Major trauma patients are to be transported to the closest Pediatric Trauma Center when possible. Contact the receiving hospital for all major trauma or critical patients. The proper size equipment is very important to resuscitation care. Refer to length based drug treatment guide (e.g. Broselow Peds Tape or similar Guide) when unsure about patient weight, age and/or drug dosage and when choosing equipment size. Cover open wounds, burns, eviscerations. With the exception of airway control, initiate ALS enroute when transporting major trauma patients. If unable to access patient airway and ventilate, then transport to the closest facility for airway stabilization. The on scene time for major trauma patients should not exceed 10 minutes without documented, acceptable reason for the delay. All major trauma patients should receive oxygen administration, an IV(s), and cardiac monitoring. Provide a documented reason if an intervention could not be performed. UH Protocols Chapter 6 Pediatric Protocols 39

194 PEDIATRIC ASSESSMENT CHARTS PEDIATRIC GLASCOW COMA SCALE EYE OPENING Spontaneous Spontaneous 4 To voice To voice 3 To pain To pain 2 None None 1 VERBAL RESPONSE Oriented Coos, babbles 5 Confused Irritable cry, inconsolable 4 Inappropriate Cries to pain, 3 Garbled speech Moans to pain 2 None None 1 MOTOR RESPONSE Obeys commands Normal movements 6 Localizes pain Withdraws to touch 5 Withdraws to pain Withdraws to pain 4 Flexion Flexion 3 Extension Extension 2 Flaccid Flaccid 1 UH Protocols Chapter 6 Pediatric Protocols 40

195 PEDIATRIC ASSESSMENT CHARTS PEDIATRIC NORMAL VITAL SIGNS AGE HEART RATE RESPIRATIONS SYSTOLIC BLOOD PRESSURE Preterm, 1 kg Preterm 1 kg Preterm 2 kg Newborn Up to 1 yo yo yo yo yo yo yo UH Protocols Chapter 6 Pediatric Protocols 41

196 SIGN PEDIATRIC ASSESSMENT CHARTS PEDIATRIC APGAR SCORING Blue / Pale Pink Body, Blue Completely Pink COLOR Extremities HEART RATE Absent Below 100 Above 100 IRRITABILITY No Response Grimace Cries (Response to Stimulation) MUSCLE TONE Limp Flexion of Extremities Active Motion RESPIRATORY EFFORT Absent Slow and Regular Strong Cry UH Protocols Chapter 6 Pediatric Protocols 42

197 MEDICATIONS ADENOSINE (Adenocard) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Slows conduction time and can interrupt re-entrant pathways through the AV node Slows the sinus rate Supra Ventricular Tachycardia (SVT) Consider in Regular Wide Complex Tachycardia Paroxysmal Supra Ventricular Tachycardia (PSVT) Wolf Parkinson White (WPW) Second or third degree AV block, sick sinus syndrome Ventricular tachycardia Hypersensitivity to Adenosine It is helpful to inform the patient of likely side effects prior to medication administration Facial flushing Shortness of breath Chest pain Palpitations Brief period of sinus arrest /Transient Dysrhythmias Headache Lightheadedness Hypotension Nausea Initial Dose 6 mg rapid IVP (over 1-3 sec) immediately followed with a 20 ml saline flush Repeat Dose If no response is observed after 1 min., administer 12 mg rapid IVP (over 1-3 sec) immediately followed with a 20 ml saline flush. Max dose 30 mg Initial Dose 0.1 mg/kg rapid IVP followed with a 10 ml saline flush Repeat Dose If no response is observed after 1-2 min., administer 0.2 mg/kg rapid IVP followed with a 10 ml saline flush. Max dose 0.5 mg/kg up to 6mg Adenosine has a short half life, and should be administered rapidly followed by a rapid IV/IO flush Reassess after each medication administration, refer to the appropriate protocol and treat accordingly. Perform a 12 Lead EKG prior to the administration of Adenosine and after the rhythm converts Record rhythm during and post administration

198 MEDICATIONS ALBUTEROL (Proventil / Ventolin) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Acts directly on beta 2 adrenergic receptors to relax bronchial smooth muscle, resulting in reduced airway resistance and relief of bronchospasm Shortness of breath caused by bronchoconstriction Peaked T-Waves with symptoms in Renal Patients Known hypersensitivity Use precaution when administering to pregnant women or patients with cardiac history Nervousness Weakness Tremor Tachycardia 2.5 mg in 3 ml via unit dose nebulizer and 6 lpm oxygen 2.5 mg in 3 ml via unit dose nebulizer and 6 lpm oxygen May repeat treatment if partial relief is obtained

199 MEDICATIONS AMIODARONE (Cordarone) ACTIONS INDICATIONS CONTRAINDICATIONS Prolongs the refractory period and action potential duration Ventricular Fibrillation (refractory to shock treatment) Pulseless Ventricular Tachycardia (refractory to shock treatment) Polymorphic VT and wide complex tachycardia Hypersensitivity (including iodine) Cardiogenic shock Second and Third degree AV block Severe sinus bradycardia Severe sinus node dysfunction SIDE EFFECTS ADULT DOSAGE Tremors, Paresthesia, Ataxia Headache, Fatigue Abdominal pain, Nausea/Vomiting, Hepatic failure Arrhythmia, Bradycardia, Sinus arrest, Heart block (Prolonged QT), Heart failure Acute Respiratory Distress Syndrome, Severe pulmonary edema Blue-Gray skin Ventricular Fibrillation and Pulseless Ventricular Tachycardia 300 mg IV/IO bolus Repeat Dose: 150 mg IV/IO in 3-5 minutes, Max 2.2 g IV/24hrs PEDIATRIC DOSAGE KEY POINTS Wide Complex Tachycardia 150 mg IV/IO over 10 minutes (15 mg/min) Repeat Dose: 150 mg IV/IO every 10 minutes prn, Max 2.2 g IV/24hrs Ventricular Fibrillation and Pulseless Ventricular Tachycardia 5 mg/kg IV/IO bolus Ventricular Arrhythmias Loading dose 5 mg/kg IV/IO over mins Avoid excessive movement and shaking of the medication

200 MEDICATIONS ATROPINE SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE PEDIATRIC DOSAGE Increases sinus node firing Increases conduction through the AV node by blocking vagal activity Increases cardiac output Decreases ectopic beats or fibrillation of the ventricles Symptomatic sinus bradycardia Organophosphate poisoning/nerve agent exposure Known hypersensitivity Atrial flutter/fibrillation where there is a rapid ventricular response Glaucoma narrow angle 2 nd and 3 rd degree AV Block with wide QRS complex Use with extreme caution in myocardial infarction May increase myocardial oxygen demand May trigger tachy-dysrhythmias Patient needs to be warned about side effects Doses smaller than 0.5 mg or administered too slowly may slow rather than speed up the heart rate Excessive doses in adults may precipitate ventricular tachycardia or fibrillation Dry mouth, thirst, urinary retention Blurred vision, pupillary dilation, headache Flushed skin Tachycardia Prefilled syringes containing 1 mg in 10 ml Auto-Injector containing 2 mg (nerve agent exposure only) Bradycardia 0.5 mg IV/IO (1.0 mg ETT) every 5 minutes Max dose 0.04 mg/kg or 3 mg Organophosphate Poisoning 2 5mg IVP, IM, or IO every 5 min Bradycardia 0.02 mg/kg IV/IO, repeated X 1, 5 minutes (minimum dose 0.1 mg), Max single dose 0.5 mg CHILD / 1.0 mg ADOLESCENT, Max total dose 1.0 mg CHILD / 2.0 mg ADOLESCENT Organophosphate Poisoning 0.2 mg/kg IV/IO, repeat every 3-5 minutes / Max dose 0.5mg Child Max dose 1.0mg Adolescent.

201 MEDICATIONS BiCarbonate (Sodium BiCarbonate) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDS DOSAGE Buffers metabolic acidosis Enhances the urinary excretion of tricyclics Metabolic Acidosis from cardiac arrest Tricyclic Overdose Hyperkalemia Post Crushing Entrapment Heart Failure Seizures Tissue necrosis if infiltration Can precipitate with Calcium 50mEq IVP for tricyclic overdose 50mEq or 1mEq/kg IVP for cardiac arrest asystole or PEA 50 meq IVP for cardiac arrest with prolonged down time(10 minutes) 50mEq to 100mEq Post Crushing Entrapment 1mEq/kg IV/IO Diluted in 1:1 NS or as advised By Med Command

202 MEDICATIONS DEXTROSE 50 % (D50) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Restores circulating blood sugar Hypoglycemia Altered mental status of unknown origin Coma of unknown origin Seizures of unknown origin Known hyperglycemia. Head trauma unless confirmed hypoglycemia Caution with chronic renal failure Intracranial hemorrhage Use with caution for stroke patients Use a large vein to administer D50 Treat known alcoholics, renal failure patients, or malnourished patients with Thiamine prior to administering glucose Extravasation of D50 may cause necrosis Hyperglycemia May precipitate severe neurologic symptoms in alcoholics Dextrose 50% (D50) 25 g IV/IO 2 ml/kg D25 IV/IO

203 MEDICATIONS DIPHENHYDRAMINE HCL (Benadryl) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Antihistamine Sedative Inhibits motion sickness (antiemetic) Anaphylactic shock and severe allergic reaction Acute dystonia Nausea/vomiting (contact Medical Control) Extrapyramidal reaction (Parkinson-like movement disorders) Known hypersensitivity / Allergy Pregnancy or lactating Avoid the use of Diphenhydramine in nursing mothers May induce vomiting Carefully monitor patient while awaiting for medication to take effect (effect of medication begins 15 minutes after administration) Drowsiness, confusion Blurring of vision Dry mouth Wheezing; thickening of bronchial secretions Hypotension ADULT DOSAGE PEDIATRIC DOSAGE Allergic Reaction or Anaphylaxis mg IV/IO/IM Behavioral Psychiatric Emergencies 50 mg IM Allergic Reaction or Anaphylaxis 1 mg/kg (without hypotension) IV/IO/IM Max 50mg

204 ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE MEDICATIONS EPINEPHRINE (Adrenaline) Alpha and Beta adrenergic agonist Bronchodilation Increases heart rate and automaticity Increases cardiac contractility Increases myocardial electrical activity Increases systemic vascular resistance Increases blood pressure Cardiac arrest Allergic reaction/anaphylaxis Respiratory distress Acute Asthma Pediatric Bradycardia A Advanced A Hypersensitivity, Tachycardia, Hypertension, Hypothyroidism Angina / Chest pain, Coronary artery disease Pregnancy Blood pressure, pulse, and EKG must be routinely monitored Palpitations, ectopic beats, tachycardia Anxiety / Tremors Hypertension VF / VT Angina Asthma and Anaphylaxis Mild / Moderate Reaction (1-1,000) mg IM ONLY Consider 1:1000 2mg mixed with 1ml NS in nebulizer for Asthma Severe Anaphylaxis (1:10,000) 0.5 mg slow IV/IO over 5 minutes - EMT-P Only Cardiac Arrest 1:10,000 1 mg IV/IO every 3-5 minutes EMT-P Only

205 MEDICATIONS NALOXONE (Narcan) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Reverses all effects from opioid agents such as respiratory depression and all central and peripheral nervous system effects Narcotics overdoses Altered mental status of unknown origin None Withdrawal syndrome in addiction Ventricular dysrhythmias Cerbral edema mg IV/IO/IM/IN. Administer in small doses. May repeat the initial dose if the patient becomes symptomatic again EMT 2 mg IN 0.1 mg/kg IV,IO,IM,IN. May be repeated at 0.1 mg/kg

206 MEDICATIONS ORAL GLUCOSE B EMT B A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Elevates blood glucose level Correction of hypoglycemia Known hypersensitivity Patient must be alert and able to sufficiently swallow Be alert for difficulty swallowing or choking due to the thick consistency Nausea/Vomiting ADULT DOSAGE One complete tube (15-25 g) PEDIATRIC DOSAGE Half a tube KEY POINTS

207 MEDICATIONS Tylenol (acetaminophen) Oral liquid A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS Analgesic Antipyretic Febrile pediatric patient associated with possible febrile seizures Liver failure Liver problems SIDE EFFECTS Allergic reaction Pediatric Dose 10-15mg/kg Orally (supplied in 2-160mg per 5ml cups) PRECAUTION Do not give if patient has already taken Tylenol in the last 4 hours.

208 MEDICATIONS VERSED (Midazolam) A Advanced A ACTION INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Sedative and hypnotic benzodiazepine Induces amnesia Conscious sedation Seizure Facilitate intubation Facilitate pacing / cardioversion Intolerance to benzodiazepines Narrow-angle glaucoma Shock Coma CNS amnesia, headache, dizziness, euphoria, comfusion, agitation, anxiety, delirium, drowsiness, muscle tremor, ataxia, dysphoria, slurred speech, and paresthesia. Cardiovascular hypotension, PVC s, tachycardia, vasocagel episode Eye blurred vision, diplopia, nystagmus, pinpoint pupils Respiratory coughing, bronchospasms, laryngospasm, apnea, hypoventilation, wheezing, airway, obstruction, tachypnea ADULT DOSAGE PEDIATRIC DOSAGE NOTE Skin swelling, burning, pain at the site of injection 2mg IV/IO max initial dose for sedation (may repeat as necessary) 5mg IV/IO max initial dose for seizures (may repeat as necessary) 5mg IV/IO for RSI and Violent Patients Versed may be administered IM or IN in actively seizing or violent patients whenever IV access is not achieved. Seizures 0.1mg/kg IV/IO/IM/IN to a max dose of 5mg 0.2mg/kg IN to a max dose of 10mg For adult patients use only if Ativan is unavailable

209 MEDICATIONS GLUCAGON A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose level Relaxes smooth muscle of GI tract Hypoglycemia when IV/IO is not able to be established and oral glucose is contraindicated Esophageal obstruction Beta Blocker overdose Known hypersensitivity Pheochromocytoma Glucagon is only effective in patients with sufficient stores of glycogen Use caution in patients with renal or cardiovascular disease Glucagon can be administered on scene, but do not wait for it to take effect Nausea/Vomiting 1mg IM/IN for Hypoglycemia 2mg IV/IO/IM/IN in esophageal foreign body obstruction 2 mg IV/IO/IM/IN for hypotension / bradycardia in Betablocker overdose and Calcium Channel overdose <20kg give 0.5mg IM / IN >20kg give 1mg IM / IN Response is usually noticed in 5-20 minutes Glucagon is NOT a substitute for D25, or D12.5. IV must be attempted prior to administering Glucagon

210 MEDICATIONS DuoNeb A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS (Albuterol) Parasympatholytic bronchodilator Dries respiratory tract secritations (Ipratropium Atrovent) B2 selective bronchodilator Increases HR Asthma exacerbation COPD exacerbation Patients that have used their prescribed inhaler more than once Pulmonary edema with wheezing Known hypersensitivity /Allergy Allergy to peanuts Acute myocardial infarction Arrhythmias Cardiovascular disease Hypertension history CHF Palpitations Anxiety Nausea Dissiness ADULT/PEDS DOSAGE Unit dose inhaled via nebulizer. May repeat as needed

211 TRAUMA PROTOCOLS Trauma Emergencies Trauma Guidelines Abdominal Trauma Burns Trauma Chest Trauma Drowning/Near Drowning Extremity / Amputation Trauma Eye Injury Trauma Head Trauma Multiple Trauma Pain Management Trauma Arrest TRAUMA ASSESSMENT CHARTS Glasgow Coma Scale Revised Trauma Score Universal Pain Assessment Tool Rule of Nines Burn Chart UH Protocols Chapter 7 Trauma Protocols 1

212 TRAUMA TRAUMA EMERGENCIES The Golden Hour GUIDELINES FOR LOAD AND GO TRAUMA TRANSPORTS INDICATIONS Uncorrectable airway obstruction Tension pneumothorax Pericardial tamponade Penetrating chest wounds with shock Hemothorax with shock Head trauma with unilaterally dilated pupils Head trauma with rapidly deteriorating condition Unconsciousness KEY POINTS A trauma victim is considered to be a pediatric patient if they are younger than 16 years old. Once the patient is determined to be an actual or potential major trauma/multiple system patient, personnel on scene and/or Medical Control must quickly determine the appropriate course of action including: 1. Requesting aeromedical evacuation from scene. 2. Ground transportation directly to an appropriate facility. Bypass of nearest facility must be approved by Medical Control. Major Trauma patients are to be transported to the closest Trauma Center, if possible. Contact the receiving hospital for all major trauma or critical patients. Cover open wounds, burns, and eviscerations. With the exception of airway control, initiate ALS enroute when transporting major trauma patients. If the EMT is unable to access patient airway and ventilate, transport to the closest facility for airway stabilization. The on scene time for major trauma patients should not exceed 10 minutes without a documented, acceptable reason for the delay. All major trauma patients should receive oxygen administration, an IV(s), and cardiac monitoring. Provide a documented reason if an intervention could not be performed. Consider Ohio Geriatric Trauma criteria. THE GOLDEN HOUR FOR THE PATIENT BEGINS WHEN THE TRAUMA HAPPENS. DO NOT WASTE VALUABLE TIME ON SCENE. UH Protocols Chapter 7 Trauma Protocols 2

213 TRAUMA TRAUMA GUIDELINES Emergency medical service personnel shall use the following criteria, consistent with their certification, to evaluate whether an injured person qualifies as an adult trauma victim or pediatric trauma victim, in conjunction with the definition of trauma according to the State of Ohio Trauma Triage Guidelines. An Adult Trauma Victim is a person 16 years of age to 69 Years of Age exhibiting one or more of the following physiologic or anatomic conditions: Physiologic conditions Glasgow Coma Scale < 13 Loss of consciousness > 5 greater minutes Deterioration in level of consciousness at the scene or during transport Failure to localize to pain Respiratory rate < 10 or > 29 Requires endotracheal intubation Requires relief of tension pneumothorax Pulse > 120 in combination with evidence of hemorrhagic shock Systolic blood pressure < 90, or absent radial pulse with carotid pulse present Anatomic conditions Penetrating trauma to the head, neck, or torso Significant, penetrating trauma to extremities proximal to the knee or elbow with evidence of neurovascular compromise Injuries to the head, neck, or torso where the following physical findings are present: Visible crush injury Abdominal tenderness, distention, or seatbelt sign Pelvic fracture Flail chest Injuries to the extremities where the following physical findings are present Amputations proximal to the wrist or ankle Visible crush injury Fractures of two or more proximal long bones Evidence of neurovascular compromise Signs or symptoms of spinal cord injury 2 nd or 3 rd Degree > 10% total BSA or other significant burns involving the face, feet, hands, genitalia, or airway A GeriatricTrauma Victim is a person >69 Years of Age and older exhibiting one or more of the following physiologic or anatomic conditions: Physiologic conditions Glasgow Coma Scale < 13 Glasgow Coma Score <15 with a known or suspected traumatic brain injury Loss of consciousness > 5 greater minutes Deterioration in level of consciousness at the scene or during transport Failure to localize to pain Respiratory rate < 10 or > 29 Requires endotracheal intubation Requires relief of tension pneumothorax Pulse > 120 in combination with evidence of hemorrhagic shock Systolic blood pressure < 100, or absent radial pulse with carotid pulse present Geriatric Mechanism Indicators Fracture of one or more proximal long bone (Humerus or Femur) sustained in a motor vehicle crash. Pedestrian Struck Falls from any height including standing with evidence of traumatic brain injury UH Protocols Chapter 7 Trauma Protocols Anatomic conditions Penetrating trauma to the head, neck, or torso Significant, penetrating trauma to extremities proximal to the knee or elbow with evidence of neurovascular compromise Injuries to the head, neck, or torso where the following physical findings are present: Visible crush injury Abdominal tenderness, distention, or seatbelt sign Pelvic fracture Flail chest Injuries to the extremities where the following physical findings are present Amputations proximal to the wrist or ankle Visible crush injury Fractures of two or more proximal long bones Evidence of neurovascular compromise Signs or symptoms of spinal cord injury Injuries sustained in two or more body regions 2 nd or 3 rd Degree > 10% total BSA or other significant burns involving the face, feet, hands, genitalia, or airway 3

214 Field Trauma Triage Criteria: Mechanism of Injury (MOI) & Special Considerations Co-Morbid Diseases and Special Considerations: Age < 5 or > 55 Cardiac disease Respiratory disease Diabetes Immunosuppression Morbid obesity Pregnancy Substance abuse/intoxication Liver disease Renal disease Bleeding disorder/anticoagulation Mechanisms of Injury (MOI) High speed MVC Ejection from vehicle Vehicle rollover Death in same passenger compartment Extrication time > 20 minutes Falls greater than 20 feet Vehicle versus bicycle / pedestrian Pedestrian thrown or run over Motorcycle crash > 20 mph with separation of rider from bike Falls from any height, including standing, with signs of traumatic brain injury KEY POINTS Exceptions to Mandatory Transport to a Trauma Center: Emergency medical service personnel shall transport a trauma victim directly to an adult or pediatric trauma center that is qualified to provide appropriate adult or pediatric care, unless one or more of the following exceptions apply: It is medically necessary to transport the victim to another hospital for initial assessment and stabilization before transfer to an adult or pediatric trauma center It is unsafe or medically inappropriate to transport the victim directly to an adult or pediatric trauma center due to adverse weather or ground conditions or excessive transport time Transporting the victim to an adult or pediatric trauma center would cause a shortage of local emergency medical service resources No appropriate adult or pediatric trauma center is able to receive and provide adult or pediatric trauma care to the trauma victim without undue delay Before transport of a patient begins, the patient requests to be taken to a particular hospital that is not a trauma center or, if the patient is less than eighteen years of age or is not able to communicate, such a request is made by an adult member of the patient's family or a legal representative of the patient UH Protocols Chapter 7 Trauma Protocols 4

215 Glasgow Coma Scale INFANT Eye Opening ADULT Birth to age 4 Age 4 to Adult 4 Spontaneously Spontaneously 4 3 To speech To command 3 2 To pain To pain 2 1 No response No Response 1 Best Verbal Response 5 Coos, babbles Oriented 5 4 Irritable cries Confused 4 3 Cries to pain Inappropriate words 3 2 Moans, grunts Incomprehensible 2 1 No response No response 1 Best Motor Response 6 Spontaneous Obeys commands 6 5 Localizes pain Localizes pain 5 4 Withdraws from pain Withdraws from pain 4 3 Flexion (decorticate) Flexion (decorticate) 3 2 Extension (decerebrate) Extension (decerebrate) 2 1 No response No response 1 = TOTAL GCS < 8? Intubate! TOTAL = UH Protocols Chapter 7 Trauma Protocols 5

216 TRAUMA ABDOMINAL TRAUMA Multiple Trauma Protocol SCENE SAFETY UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Airway Protocol Spinal Immobilization Protocol Determine if Load & Go Control Hemorrhage / Dress Wounds Evisceration: cover, clean saline dressing to loosely stabilize. Penetrating Object: cover, clean saline dressing immobilize object. If too large to transport attempt to cut with care, attempt to not further injure tissue. Penetrating Wounds: cover, clean saline dressing. Look for exit wound. Blunt Trauma: Assess for change distention. Note mechanism. NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic, (100 Systolic >70 Yrs Old) or MAP >70 (if NIBP is available) Cardiac Monitor Shock Protocol Monitor and Reassess CONTACT MEDICAL CONTROL UH Protocols Chapter 7 Trauma Protocols TRANSPORT 6

217 TRAUMA ABDOMINAL TRAUMA MECHANISM Blunt Altered mental status Shock Distention Swelling Bulging Nausea and vomiting Discoloration Tenderness Pain SIGNS & SYMPTOMS Penetrating Altered mental status Bleeding Tenderness Pain Distention Eviseration Discoloration Entrance/exit wounds Nausea & vomiting KEY POINTS Trauma to the abdomen is either blunt or penetrating. Blunt injuries are harder to detect and diagnose, and have a death rate twice that of penetrating wounds. Key signs and symptoms of blunt trauma include a patient in shock with no obvious injuries. Distention of the abdomen is an indication of internal hemorrhage. Pain may not be a significant factor. Many abdominal trauma injuries are Load & Go cases. Look for both an entrance and exit wound for all penetrating trauma, and treat accordingly. For all major trauma patients, the on scene time should be less than ten minutes. UH Protocols Chapter 7 Trauma Protocols 7

218 TRAUMA BURNS UNIVERSAL PATIENT CARE PROTOCOL Airway Protocol Intubate inhalation burn patients as soon as possible B EMT B A Advanced A M MED CONTROL M Consider Spinal Immobilization Remove rings, bracelets, and other constricting items Thermal If burn < 10% body surface area (Rule of Nines) Cool down wound with NORMAL SALINE and dress accordingly Chemical Eye Injury Continuous flushing with Normal Saline Cover burn with dry sterile sheet or dressings Remove clothing and/or expose area NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic (100 systolic >70 yrs old) or MAP >70 (if NIBP is available) Pain Control Protocol Pain Control Protocol CONTACT MEDICAL CONTROL TRANSPORT Consider transport to burn center UH Protocols Chapter 7 Trauma Protocols 8

219 TRAUMA BURNS HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Type of exposure (heat, gas, chemical) Inhalation injury Time of injury Past medical history Medications Other trauma Loss of consciousness Tetanus / Immunization status Burns, pain, swelling Dizziness Loss of consciousness Hypotension / shock Airway compromise / distress Singed facial or nasal hair Hoarseness / wheezing Superficial (1 ): red and painful Partial thickness (2 ): superficial partial thickness, deep partial thickness, blistering Full thickness (3 ): painless and charred or leathery skin Chemical Thermal Electrical Radiation KEY POINTS Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, Neuro. Critical Burns: >25% body surface area (BSA); full thickness burns >10% BSA; partial thickness superficial partial thickness, deep partial thickness and full thickness burns to face, eyes, hands or feet; electrical burns; respiratory burns; deep chemical burns; burns with extremes of age or chronic disease; and burns with associated major traumatic injury. These burns may require hospital admission or transfer to a burn center. Early intubation is required in significant inhalation injuries. Potential CO exposure should be treated with 100% oxygen via non-rebreather mask. Circumferential burns to extremities are dangerous due to potential vascular compromise. Burn patients are prone to hypothermia Never apply ice or cool burns that involve >10% body surface area. Do not overlook the possibility of multiple system trauma. Do not overlook the possibility of child abuse with children and burn injuries. Handle patients gently to avoid further damage of the patient s skin. If the patient is exposed to a chemical, whenever possible, get the name of the chemical, and document it on the patient run report. DO NOT transport any hazardous materials with the patient. Look for signs of dehydration and shock. Patients with large surface burns lose the ability to regulate their body temperature. Avoid heat loss by covering the patient. Types of burns Thermal (dry and moist) Stop burning process: remove patient from heat source, cool skin, remove clothing. If patient starts to shiver or skin is cool, stop cooling process. Estimate extent (%) and depth of burn. Determine seriousness of burn. Contact Medical Control and transport accordingly. Cover burn areas with sterile dressing. Radiation Burns Treat as thermal burns except when burn is contaminated with radioactive source, then treat as chemical burn. Wear appropriate protective clothing when dealing with contamination. Contact HAZ MAT team for assistance in contamination cases. Chemical Burns Wear appropriate protective clothing and respirators. Remove patient from contaminated area to decontamination site (NOT SQUAD). Determine chemicals involved; contact appropriate agency for chemical information. Remove patient's clothing and flush skin. Leave contaminated clothes at scene. Cover patient over and under before loading into squad. Patient should be transported by personnel not involved in decontamination process. Determine severity, contact Medical Control and transport accordingly. Relay type of substance involved to Medical Control. Electrical Burns Shut down electrical source; do not attempt to remove patient until electricity is CONFIRMED to be shut off. Assess for visible entrance and exit wounds and treat as thermal burns. Assess for internal injury (vascular damage, tissue damage, fractures) and treat accordingly. Determine severity of burn, contact Medical Control and transport accordingly. Inhalation Burns: Always suspect inhalation burns when the patient is found in a closed smoky environment and/or exhibits any of the following: burns to face/neck, singed nasal hairs, cough and/or stridor, soot in sputum. Provide oxygen therapy, contact Medical Control and transport. UH Protocols Chapter 7 Trauma Protocols 9

220 TRAUMA CHEST TRAUMA UNIVERSAL PATIENT CARE PROTOCOL C-Spine Immobilization Evidence of Trauma Blunt or Penetrating Abnormal breath sounds, inadequate respiratory rate, unequal symmetry, diminished chest excursion, cyanosis B EMT B A Advanced A M MED CONTROL M Jaw Thrust Airway Maneuver Give High Flow Oxygen Needle CRIC procedure if needed and if trained Flail Chest: Stabilize flail segment with manual pressure then apply bulky dressing and tape. Intubate. Watch for Tension Pneumothorax to develop. Cardiac Tamponade: Assess for Beck s Triad (Hypotension, JVD and muffled heart sounds). Paradoxical Pulse (no radial pulse when breathing in) is likely. EKG monitor. This is a Load & Go. Massive Hemothorax: Shock, then difficulty breathing. No JVD, decreased breath sounds, dull to percussion. This is a Load & Go. IV/IO to keep 90 systolic (100 Systolic >70 Yrs Old Open Pneumothorax: Close wound with occlusive dressing secured on THREE SIDES, allowing air to escape. Use Commerical device if available. Tension Pneumothorax: Patient is decompensating (cyanotic, respiratory distress, no radial pulse, decreasing LOC). Decompress affected side of chest wall if trained. Suspected: Traumatic Aortic Rupture, Tracheal or Bronchial Tree Injury, Myocardial Contusion, Diaphragmatic Tears, Esophageal Injury, Pulmonary Contusion: Ensure an Airway, Administer Oxygen. This is a Load & Go. Cardiac Monitor NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic, (100 Systolic >70 Yrs Old) or MAP >70 (if NIBP is available) CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 10

221 TRAUMA CHEST TRAUMA SIMPLE PNEUMOTHORAX Shortness of breath Dyspnea Tachypnea Cyanosis Chest pain Absent / Diminished lung sounds on the affected side SIGNS AND SYMPTOMS OPEN PNEUMOTHORAX Shortness of breath Dyspnea Cyanosis Sucking chest wound Shock Absent / Diminished lung sounds on affected side TENSION PNEUMOTHORAX Shortness of breath Cyanosis Shock Absent / Diminished lung sounds Tracheal deviation Hypotension JVD Tachycardia Dyspnea (late sign) HEMOTHORAX Shortness of breath Dyspnea Cyanosis Dullness to percussion sounds Flat neck veins Hypotension Shock Absent / Diminished breath sounds Tachycardia CARDIAC TAMPONADE TRAUMATIC ASPHYXIA FLAIL CHEST Hypotension Bloodshot, bulging eyes Paradoxical chest wall Decreasing pulse pressure Blue, bulging tongue movement Elevated neck veins JVD Asymmetric chest movement Muffled heart tones Cyanotic upper body upon inspiration Bruising over the sternum Dyspnea Tachycardia Unstable chest segment Significant chest wall pain KEY POINTS Thoracic injuries have been called the deadly dozen. The first six are obvious at the primary assessment: Airway Obstruction Open Pneumothorax Massive Hemothorax Cardiac Tamponade Flail Chest Tension Pneumothorax The second six injuries may be more subtle and not easily found in the field: Traumatic Aortic Rupture Esophageal Injury Myocardial Contusion Diaphragmatic Tears Tracheal/Bronchial Tree Injury Pulmonary Contusion A sucking chest wound is when the thorax is open to the outside. The occlusive dressing may be anything such as petroleum gauze, plastic, or a defibrillator pad. Tape only 3 sides down so that excess intrathoracic pressure can escape, preventing a tension pneumothorax. May help respirations to place patient on the injured side, allowing unaffected lung to expand easier. A flail chest is when there are extensive rib fractures present, causing a loose segment of the chest wall resulting in paradoxical and ineffective air movement. This movement must be stopped by applying a bulky pad to inhibit the outward excursion of the segment. Positive pressure breathing via BVM will help push the segment and the normal chest wall out with inhalation and to move inward together with exhalation, getting them working together again. Do not use too much pressure to prevent additional damage or pneumothorax. A penetrating object must be immobilized by any means possible. If it is very large, cutting may be possible, with care taken not to move it about when making the cut. Place an occlusive and bulky dressing over the entry wound. A tension pneumothorax is life threatening. Look for unequal breath sounds, JVD, increasing respiratory distress, decrease mental status, and lastly, tracheal displacement. The pleura must be decompressed with a needle to provide relief. Use either the midclavicular (2 nd or 3 rd intercostals space) going in on the top side of the rib. Once the catheter is placed, watch closely for reocclusion. Repeat if needed. You may attach the finger of a glove to the outside end of the catheter to assist in watching air movement. UH Protocols Chapter 7 Trauma Protocols 11

222 TRAUMA DROWNING/NEAR DROWNING UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Airway Protocol Initiate ventilation while patient is still in water if not breathing. Provide high flow oxygen ASAP. Spinal Immobilization Protocol Place backboard while still in water if able. Cardiac Monitor IV/IO PROTOCOL If V-Fib defibrillate per ACLS or use AED HYPOTHERMIC Appropriate Protocol If Cardiac Arrest May attempt Defib. BLS only for all other arrests If Spontaneously Breathing Consider CPAP DECOMPRESSION give oxygen no positive pressure unless NOT breathing. Position patient on left side with head down. Monitor and Reassess CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 12

223 TRAUMA DROWNING/NEAR DROWNING HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Submersion in water regardless of depth Period of unconsciousness Trauma Pre-existing medical Possible trauma: fall, Unresponsive problem diving board Mental status changes Barotrauma (diving) Duration of immersion Decreased or absent vital Decompression sickness Temperature of water signs Salt or fresh water Vomiting Coughing KEY POINTS Exam: Trauma Survey, Head, Neck, Chest, Lungs, Abdomen, Pelvis, Back, Extremities, Skin, Neuro Drowning due to suffocation from submersion in water. 2 causes breath holding which leads to aspiration of water & laryngospasm which closes the glottis. Both causes lead to profound hypoxia and death. Fresh water drowning ventricular fibrillation may be likely. Salt water drowning may cause pulmonary edema in time. Pulmonary edema can develop within hours after submersion. All victims should be transported for evaluation due to potential for worsening over the next several hours. Drowning is a leading cause of death among would-be rescuers. Allow appropriately trained and certified rescuers to remove victims from areas of danger. With pressure injuries (decompression/barotrauma), consider transport for availability of a hyperbaric chamber. All hypothermic drowning/near-drowning patients should have resuscitation performed until care is transferred, or if there are other signs of obvious death (putrification, traumatic injury unsustainable to life). Consider a c-spine injury in all drowning cases. Always immobilize a drowning patient. Patients with low core temperatures will not respond to ALS drug interventions. Maintain warming procedure and supportive care. DO NOT perform the Heimlich maneuver to remove water from the lungs prior to resuscitation. UH Protocols Chapter 7 Trauma Protocols 13

224 TRAUMA EXTREMITY / AMPUTATION TRAUMA B EMT B A Advanced A M MED CONTROL M UNIVERSAL PATIENT CARE PROTOCOL Wound Care / Hemorrhage Control Consider Splinting If unable to control major, life threatening, bleeding consider application of a commercially made tourniquet Multiple Trauma Protocol Life or Limb Threatening Event? IV/IO PROTOCOL Pain Management Protocol Amputation? Clean amputated part with NS or sterile water Wrap part in Sterile Dressing and place in plastic bag if able Place on Ice if available no direct contact to tissue CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 14

225 TRAUMA EXTREMITY / AMPUTATION TRAUMA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Type of injury Mechanism: crush / penetrating / amputation Time of injury Open vs. closed wound / fracture Wound contamination Medical history Medications Pain, swelling Deformity Altered sensation / motor function Diminished pulse / capillary refill Decreased extremity temperature Abrasion Contusion Laceration Sprain Dislocation Fracture Amputation KEY POINTS Exam: Mental Status, Extremity, Neuro. In amputations, time is critical. Transport and notify Medical Control immediately, so that the appropriate destination can be determined. Hip dislocations and knee and elbow fracture / dislocations have a high incidence of vascular compromise. Urgently transport any injury with vascular compromise. Blood loss may be concealed or not apparent with extremity injuries. Lacerations must be evaluated for repair within 6 hours from the time of injury. Extremity Trauma In cases of major trauma, the backboard can work as a whole body splint. DO NOT take the time to splint injured extremities in major trauma patients unless it does not delay the scene time or prevents you from performing more pertinent patient care. Splint the extremity if the patient has signs and symptoms of a fracture or dislocation. Treat all suspected sprains or strains as fractures until proven otherwise. Splint the joint above and below for all suspected fractures. Splint the bone above and below for all suspected joint injuries. Check and document the patient s MSPs before and after splinting. A traction splint with a backboard is the preferred splint to use for femur fractures. Traumatic Amputation Care of the amputated extremity include: Cleanse an amputated extremity with normal saline or sterile water. DO NOT place any amputated tissue directly on ice or cold pack. Instead, place the amputated limb into a plastic bag. Put the bag into a container of cool water with a few ice cubes (if available). Contact the receiving hospital with the patient information and include the status of the amputated limb. Focus on patient care and not on the amputated extremity. Do not use improvised Tourniquets. Only commercially made tourniquets may be used to control major, life threatening, bleeding. Remember to calm and reassure the patient. Do not give the patient or their family members false hope of re-attachment of the affected limb. A medical team at the receiving hospital makes this decision. Delegate someone to do an on scene search for the amputated part when it cannot be readily found and continue with patient care. UH Protocols Chapter 7 Trauma Protocols 15

226 TRAUMA EYE INJURY UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M Determine type of injury Remove Contact Lens (If Applicable) Trauma Burn Non - Penetrating Soft Tissue Apply Dressing Dust Dirt Flush with Normal Saline Penetrating Secure Object (Do Not Remove) Cover both eyes Determine Substance Flush with Copious Amounts of Normal Saline Eye extraction cover with sterile 4 x 4 normal saline and stabilize Pain Control: Tetracaine 2 drops q 5 min PRN CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 16

227 TRAUMA EYE INJURY HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Trauma of any type that results in injury to one or both eyes Irritation to eye Visual disturbances Obvious penetrating injury Burn (chemical, thermal) Loss of vision Dizziness Loss of consciousness Nausea Hypertension Contact lens problem KEY POINTS If unsure if something can be flushed with water, contact Medical Control. A low pressure water source can be used to help flush the patient s eye(s) if available. DO NOT use a high-pressure hose or at a high force. If needed, irrigate the patient s eyes for approximately 5-15 minutes. Begin irrigating immediately; irreversible damage can occur in a few minutes. TRAUMA Do not allow eye injury to distract you from the basics of trauma care. Do not remove any foreign body imbedded in the eye or orbit. Stabilize any large protruding foreign bodies. With blunt trauma to the eye, if time permits, examine the globe briefly for gross laceration as the lid may be swollen tightly shut later. Sclera rupture may lie beneath an intact conjunctiva. Covering both eyes when only one eye is injured may help to minimize trauma to the injured eye, but in some cases the patient is too anxious to tolerate this Transport patient sitting supine unless other life threats prohibit this from being done. CHEMICAL BURNS When possible determine type of chemical involved first. The eye should be irrigated with copious amounts of water or saline, using IV tubing wide open for a minimum of 15 minutes started as soon as possible. Any delay may result in serious damage to the eye. Always obtain name and, if possible, a sample of the contaminant or ask that it be brought to the hospital as soon as possible. CONTACT LENSES If possible, contact lenses should be removed from the eye; be sure to transport them to the hospital with the patient. If the lenses cannot be removed, notify ED personnel as soon as possible. If the patient is conscious and alert, it is much safer and easier to have the patient remove their lenses ACUTE, UNILATERAL VISION LOSS When a patient suddenly loses vision in one eye with no pain, there may be a central retinal artery occlusion. Urgent transport and treatment is necessary. Patient should be transported flat. UH Protocols Chapter 7 Trauma Protocols 17

228 TRAUMA HEAD TRAUMA Multiple Trauma Protocol No UNIVERSAL PATIENT CARE PROTOCOL Isolated Head Trauma? Spinal Immobilization Protocol B EMT B A Advanced A M MED CONTROL M Airway Protocol Hyper-ventilate when there are signs of cerebral herniation: Blown pupils, bradycardia, posturing High Flow O2 via NRB Obtain Glasgow Score Repeat every 5 minutes Consider altered LOC protocol Control Bleeding, Apply Dressing NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic, (100 Systolic >70 Yrs Old) or MAP >70 (if NIBP is available) Seizure Protocol Yes Seizure Activity No Monitor and Reassess If nausea/vomiting consider Zofran 4 mg Slow IV/IO/IM Zofran Oral Disolving Tabs 8 mg Oral CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 18

229 TRAUMA HEAD TRAUMA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Time of injury Mechanism: blunt / penetrating Loss of consciousness Bleeding Medical history Medications Evidence of multi-trauma Helmet use or damage to helmet Pain, swelling, bleeding Altered mental status Unconscious Respiratory distress / failure Vomiting Significant mechanism of injury Skull fracture Brain injury (concussion, contusion, hemorrhage, or laceration) Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Spinal injury Abuse Glasgow Coma Scale INFANT Eye Opening ADULT Birth to age 4 Age 4 to Adult 4 Spontaneously Spontaneously 4 3 To speech To command 3 2 To pain To pain 2 1 No response No Response 1 Best Verbal Response 5 Coos, babbles Oriented 5 4 Irritable cries Confused 4 3 Cries to pain Inappropriate words 3 2 Moans, grunts Incomprehensible 2 1 No response No response 1 Best Motor Response 6 Spontaneous Obeys commands 6 5 Localizes pain Localizes pain 5 4 Withdraws from pain Withdraws from pain 4 3 Flexion (decorticate) Flexion (decorticate) 3 2 Extension (decerebrate) Extension (decerebrate) 2 1 No response No response 1 = TOTAL GCS < 8? Intubate! TOTAL = UH Protocols Chapter 7 Trauma Protocols KEY POINTS Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro. If GCS < 12 consider Air / Rapid Transport and if GCS < 8 intubation should be anticipated. Do not hyperventilate patients with head injuries. Ventilate at breaths with high flow Oxygen. In absence of capnometer, hyper-oxygenate the patient (adult: 20 breaths / min, child: 30, infant: 35) only if ongoing evidence of brain herniation (blown pupil, decorticate or decerebrate posturing, or bradycardia). Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Look for widened pulse pressure. Hypotension usually indicates injury or shock unrelated to the head injury and should be aggressively treated. The most important item to monitor and document is a change in the level of consciousness. Consider Restraints if necessary for patient's and/or personnel's protection per the Restraint Protocol. Limit IV fluids unless patient is hypotensive (systolic BP < 90) (100 systolic >70yrs old). Concussions are periods of confusion or LOC associated with trauma, which may have resolved by the time EMS arrives. A physician ASAP should evaluate any prolonged confusion or mental status abnormality, which does not return to normal within 15 minutes or any documented loss of consciousness. Herniation may occur. Signs are: Cushing s response. Bradycardia, widen pulse pressure, altered mentation Decreasing level of consciousness progressing towards coma Dilation and outward downward deviation of the pupil on the affected side. Paralysis of the arm and leg on the opposite side of the injury or decerebrate posturing (arms and legs extended). IV therapy must be used prudently and is restricted in most isolated head injuries. Too much fluid can increase intracranial pressure. Continually reassess the patient. Consider Zofran if nausea/vomiting present. 19

230 TRAUMA MULTIPLE TRAUMA Consider Rapid Air Transport if Delay Due to Extrication UNIVERSAL PATIENT CARE PROTOCOL Rapid Trauma Assessment Airway Protocol B EMT B A Advanced A M MED CONTROL M Consider DOA / Termination of Efforts Spinal Immobilization Protocol NORMAL SALINE BOLUS 20 ml/kg IV/IO (To Maintain B/P > 90 Systolic, (100 Systolic >70 Yrs Old) or MAP >70 (if NIBP is available) Assess Vital Signs / Perfusion Cardiac Monitor Abnormal NORMAL SALINE IV/IO BOLUS 20mL/kg Reassess Airway Protocol Monitor Airway Ventilate Appropriately Monitor and Reassess Continued Hypotension? Witnessed Trauma Arrest? Consider Chest Decompression if trained Normal Monitor and Reassess Pain Management Protocol Treat per Appropriate Protocol If Nausea/Vomiting Consider Zofran 4 mg slow IV/IO/IM Zofran Oral Disolving Tabs 8 mg Oral CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 20

231 TRAUMA MULTIPLE TRAUMA HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Time and mechanism of Pain, swelling Tension pneumothorax injury Deformity, lesions, bleeding Flail chest Damage to structure or Altered mental status or Pericardial tamponade vehicle unconscious Open chest wound Location in structure or Hypotension or shock Hemothorax vehicle Arrest Intra-abdominal bleeding Others injured or dead Pelvis / Femur fracture Speed and details of Spine fracture / spinal trauma cord injury Restraints / protective Head injury equipment Extremity fracture / Past medical history dislocation Medications Airway obstruction Hypothermia KEY POINTS Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro. In prolonged extrications or serious trauma, consider air transportation for transport times and the ability to give blood. Use commercial device if available. Consider PASG in "load and go" situations with suspected pelvic or femur fractures. Do not overlook the possibility of associated domestic violence or abuse. UH Protocols Chapter 7 Trauma Protocols 21

232 TRAUMA PAIN MANAGEMENT UNIVERSAL PATIENT CARE PROTOCOL Treat per Appropriate Trauma Protocol B EMT B A Advanced A M MED CONTROL M NITROUS OXIDE Self Administered with Mask Not for Abdominal Trauma, Altered Mentation, Suspected Pneumothorax, Head Injury, COPD, SBO, Psychiatric, Respiratory Distress IV/IO PROTOCOL MORPHINE SULFATE 2 4 mg IV/IO/IM/IN Not for Altered Mentation, Head Trauma, Hypotension, Sever Respiratory Distress May repeat to a total of 10 mg - contact med control for further dose OR Toradol (NSAID) 30mg IV/IO, 60mg IM x1 (If <65 Years old only) Not for :Altered Mentation, Abdominal Pain, Head Trauma, Hypovolemia, Multiple Trauma, Use With or Hypersensitivity to Aspirin, Active or History of Peptic Ulcer Disease, GI Bleeding, Cerebrovascular Bleeding, Risk of Any Bleeding, Prior to Surgery, Possible Pregnancy OR Fentanyl mcg IV/IO/IM/IN slow over at least1-2 minutes, every minutes PRN, titrated to Systolic BP of > 90 mm/hg or for proper analgesic effect. Follow Morphine Sulfate with Zofran 4 mg slow IV/IO/IM Zofran Oral Disolving Tabs 8 mg Oral Monitor and Reassess CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 22

233 TRAUMA PAIN MANAGEMENT HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Age Severity (pain scale) Musculoskeletal Location Quality (sharp, dull, etc.) Visceral (abdominal) Duration Radiation Cardiac Severity (0-10) Relation to movement, Pleural / Respiratory Past medical history respiration Neurogenic Medications Increased with palpation Renal (colic) Drug allergies of area KEY POINTS Exam: Mental Status, Area of Pain, Neuro, Lungs. Pain severity (0-10) is a vital sign to be recorded pre and post IV/IO/IM/IN medication delivery and at disposition. Vital signs should be obtained pre, 15 minutes post, and at disposition with all pain medications. Contraindications to pain management include hypotension, head injury or severe respiratory distress. All patients should have drug allergies documented prior to administering pain medications. All patients who receive IV/IO/IM/IN medications must be observed 15 minutes for drug reaction. All patients who receive medication for pain must have continuous ECG monitoring, pulse oximetry, and oxygen administration. The patient s vital signs must be routinely reassessed. The routine reassessments must be documented on the run report. Have Narcan on hand if the patient has respiratory depression or hypotension after narcotic administration (Dose-Narcan 0.4mg-2.0mg IV/IO/IM/IN). When in doubt, contact medical control UH Protocols Chapter 7 Trauma Protocols 23

234 TRAUMA TRAUMA ARREST UNIVERSAL PATIENT CARE PROTOCOL Airway Protocol C-Spine Precautions B EMT B A Advanced A M MED CONTROL M If necessary and trained Consider Needle Cricothyrotomy IV/IO PROTOCOL Appropriate Protocol based on Signs and Symptoms Apply Cardiac Monitor/AED CONTACT MEDICAL CONTROL TRANSPORT UH Protocols Chapter 7 Trauma Protocols 24

235 TRAUMA TRAUMA ARREST HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Time of injury Mechanism: blunt / penetrating Loss of consciousness Bleeding Medications Evidence of multi-trauma Excessive bleeding Unresponsive; not breathing Cardiac arrest Significant mechanism of injury Obvious DOA Death KEY POINTS Immediately transport traumatic cardiac arrest patients. With the exception of endotracheal intubation, traumatic cardiac arrests are load and go situations. Resuscitation should not be attempted in cardiac arrest patients with hemicorporectomy, decapitation, or total body burns, nor in patients with obvious, severe blunt trauma that are without vital signs, pupillary response, or an organized or shockable cardiac rhythm at the scene. Patients in cardiac arrest with deep penetrating cranial injuries and patients with penetrating cranial or truncal wounds associated with asystole and a transport time of more than 15 minutes to a definitive care facility are unlikely to benefit from resuscitative efforts. Extensive, time-consuming care of trauma victims in the field is usually not warranted. Unless the patient is trapped, they should be enroute to a Medical Facility within 10 minutes after arrival of the ambulance on the scene UH Protocols Chapter 7 Trauma Protocols 25

236 EYES TRAUMA ASSESSMENT CHARTS GLASCOW COMA SCALE GCS SPONTANEOUSLY 4 TO VERBAL COMMAND 3 TO PAIN 2 NO RESPONSE 1 BEST OBEYS VERBAL COMMAND 6 MOTOR LOCALIZES PAIN 5 RESPONSE WITHDRAWAL FROM PAIN 4 FLEXION DECORTICATE 3 EXTENSION - DECEREBRATE 2 NO RESPONSE 1 BEST ORIENTED & CONVERSES 5 VERBAL DISORIENTED & CONVERSES 4 RESPONSE INAPPROPRIATE WORDS 3 INCOMPREHENSIBLE SOUNDS 2 NO RESPONSE 1 UH Protocols Chapter 7 Trauma Protocols 26

237 GLASGOW TRAUMA ASSESSMENT CHARTS REVISED TRAUMA SCORE RTS COMA SCALE RESPIRATORY RATE MORE THAN SYSTOLIC MORE THAN 89 4 BLOOD PRESSURE UH Protocols Chapter 7 Trauma Protocols 27

238 UH Protocols Chapter 7 Trauma Protocols 28

239 TRAUMA ASSESSMENT CHARTS RULE OF NINES RULE OF NINES 1% is equal to the surface of the palm of the patient's hand. If unsure of %, describe injured area. MAJOR BURN CRITERIA 2 and 3 burns more than 10% body surface area. Burns of the face, hands, feet, genitalia, or major joints. Electrical shock with burn injury. Burn with inhalation injury and/or any burn with potential functional or cosmetic impairment. Chemical Burns. Burns > 25% total body surface area. Burns in extremes of ages or chronic diseases. Burns with associated trauma. UH Protocols Chapter 7 Trauma Protocols 29

240 MEDICATIONS TETRACAINE (Pontocaine, Ophthalmic) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Local anesthesia for eyes Irritation and/or pain of the eyes (With no penetrating trauma) Hypersensitivity or Allergy to tetracaine and other local anesthetics Penetrating or open eye injury Burning sensation in eyes Redness, tearing ADULT DOSAGE 1-2 drops in effected eye every 5-10 minutes prn for pain control PEDIATRIC DOSAGE CALL MEDICAL COMMAND KEY POINTS Keep dropper sterile Single patient use only

241 MEDICATIONS ONDANSETRON (Zofran) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Antiemetic Nausea & vomiting Hypersensitivity Drowsiness, vertigo Blurred vision, headache Hypotension 4 mg slow IV/IO/IM - 8 mg Oral Dissolving Tabs Contact Medical Control

242 MEDICATIONS NITROUS OXIDE A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS Provides rapid, easily reversible relief of pain Abdominal pain Chest pain secondary to infarction or angina Acute urinary retention Fractures Severe exterior burns Kidney stones Musculoskeletal trauma Patients under 12 years of age Severe COPD Head injury ABD pain or trauma Intoxication or drug ingestion Shortness of breath Chest trauma with a possible pneumothorax (during prolonged transport) SIDE EFFECTS SUPPLIED ADULT DOSAGE Discontinue if any of the following arise Apnea, cyanosis Nausea/vomiting Deteriorating vital signs (administer O2 100%) Ambulance crew may experience giddiness if the vehicle is not properly vented Nitronox, a set containing an oxygen cylinder and a nitrous oxide cylinder joined by a valve that regulates flow to provide a 50:50 mixture of the two gases - the mixture is piped to a demand valve apparatus Invert cylinder several times before use; instruct the patient to inhale deeply though a patient-held demand valve mouthpiece PEDIATRIC DOSAGE KEY POINTS Self-administered by mask: a good seal around the mouth and nose is important; the gas is breathed deeply and may give relief after about two minutes; the patient should stop when relief is obtained The paramedic should not hold the face mask in place for the patient

243 MEDICATIONS MORPHINE SULFATE A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Narcotic Analgesic Causes peripheral vasodilation Pulmonary edema MI pain unrelieved with nitro Pain management Pain secondary to burns Known hypersensitivity / Allergy Head injury or head trauma Hypotension Altered LOC Undiagnosed abdominal pain(consult Med Command) COPD Bradycardia Multiple trauma patients If the patient responds with respiratory depression or hypotension, administer Narcan to reverse the effects Routinely monitor the patient s respiratory effort and SpO2 Respiratory depression Altered LOC, constricted pupils Bradycardia Nausea/Vomiting Hypotension 2-4 mg slow IV/IO/IM/IN (If no relief, may repeat at 2 to 4 mg) For further doses over 10mg of Morphine, contact medical direction. Follow with Zofran Pain Management: mg/kg slow IV/IO/IM/IN KEY POINTS

244 MEDICATIONS KETOROLAC (Toradol) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE NSAID analgesic Reduces pain Moderate pain Pain associated with kidney and gall stones >65 Years Old Hypersensitivity including aspirin or other NSAIDS Advanced renal impairment Suspected cerebrovascular bleeding Recent GI bleeding Nursing mothers Labor and delivery Asthma Edema Hypertension Rash Nausea Dizziness 30 mg IV, 60 mg IM (If <65 Year Old Only) 0.15 mg/kg IV or 0.3 mg/kg IM

245 MEDICATIONS Fentanyl (Sublimaze) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Pediatric Dose Analgesic anesthetic narcotic Pain Management Acute Coronary Syndrome STEMI Hypersensitivity Hemorrhage Shock Decreases in Respiratory Apnea Bradycardia Muscle Rigidity 25-50mcg IV, IM, or IN (May repeat in minutes) Children 2-12 years of age 1mcg/kg IV, IO, IM, or IN

246 OBSTETRICS PROTOCOLS CHILDBIRTH / OBSTETRICAL EMERGENCIES Abnormal Birth Emergencies Obstetrical Emergencies Uncomplicated / Imminent Delivery UH Protocols Chapter 8 Childbirth/Obstetrical Emergencies

247 CHILDBIRTH / OBSTETRICAL EMERGENCIES ABNORMAL BIRTH EMERGENCIES UNIVERSAL PATIENT CARE PROTOCOL IV/IO PROTOCOL B EMT B A Advanced A M MED CONTROL M CORD AROUND NECK PROLAPSED CORD BREECH BIRTH SHOULDER DYSTOCIA Loosen cord or clamp and cut if too tight Continue Delivery Transport mother with hips elevated and knees to chest Insert fingers to relieve pressure on cord Transport unless delivery is imminent Do not encourage mother to push Support but do not pull presenting parts Transport mother with hips elevated and knees to chest Insert fingers to relieve pressure on cord Place pressure on symphisis pubis If delivery is in process and the head is caught inside vagina, create air passage by supporting body of infant and placing 2 fingers along sides of nose, and push away from face to facilitate an airway passage If unable to deliver, transport mother with hips elevated and knees to chest CONTACT MEDICAL CONTROL TRANSPORT Consider transport to a facility with specialized OB resources UH Protocols Chapter 8 Childbirth/Obstetrical Emergencies

248 CHILDBIRTH / OBSTETRICAL EMERGENCIES ABNORMAL BIRTH EMERGENCIES CONTACT MEDICAL CONTROL IMMEDIATELY WHEN ANY ABNORMAL BIRTH PRESENTATION IS DISCOVERED HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Hypertension meds Prenatal care Prior pregnancies / births Gravida / Para Ultrasound findings in prenatal care Frank Breech (buttocks presents first) Footling Breech (one foot or both feet presenting) Transverse Lie (fetus is on his/her side with possible arm or leg presenting) Face First Presentation Prolapsed Cord (umbilical cord presents first) Miscarriage Stillbirth KEY POINTS General Information DO NOT pull on any presenting body parts. These patients will most likely require a c-section, so immediate transport is needed. Prolonged, non-progressive labor distresses the fetus and mother. Be sure to reassess mother s vital signs continuously. Cord Around Baby's Neck As baby's head passes out of the vaginal opening, feel for the cord. Initially try to slip cord over baby s head; if too tight, clamp cord in two places and cut between the clamps. Breech Delivery Footling Breech (one or both feet delivered first) Frank Breech (buttocks first presentation) When the feet or buttocks first become visible, there is normally time to transport patient to nearest facility. If upper thighs or the buttock have come out of the vagina, delivery is imminent. If the child's body has delivered and the head appears caught in the vagina, the EMT must support the child's body and insert two fingers into the vagina along the child's neck until the chin is located. At this point, the two fingers should be placed between the chin and the vaginal canal and then advanced past the mouth and nose. After achieving this position a passage for air must be created by pushing the vaginal canal away from the child's face. This air passage must be maintained until the child is completely delivered. Prolapsed Cord When the umbilical cord passes through the vagina and is exposed, the EMT should check cord for a pulse. The patient should be transported with hips elevated or in the knee chest position and a moist dressing placed around the cord. If umbilical cord is seen or felt in the vagina, insert two fingers to elevate presenting part away from cord, distribute pressure evenly when the occiput presents. DO NOT attempt to push the cord back. High flow oxygen and transport IMMEDIATELY. Shoulder Dystocia Following delivery of the head, the shoulder(s) become stuck behind the symphysis pubis or sacrum of the mother. Occurs in approximately 1% of births. Excessive Bleeding Pre-Delivery If bleeding is excessive during this time and delivery is imminent, in addition to normal delivery procedures, the EMT should use the Hypovolemic Shock Protocol. If delivery is not imminent, patient should be transported on her left side and Shock Protocol followed. Excessive Bleeding Post-Delivery If bleeding appears to be excessive, start IV of saline. If placenta has been delivered, massage uterus and put baby to mother's breast. Follow Hypovolemic Shock Protocol. UH Protocols Chapter 8 Childbirth/Obstetrical Emergencies

249 CHILDBIRTH / OBSTETRICAL EMERGENCIES OBSTETRICAL EMERGENCIES UNIVERSAL PATIENT CARE PROTOCOL B EMT B A Advanced A M MED CONTROL M IV/IO PROTOCOL Vaginal Bleeding / Abdominal Pain? No Hypertension? Yes Known Pregnancy / Missed Period? Yes No Yes No Eclampsia Seizures No 1 st Trimester Miscarriage, Ectopic Pregnancy 2 nd & 3 rd Trimester Placeta Previa Abruptio Placenta Yes See Abdominal Pain Protocol Transport Magnesium sulfate 2 6 grams slow IV/IO push over 2-3 minutes Until seizure stops of loss or deep tendon reflexes NORMAL SALINE BOLUS 20 ml/kg IF MAGNESIUM FAILS TO WORK at 6 grams Ativan 1-2 mg IV/IM/IO/IN or Versed 2mg IV/IO or 5mg IM/IN If Ativan is unavailable Rapid Transport Consider transport to a facility with specialized OB resources Pad bleeding, save and bring with patient Childbirth Imminent Delivery Protocol Rapid Transport Consider transport to a facility with specialized OB resources CONTACT MEDICAL CONTROL UH Protocols Chapter 8 Childbirth/Obstetrical Emergencies

250 CHILDBIRTH / OBSTETRICAL EMERGENCIES OBSTETRICAL EMERGENCIES HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Past medical history Hypertension meds Prenatal care Prior pregnancies / births Gravida / Para Vaginal bleeding Abdominal pain Seizures Hypertension Severe headache Visual changes Edema of hands and face Pre-eclampsia / Eclampsia Placenta previa Placenta abruptio Spontaneous abortion KEY POINTS General Information Exam: Mental Status, Abdomen, Heart, Lungs, Neuro. May place patient in a left lateral position to minimize risk of supine hypotensive syndrome if in late 2 nd or 3 rd trimester. Ask patient to quantify bleeding - number of pads used per hour. Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation and fetal monitoring. DO NOT apply packing to the vagina. Be alert for fluid overload when administering fluids. Consider starting a second IV if the patient is experiencing excessive vaginal bleeding or hypotension. Transport to an appropriate OB facility if the patient is pregnant. Abortion/Miscarriage The patient may be complaining of cramping, nausea, and vomiting. Be sure to gather any expelled tissue and transport it to the receiving facility. Signs of infection may not be present if the abortion/miscarriage was recent. An abortion is any pregnancy that fails to survive over 20 weeks. When it occurs naturally, it is commonly called a miscarriage. Abruptio Placenta Usually occurs after 20 weeks. Dark red vaginal bleeding. May only experience internal bleeding. May complain of a tearing abdominal pain Ectopic Pregnancy The patient may have missed a menstrual period or had a positive pregnancy test. Acute unilateral lower abdominal pain that may radiate to the shoulder. Any female of childbearing age complaining of abdominal pain is considered to have an ectopic pregnancy until proven otherwise. Pelvic Inflammatory Disease Be tactful when questioning the patient to prevent embarrassment. Diffuse back pain. Possibly lower abdominal pain. Pain during intercourse. Nausea, vomiting, or fever. Vaginal discharge. May walk with an altered gait due to abdominal pain. Placenta Previa Usually occurs during the last trimester. Painless. Bright red vaginal bleeding. Post Partum Hemorrhage Post partum blood loss greater than ml. Bright red vaginal bleeding. Be alert for shock and hypotension. Uterine Inversion The uterine tissue presents from the vaginal canal. Be alert for vaginal bleeding and shock. Pre-Eclampsia/Eclampsia Severe headache, vision changes, or RUQ pain may indicate pre - eclampsia. In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic and greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient's normal (pre-pregnancy) blood pressure. Uterine Rupture Often caused by prolonged, obstructed, or non-progressive labor. Severe abdominal pain. Vaginal Bleeding If the patient is experiencing vaginal bleeding, DO NOT pack the vagina, pad on outside only. UH Protocols Chapter 8 Childbirth/Obstetrical Emergencies

251 CHILDBIRTH / OBSTETRICAL EMERGENCIES UNCOMPLICATED DELIVERY UNIVERSAL PATIENT CARE PROTOCOL Observe Head Crowning B EMT B A Advanced A M MED CONTROL M Contact Medical Control to Notify of Delivery Prepare Patient for Delivery Set-Up Equipment IV/IO Protocol if Time Run Normal Saline at 150 ml/hour Delivery of Head Firm, gentle pressure with flat of hand to slow expulsion. Allow head to rotate normally, check for cord around neck, and wipe face free of debris. Suction mouth and nose with bulb syringe. Delivery of Body Place one palm over each ear with next contraction gently move downward until upper shoulder appears. Then lift up gently to ease out lower shoulder Support the head and neck with one hand and buttocks with other. REMEMBER THE NEWBORN IS SLIPPERY Newborn and Cord Keep newborn at level of vaginal opening. Keep warm and dry. After 10 seconds, clamp cord in two places with sterile equipment at least 6-8 from newborn. Cut between clamps. Allow placenta to deliver itself but do not delay transport waiting. DO NOT PULL ON CORD TO DELIVER PLACENTA. Take placenta to hospital with patient. CONTACT MEDICAL CONTROL TRANSPORT Consider transport to a facility with specialized OB resources UH Protocols Chapter 8 Childbirth/Obstetrical Emergencies

252 CHILDBIRTH / OBSTETRICAL EMERGENCIES UNCOMPLICATED DELIVERY CONTACT MEDICAL CONTROL IMMEDIATELY WHEN DELIVERY IS IMMINENT HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Due date Time contractions started / how often Rupture of membranes Time / amount of any vaginal bleeding Sensation of fetal activity Past medical and delivery history Medications Spasmotic pain Vaginal discharge or bleeding Crowning or urge to push Meconium Left lateral position Inspect perineum (No digital vaginal exam) Abnormal presentation Buttock Foot Hand Prolapsed cord Placenta previa Abruptio placenta KEY POINTS Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro. Document all times (delivery, contraction frequency, and length). If maternal seizures occur, refer to the Obstetrical Emergencies Protocol. After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to control post-partum bleeding. Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal. Prepare to deliver on scene (protecting the patient s privacy). If delivery becomes imminent while enroute, stop the squad and prepare for delivery. Newborns are very slippery, so be careful not to drop the baby. There is no need to wait on scene to deliver the placenta. If possible, transport between deliveries if the mother is expecting twins. Allow the placenta to deliver, but DO NOT delay transport while waiting. DO NOT PULL ON THE UMBILICAL CORD WHILE PLACENTA IS DELIVERING. UH Protocols Chapter 8 Childbirth/Obstetrical Emergencies

253 MEDICATIONS MAGNESIUM SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Anticonvulsant Antiarrhythmic CNS depressant Seizures secondary to eclampsia Ventricular ectopy refractory to Amiodarone Torsades Adjunct to alleviate acute asthma attack Renal disease Heart blocks Respiratory depression CNS depression Hypotension Cardiac arrest ADULT DOSAGE Torsades grams SLOW IVP over 5 minutes (Max dose 4 grams) Eclampsia grams over 2-3 minutes PEDIATRIC DOSAGE KEY POINTS Asthma dose 45mg/kg IV to a total of 75mg/kg (approx 2 grams in adult Not recommended for pediatric use 27

254 Medications Pharmacology Review MEDICATIONS Adenosine (Adenocard) Albuterol (Proventil/ Ventolin) Amiodarone (Cordarone) Aspirin Ativan (Lorazepam)..,9-9 Atropine Sulfate BiCarbonate (Sodium BiCarbonate).9-11 Brilinta (tricagrelor) Calcium Chloride Dextrose 50% (D50) Diphenhydramine (Benadryl) Dopamine.9-16 DuoNeb 9-17 Epinephrine (Adrenalin) Fentanyl (Sublimaze) Furosemide (Lasix) Glucagon Haldol (Haloperidol) 9-22 Heparin.9-23 Ketorlac (Toradol) Lidocaine (Xylocaine) Lopressor (Metoprolol) 9-26 Magnesium Sulfate.9-27 Mark 1 Kit (Atropine and 2-PAM Chloride) Methylprednisolone (Solumedrol) 9-29 Morphine Sulfate Naloxone (Narcan) Nitroglycerin Nitrous Oxide Ondansetron Hydrochloride (Zofran) Oral Glucose Oxygen Plavix (Clopidogril) Praxidoxime Chloride / 2 PAM Chloride TNKase (Tenecteplase) Tetracaine (Pontocaine) Ophthalmic Thiamine (Vitamin B12) Tylenol (acetaminophen) oral liquid.9-42 Vasopressin (Pitressin) Versed (Midazolam) 9-44 SPECIAL USE DRUGS Doxycycline (Vobramycin).9-45 Ciprofloxacin (Cipro) Hydroxycoblamine (Cyanokit)

255 MEDICATIONS PHARMACOLOGY REVIEW I. ACTIONS OF DRUGS a. Local Effects b. Systemic Effects II. EFFECTS DEPEND UPON a. Age of Patient b. Condition of Patient c. Dosage d. Route of Administration III. ROUTE OF ADMINISTRATION a. Intravenous (IV) Most Rapidly Effective Most Dangerous Give Slowly Through an Established IV Line b. Intraosseous (IO) IO To Be Given Only If IV is Unobtainable in an Unconscious Patient. c. Intramuscular (IM) Takes Longer to Act Longer Duration of Action Deltoid or Gluteus Maximus Site Absorption Very Dependent on Blood Flow d. Subcutaneous (SQ) Slower and More Prolonged Absorption Under Skin of Upper Arms, Thigh, Abdomen e. Intranasal Only 1cc per Nare f. Inhalation Bronchodilators Steroids g. Endotracheal (Only administer through ET as a last resort) Epinephrine, Atropine, Lidocaine, Narcan Dilute Usual IV Dose with 10cc of Sterile Water Medication Dose Must Be Doubled. h. Sublingual (SL) Rapid Absorption i. Oral (PO) Instant Glucose Baby Aspirin j. Rectal (PR) Rapid but Unpredictable Absorption IV. RATES OF ABSORPTION a. Directly Related to Route of Administration IV (Fastest) IO IN IM SL SQ PO (Slowest) V. ELIMINATION a. Many Methods b. Usually Metabolized by the Liver c. Eliminated by the Kidneys, Lungs, Skin 3

256 VI. TERMS a. Indications Conditions Drugs Used For b. Contraindications Conditions Drugs Not To Be Used For c. Depressants - Lessens / Decreases Activity d. Stimulant - Increases Activity e. Physiologic Action - Action From Normal Body Amounts of Drug f. Therapeutic Action - Beneficial Action Expected g. Untoward Reaction - Harmful Side Effect h. Irritation - Damage to Tissue i. Antagonism - Opposition Between Effects of Drugs j. Cumulative Action - Increased Action After Several Doses k. Tolerance - Decreased Effects After Repeated Doses l. Synergism - Combined Effects Greater Than Sum of Parts m. Potentiation - Enhancement of One Drug by Another n. Habituation - Drug Necessary for Feeling of "Well Being" o. Idiosyncrasy - Unexpected, Abnormal Response to a Drug p. Hypersensitivity - Exaggerated Response, Allergy VII. AUTONOMIC NERVOUS SYSTEM a. Parasympathetic - Controls Vegetative Functions b. Sympathetic - " Fight or Flight " VIII. PARASYMPATHETIC NERVOUS SYSTEM a. Mediated by Vagus Nerve b. Acetylcholine is Transmitter (Cholinergic) c. Atropine is Acetylcholine Blocker IX. SYMPATHETIC NERVOUS SYSTEM a. Mediated by Nerves from Sympathetic Chain b. Norepinephrine is Transmitter (Adrenergic) c. Epinephrine is Released from Adrenals X. SYMPATHETIC RECEPTORS a. Alpha b. Beta XI. COMMON SYMPATHETIC AGENTS a. Epinephrine (Adrenalin) - predominately BETA b. Dobutamine (Dobutrex) - predominately BETA, slight ALPHA c. Norepinephrine (Levophed) - predominately ALPHA d. Dopamine (Intropin) - BETA at low dose: ALPHA at high dose e. Phenylephrine (Neo-Synephrine) - pure ALPHA XII. SYMPATHETIC BLOCKERS a. Propranolol (Inderal) - BETA (Blocker) XIII. DRUG ADMINISTRATION a. Appropriate Medication selection based on protocol Visually examine medication for particulates or discoloration and expiration date Contraindications are reviewed prior to administration Route is determined by protocol Dose selection based on protocol Dilution is per protocol Rate is per protocol 4

257 MEDICATIONS ADENOSINE (Adenocard) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Slows conduction time and can interrupt re-entrant pathways through the AV node Slows the sinus rate Supra Ventricular Tachycardia (SVT) Consider in Regular Wide Complex Tachycardia Paroxysmal Supra Ventricular Tachycardia (PSVT) Wolf Parkinson White (WPW) Second or third degree AV block, sick sinus syndrome Ventricular tachycardia Hypersensitivity to Adenosine It is helpful to inform the patient of likely side effects prior to medication administration Facial flushing Shortness of breath Chest pain Palpitations Brief period of sinus arrest /Transient Dysrhythmias Headache Lightheadedness Hypotension Nausea Initial Dose 6 mg rapid IVP (over 1-3 sec) immediately followed with a 20 ml saline flush Repeat Dose If no response is observed after 1 min., administer 12 mg rapid IVP (over 1-3 sec) immediately followed with a 20 ml saline flush. Max dose 30 mg Initial Dose 0.1 mg/kg rapid IVP followed with a 10 ml saline flush Repeat Dose If no response is observed after 1-2 min., administer 0.2 mg/kg rapid IVP followed with a 10 ml saline flush. Max dose 0.5 mg/kg up to 6mg Adenosine has a short half life, and should be administered rapidly followed by a rapid IV/IO flush Reassess after each medication administration, refer to the appropriate protocol and treat accordingly. Perform a 12 Lead EKG prior to the administration of Adenosine and after the rhythm converts Record rhythm during and post administration 5

258 MEDICATIONS ALBUTEROL (Proventil / Ventolin) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Acts directly on beta 2 adrenergic receptors to relax bronchial smooth muscle, resulting in reduced airway resistance and relief of bronchospasm Shortness of breath caused by bronchoconstriction Peaked T-Waves with symptoms in Renal Patients Known hypersensitivity Use precaution when administering to pregnant women or patients with cardiac history Nervousness Weakness Tremor Tachycardia 2.5 mg in 3 ml via unit dose nebulizer and 6 lpm oxygen 2.5 mg in 3 ml via unit dose nebulizer and 6 lpm oxygen May repeat treatment if partial relief is obtained 6

259 MEDICATIONS AMIODARONE (Cordarone) ACTIONS INDICATIONS CONTRAINDICATIONS Prolongs the refractory period and action potential duration Ventricular Fibrillation (refractory to shock treatment) Pulseless Ventricular Tachycardia (refractory to shock treatment) Polymorphic VT and wide complex tachycardia Hypersensitivity (including iodine) Cardiogenic shock Second and Third degree AV block Severe sinus bradycardia Severe sinus node dysfunction SIDE EFFECTS ADULT DOSAGE Tremors, Paresthesia, Ataxia Headache, Fatigue Abdominal pain, Nausea/Vomiting, Hepatic failure Arrhythmia, Bradycardia, Sinus arrest, Heart block (Prolonged QT), Heart failure Acute Respiratory Distress Syndrome, Severe pulmonary edema Blue-Gray skin Ventricular Fibrillation and Pulseless Ventricular Tachycardia 300 mg IV/IO bolus Repeat Dose: 150 mg IV/IO in 3-5 minutes, Max 2.2 g IV/24hrs PEDIATRIC DOSAGE KEY POINTS Wide Complex Tachycardia 150 mg IV/IO over 10 minutes (15 mg/min) Repeat Dose: 150 mg IV/IO every 10 minutes prn, Max 2.2 g IV/24hrs Ventricular Fibrillation and Pulseless Ventricular Tachycardia 5 mg/kg IV/IO bolus Ventricular Arrhythmias Loading dose 5 mg/kg IV/IO over mins Avoid excessive movement and shaking of the medication 7

260 MEDICATIONS ASPIRIN B EMT B A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE PEDIATRIC DOSE Blocks platelet aggregation Chest pain suggestive of a MI 12-Lead EKG indicating a possible MI Hypersensitivity Active ulcer disease Impaired renal function Upset stomach GI bleeding Mucosal lesions Bronchial spasm in some asthma patients 325 mg tablet or 81 mg chewable tablet 325 mg tablet or 324 mg (81 mg x 4 tablets) PO Not Recommended for Pediatric Use 8

261 MEDICATIONS ATIVAN (LORAZEPAM) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSE Sedative Anticonvulsant Amnestic (induces amnesia) Status epilepticus Sedation prior to transcutaneous pacing and synchronized cardioversion in the conscious patient Known hypersensitivity Altered mental status of unknown origin Head injury Respiratory insufficiency May cause respiratory depression, respiratory effort must be continuously monitored with Capnography Should be used with caution with hypotensive patients and patients with altered mental status Lorazepam (Ativan) potentiates alcohol or other CNS depression Respiratory depression Hypotension Lightheadedness Confusion Slurred speech Amnesia 1 2 mg IV / IO / IM / IN Not Recommended for Pediatric Use 9

262 MEDICATIONS ATROPINE SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE PEDIATRIC DOSAGE Increases sinus node firing Increases conduction through the AV node by blocking vagal activity Increases cardiac output Decreases ectopic beats or fibrillation of the ventricles Symptomatic sinus bradycardia Organophosphate poisoning/nerve agent exposure Known hypersensitivity Atrial flutter/fibrillation where there is a rapid ventricular response Glaucoma narrow angle 2 nd and 3 rd degree AV Block with wide QRS complex Use with extreme caution in myocardial infarction May increase myocardial oxygen demand May trigger tachy-dysrhythmias Patient needs to be warned about side effects Doses smaller than 0.5 mg or administered too slowly may slow rather than speed up the heart rate Excessive doses in adults may precipitate ventricular tachycardia or fibrillation Dry mouth, thirst, urinary retention Blurred vision, pupillary dilation, headache Flushed skin Tachycardia Prefilled syringes containing 1 mg in 10 ml Auto-Injector containing 2 mg (nerve agent exposure only) Bradycardia 0.5 mg IV/IO (1.0 mg ETT) every 5 minutes Max dose 0.04 mg/kg or 3 mg Organophosphate Poisoning 2 5mg IVP, IM, or IO every 5 min Bradycardia 0.02 mg/kg IV/IO, repeated X 1, 5 minutes (minimum dose 0.1 mg), Max single dose 0.5 mg CHILD / 1.0 mg ADOLESCENT, Max total dose 1.0 mg CHILD / 2.0 mg ADOLESCENT Organophosphate Poisoning 0.2 mg/kg IV/IO, repeat every 3-5 minutes / Max dose 0.5mg Child Max dose 1.0mg Adolescent. 10

263 MEDICATIONS BiCarbonate (Sodium BiCarbonate) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDS DOSAGE Buffers metabolic acidosis Enhances the urinary excretion of tricyclics Metabolic Acidosis from cardiac arrest Tricyclic Overdose Hyperkalemia Post Crushing Entrapment Heart Failure Seizures Tissue necrosis if infiltration Can precipitate with Calcium 50mEq IVP for tricyclic overdose 50mEq or 1mEq/kg IVP for cardiac arrest asystole or PEA 50 meq IVP for cardiac arrest with prolonged down time(10 minutes) 50mEq to 100mEq Post Crushing Entrapment 1mEq/kg IV/IO Diluted in 1:1 NS or as advised By Med Command 11

264 MEDICATIONS BRILINTA (ticagrelor) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE A P2Y12 platelet inhibitor indicated to reduce the rate of thrombotic cardiovascular events in patients with acute coronary syndrome, Acute Coronary Syndrome / STEMI 12-Lead EKG indicating a ST elevation MI History of intracranial hemorrhage Active pathological bleeding Severe hepatic impairment Increased risk of bleeding Dyspnea Bleeding Dyspnea 180mg PO (2 90mg Tablets) NOT RECOMMENDED FOR PEDIATRIC USE 12

265 MEDICATIONS CALCIUM CHLORIDE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Reverses overdose with magnesium sulfate or calcium channel blockers (such as verapamil) Antidote magnesium sulfate and calcium channel blocker toxicity Hyperkalemia Beta Blocker overdose Known dialysis patient in cardiac arrest Hypersensitivity to calcium chloride Do not infuse with sodium bicarbonate will combine to form an insoluble precipitate Can cause ventricular fibrillation when pushed too fast or given to a patient who has been taking digitalis 1 gram (10cc) slow IVP NOT RECOMMENDED FOR PEDIATRIC USE Previously, calcium was used in resuscitation because it was believed to stimulate the heart to beat in asystole and to strengthen cardiac contractions in electromechanical dissociation careful recent studies have failed to show any benefit from using calcium in cardiac arrest, and indeed the effects of calcium may be harmful in that situation 13

266 MEDICATIONS DEXTROSE 50 % (D50) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Restores circulating blood sugar Hypoglycemia Altered mental status of unknown origin Coma of unknown origin Seizures of unknown origin Known hyperglycemia. Head trauma unless confirmed hypoglycemia Caution with chronic renal failure Intracranial hemorrhage Use with caution for stroke patients Use a large vein to administer D50 Treat known alcoholics, renal failure patients, or malnourished patients with Thiamine prior to administering glucose Extravasation of D50 may cause necrosis Hyperglycemia May precipitate severe neurologic symptoms in alcoholics Dextrose 50% (D50) 25 g IV/IO 2 ml/kg D25 IV/IO 14

267 MEDICATIONS DIPHENHYDRAMINE HCL (Benadryl) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Antihistamine Sedative Inhibits motion sickness (antiemetic) Anaphylactic shock and severe allergic reaction Acute dystonia Nausea/vomiting (contact Medical Control) Extrapyramidal reaction (Parkinson-like movement disorders) Known hypersensitivity / Allergy Pregnancy or lactating Avoid the use of Diphenhydramine in nursing mothers May induce vomiting Carefully monitor patient while awaiting for medication to take effect (effect of medication begins 15 minutes after administration) Drowsiness, confusion Blurring of vision Dry mouth Wheezing; thickening of bronchial secretions Hypotension ADULT DOSAGE PEDIATRIC DOSAGE Allergic Reaction or Anaphylaxis mg IV/IO/IM Behavioral Psychiatric Emergencies 50 mg IM Allergic Reaction or Anaphylaxis 1 mg/kg (without hypotension) IV/IO/IM Max 50mg 15

268 MEDICATIONS DOPAMINE (Intropine) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE Alpha and beta adrenergic receptor stimulator Dopaminergic receptor stimulator Dilates renal and mesenteric blood vessels Vasoconstriction Arterial resistance Increases cardiac output Increases preload Cardiogenic shock Distributive Shock Cyanide poisoning (contact Medical Control) Known hypersensitivity /Allergy Hypovolemic hypotension VF or VT Do not mix with bicarbonate, dopamine may be inactivated by alkaline solutions Extravasation may cause tissue necrosis Ectopic beats, palpitations Tachycardia, angina Nausea/vomiting VF or VT Dyspnea Headache 2-20mcg/kg/min IV drip. Start 5 micrograms/kg/minute IV/IO infusion, titrate to effect Simple calculation for approx 5 mcg/kg/min (must be 1600 mcg/ml concentration) *Take the Patients weight in lbs and remove the last digit (175lbs = 17) * Subtract 2 from that figure (17-2=15) *This gives you the number of drops per min using a 60gtts set. (titrate to desired effect) Example: 175lbs patient. 175 remove the 5 is =15 drops per min (approx 5 mcg/kg/min) 16

269 MEDICATIONS DuoNeb A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS (Albuterol) Parasympatholytic bronchodilator Dries respiratory tract secritations (Ipratropium Atrovent) B2 selective bronchodilator Increases HR Asthma exacerbation COPD exacerbation Patients that have used their prescribed inhaler more than once Pulmonary edema with wheezing Known hypersensitivity /Allergy Allergy to peanuts Acute myocardial infarction Arrhythmias Cardiovascular disease Hypertension history CHF Palpitations Anxiety Nausea Dissiness ADULT/PEDS DOSAGE Unit dose inhaled via nebulizer. May repeat as needed 17

270 ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE MEDICATIONS EPINEPHRINE (Adrenaline) Alpha and Beta adrenergic agonist Bronchodilation Increases heart rate and automaticity Increases cardiac contractility Increases myocardial electrical activity Increases systemic vascular resistance Increases blood pressure Cardiac arrest Allergic reaction/anaphylaxis Respiratory distress Acute Asthma Pediatric Bradycardia A Advanced A Hypersensitivity, Tachycardia, Hypertension, Hypothyroidism Angina / Chest pain, Coronary artery disease Pregnancy Blood pressure, pulse, and EKG must be routinely monitored Palpitations, ectopic beats, tachycardia Anxiety / Tremors Hypertension VF / VT Angina Asthma and Anaphylaxis Mild / Moderate Reaction (1-1,000) mg IM ONLY Consider 1:1000 2mg mixed with 1ml NS in nebulizer for Asthma Severe Anaphylaxis (1:10,000) 0.5 mg slow IV/IO over 5 minutes - EMT-P Only Cardiac Arrest 1:10,000 1 mg IV/IO every 3-5 minutes EMT-P Only PEDIATRIC DOSAGE Asthma and Anaphylaxis Mild Reaction Ages yrs (1:1,000) 0.03 mg/kg IM Under 10 yrs (1:1,000) 0.01mg/kg IM May use 1:1000 2mg mixed with 1ml NS in nebulizer aerosolized Severe Anaphylaxis Pending Arrest Ages yrs (1:10,000) 0.01mg/kg IV/IO over 5 minutes EMT-P Only Cardiac Arrest 1:10, mg/kg IV/IO push 0.1ml/kg EMT-P Only or 0.1 mg/kg 1:1000 ETT 0.1ml/kg EMT-P Only 18

271 MEDICATIONS Fentanyl (Sublimaze) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Pediatric Dose Analgesic anesthetic narcotic Pain Management Acute Coronary Syndrome STEMI Hypersensitivity Hemorrhage Shock Decreases in Respiratory Apnea Bradycardia Muscle Rigidity 25-50mcg IV, IM, or IN (May repeat in minutes) Children 2-12 years of age 1mcg/kg IV, IO, IM, or IN 19

272 MEDICATIONS FUROSEMIDE (Lasix) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Potent diuretic Decreases preload Vasodilator Acute pulmonary edema Congestive heart failure Acute pulmonary edema secondary to hypertension Hypokalemia Dehydration Pneumonia Allergy to Lasix Hypokalemia Dehydration Depletion of potassium Hypotension 1.0mg/kg SLOW IV/IO or double the daily oral dose. 100mg maximum dose 1 mg/kg slow IVP CONTACT MEDICAL COMMAND 20

273 MEDICATIONS GLUCAGON A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose level Relaxes smooth muscle of GI tract Hypoglycemia when IV/IO is not able to be established and oral glucose is contraindicated Esophageal obstruction Beta Blocker overdose Known hypersensitivity Pheochromocytoma Glucagon is only effective in patients with sufficient stores of glycogen Use caution in patients with renal or cardiovascular disease Glucagon can be administered on scene, but do not wait for it to take effect Nausea/Vomiting 1mg IM/IN for Hypoglycemia 1mg IV in esophageal foreign body obstruction 2 mg IV/IO/IM/IN for hypotension / bradycardia in Betablocker overdose and Calcium Channel overdose <20kg give 0.5mg IM / IN >20kg give 1mg IM / IN Response is usually noticed in 5-20 minutes Glucagon is NOT a substitute for D25, or D12.5. IV must be attempted prior to administering Glucagon 21

274 MEDICATIONS HALDOL (Haloperidol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE KEY POINTS Antipsychotic Major tranquilizer Combative patient Acute psychotic episodes Known hypersensitivity Head injury or head trauma Seizure or history of seizure Children less than 16 years old Altered LOC/ Coma Nausea/Vomiting Hypotension Tremors Known Hypersensitivity 5 mg IM Call Medical Direction for orders of repeat single dose after 5 minutes The patient MUST be routinely Monitored for respiratory depression and or hypotension. The run documentation MUST clearly support the use of this medication. 22

275 MEDICATIONS HEPARIN ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Anticoagulant Acute Coronary Syndrome LVAD malfunction Hypersensitivity to Heparin Active bleeding Trauma Severe hypertension Aortic dissection Pregnancy Major surgery within the last 14 days Symptoms of CVA Bleeding 60 units/kg IV Maximum dose (4000 units) KEY POINTS 23

276 MEDICATIONS KETOROLAC (Toradol) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE NSAID analgesic Reduces pain Moderate pain Pain associated with kidney and gall stones >65 Years Old Hypersensitivity including aspirin or other NSAIDS Advanced renal impairment Suspected cerebrovascular bleeding Recent GI bleeding Nursing mothers Labor and delivery Asthma Edema Hypertension Rash Nausea Dizziness 30 mg IV, 60 mg IM (If <65 Year Old Only) 0.15 mg/kg IV or 0.3 mg/kg IM 24

277 MEDICATIONS LIDOCAINE (Xylocaine) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS Suppresses ventricular ectopy Anesthetic IO anesthetic Allergy to Lidocaine Known hypersensitivity Second or third degree heart block Bradycardia Sinus arrest Hypotension SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Bradycardia Hypotension Dizziness, numbness Drowsiness, confusion Seizure EZ IO anesthetic dose 1-2 cc s (20 40 mg IO) Allow Lidocaine to dwell in the IO space at least 60 seconds. Then flush with 10cc NS EZ IO anesthetic dose 0.5mg/kg IO not to exceed 40mg. Allow Lidocaine to dwell in the IO space at least 60 seconds. Then flush with 10cc NS 25

278 MEDICATIONS LOPRESSOR (Metoprolol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Beta Blocker Decreases HR Decreases systolic BP Convert or slow ventricular response in SVT (adenosine preferred) Rate Control in SVT that will not convert Bronchial asthma CHF Second or third degree heart block Bradycardia Cardiogenic shock Cocaine use Bradycardia Heart block CHF Bronchospasm Hypotension ADULT DOSAGE PEDIATRIC DOSAGE 5 mg IV/IO over 1 minute. May repeat 5 mg after 3 minutes if inadequate response and B/P>110 and HR>60 Not recommended for Pediatric use 26

279 MEDICATIONS MAGNESIUM SULFATE ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Anticonvulsant Antiarrhythmic CNS depressant Seizures secondary to eclampsia Ventricular ectopy refractory to Amiodarone Torsades Adjunct to alleviate acute asthma attack Renal disease Heart blocks Respiratory depression CNS depression Hypotension Cardiac arrest ADULT DOSAGE Torsades grams SLOW IVP over 5 minutes (Max dose 4 grams) Eclampsia grams over 2-3 minutes PEDIATRIC DOSAGE KEY POINTS Asthma dose 45mg/kg IV to a total of 75mg/kg (approx 2 grams in adult Not recommended for pediatric use 27

280 MEDICATIONS MARK 1 KIT - Atropine and 2-PAM Chloride ACTIONS Atropine Blocks a nerve agent s effect of overstimulation and relieves smooth muscle constriction in the lungs and gastrointestinal tract 2-PAM Acts to restore normal functions at the nerve ending by removing the nerve agent and affecting toxin irreversibility INDICATIONS Suspected or confirmed nerve agent exposure CONTRAINDICATIONS Both drugs in the kit should be used with caution (but not withheld) in patients with pre-existing cardiac disease, HTN, or CVA history PRECAUTIONS SIDE EFFECTS SUPPLIED Chest pain Exacerbation of angina Induction of myocardial infarction Blurred vision Headache Drowsiness Nausea Rapid heart rate Increased blood pressure Hyperventilation Atropine 2 mg Auto Injector ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS 2-PAM 600 mg Auto Injector Up to 3 Auto Injectors may be administered to one patient as determined acceptable by Medical Control based upon signs and symptoms Mark I Kits are not authorized for use in children under the age of 9 years 28

281 MEDICATIONS METHYLPREDNISOLONE (Solumedrol) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Anti-inflammatory steroid Anaphylaxis Asthma COPD NONE in emergency setting GI bleeding Prolonged wound healing Suppression of natural steroids 125 mg IV/IO 1-2 mg/kg IV/IO KEY POINTS 29

282 MEDICATIONS MORPHINE SULFATE A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Narcotic Analgesic Causes peripheral vasodilation Pulmonary edema MI pain unrelieved with nitro Pain management Pain secondary to burns Known hypersensitivity / Allergy Head injury or head trauma Hypotension Altered LOC Undiagnosed abdominal pain(consult Med Command) COPD Bradycardia Multiple trauma patients If the patient responds with respiratory depression or hypotension, administer Narcan to reverse the effects Routinely monitor the patient s respiratory effort and SpO2 Respiratory depression Altered LOC, constricted pupils Bradycardia Nausea/Vomiting Hypotension 2-4 mg slow IV/IO/IM/IN (If no relief, may repeat at 2 to 4 mg) For further doses over 10mg of Morphine, contact medical direction. Follow with Zofran Pain Management: mg/kg slow IV/IO/IM/IN KEY POINTS 30

283 MEDICATIONS NALOXONE (Narcan) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Reverses all effects from opioid agents such as respiratory depression and all central and peripheral nervous system effects Narcotics overdoses Altered mental status of unknown origin None Withdrawal syndrome in addiction Ventricular dysrhythmias Cerbral edema mg IV/IO/IM/IN. Administer in small doses. May repeat the initial dose if the patient becomes symptomatic again EMT 2 mg IN 0.1 mg/kg IV,IO,IM,IN. May be repeated at 0.1 mg/kg 31

284 MEDICATIONS NITROGLYCERIN A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Decreases preload and afterlead Increases coronary blood flow Cardiac chest discomfort, angina STEMI Pulmonary edema Known hypersensitivity Hypotension (systolic BP <110, diastolic BP <60 Increased intracranial pressure Glaucoma CVA Erectile dysfunction drugs (contact med control) Headache Hypotension Dizziness, weakness Syncope Dilated pupils Cardiac Chest Discomfort 0.4 mg SL or spray May repeat every 5 minutes up to 3 doses if B/P systolic > 100mmHg PEDIATRIC DOSAGE KEY POINTS Not recommended in the prehospital setting 32

285 MEDICATIONS NITROUS OXIDE A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS Provides rapid, easily reversible relief of pain Abdominal pain Chest pain secondary to infarction or angina Acute urinary retention Fractures Severe exterior burns Kidney stones Musculoskeletal trauma Patients under 12 years of age Severe COPD Head injury ABD pain or trauma Intoxication or drug ingestion Shortness of breath Chest trauma with a possible pneumothorax (during prolonged transport) SIDE EFFECTS SUPPLIED ADULT DOSAGE Discontinue if any of the following arise Apnea, cyanosis Nausea/vomiting Deteriorating vital signs (administer O2 100%) Ambulance crew may experience giddiness if the vehicle is not properly vented Nitronox, a set containing an oxygen cylinder and a nitrous oxide cylinder joined by a valve that regulates flow to provide a 50:50 mixture of the two gases - the mixture is piped to a demand valve apparatus Invert cylinder several times before use; instruct the patient to inhale deeply though a patient-held demand valve mouthpiece PEDIATRIC DOSAGE KEY POINTS Self-administered by mask: a good seal around the mouth and nose is important; the gas is breathed deeply and may give relief after about two minutes; the patient should stop when relief is obtained The paramedic should not hold the face mask in place for the patient 33

286 MEDICATIONS ONDANSETRON (Zofran) A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS Antiemetic Nausea & vomiting Hypersensitivity Drowsiness, vertigo Blurred vision, headache Hypotension 4 mg slow IV/IO/IM - 8 mg Oral Dissolving Tabs Contact Medical Control 34

287 MEDICATIONS ORAL GLUCOSE B EMT B A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Elevates blood glucose level Correction of hypoglycemia Known hypersensitivity Patient must be alert and able to sufficiently swallow Be alert for difficulty swallowing or choking due to the thick consistency Nausea/Vomiting ADULT DOSAGE One complete tube (15-25 g) PEDIATRIC DOSAGE Half a tube KEY POINTS 35

288 MEDICATIONS OXYGEN ACTIONS INDICATIONS Increases oxygen content of blood Improves tissue oxygenation Decreases energy expended for respirations Cardiac chest discomfort Hypoxemia Cardiopulmonary arrest Trauma Shortness of breath Sedative drug administrations CONTRAINDICATIONS None in the prehospital setting PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE PEDIATRIC DOSAGE KEY POINTS B EMT B A Advanced A Never withhold oxygen from those who need it Be aware for respiratory depression in COPD patients on prolonged high flow oxygen Simple or partial rebreather face masks must be supplied with a minimum 10 Lpm Non-rebreather face masks must be supplied with a minimum 12 Lpm T-Piece Nebulizers must be supplied with 6 lpm High concentrations of oxygen may reduce the respiratory drive in some COPD patients; these patients should be carefully monitored As a compressed gas in cylinders of varying sizes lpm via NRB mask, 2-6 lpm via nasal cannula, 6 lpm via small volume nebulizer, unless otherwise indicated lpm via NRB mask or 2-6 lpm via nasal cannula, or 6 lpm via unit dose nebulizer, unless otherwise indicated 36

289 MEDICATIONS Plavix (CLOPIDOGREL) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Blocks platelet aggregation Acute Coronary Syndrome / STEMI 12-Lead EKG indicating a ST elevation MI Hypersensitivity Active bleeding Active ulcer disease Pathological bleeding Upset stomach Nose bleeds, coughing up Chest pains Numbness in body, weakness GI bleeding Mucosal lesions 600 mg tablet PO Not recommended for pediatric use 37

290 MEDICATIONS PRALIDOXIME CHLORIDE / 2-PAM CHLORIDE ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE Reactivates cholinesterase inactivated by organophosphate pesticides or other nerve agents, permitting degradation of accumulated acetylcholine and facilitating normal functioning of neuromuscular junctions Antidote for organophosphate poisoning Hypersensitivity Children under 9 years of age or less than 50 kg Not effective on blister agents, blood agents, pepper spray, mace, tear gas, or other TICs Use antidotes only when signs and symptoms of exposure are present; they will not protect if given before exposure Dizziness, blurred/double vision Nausea, headache, drowsiness Muscular weakness Hyperventilation Tachycardia Increased blood pressure 2 ml mg/ml prefilled Auto-Injector Use Auto-Injector if exposed to nerve agent Deliver Atropine 2 mg IM; Follow with 2-PAM 600 mg IM Repeat in 5-10 minutes if symptoms are still present Max 3 kits 38

291 MEDICATIONS TNKase (Tenecteplase) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Thrombolytic agent; biosynthetic (recombinant DNA origin) form of human tissue-type plasminogen activator (t-pa). Management of Acute Myocardial Infarction (STEMI) Used in the management of Acute Myocardial Infarction for lysis (dissolving) of thrombi (clots) obstructing coronary arteries Active internal bleeding History of CVA Recent (within two months) intracranial or intraspinal surgery or trauma Intracranial neoplasm, arteriovenous malformation, or aneurysm Known bleeding condition Severe uncontrolled hypertension Possible bleeding involving internal bleeding at intracranial or retroperitoneal sites or bleeding from the GI, GU, or respiratory tract. Superficial or surface bleeding at vascular puncture and access sites (e.g., venous cutdowns, arterial punctures) or sites of recent surgical intervention also may occur. 1 Bleeding ADULT DOSAGE <60kg 30mg IV 6ml 60 to <70kg 35mg IV 7ml 70 to <80kg 40mg IV 8ml 80 to <90kg 45mg IV 9ml >90kg 50mg IV 10ml 39

292 MEDICATIONS TETRACAINE (Pontocaine, Ophthalmic) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS Local anesthesia for eyes Irritation and/or pain of the eyes (With no penetrating trauma) Hypersensitivity or Allergy to tetracaine and other local anesthetics Penetrating or open eye injury Burning sensation in eyes Redness, tearing ADULT DOSAGE 1-2 drops in effected eye every 5-10 minutes prn for pain control PEDIATRIC DOSAGE CALL MEDICAL COMMAND KEY POINTS Keep dropper sterile Single patient use only 40

293 MEDICATIONS Thiamine / Vitamin B1 ACTIONS INDICATIONS Allows normal breakdown of glucose Indicated for use in adult patients only Altered mental status. Given prior to D50 to avoid Wernicke Karsakoff Syndrome. (alcoholic, renal failure patients, or malnourished patients may have a Thiamine deficiency) CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE PEDIATRIC DOSAGE Alcohol abuse None None 100 mg IVP prior to administering D50 Not recommended for pediatric use 41

294 MEDICATIONS Tylenol (acetaminophen) Oral liquid A Advanced A ACTIONS INDICATIONS CONTRAINDICATIONS Analgesic Antipyretic Febrile pediatric patient associated with possible febrile seizures Liver failure Liver problems SIDE EFFECTS Allergic reaction Pediatric Dose 10-15mg/kg Orally (supplied in 2-160mg per 5ml cups) PRECAUTION Do not give if patient has already taken Tylenol in the last 4 hours. 42

295 MEDICATIONS VASOPRESSIN (Pitressin) ACTIONS INDICATIONS CONTRAINDICATIONS PRECAUTIONS SIDE EFFECTS SUPPLIED ADULT DOSAGE Alpha agonist Causes vasoconstriction Increases smooth muscle activity Ventricular Fibrillation Pulseless Ventricular Tachycardia Known hypersensitivity Nephritis (inflammation of the kidney) Not recommended for responsive patients with CAD May provoke cardiac ischemia and angina Nausea/Vomiting Diarrhea Confusion Pain at IV site 20 Units / ml in a vial Cardiac Arrest / Ventricular Fibrillation / Pulseless Ventricular Tachycardia 40 Units IV/IO push (administered in place of the first or second dose of Epinephrine) PEDIATRIC DOSAGE Not recommended for pediatric use KEY POINTS The half-life of Vasopressin is approximately minutes 43

296 MEDICATIONS VERSED (Midazolam) A Advanced A ACTION INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Sedative and hypnotic benzodiazepine Induces amnesia Conscious sedation Seizure Facilitate intubation Facilitate pacing / cardioversion Intolerance to benzodiazepines Narrow-angle glaucoma Shock Coma CNS amnesia, headache, dizziness, euphoria, comfusion, agitation, anxiety, delirium, drowsiness, muscle tremor, ataxia, dysphoria, slurred speech, and paresthesia. Cardiovascular hypotension, PVC s, tachycardia, vasocagel episode Eye blurred vision, diplopia, nystagmus, pinpoint pupils Respiratory coughing, bronchospasms, laryngospasm, apnea, hypoventilation, wheezing, airway, obstruction, tachypnea ADULT DOSAGE PEDIATRIC DOSAGE NOTE Skin swelling, burning, pain at the site of injection 2mg IV/IO max initial dose for sedation (may repeat as necessary) 2mg IV/IO or 5mg IM/IN max initial dose for seizures (may repeat as necessary) 5mg IV/IO for RSI and Violent Patients Versed may be administered IM or IN in actively seizing or violent patients whenever IV access is not achieved. Always be ready to assist ventilations Seizures 0.1mg/kg IV/IO/IM/IN to a max dose of 5mg 0.2mg/kg IN to a max dose of 10mg For adult patients use only if Ativan is unavailable 44

297 Special Use Drugs MEDICATIONS DOXYCYCLINE (Vobramycin) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Tetracycline antibiotic Anthrax Plague Allergy Pregnancy Pediatrics None 100mg tablet PO. Max dose 200mg 45

298 MEDICATIONS CIPROFLOXACIN (Cipro) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Antimicrobial Exposure to Anthrax and other microorganisms as deemed necessary by public health and medical direction Hypersensitivity Nausea / Vomiting 500mg tablet PO 400mg IV 46

299 MEDICATIONS HYDROXYCOBALAMINE (Cyanokit) ACTIONS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Reverses cellular hypoxia in cyanide poisonings Known or suspected cyanide poisoning None Hypertension Chromaturia Erythema Nausea Headache 5g IV over 5 minutes May repeat in 5 minutes with Medical Command Approval 47

300 P MEDICAL EMERGENCIES DIFFICULT AIRWAY RAPID SEQUENCE INTUBATION CRITERIA *S P O 2 < 90% while on high flow O2 *Respiratory Rate < 10 or > 32 BPM * Partial airway obstruction from blood/secretions or trauma, or GCS of 8 or less Respiratory exhaustion or inevitable loss of the airway RESTRICTION YOU MUST BE APPROVED AND TRAINED IN RAPID SEQUENCE INTUBATION BY MEDICAL COMMAND TO INITIATE THIS PROCEDURE UNIVERSAL PATIENT CARE PROTOCOL Support ventilation with BVM using OPA or NPA as necessary If patient is lethargic, in respiratory distress, has a gag reflex, is combative, alert, or otherwise unable to intubate. Proceed to Rapid Sequence Intubation No Obtain IV Access Attempt Intubation Successful?? Yes Confirm placement maintain Airway and Ventilatory support Suspected Increased Intracranial Pressure Consider Lidocaine 1 mg/kg as adjunct medication when intubating patients with suspected increased intracranial pressure Administer - Etomidate (Amidate) mg/kg IVP Unless hemodynamically unstable or systolic BP < 90 Yes No Administer - Etomidate (Amidate) mg/kg IVP Unless hemodynamically unstable or systolic BP < 90 or Ketamine 2mg/kg IVP (Do not give Ketamine to Suspected head injury or increased ICP If there is no jaw relaxation or decreased resistance to ventilation within 2 minutes, or if the Patient begins to resist. Repeat Succinylcholine - 2mg/kg IVP Administer Versed 5mg Maintain Cricoid Pressure (Sellick s Maneuver) until intubation is successful Administer Succinylcholine (Anectine) 2 mg/kg IVP Unless patient is known or suspected to be hyperkalemic or have increased intraocular pressure Intubate after muscle relaxation CONTACT MEDICAL CONTROL

301 MEDICAL EMERGENCIES DIFFICULT AIRWAY - RAPID SEQUENCE INTUBATION HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS Difficulty maintaining an airway Unable to intubate a patient due to gag reflex or combativeness *S P O 2 < 90% while on high flow O2 *Respiratory Rate < 10 or > 32 BPM Partial airway obstruction from blood/secretions or trauma, or GCS of 8 or less Respiratory exhaustion or inevitable loss of the airway Any patient with the inability to maintain an airway and ventilate themselves when conventional intubation attempts have failed Inability to intubate a patient due to an intact gag reflex KEY POINTS ***YOU MUST BE APPROVED AND TRAINED IN RAPID SEQUENCE INTUBATION TO INITIATE THIS PROCEDURE*** 1. No more then 2 total attempts at intubation should be attempted by the crew. 2. If unable to intubate using RSI protocol insert a King airway or Combitube or use BVM alone with an OPA and ventilate patient. 3. Use Capnography to continuously monitor PCO 2 and tube placement. 4. If S P O 2 remains <95 % after intubation, consider possible etiologies (e.g. CHF, Pneumothorax, mechanical failure, ect. 5. Succinylcholine is contraindicated in patients with known or suspected to be hyperkalemic, patients with increased intraocular pressure, and patients with burns >8 hours old.

302 MEDICATIONS ETOMIDATE (Amidate) ACTIONS INDICATIONS CONTRAINDICATIONS Anesthetic Hypnotic Drug For use in Rapid Sequence Intubation protocol for anesthesia induction Known sensitivity to the drug SIDE EFFECTS ADULT DOSAGE Transient venous pain Skeletal muscle movement 0.3 mg/kg IVP

303 MEDICATIONS LIDOCAINE (Xylocaine) ACTIONS INDICATIONS CONTRAINDICATIONS Suppresses ventricular ectopy Anesthetic IO anesthetic Rapid Sequence Intubation in patients with increased intracranial pressure Allergy to Lidocaine Known hypersensitivity Second or third degree heart block Bradycardia Sinus arrest Hypotension SIDE EFFECTS Bradycardia Hypotension Dizziness, numbness Drowsiness, confusion Seizure ADULT DOSAGE EZ IO anesthetic dose 1-2 cc s (20 40 mg IO) into bone marrow prior to NS flush in conscious patient Rapid Sequence Intubation 1 mg/kg IVP. Administer with Etomidate before giving Succinycholine

304 MEDICATIONS SUCCINYLCHOLINE CHLORIDE (Anectine) ACTIONS INDICATIONS CONTRAINDICATIONS Skeletal Muscle Relaxant Facilitate tracheal intubation During Rapid Sequence Intubation Adjunct to general anesthesia Skeletal muscle relaxant History of malignant Hyperthermia Skeletal muscle myopathies Known hypersensitivity to the drug SIDE EFFECTS ADULT DOSAGE Apnea Cardiac arrythmias Increased intraocular pressure Muscle fasciculations 2 mg/kg IVP May be repeated once if there is not jaw relaxation or decreased resistance to ventilations within 2 minutes, or patient begins to resist.

305 VEDICATIONS VERSED (Midazolam) ACTION INDICATIONS CONTRAINDICATIONS SIDE EFFECTS Sedative and hypnotic benzodiazepine Induces amnesia Conscious sedation RSI to help with sedation Seizure Facilitate intubation Facilitate pacing / cardioversion Intolerance to benzodiazepines Narrow-angle glaucoma Shock Coma CNS amnesia, headache, dizziness, euphoria, comfusion, agitation, anxiety, delirium, drowsiness, muscle tremor, ataxia, dysphoria, slurred speech, and paresthesia. Cardiovascular hypotension, PVC s, tachycardia, vasocagel episode Eye blurred vision, diplopia, nystagmus, pinpoint pupils Respiratory coughing, bronchospasms, laryngospasm, apnea, hypoventilation, wheezing, airway, obstruction, tachypnea ADULT DOSAGE PEDIATRIC DOSAGE Skin swelling, burning, pain at the site of injection 2mg IV/IO max initial dose for sedation (may repeat as necessary) 5mg IV/IO max initial dose for seizures (may repeat as necessary) 5mg IV/IO for RSI and Violent Patients Versed may be administered IM or IN in actively seizing or violent patients whenever IV access is not achieved Seizures 0.1mg/kg IV/IO/IM/IN a max of 5mg 0.2mg/kg Intranasal to a max dose of 10mg

306 MEDICATIONS KETAMINE ACTION INDICATIONS Non-barbiturate anesthetic Anesthetic A commonly used induction agent to facilitate endotracheal intubation. CONTRAINDICATIONS SIDE EFFECTS ADULT DOSAGE Increased intracranial pressure Hypertension Aneurysm CHF Hallucinations Vivid Dreams Hypertension Increased cardiac output Tachycardia Paradoxical direct myocardial depression Increased ICP Tonic-clonic movements 2mg/kg IV/IO NOTE The use of Etomidate is preferred however Ketamine is an option in patients with no suspected head trauma or increased ICP

307 Rapid Sequence Intubation Pre-Hospital Procedure Report EMS Agency EMS Run Number DATE Indications for RSI (Before Intubation) GCS Pupil Status SPO2 Ventilation Rate Heart Rate B/P / To be filed out by the Paramedic Performing RSI: Physical Findings or Justification for RSI: Estimated Patients Weights in KG Post Intubation GCS Pupil Status SPO2 Ventilation Rate Heart Rate B/P / Number of attempts Successful Tube Size Medication Usage for RSI Drug Dosage Time Etomidate Lidocaine Succinylcholine Vecuronium Patient Transported to Paramedic Signature Receiving RN Signature Leave a copy at the ED, keep a copy for your records, and give a copy to Dan Ellenberger

308 APPENDIX #2: MEDICAL PROCEDURES Adult Patient Assessment Procedure Pediatric Patient Assessment Procedure AIRWAY / BREATHING Aerosol / Inhaler Treatment Procedure Continuous Positive Airway Pressure (CPAP) Device Procedure King Airway Device Procedure Endotracheal Intubation Procedure End Tidal CO 2 Device Procedure Needle Cricothyrotomy Procedure Needle Decompression Procedure Pulse Oximetry Procedure Suctioning Procedure Transport Ventilation Device Procedure CIRCULATION / SHOCK MEDICAL TRAUMA Peripheral Intravascular (IV Line) Procedure External Jugular Intravascular (IV Line) Procedure Saline Lock Procedure Intraosseous (IO) Infusion Procedure F.A.S.T.1 SYSTEM Intraosseous (IO) Infusion Procedure EZ IO Adult Intraosseous (IO) Infusion Procedure Pediatric Manual Intraosseous (IO) Infusion Procedure EZ IO Pediatric ResQPOD ResQGard NICOM Blood Glucose Analysis Procedure Medication Injections Procedure Orthostatic Blood Pressure Measurement Procedure Pain Assessment Patient Restraint Procedure Excel Cryo Cooling System (Cooling Collar) Cervical Spine Immobilization Helmet Removal Procedure OBSTETRICS Childbirth Procedure

309 PHARMACOLOGY Nitronox - Nitrous Oxide Administration Procedure SPECIAL OPERATIONS Nerve Agent Exposure / MARK 1 Kit Procedure Tasered Patient Procedure OTHER OPERATIONS INFECTIOUS EXPOSURE Blood Collection for Evidence (Ohio Senate Bill 58)

310 MEDICAL PROCEDURES ADULT PATIENT ASSESSMENT INDICATIONS Any patient requesting a medical evaluation that is too large to be measured with a Broselow - Luten Resuscitation Tape PROCEDURE 1. Scene size-up: universal precautions, scene safety, environmental hazards assessment, bystander safety, and patient/caregiver interaction 2. Assess need for additional resources 3. Initial assessment: general impression as well as the status of a patient s airway, breathing, and circulation 4. Control major hemorrhage and assess overall priority of patient 5. Assess mental status and disability (e.g., GCS, AVPU) 6. Perform a focused history and physical based on patient s chief complaint 7. Assess need for critical interventions 8. Complete critical interventions and perform a complete secondary exam to include a baseline set of vital signs as directed by protocol 9. Maintain an ongoing assessment throughout transport, to include patient response/possible complications of interventions, need for additional interventions, and assessment of evolving patient complaints/conditions KEY POINTS Dealing with the family: REMAIN CALM, show efficiency and competence, even if you don t really feel it. Show a caring concerned manner for both the family and the patient. If you have negative feelings about the situation (for example if it is an injury as a result of neglect or abuse), try to not let them show. This will only increase hostility between yourself and the family. Honestly inform them of what you are doing and what you think is wrong with the patient. Reassurance is important for the family as well. Involve them in the care (for example, holding the oxygen or talking to the patient to calm them). This will help develop some trust between you and the family. B EMT B A Advanced A 3

311 PEDIATRIC PATIENT ASSESSMENT MEDICAL PROCEDURES INDICATIONS Any child that can be measured with the Broselow Luten Resuscitation Tape B EMT B A Advanced A PROCEDURE 1. Scene size-up: universal precautions, scene safety, environmental hazards assessment, need for additional resources, bystander safety, and patient/caregiver interaction 2. Assess patient using the pediatric triangle of ABCs: Airway and appearance: speech/cry, muscle tone, inter-activeness, look/gaze, movement of extremities Work of breathing: absent or abnormal airway sounds, use of accessory muscles, nasal flaring, body positioning Circulation to skin: pallor, mottling, cyanosis 3. Establish spinal immobilization if suspicion of spinal injury 4. Establish responsiveness appropriate for age (e.g. AVPU, GCS) 5. Color code using Broselow - Luten tape 6. Assess disability (pulse, motor function, sensory function, pupillary reaction) 7. Perform a focused history and physical exam (pediatric patients easily experience hypothermia and thus should not be left uncovered any longer than necessary to perform an exam). Include Immunizations, Allergies, Medications, Past Medical History, last meal, and events leading up to injury or illness where appropriate 8. Record vital signs (BP > 3 years of age, cap refill < 3 years of age) 9. Treat chief complaint as per protocol KEY POINTS Illness and injuries in children can cause significant anxiety for prehospital personnel as well as panic in the patient, family, and bystanders. It is important for the EMT to remain calm and take control of the patient and situation. Dealing with the child: Tell them what s happening. It is important to remember to communicate with the child. Relate and speak on their developmental level. Be honest with them. Don t say this won t hurt if it will. Explain actions. Try to enlist their cooperation, if possible. Do not separate child from the parent unless they are ill enough to require significant interventions like airway positioning and ventilation. Reassure the child frequently. Dealing with the family: REMAIN CALM - Show efficiency and competence, even if you don t really feel it. Show a caring concerned manner for both the family and the patient. If you have negative feelings about the situation (for example, if it is an injury as a result of neglect or abuse), try to not let them show. This will only increase hostility between yourself and the family. Honestly inform them of what you are doing and what you think is wrong with the patient. Reassurance is important for the family as well. Involve them in the care (for example, holding the oxygen or talking to the patient to calm them). This will help develop some trust between you and the family. 4

312 AEROSOL / INHALER TREATMENT AEROSOL TREATMENT AIRWAY / BREATHING INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Patients experiencing bronchospasm PROCEDURE Shortness of breath Wheezing History of COPD / Asthma Unable to complete full sentences Accessory muscle use Nasal flaring Fatigue Allergy to medication Arrhythmias A Advanced A 1. Gather the necessary equipment 2. Assemble the nebulizer kit 3. Instill the premixed medication into the reservoir well of the nebulizer 4. Connect the nebulizer device to oxygen at 6 liters per minute or adequate flow to produce a steady, visible mist 5. Instruct the patient to inhale normally through the mouthpiece of the nebulizer - the patient needs to have a good lip seal around the mouthpiece 6. The treatment should last until the solution is depleted - tapping the reservoir well near the end of the treatment will assist in utilizing all of the solution 7. Monitor the patient for medication effects - this should include the patient s assessment of his/her response to the treatment and reassessment of vital signs, EKG, and breath sounds 8. Document the treatment, dose, and route in the patient care report (PCR PERSONAL INHALER TREATMENT INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Patients experiencing bronchospasm Shortness of breath Wheezing Patient has own prescribed inhaler Medication has expired Patient has received maximum dose EMT B PROCEDURE 1. Make sure that personal inhaler is at room temperature or warmer 2. Follow the instructions for either gentle or vigorous shaking 3. Instruct patient to seal lips around opening of inhaler, using spacer if present 4. Instruct patient to inhale deeply while depressing the inhaler 5. Instruct patient to hold breath as long as possible 6. Follow Airway Protocol KEY POINTS Use mouthpiece if patient is able to hold nebulizer effectively Use nebulizer mask if patient is unable to hold nebulizer effectively 5

313 AIRWAY / BREATHING CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Breathing patient whose condition is not improving with oxygen therapy Respiratory distress due to pulmonary edema, asthma, CHF, or COPD Patients 15 years of age or older Dyspnea and tachypnea Chest pain Hypertension Tachycardia Anxiety Altered LOC Rales and wheezes Frothy sputum (severe cases) Accessory muscle use SPO 2 < 94% Respiratory arrest Agonal respirations Unconscious Shock Pneumothorax Penetrating chest trauma Persistent nausea and vomiting Facial anomalies, facial trauma Known blebs Apnea Hypercarbia Respiratory compromise B/P < 90 systolic B EMT PROCEDURE Ensure there is a patent airway Administer 100% oxygen via appropriate delivery system and perform appropriate patient assessment, including vital signs, S P O 2 reading and cardiac rhythm Verbally instruct the CPAP procedure to the patient Apply CPAP device, starting at 5 cm H 2 0 Slowly titrate the pressure appropriately: CHF / PULMONARY EDEMA = 10 cm H 2 0 ALL OTHER SOB / DYSPNEA = 5 cm H 2 0 Continuously reassess the patient, obtaining vital signs every 5 minutes Monitor continuous SPO 2 Monitor continuous end tidal carbon dioxide monitoring (with nasal prongs) if available Follow the appropriate set of standing orders for your specific device for continued treatment Contact Medical Control as soon as possible to allow for prompt availability of hospital CPAP equipment and respiratory personnel KEY POINTS The use of CPAP has long been recognized as an effective treatment for patients suffering from exacerbation of congestive heart failure and COPD. CPAP has recently shown promise in the out-of-hospital setting as well, by demonstrating favorable results in the treatment of acute congestive heart failure. You may use an aerosol treatment inline with CPAP The use of CPAP for the treatment of patients who might otherwise receive endotracheal intubation holds several benefits: 1. CPAP is a less invasive procedure with lesser risk of infection 2. CPAP eliminates the necessity of weaning the patient off an ET tube and ventilator 3. CPAP eliminates the necessity of sedating or paralyzing an alert patient by ALS or the emergency department staff in order to perform laryngoscopy 4. CPAP allows the alert patient to have a continued dialogue with his / her caregivers, allowing for the exchange of additional medical history. It also allows for the patient to be involved in the decisionmaking process for his / her care B A Advanced A For circumstances in which the patient does not improve or continues to deteriorate despite CPAP and/or medicative therapy, terminate CPAP administration and perform BVM ventilation and endotracheal intubation if necessary 6

314 ESOPHAGEAL KING LT AIRWAY AIRWAY / BREATHING INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS In an apneic patient when endotracheal intubation is not possible or not available Patient must be unconscious PROCEDURE Respiratory and/or cardiac arrest Respiratory insufficiency when the patient is totally unconscious and unresponsive to outside stimuli After attempts at endotracheal intubation have not been successful EMTs and Advanceds may use the King Lt Airway as a primary airway in the above stated situations Responsive victims (gag reflex present) Known esophageal disease or cirrhosis Caustic poison ingestion Foreign body in the trachea History of esophageal trauma or injury Presence of a tracheostomy or laryngectomy Suspected narcotic overdose or hypoglycemia prior to the administration of Narcan and/or Glucose A Advanced A 1. Choose the proper size tube based on patient s height, test all cuffs, have a spare King Airway ready 2. Lubricate the tube, avoid the ventilatory openings 3. Preoxygenate the patient with 100% O 2 4. Remove dentures and/or suction any secretion from mouth and oropharynx 5. Remove oral airway if in use; place head and neck in sniffing or neutral position insuring no gag reflex present 6. With the King Airway rotated laterally such that the blue orientation line is touching the corner of the mouth, introduce tip into moth and advance behind base of tongue. Never force the tube into position. 7. As tube passes under tongue. Rotate tube back to midline (blue orientation line faces chin). 8. Without exerting excessive force, advance King Airway until base of connector aligns with teeth or gums. 9. Fully inflate cuffs using the maximum volume of the syringe included in the EMS kit. 10. Attach the breathing circuit or resuscitator bag to the 15 mm connector of the King Airway. While gently bagging the patient to assess ventilatorn, simultaneously withdrawl the airway until ventilation is easy and free flowing (large tidal volume with minimal airway pressure). 11. Depth markings are provided at the proximal end of the King Airway which refer to the distance from the distal ventilatory openings. When properly placed with the distal tip and cuff in the upper esophagus and the ventilatory openings aligned with the opening to the larynx, the depth markings give an indication of the distance, in cm, to the vocal cords. 12. Confirm proper position by auscultation, chest movement and verification of co 2 by capnography. 13. Readjust cuff inflation to 60 cm H 2 o (or to just seal volume). 14. Secure King Airway to patient using tape or other accepted means. A bite block can also be used, if desired. DO NOT COVER THE PROXIMAL OPENING OF THE GASTRIC ACCESS LUMEN OF THE King Airway. 15. Monitor SPO 2 and/or end tidal CO 2 B EMT B 7

315 REMOVAL OF THE KING AIRWAY Once it is in the correct position, the King Airway is well tolerated until the return of protective reflexes. King Airway removal should always be carried out in an area where suction equipment and ability for rapid intubations are present. For the King airway removal, it is important that both cuffs are completely deflated. KEY POINTS The King Airway is a single patient use device and is not to be cleaned and reused You should not take more than ten seconds during any one attempt at inserting the Airway, this will help prevent hypoxia Insertion of the suction catheter may be initiated any time it is desirable to evacuate the stomach contents In the event of cervical spine injury, be sure that the head, neck and back are secured in place during insertion of the tube, this is done to prevent any further injury 8

316 ENDOTRACHEAL INTUBATION AIRWAY / BREATHING INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate respiratory effort Unstable airway Respiratory arrest Cardiac arrest GCS less than 8 without a treatable cause (for example, hypoglycemia) Patient intolerance is only a relative contraindication to this procedure. A Advanced A PROCEDURE 1. Cervical immobilization should be applied to the patient when indicated by mechanism of injury or when it is deemed necessary 2. Prepare all equipment and have suction ready 3. Hyperoxygenate the patient with 100% O 2 prior to attempt 4. Suction the pharynx as needed 5. Open the patient s airway and holding the laryngoscope in the left hand, insert the blade into the right side of the mouth and sweep the tongue to the left 6. Use the blade to lift the tongue and epiglottis (either directly with the straight blade or indirectly with the curved blade) 7. Once the glottic opening is visualized, slip the tube through the cords and continue to visualize until the cuff is past the cords 8. No more than 30 seconds may be used per attempt a. Re-ventilation for at least 30 seconds after each attempt b. Some situations such as copious vomiting or bleeding may require suction attempts longer than 30 seconds; these are the exception, not the norm 9. Remove the stylet 10. Inflate the cuff of the endotracheal tube with 10 cc of air 11. Attach the bag-valve device to the ET tube and ventilate the patient 12. Assess for tube placement: a. Confirmation of lung sounds in the apices and bases bilaterally, absence of epigastric sounds b. Good compliance with bag-valve ventilation. c. Color change of end tidal CO2 detector (purple to yellow) Not reliable in cardiac arrest with a long down time d. Chest rise with ventilation 13. If placement cannot be confirmed or obtained, the ETT shall be removed, an oral airway placed, and the patient shall be ventilated with a bag-valve-mask 14. If proper placement is confirmed, the cm markings on the tube at the level of the teeth shall be noted and secure the tube with a commercial tube holder 15. Document ETT size, time, result (success), and placement location by the centimeter marks either at the patient s teeth or lips in the patient care report (PCR); document all devices used to confirm initial tube placement and document positive or negative breath sounds before and after each movement of the patient 16. Routinely reassess for proper tube placement; the initial tube placement and all reassessments must be documented KEY POINTS It is essential to have complete and detailed documentation concerning the placement of the endotracheal tube. The documentation MUST include: Placement- direct visualization of the tube passing through the vocal cords Confirmation- equal lung sounds, no sounds over the epigastric area, positive color change in the CO 2 detector, and chest wall movement with ventilations. Also, consider changes in the patient s SpO 2. Applying c-collar may assist in minimizing ETT movement Tube placement must be confirmed;: after it is initially placed, after every movement, any significant change in patient status, and prior to entering the Emergency Department. If there is any doubt about proper placement, the tube shall be removed Continually monitor the patient s SpO 2, ease of ventilation, heart rate, and presence of JVD A common complication of endotracheal intubation and/or manual ventilation is a pneumothorax and tension pneumothorax. Refer to the Chest Decompression Protocol. Intubation does NOT have to be attempted in pediatric patients if their airway can be effectively managed with BVM Ventilations 9

317 TUBE REMOVAL If the patient begins to breathe spontaneously and effectively and is resisting the presence of the tube, removal of the tube may be necessary. The following procedures will be followed: 1. Explain procedure to victim 2. Prepare suction equipment with large-bore catheter and suction secretions from endotracheal tube, mouth and pharynx 3. The lungs should be completely inflated so that the patient will initially cough or exhale as the tube is taken from the larynx; this is accomplished in 2 ways: a. The patient is asked to take the deepest breath they possibly can and, at the very peak of the inspiratory effort, the cuff is deflated and the tube removed rapidly; or b. Positive pressure is administered with a hand-held ventilator and, at the end of deep inspiration, the cuff is deflated and the tube rapidly removed 4. Prepare to suction secretions and gastric content if vomiting occurs 5. Appropriate oxygen is then administered 6. The patient's airway is immediately evaluated for signs of obstruction, stridor or difficulty breathing; the patient should be encouraged to take deep breaths and to cough TUBE SIZING The size of tube that can be passed easily into most adults is 8.0 mm (id). Therefore this tube should be tried first on the average adult. The size of tube is judged by the size of the adult, not by age. For children, the proper tube is usually equal to the size of the child's little finger. The following guide will also help in determining the proper size tube: Premature...3mm (id) months...5-6mm (id) weeks...4mm (id) 2-4 years...6mm (id) 6-12 months...4-5mm (id) 4-7 years...6-7mm (id) months...5mm (id) 7-10 years...7mm (id) KEY POINTS All the above tube sizes are still dependent on the child's size rather than consideration of age Children before puberty should have a cuffless tube, or if the tube has a cuff it should not be inflated after insertion 10

318 AIRWAY / BREATHING END TIDAL CO2 DEVICE INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS The end-tidal CO 2 detector shall be used with all endotracheal, Combitube, or King airways Shortness of breath Wheezing History of COPD / Asthma Unable to complete full sentences Accessory muscle use Nasal flaring Fatigue This device is not to be used for: Detection of hypercarbia Detect mainstem bronchial intubation During mouth to tube ventilation B EMT B A Advanced A PROCEDURE 1. Remove detector from package (Do not remove end caps until ready to use device) 2. Attach end-tidal CO 2 detector to King airway or endotracheal tube 3. Ventilate the patient with six breaths of moderate tidal volume 4. Note color change - a color change or CO 2 detection will be documented on each respiratory failure or cardiac arrest patient 5. Compare color of indicator on full end-expiration to color chart on product dome 6. The CO 2 detector shall remain in place with the airway and monitored throughout the prehospital care and transport - Any loss of CO 2 detection or color change is to be documented and monitored as procedures are done to verify or correct the airway problem 7. Tube placement should be verified frequently and always with each patient move or loss of color change in the end-tidal CO 2 detector 8. The detector may left in place during ventilation to assist in monitoring tube placement 9. If initial intubation attempts fail, the detector can be used for re-intubation on the same patient provided the indicator color still matches the "CHECK" color standard on product dome 10. Document the procedure and the results on/with the Patient Care Report (PCR) 11

319 AIRWAY / BREATHING NEEDLE CRICOTHYROTOMY (ONLY IF TRAINED) INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Failed Airway Protocol Management of an airway when standard airway procedures cannot be accomplished or have failed in a patient greater than or equal to 8 years of age Unable to intubate by another route Cervical spine injuries Maxillo/facial trauma Laryngeal trauma PROCEDURE 1. If time permits, prep with appropriate antiseptic solution 2. Have suction supplies available and ready 3. Locate the cricothyroid membrane utilizing anatomical landmarks 4. Secure larynx laterally between thumb and forefinger 5. Relocates the cricothyroid membrane (in the midline between thyroid cartilage and cricoid cartilage) 6. Using the syringe and the finder needle supplied in the commercial needle cricothyrotomy kit (or a 5-cc syringe attached to a 10 to 14 gauge catheter-over-needle device if needed), insert the needle through the cricothyroid membrane at a 45 to 60 degree caudal angle 7. Confirm entry of needle in trachea by aspirating air through the syringe 8. If air is present, change the angle of insertion to 60 degrees 9. Advance the device to the level of the stop guide 10. Slide the plastic cannula along the needle into the trachea until the flange rests against the neck 11. Carefully remove the needle and syringe 12. Secure the cannula with the provided anchoring device 13. Attach the connecting tube to the 15mm connection 14. Attach a BVM to the connecting tube 15. Confirm placement by auscultation and observing patient for adequate chest rise; make certain ample time is used not only for inspiration but expiration as well 16. If unable to obtain an adequate airway, resume basic airway management and transport the patient as soon as possible 17. Regardless of success or failure of needle cricothyrotomy, notify the receiving hospital at the earliest possible time of a surgical airway emergency 18. Document time/procedure/confirmation/change in patient condition/time on the patient care record (PCR) KEY POINTS Guidelines for Sizing Oropharyngeal obstruction from: Edema from infection, caustic ingestion, allergic reaction, and/or inhalation injuries Foreign body Mass lesion Postoperative bleeding Late bleeding Abcess behind packing Cellulitis of neck Subcutaneous emphysema Voice change Feeling of lump in throat Persistent stoma Obstructive problems Misplacement of the airway Adult (4.0 mm) Quick Trach: Any patient greater than 100 pounds (45kg) and greater than 2 years (24 months) in age Pediatric (2.0 mm) Quick Trach: Any patient less than 100 pounds (45 kg) and greater than 2 years (24 months) in age 12

320 NEEDLE CHEST DECOMPRESSION AIRWAY / BREATHING INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Tension pneumothorax with significant dyspnea Severe or significant dyspnea Increasing dyspnea Tachypnea Hyporresonance Absent breath sounds on the affected side Tachycardia Possibly diminished breath sounds on the unaffected side Tracheal deviation (rare/late sign) Hypotension Distended neck veins Chest pain Extreme anxiety Altered LOC/coma Insufficient training PROCEDURE Confirm presence of a tension pneumothorax or identify strong clinical evidence in a rapidly deteriorating patient in the setting of major trauma Locate the insertion site at the second intercostal space at the midclavicular line on the affected side of the chest Prep the insertion site; use sterile gloves and utilize aseptic procedure to the fullest extent possible under the circumstances. Insert the 3 inch, 14 gauge angiocath (1 inch, 18 gauge angiocath in patients less than 8 years) with a 10cc syringe attached, by directing the needle just over the top of the third rib (2nd intercostal space) to avoid intercostal nerves and vessels which are located on the inferior rib borders Advance the catheter 1-2 inches (3/4-1 inch in patients less than 8 years) through the chest wall; pull back on the plunger of the syringe as the needle is advanced; tension should be felt until the needle enters the pleural space (a pop or give may also be felt); do not advance the needle any further. In a tension pneumothorax, air under pressure should be released when the needle enters the pleural cavity. This will be heard as a rush of air through an open catheter-over-the-needle. If you are using a syringe attached to the catheter-over-the-needle you should be able to withdraw air by pulling out on the barrel of the syringe. Withdraw the needle and advance the catheter until flush with the skin. Listen for a gush or hiss of air which confirms placement and diagnosis. Caution: this is frequently missed due to ambient noise. Dispose of the needle properly and never reinsert into the catheter Once the presence of a tension pneumothorax has been confirmed: Remove the needle, leaving the catheter in place Tape the catheter in place A three-way stopcock can be used Secure the catheter and rapidly transport the patient providing appropriate airway assistance KEY POINTS A tension pneumothorax can occur in any situation in which a simple pneumothorax occurs A tension pneumothorax can occur WITHOUT trauma Some patients who are at risk of developing a tension Pneumothorax include those receiving positive pressure ventilation, any patient with blunt or penetrating trauma, and those with pre-existing lung diseases such as COPD Cover all penetrating chest trauma with an occlusive dressing taped on three sides In some cases of penetrating chest trauma, placing an occlusive dressing on the wound will convert an open pneumothorax to a closed tension pneumothorax. In these cases, treatment consists of removing the dressing and converting the wound back to an open pneumothorax. This may be the only treatment needed. DO NOT perform a chest decompression if the patient is not in significant respiratory distress and is otherwise stable. Major trauma victims should have catheter-over-the-needles placed on both sides of the chest with or without one-way valve devices, if all of the following are present: 2 Obvious chest trauma 3 Patient intubated Difficulty bagging, tracheal deviation, or absent breath sounds on one/both sides 13

321 AIRWAY / BREATHING PULSE OXIMETRY INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Patients with suspected hypoxemia All cases of respiratory distress For the treatment of primary respiratory or cardiac disease All cases of altered or depressed level of consciousness Drug overdoses Any patient requiring intubation or BVM support Major trauma Smoke Inhalation (may not be accurate due to CO) Any patient on home oxygen, home ventilator, or BiPAP Dyspnea Tachypnea Tachycardia Bradycardia (late sign in adults) Altered mental status Pallor, cyanosis Diaphoresis Prolonged capillary refill Accessory muscle use Abnormal breath sounds Poor perfusion; must be applied with good perfusion Patients with history of anemia Patients with suspected high carboxyhemoglobin / methemyglobin (CO poisoning, smoke inhalation, heavy cigarette smokers) B EMT B A Advanced A PROCEDURE 1. Turn the machine on and allow for self-tests 2. Apply probe to patient s finger or any other digit as recommended by the device manufacturer 3. Allow machine to register saturation level 4. Record time and initial saturation percent on room air if possible on/with the patient care report (PCR) 5. Verify pulse rate on machine with actual pulse of the patient 6. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary 7. Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to correct hypoxemia 8. In general, normal saturation is 94-99%. Below 94%, suspect a respiratory compromise. 9. Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data provided by the device. 10. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain 11. Factors which may reduce the reliability of the pulse oximetry reading include: Poor peripheral circulation (blood volume, hypotension, hypothermia) Excessive pulse oximeter sensor motion Fingernail polish (may be removed with acetone pad) Carbon monoxide bound to hemoglobin Irregular heart rhythms (atrial fibrillation, SVT, etc.) Jaundice 14

322 All patients who require vital signs to be taken should have oxygen saturation measured and recorded as part of the vital signs Measure oxygen saturation before applying oxygen and repeat the measurement after oxygen has been applied, do not delay oxygen administration in patients experiencing severe respiratory distress TREATMENT GUIDELINES S P O 2 READING INTERPRETATION ACTION 100% TO 95% Ideal Range No supplemental oxygen is needed 95% TO 90% Mild to Moderate Check airway, start oxygen therapy via nasal 4-6 lpm Hypoxemia 90% TO 85% Severe Hypoxemia Check airway, start aggressive oxygen therapy, high flow oxygen via nonrebreather 15 lpm. Consider bag valve mask ventilation with 100% oxygen if the patient does not have adequate ventilations. 85% OR LESS Respiratory Failure Assist ventilations with 100% oxygen and bag valve mask; consider CPAP or intubation KEY POINTS 100% oxygen should be administered to all patients despite a good SpO 2 if they are hypoxic Make sure that all dirt and nail polish or any obstructive covering is removed to prevent the unit from giving a false reading Attempt to obtain a room air reading and a reading with supplemental oxygen Do not read while B/P being taken, may give false readings Oxygen saturation measurements must routinely be recorded as part of the run report; include those measurements taken as part of routine vital signs and those measurements taken before and after oxygen administration. Although the pulse oximeter displays the heart rate, the unit should not be used in place of the cardiac monitor and a physical assessment of the heart rate Oxygen saturation readings may be inaccurate in any situation where the flow of blood through the finger is impaired, such as: 1. Hypotension or shock with poor peripheral perfusion 2. Peripheral vascular disease 3. Extremity injury with restriction of peripheral perfusion 4. Cold extremities Oxygen saturation readings may be incorrectly high in situations such as carbon monoxide poisoning Many patients with COPD have chronic low oxygen readings and may lose their respiratory drive if administered prolonged high oxygen therapy; routinely assess pulse oximetry as well as respiratory drive when administering oxygen to these patients; do not withhold oxygen from any patient that requires it. The room air pulse oximetry reading is NOT required if the patient has been placed on supplemental oxygen prior to EMS arrival 15

323 AIRWAY / BREATHING SUCTIONING INDICATIONS SIGNS AND SYMPTOMS PRECAUTIONS Any patient who is having trouble maintaining an airway and fluid is noted in the oropharynx, endotracheal tube, or tracheostomy Tracheal suctioning should also be performed when rhonchi is heard in the intubated patient or tracheotomy patients Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient currently being assisted by an airway adjunct such as a naso-tracheal tube, endotracheal tube, Combitube, tracheostomy tube, or a cricothyrotomy tube The patient must be well oxygenated before attempting this procedure PROCEDURE: B EMT B A Advanced A ORAL SUCTIONING 1. Body substance isolation procedures must be used 2. Assess the need for suctioning 3. If the patient requires artificial ventilations, hyperventilate the patient for 30 seconds prior to suctioning 4. Select an appropriate size suction catheter i. A. A soft flexible suction catheter or a whistle tip can be used if only fluids need to be removed ii. B. A Yankauer or a Tonsil Tip should be used for thick fluids, small particles, or large volumes 5. Prepare a cup of sterile water or saline to flush the catheter after suctioning and in between attempts 6. While maintaining aseptic technique, quickly insert the catheter into the patient s mouth until it is at the desired depth 7. Apply suction and withdraw the catheter. Suction no more than 15 seconds per attempt. 8. Immediately after each suction attempt, hyperventilate the patient (one breath every two seconds) for thirty seconds with 100% oxygen if the patient s ventilations require assistance 9. Repeat this procedure as needed until the airway is clear TRACHEAL SUCTIONING 1. Body substance isolation procedures must be used 2. Assess the need for suctioning 3. Hyperventilate the patient prior to suctioning 4. Select an appropriate size suction catheter i. A soft flexible suction catheter or a whistle tip should be used ii. B Yankauer or a Tonsil Tip should NOT be used 5. Prepare a cup of sterile water or saline to flush the catheter after suctioning and in between attempts 6. While maintaining aseptic technique, quickly insert the catheter into the endotracheal or tracheal tube until it is at the desired depth 7. Apply suction and withdraw the catheter using a gentle rotating motion. Suction no more than 15 seconds per attempt 8. Immediately after each suction attempt, hyperventilate the patient (one breath every two seconds) for thirty seconds with 100% oxygen 9. Repeat this procedure as needed until the airway is clear 16

324 KEY POINTS General In order to maintain aseptic technique, keep the distal end of the catheter in the wrapper when not being used If the suction catheter needs to be set down between suction attempts, place it back inside it s wrapper Patients who require assisted ventilations should be hyperventilated before and after every suction attempt DO NOT suction for more than 15 seconds per attempt DO NOT insert farther than the desired depth If a backboarded patient vomits, turn the board on its side and then suction Oral Suctioning If using a soft flexible suction catheter, determine the length by holding it against the patient s face; measure from the edge of the patient s mouth to the tip of the ear lobe Tracheal Suctioning Even though endotracheal tubes isolate the trachea, if there is fluid present in the lower airway, oxygenation will be reduced There are many patients at home with tracheotomy tubes; these tubes have a tendency to become obstructed because the patient cannot cough normally; EMS is often called when these tubes become obstructed This procedure should be performed with aseptic technique; use an unopened sterile catheter for every patient Use the largest sized suction catheter that will fit down the endotracheal tube Estimate the length by looking at the distance between the end of the tube and the sternal notch; this approximates the level of the carina If tracheal secretions are extremely thick and unable to be removed, administer 2-3 ml of sterile saline followed by 2 BVM ventilations and then perform suctioning 17

325 TRANSPORT VENTILATION DEVICE AIRWAY / BREATHING INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Transport of an intubated patient Pt. currently breathing with ventilation device Insufficient training PROCEDURE 1. Confirm the placement of tube as per Airway Protocol 2. Ensure adequate oxygen delivery to the respirator device 3. Pre - oxygenate the patient as much as possible with bag-valve mask 4. Remove BVM and attach tube to respiration device 5. Per instructions of device, set initial respiration values. For example, set an inspiratory:expiratory ratio of 1:4 (for every 1 second of inspiration, allow 4 seconds and expiration) with a rate of 12 to Assess breath sounds; allow for adequate expiratory time; adjust respirator setting as clinically indicated 7. If any worsening of patient condition, decrease in oxygen saturation, or any question regarding the function of the respirator, remove the respirator and resume bag-valve mask ventilations 8. Document time, complications, and patient response on the patient care report (PCR) KEY POINTS Transportation ventilators may be used on successfully intubated patients according to the manufacturer s directions It must be noted that this is a short term adjunct, which must be monitored at all times to prevent tube displacement; if the patient begins to show any signs of further deterioration, the entire airway must be reevaluated and a bag-valve mask should be used until the airway can be successfully stabilized 18

326 PERIPHERAL INTRAVASCULAR (IV) LINE CIRCULATION / SHOCK INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Any patient where intravenous access is indicated (significant trauma or mechanism, emergent or potentially emergent medical condition) Dehydration Hypovolemia Need for drug therapy Hypersensitivity to IV catheter PROCEDURE A Advanced A 1. Universal precautions 2. Prepare equipment 3. Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles 4. Connect IV tubing to the solution in a sterile manner, fill the drip chamber half full and then flush the tubing bleeding all air bubbles from the line 5. Place a tourniquet around the patient s extremity to restrict venous flow only 6. Select a vein and an appropriate gauge catheter for the vein and the patient s condition; the initial attempt should be the dorsum of hand, further attempts should proceed to the forearm and then the antecubital fossa if necessary 7. Prep the skin with an antiseptic solution 8. Insert the needle with the bevel up into the skin in a steady, deliberate motion until the bloody flashback is visualized in the catheter 9. Advance the catheter into the vein, never reinsert the needle through the catheter, dispose of the needle into the proper container without recapping 10. Draw blood samples when appropriate 11. Remove the tourniquet and connect the IV tubing 12. Open the IV to ensure free flow of the fluid and then adjust the flow rate as per protocol or as clinically indicated 13. Secure IV using appropriate measures to ensure stability of the line 14. Check for signs of infiltration 15. Adjust flow rate 16. Document the procedure, time and result (success) in the patient care report (PCR) KEY POINTS IV s will be started by the Advanced and/or the Paramedic as allowed by each patient care protocol IV placement must not delay transport of any critical patient involved in trauma Generally, no more than two (2) attempts or more than two minutes should be spent attempting an IV; if unable to initiate IV line, transport patient and notify hospital IV was not able to be started IVs may be started on patients of any age providing there are adequate veins and patient's condition warrants an IV All IV rates should be at KVO (minimal rate to keep vein open) unless administering fluid bolus Extreme care should be made to discard of all IV sharps in the appropriate sharps container immediately after cannulation, no sharps should be found on patient/ sheets after transport to the hospital Upper extremity IV sites are preferable to lower extremity sites Lower extremity IV sites are contraindicated in patients with vascular disease or diabetes In post-mastectomy patients, avoid IV, blood draw, injection, or blood pressure in arm on affected side Do not use any indwelling catheters or ports for IV access. Use EZ IO if patient is in critical need of an IV. 19

327 CIRCULATION / SHOCK EXTERNAL JUGULAR INTRAVASCULAR (IV) LINE A Advanced A INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS External jugular vein cannulation is indicated in a critically ill patient > 12 years of age who requires intravenous access for fluid or medication administration and in whom an extremity vein is not obtainable External jugular cannulation can be attempted initially in life threatening events where no obvious other peripheral site is noted Dehydration Hypovolemia Need for drug therapy Only (1) attempt per patient Start IV away from head, towards feet PROCEDURE 1. Place the patient in a supine head down position. This helps distend the vein and prevents air embolism. 2. Turn the patient s head toward the opposite side if no risk of cervical injury exists. 3. Position yourself at patient s head 4. Locate external jugular vein 5. Prep the site as per peripheral IV site 6. Select IV catheter a. On adults, a large bore (16ga or 18ga) may be used b. Use 2" IV catheter when available 7. Align the catheter with the vein and aim toward the same side shoulder 8. Tourniqueting the vein lightly with one finger above the clavicle, puncture the vein midway between the angle of the jaw and the clavicle and cannulate the vein in the usual method 9. Attach the IV and secure the catheter avoiding circumferential dressing or taping 10. Secure IV using appropriate measures to ensure stability of the line 11. Check for signs of infiltration 4 Adjust flow rate ONLY (1) ATTEMPT SHOULD BE MADE DURING EXTERNAL JUGULAR IV DO NOT ATTEMPT AN IV ON THE OTHER SIDE OF THE NECK Document the procedure, time, and result (success) on/with the patient care report (PCR) 20

328 CIRCULATION / SHOCK SALINE LOCK PROCEDURE A Advanced A PROCEDURE 1. Prepare equipment: Attach pre-pierced adapter to extension tubing, inject saline (approx. 1cc) in to tubing and leave syringe attached to tubing 2. The initial attempt should be the dorsum of hand, further attempts should proceed to the forearm; the antecubital fossa should not be used for saline locks 3. Apply tourniquet 4. Cleanse site with alcohol 5. Insert the needle with the bevel up into the skin in a steady, deliberate motion until the bloody flashback is visualized in the catheter 6. Advance the catheter into the vein; never reinsert the needle through the catheter, dispose of the needle into the proper container without recapping 7. Draw blood samples when appropriate 8. Remove the tourniquet and connect the IV tubing 9. Attach IV tubing and push remaining saline through tubing and catheter, remove syringe 10. Secure IV using appropriate measures to ensure stability of the line 11. Check for signs of infiltration KEY POINTS Saline lock is preferred for patients who do not need immediate IV medication or fluids Saline locks can be used whenever a patient requires an IV primarily for medication administration, or for any patient where the IV would have been ran at TKO rate (except for traumas and cardiac/respiratory arrest) A saline lock should not be used with a 14 or 16 gauge IV unless attached to IV tubing and a bag of normal saline Extreme care should be made to discard of all IV sharps in the appropriate sharps container immediately after cannulation, no sharps should be found on patient/ sheets after transport to the hospital Blood Draws Blood specimen drawing should be performed whenever the patient has a medical condition requiring an IV Blood draws are not required if the IV site may become compromised, trauma, or the patient s condition dictates otherwise Blood tubes should be labeled with the patient s name and initialized by the drawer of the specimen, and placed in a biohazard bag If the tube does not draw a vacuum, discard tube and try another of the same color Tube should be rotated upright, not shaken, when mixing additives and blood Blood alcohol levels are to be taken in the ED, not the EMS vehicle 21

329 CIRCULATION / SHOCK INTRAOSSEOUS (IO) INFUSION ADULT INTRAOSSEOUS INFUSION - F. A. S. T. 1 SYSTEM: (For Paramedics trained in technique) INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Inability to obtain peripheral access in a patient greater than 12 years of age that requires access in an emergency manner May administer all medication and dose the same as a peripheral IV Unresponsive Cardiopulmonary arrest Decompensated shock The patient is NOT unconscious and unresponsive The patient is postictal and is awakening The patient has an estimated weight of less than 100 lbs. (45kg) Vascular access is prophylactic and is not emergently required Patient has an infection or injury overlying the upper sternum (manubrium) Inability to accurately determine the landmarks require for placement PROCEDURE: F.A.S.T. 1 SYSTEM A Advanced A 1. Identify the insertion site. The F.A.S.T. 1 Intraosseous Sternal Infusion System recommended site is the manubrium on the midline and 1.5 cm below and inferior to the suprasternal notch; proper placement of the patch helps assure insertion at this site; this is referred to as the ATarget Zone@. 2. Use universal precautions 3. Explain procedure to patient if they are conscious 4. Prep site with sterile iodine solution such as Betadine and clean with alcohol as a sterile procedure 5. Locate the sternal notch with index finger and apply patch; verify that target zone is midline over the manubrium 6. Remove sharp protector and position introducer in the target perpendicular to the skin 7. Push introducer with gradually increasing force until the introducer release is heard and felt 8. Remove the introducer and replace the sharp protector 9. Connect the infusion tubing to the male connector on the patch 10. Attach the female connector and begin running fluids; check for infiltration. 12. Apply protector dome to site 13. Ensure the removal kit accompanies patient to the hospital and is given to ED personnel with removal instructions taped to IV bag for transport ONLY (1) ATTEMPT SHOULD BE MADE USING THIS DEVICE 22

330 INTRAOSSEOUS (IO) INFUSION EZ-IO CIRCULATION / SHOCK INTRAOSSEOUS INFUSION EZ-IO ADULT SYSTEM: (For Paramedics trained in technique) INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Wt. >40 kg Unable to access peripheral IV Altered level of consciousness Arrhythmias Burns Cardiac arrest Dehydration Head injury Hypotension Respiratory arrest Seizures Shock Traumatic injuries Other medical conditions when immediate vascular access is required Fracture of the tibia or humerus Previous orthopedic procedures Pre-existing medical condition Infection at the insertion Inability to locate landmarks Excessive tissue over the insertion site PROCEDURE A Advanced A 1. Select site: Tibia medial to the tibial tuberosity on flat plane of tibia or Humerus upper lateral humeral head, outer aspect 2. Provide routine medical care 3. Locate the anatomical site and prep with Betadine and/or alcohol 4. Infiltrate the site (just below the dermis) with several cc s of 1% Lidocaine 5. Load the needle onto the driver 6. Firmly stabilize the area near (not under) the insertion site 7. Firmly press the needle against the site at a 90 0 angle and operate the driver, use firm, gentle pressure 8. As the needle reaches the bone, stop and be sure that the 5mm marking on the needle is visible; if it is, continue to operate the driver 9. When a sudden decrease in resistance is felt and the flange of the needle rests against the skin, remove the driver and remove the stylet from the catheter 10. Slowly Inject 1-2cc (20-40mg) bolus of Lidocaine into bone marrow for adult patients. Allow Lidocaine to dwell in IO space for at least 60 seconds prior to NS flush in conscious patients 11. Use a syringe to infuse cc s 9%NS 12. If no s/s of infiltration are found, attach the IV line and infuse fluids and medications as normal (IV bag will need to be under pressure) 13. Secure the needle and dress the site 23

331 CIRCULATION / SHOCK INTRAOSSEOUS (IO) INFUSION MANUAL PEDIATRIC SYSTEM INTRAOSSEOUS INFUSION - PEDIATRIC SYSTEM: INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Life threatening illness or injury in a child 6 years of age (72 months) after effective ventilation is established Unresponsive Cardiopulmonary arrest Decompensated shock This procedure is indicated primarily in children less than 8 years old A pediatric patient who is conscious or responsive to pain A pediatric patient who is 7 years old or older Gross infection, osteomelitis, or cellulitis at the intended site (use the other leg if possible) Fracture at or above the intended site (use the other leg if possible) Unsuccessful IO attempt (use the other leg if possible) A Advanced A PROCEDURE: Manual IO Device: Expose the lower leg Identify the tibial tubercle (bony prominence below the knee cap) on the proximal tibia; the insertion location will be 1-2 cm (2 finger widths) below this and medially Prep the site as per peripheral IV site Attempt to have feet in flexed position against board or sandbag Needle insertion varies between 70 and 90 degree angle to the skin surface, approximately one to two finger breadths distal to the tibial tuberosity; with a straight steady push and/or rotary motion, push needle through subcutaneous tissue and bone until a drop or pop is felt Remove the trocar and attach the IV Once the needle has reached the bone marrow, saline should be injected via syringe to clear needle Observe for signs of subcutaneous infiltration The needle should feel firm in position and stand upright without support Stabilize and secure the needle with a hemostat, 4x4 pads and tape Infusion via this route is the same as venous access without limit to rate of administration, drugs pushed or fluid type infused, pressure infusor may be necessary to facilitate flow Document the procedure, time, and result (success) on/with the patient care report (PCR) 24

332 CIRCULATION / SHOCK INTRAOSSEOUS (IO) INFUSION EZ-IO PEDIATRIC A Advanced A INTRAOSSEOUS INFUSION EZ-IO PEDIATRIC SYSTEM: (For Paramedics Trained in Technique) Patient Weight between 3 to 39 Lbs. Follow procedures for EZ-IO Adult System protocol however EZ IO anesthetic dose 0.5mg/kg IO not to exceed 40mg. Allow Lidocaine to dwell in the IO space at least 60 seconds. Then flush with 10cc NS IF ATTEMPT UNSUCCESSFUL, REMOVE NEEDLE AND APPLY PRESSURE TO AREA FOR 5 MINUTES. INTRAOSSEOUS INFUSIONS OF FLUID MAY CAUSE SUBCUTANEOUS INFILTRATION, OSTEOMYELITIS, OR SUBCUTANEOUS INFECTIONS. KEY POINTS An IO can administer any medication or fluid that can be administered by an IV. Consider using a three-way stopcock, and a syringe with the IV tubing. Use the pull-push method to infuse fluid. A blood pressure cuff may have to be used to apply pressure to the IV bag to maintain an adequate flow rate. An IO can be attempted prior to attempting an IV if the patient is in cardiac arrest or is in decompensated shock 25

333 CIRCULATION / SHOCK RESQPOD An Impedance Threshold Device (ITD) that provides Perfusion on Demand (POD) by regulating pressure in the thorax during CPR. INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS To be used during CPR with either a BVM, ET tube or BID (King LT / LTSD or Combitube) Cardiac Arrest Spontaneously breathing patients The ResQPOD: o Doubles blood flow to the heart o Increases blood flow to the brain by 50% o Doubles systolic BP o Increases survival rates o Increases the likelihood of successful defibrillation o Circulates drugs more effectively B EMT B A Advanced A Using the ResQPOD on a facemask (BVM) 1. Connect the ResQPOD to the facemask 2. Open the airway. Maintain a tight face seal throughout chest compressions using the 2 handed technique. 3. Connect the ventilation source to the ResQPOD. (Bag or mouthpiece) 4. Perform CPR at 30:2 ratio Using the ResQPOD on an ET tube or BIAD. 1. Confirm tube placement and secure. 2. Connect the ResQPOD to the tube. 3. Connect the ventilation source 4. Perform continuous chest 100/min. 5. Remove clear tab and turn on the timing assist light. Ventilate asynchronously at the timing light flash rate of 10/min. DO NOT HYPERVENTILATE 6. Place Capnography or ETCO2 detector between the ResQPOD and the ventilation source. 26

334 CIRCULATION / SHOCK RESQGARD An Impedance Threshold Device (ITD) that provides a rapid non-invasive way to treat low blood pressure in spontaneously breathing patients. INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Treats Hypotension due to: Orthostatic Intolerance Early sepsis Anesthesia & analgesia Dehydration Blood Loss Unknown causes PROCEDURE: Hypotension in Breathing patients Low or no respiratory drive Intolerance to device B EMT B A Advanced A` Using the ResQGard on a facemask: 1. Connect the ResQGard to the facemask 2. Explain to the patient that they will feel slight resistance when inhaling. This means the device is working and helping to improve blood flow. 3. Hold the mask over the nose and mouth, maintaining a tight facemask seal. Attach the strap when patient is comfortable with the device. 4. Have the patient 10-16/min. Inhaling slowly (over 2-3 secs.) and deeply: exhale normally. Using the ResQGard with a mouthpiece: 1. Connect the ResQGard to the mouthpiece. 2. Explain to the patient that they will feel slight resistance when inhaling. This means the device is working and helping to improve blood flow. 3. Place the mouthpiece into the mouth and maintain a tight seal with the lips. 4. Breathe in through the mouth 10-16/min. An optional nose clip prevents breathing through the nose. 5. Have the patient 10-16/min. Inhaling slowly (over 2-3 secs.) and deeply: exhale normally. o Attach supplemental O2 as needed. o Monitor vitals frequently. o If BP rises to acceptable level or patient will not tolerate, remove the ResQGard. o Reapply if BP drops again. 27

335 MEDICAL PROCEDURES NICOM Monitor B EMT B A Advanced A INDICATIONS Any medical patient that meets the following will have the NICOM Monitor applied: o Any patient is Hypotensive with a systolic blood pressure of <90 PROCEDURE 7. Scene size-up: universal precautions, scene safety, environmental hazards assessment, bystander safety, and patient/caregiver interaction 8. Assess need for additional resources 9. Initial assessment: general impression as well as the status of a patient s airway, breathing, and circulation 10. Control major hemorrhage and assess overall priority of patient 11. Assess mental status and disability (e.g., GCS, AVPU) 12. Perform a focused history and physical based on patient s chief complaint 13. Assess need for critical interventions 14. Complete critical interventions and perform a complete secondary exam to include a baseline set of vital signs as directed by protocol 15. Establish IV/IO access 16. Apply the NICOM Monitor as indicated per the manufacture 17. Wait approximately 90 seconds for monitor to calibrate 18. Record the baseline readings for the CI (Cardiac Index), CO (Cardiac Output) and SVI (Stroke Volume Index) and report these findings to Medical Command 19. Treat the patient as per the appropriate protocol 20. Start IV Fluid Bolus if indicated prior to arrival at the Emergency department. Normal Values CI I/min/m 2 CO I/min SVI ml/m 2 /beat 28

336 MEDICAL BLOOD GLUCOSE ANALYSIS INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Patients with suspected hypoglycemia (diabetic emergencies, change in mental status, bizarre behavior, etc.) Medical alert tags Drug / Toxic ingestion PROCEDURE Decreased mental status Change in baseline mental status Bizarre behavior Hypoglycemia: cool, diaphoretic skin Hyperglycemia: warm, dry skin; fruity breath; Kussmal resps; signs of dehydration Insufficient training B EMT B A Advanced A 1. Gather and prepare equipment 2. Blood samples for performing glucose analysis may be obtained simultaneously with intravenous access 3. Place correct amount of blood on reagent strip or site on glucometer per the manufacturer's instructions 4. Time the analysis as instructed by the manufacturer 5. Document the glucometer reading and treat the patient as indicated by the analysis and protocol 6. Repeat glucose analysis as indicated for reassessment after treatment and as per protocol KEY POINTS Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia. Low glucose (< 70), normal glucose (70-120), high glucose ( > 250). Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure. 29

337 MEDICAL MEDICATION INJECTION INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS When medication administration is necessary and the medication must be given via the SQ or IM route or as an alternative route in selected medications Determined per protocol Allergy to medication per protocol Aspiration of blood INTRAMUSCULAR (IM) A Advanced A PROCEDURE 1. Receive and confirm medication order or perform according to standing orders 2. Prepare equipment and medication expelling air from the syringe 3. Explain the procedure to the patient and reconfirm patient allergies 4. The possible injection sites for intramuscular injection include the arm, buttock and thigh, injection volume should not exceed 1 cc for the arm and not more than 2 cc in the thigh or buttock. 5. The thigh should be used for injections in pediatric patients and injection volume should not exceed 1 cc 6. Expose the selected area and cleanse the injection site with alcohol 7. Hold intramuscular syringe at 90 degree angle, with skin pinched and flattened 8. Insert the needle into the skin with a smooth, steady motion 9. Aspirate for blood 10. Inject the medication 11. Withdraw the needle quickly and dispose of properly without recapping 12. Apply pressure to the site 13. Monitor the patient for the desired therapeutic effects as well as any possible side effects 14. Document the medication, dose, route, and time on/with the patient care report (PCR) SUBCUTANEOUS (SG) PROCEDURE 1. Receive and confirm medication order or perform according to standing orders 2. Prepare equipment and medication expelling air from the syringe 3. Explain the procedure to the patient and reconfirm patient allergies 4. The most common site for subcutaneous injection is the arm. Injection volume should not exceed 1 cc 5. The thigh should be used for injections in pediatric patients and injection volume should not exceed 1 cc 6. Expose the selected area and cleanse the injection site with alcohol 7. Hold subcutaneous syringe at 45 degree angle 8. Insert the needle into the skin with a smooth, steady motion 9. Aspirate for blood 10. Inject the medication 11. Withdraw the needle quickly and dispose of properly without recapping 12. Apply pressure to the site 13. Monitor the patient for the desired therapeutic effects as well as any possible side effects 14. Document the medication, dose, route, and time on/with the patient care report (PCR) 30

338 MEDICAL ORTHOSTATIC BLOOD PRESSURE MEASUREMENT INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Patient situations with suspected blood / fluid loss / dehydration Patients > 8 years of age, or patients larger than the Broselow-Luten tape Abdominal pain Dizziness / Lightheaded Pregnancy Syncope Prepare for patient being unsteady on feet Unstable patient B EMT B A Advanced A PROCEDURE 1. Assess the need for orthostatics 2. Obtain patient s pulse and blood pressure while supine 3. Have patient stand for one minute 4. Obtain patient s pulse and blood pressure while standing 5. If pulse has increased by 20 bpm or systolic blood pressure decreased by 20 mmhg, the orthostatics are considered positive 6. If patient is unable to stand, orthostatics may be taken while the patient is sitting with feet dangling 7. If positive orthostatic changes occur while sitting, DO NOT continue to the standing position 8. Document the time and vital signs for supine and standing positions in the patient care report (PCR) 9. Determine appropriate treatment based on protocol 31

339 MEDICAL PAIN ASSESSMENT PROCEDURE INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Injury / Illness requiring pain management Abdominal pain Chest pain secondary to infarction or angina Acute urinary retention Fractures Severe burns Kidney stones Musculoskeletal trauma Altered level of consciousness Head injuries Chest injuries (blunt or penetrating) Intoxication Maxillofacial injuries Psychiatric problems Pediatric patients under 12 years of age Pregnancy Respiratory distress B EMT B A Advanced A 1. Initial and ongoing assessment of pain intensity and character is accomplished through the patient s self report 2. Pain should be assessed and documented during initial assessment, before and after starting pain control treatment, and with each set of vitals 3. Pain should be assessed using the appropriate approved scale 4. Two pain scales are available: the 0-10 and the Wong - Baker "Faces" scale Scale: the most familiar scale used by EMS for rating pain with patients. It is primarily for adults and is based on the patient being able to express their perception of the pain as related to numbers. Avoid coaching the patient, simply ask them to rate their pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst pain ever. 6. Wong - Baker Faces scale: this scale is primarily for use with pediatrics but may also be used with geriatrics or any patient with a language barrier. The faces correspond to numeric values from This scale can be documented with the numeric value or the textual pain description. KEY POINTS Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain is subjective (whatever the patient says it is) The Wong-Baker Faces Pain Rating Scale Designed for children aged 3 years and older, the Wong-Baker Faces Pain Rating Scale is also helpful for elderly patients who may be cognitively impaired. If offers a visual description for those who don't have the verbal skills to explain how their symptoms make them feel. To use this scale, your doctor should explain that each face shows how a person in pain is feeling. That is, a person may feel happy because he or she has no pain (hurt), or a person may feel sad because he or she has some or a lot of pain. A Numerical Pain Scale A numerical pain scale allows you to describe the intensity of your discomfort in numbers ranging from 0 to 10. Rating the intensity of sensation is one way of helping your doctor determine treatment. Numerical pain scales may include words or descriptions to better label your symptoms, from feeling no pain to experiencing excruciating pain. Some researchers believe that this type of combination scale may be most sensitive to gender and ethnic differences in describing pain. 32

340 MEDICAL PATIENT RESTRAINT INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Immobilization of an extremity for transport, either due to suspected fracture, sprain, or injury Immobilization of an extremity for transport to secure medically necessary devices such as intravenous catheters Patient out of control and may cause harm to self or others Necessary force required for patient control without causing harm Head trauma Alcohol/Drug related problems Metabolic disorders (i.e. hypoglycemia, hypoxia, etc.) Psychiatric/Stress related disorders None if warranted B EMT B A Advanced A Secure Cot Straps nips, hips, knees Tie to Bottom Rail Tie to Bottom Rail Tie to Bottom Rail Use Oxygen Mask or PPF Tie to Bottom Rail Use Kerlix or Kling to tie arms and legs Or Soft Restraints KEY POINTS Soft restraints are to be used only when necessary in situations where the patient is potentially violent and may be of danger to themselves or others. EMS providers must remember that aggressive violent behavior may be a symptom of medical conditions. Patient heath care management remains the responsibility of the EMS provider. The method of restraint shall not restrict the adequate monitoring of vital signs, ability to protect the patient s airway, compromise peripheral neurovascular status or otherwise prevent appropriate and necessary therapeutic measures. It is recognized that evaluation of any patient parameters requires patient cooperation and thus may be difficult or impossible. All restraints should have the ability to be quickly released, if necessary. Restraints applied by law enforcement (i.e. handcuffs) require a law enforcement officer to remain available to adjust restraints as necessary for the patient s safety. This policy is not intended to negate the need for law enforcement personnel to use appropriate restraint equipment to establish scene control. Patients shall not be transported in a face down prone position to endure adequate respiratory and circulatory monitoring and management. Restrained extremities should be monitored for color, nerve and motor function, and pulse quality. Place mask on patient for body secretion protection. May use TB mask, or non-rebreather if patient needs oxygen. Use supine or lateral positioning ONLY. Frequent distal neurovascular checks are required. DOCUMENT methods used and reason for restraint. 33

341 Excel Cryo Cooling System (Cool Collar) MEDICAL B EMT B A Advanced A The Excel Cryo Cooling System is a unique, single use device to induce mild cerebral therapeutic hypothermia. It should be used on all cardiac arrest patients who have achieved a return to spontaneous circulation ROSC as per the Induced Hypothermia Protocol. This system is composed of a unique collar with a specialized door that works in conjunction with the Excel Cryo Cooling Elements, properly aligning the Excel Cryo Cooling Element with the patient s carotid triangle and immobilizing the patient s cervical spine. Heat is extracted from the blood as it passes through the arteries inducing mild hypothermia. PROCEDURE 1. Place the collar on the person neck as you would any other C-Collar 2. Once the collar is properly placed on the patient, the Excel Cryo Cooling Element must be activated. (Manufacture supplied cold pack) 3. Once activated, open the collar door and insert the Excel Cryo Cooling Element 4. The Excel Cryo Cooling Element should be replaced every 20 minutes. 5. Cooling should be maintained throughout transport of the non-responsive ROSC patient 6. If the patient begins to respond of shiver remove the cooling element and notify Medical Command. 34

342 TRAUMA CERVICAL SPINE IMMOBILIZATION INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Need for spinal immobilization as determined by protocol Traumatic injury Suspected traumatic injury Unresponsive / Altered LOC of unkown origin Mechanism of Injury Insufficient training B EMT B A Advanced A PROCEDURE 1. Gather a backboard, straps, C-collar appropriate for patient s size, tape, and head rolls or similar device to secure the head 2. Explain the procedure to the patient 3. Place the patient in an appropriately sized C-collar while maintaining in-line stabilization of the C-spine. This stabilization, to be provided by a second rescuer, should not involve traction or tension but rather simply maintaining the head in a neutral, midline position while the first rescuer applies the collar. 4. Once the collar is secure, the second rescuer should still maintain their position to ensure stabilization (the collar is helpful but will not do the job by itself) 5. Place the patient on a long spine board with the log-roll technique if the patient is supine or prone. For the patient in a vehicle or otherwise unable to be placed prone or supine, place them on a backboard by the safest method available that allows maintenance of inline spinal stability. 6. Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is secured to the backboard, the second rescuer may release manual in-line stabilization. 7. NOTE: Some patients, due to size or age, will not be able to be immobilized through inline stabilization with standard backboards and C-collars. Never force a patient into a non-neutral position to immobilize them. Such situations may require a second rescuer to maintain manual stabilization throughout transport to the hospital. 8. Document the time of the procedure in the patient care report (PCR) 35

343 KEY POINTS Use of a backboard for stabilization injuries other than the neck or to move the patient, does not automatically require cervical immobilization Never leave patients alone if they are fully immobilized; be prepared to turn the long board while maintaining C-spine stabilization if the patient begins to vomit A C-collar by itself does NOT adequately immobilize the patient Document the decision to not provide cervical spine immobilization if not performed Trauma In trauma cases the neck should be immobilized under any of the following circumstances: The patient complains of neck pain, pain on palpation, or pain with range of motion The patient complains of numbness, tingling, or motor weakness in any extremity Mechanism of injury with other distracting injuries The patient has a head injury, altered mental status, or language barrier, which limits the patient s ability to describe pain, numbness or weakness Any time the paramedic or EMT judges that cervical immobilization is necessary Mechanism of injury with patient intoxication If the history suggests a mechanism of injury, which could result in cervical injury in a patient who is intoxicated, cervical immobilization must be provided whether or not the patient is alert and oriented This does not mean that every grossly intoxicated patient who is unable to provide reliable responses should have cervical immobilization If the mechanism of injury is such that a neck injury is not a reasonable possibility, cervical immobilization is not indicated ; I.E. if a call involves a grossly intoxicated person who has an isolated ankle injury after a simple fall Pediatric Considerations: Small children (less than 8 years of age) have relatively large heads. Use of standard cervical immobilization and backboards will result in cervical flexion. Use an immobilization method that avoids flexion of the neck. Current approved methods include, but are not limited to;: Devices which have a recess for the child s occiput (Pedipak with padding applied) Placing the patient into the sniffing position by placing padding under the shoulders and lower back Cervical collars should be used along with any of these modifications, unless there is not an appropriate size c-collar; if a circumstance prevents the use of a c-collar, other approved methods of immobilization include; Manual immobilization Blanket or towel roll immobilization Tape immobilization 36

344 TRAUMA HELMET REMOVAL REMOVAL OF HELMET Inability to access, assess and maintain airway and breathing Improperly fitted helmet allowing for excessive head movement within helmet Proper C-spine alignment and immobilization cannot be achieved Cardiac arrest EMT s are trained in technique LEAVE HELMET IN PLACE Helmet fits well with little or no movement of head in helmet No impending airway or breathing problems Removal may cause further injury Proper C-spine alignment and immobilization can be achieved with helmet in place There is no interference with the ability to assess and reassess airway and breathing B EMT B A Advanced A KEY POINTS Helmet Types 1. Sport (Football, Ice Hockey, Field Hockey, Fencing, Baseball) Typically open anteriorly Easier to access airway If shoulder pads are used in conjunction with helmet and helmet is removed then shoulder pads need to be removed simultaneously for proper C-spine alignment 2. Motorcycle/ Bike/ Skateboarding When full-faced, airway is harder to access and maintain Face shield may be removed for airway access SPORT HELMET PROCEDURE 1. Most athlete type helmets fit tightly, especially football. They should be left in place. 2. All are equipped to have the facemask removed separate from the helmet. In most cases, removal of facemask is all that is needed, as the alignment of the C-spine can be done with shoulder pads and helmet in place. 3. Removal of the facemask may be done by cutting snubber straps that hold it in place to access the airway. 4. Removal: If the helmet must be removed due to unusual circumstances, at least 4 people are needed. Shoulder pads need to simultaneously be removed. When shoulder pads are involved, use forearms to stabilize helmet and place hands at the base of the neck grasping the shoulder area. While maintaining manual c-spine, the helmet s inside face pads may be loosened by use of a tongue blade to unsnap them with a twisting motion. Then, cut the shoulder pads laces and straps and all shirts and jerseys from the end of the sleeve to the center to allow for quick removal. 37

345 Lift the patient flat up for removal of equipment. The helmet should be grasped and tilted slightly to remove DO NOT SPREAD SIDES OR BACK EDGE OF HELMET, IT WILL IMPINGE UPON NECK. At same lift, pull off shoulder pads and clothing. Lower patient down and apply C-collar. MOTORCYCLE/ BIKE/ SKATEBOARDING HELMET PROCEDURE 1. Usually do not fit tightly and may allow movement of head inside helmet 2. If head can move, no C-spine immobilization is possible 3. Some have separate face piece that can be moved for airway access 4. Some have full face design that is not moveable where chin section is a rigid continuation of the helmet 5. C-spine alignment is difficult due to no shoulder padding; must create a pad to form straight alignment 6. If unable to secure C-spine or airway, the helmet should be removed at the scene 7. Removal: Take eyeglasses off before removal of the helmet One EMT stabilizes the helmet by placing hands on each side of the helmet with fingers on mandible to prevent movement Second EMT removes any straps by cutting them Second EMT places one hand on the mandible at the angle of the jaw and the other hand posteriorly at the occipital region The EMT holding the helmet pulls the sides of the helmet outwards away from the head and gently slips the helmet halfway off and stops The EMT maintaining stabilization of the neck repositions hold by sliding the posterior hand superiorly to secure the head from falling back after complete helmet removal Helmet is then completely removed 38

346 OBSTETRICS NORMAL CHILDBIRTH INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Imminent delivery with crowning Urge to push Visible crowning See Gynecological Emergencies PROCEDURE B EMT B A Advanced A 1. Delivery should be controlled so as to allow a slow controlled delivery of the infant. this will prevent injury to the mother and infant 2. Support the infant s head as needed 3. Check the umbilical cord surrounding the neck; if it is present, slip it over the head, if unable to free the cord from the neck, double clamp the cord and cut between the clamps 4. Suction the airway with a bulb syringe (mouth then nose) 5. Grasping the head with hands over the ears, gently pull down to allow delivery of the anterior shoulder 6. Gently pull up on the head to allow delivery of the posterior shoulder 7. Slowly deliver the remainder of the infant 8. Clamp the cord 2 inches from the abdomen with 2 clamps and cut the cord between the clamps 9. Record APGAR scores at 1 and 5 minutes 10. Follow the Newly Born Protocol for further treatment 11. The placenta will deliver spontaneously, within 5-15 minutes of the infant, do not force the placenta to deliver; contain all tissue in a plastic bag and transport 12. Massaging the uterus may facilitate delivery of the placenta and decrease bleeding by facilitating uterine contractions 13. Continue rapid transport to the hospital 39

347 PHARMACOLOGY NITRONOX - NITROUS OXIDE ADMINISTRATION INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Injury/illness requiring pain management Patient able to self-administer Chest pain secondary to infarction or angina Acute urinary retention Fractures Severe burns Kidney stones Musculoskeletal trauma Altered level of consciousness Head injuries Chest injuries (blunt or penetrating) Intoxication Maxillofacial injuries Psychiatric problems COPD (because of the 50% oxygen mixture) Pediatric patients under 12 years of age Pregnancy Respiratory distress Abdominal pain A Advanced A PROCEDURE 1. Instruct patients to administer Nitronox to themselves by placing the mask tightly against their face and breathing deeply and slowly 2. Allow mask to fall away from face spontaneously when effects are felt 3. Check blood pressure - Nitronox may cause BP to drop in some cases KEY POINTS Nitronox is a self-administered analgesic gas containing a mixture of 50% oxygen and 50% nitrous oxide Nitronox is supplied in a carrying case containing two cylinders, one of nitrous oxide and one containing oxygen, with a mixing valve and supply tubing. These agents are mixed on administration to deliver a 50% concentration of each to the patient. Negative pressure is required to open the valve, so the patient must have an airtight seal at the face mask. Nitronox can be given to any patient who is alert and complaining of severe pain Nitronox should never be administered by the EMT or Paramedic, only self-administration by the patient is to be used Upon administration of Nitronox, constantly monitor patient to see that he/she does not fall asleep with mask in place The side effects of nitrous oxide, in addition to analgesia, include lightheadedness, drowsiness, nausea and vomiting, changes in heart rate and respiratory rate are minimal Nitrous oxide and oxygen are both non-flammable gases, but both support combustion, for this reason do not use Nitronox in areas where there is a combustion hazard. There is an increased risk of liver cancer and birth defects to individuals who are exposed to repeated applications of nitrous-oxide. For this reason Nitronox should be used in a well-ventilated environment. 40

348 NERVE AGENT EXPOSURE - MARK 1 KIT SPECIAL OPERATIONS INDICATIONS SIGNS AND SYMPTOMS CONTRAINDICATIONS Exposure to chemical, biologic, radiologic, or nuclear hazard Potential exposure to unknown substance/hazard For use by Fire, EMS, and Police personnel only Visual disturbances Headache Nausea/Vomiting Salivation Lacrimation Respiratory distress Diaphoresis Seizure activity Respiratory arrest Nerve agent exposure (e.g. VX, Sarin, Soman, etc.) Organophosphate exposure (pesticide) Vesicant exposure (e.g. Mustard Gas, etc.) Respiratory Irritant exposure (e.g. Hydrogen Sulfide, Ammonia, Chlorine, etc.) KEY POINTS If Triage/MCI issues exhaust supply of Mark 1 kits, use atropine, give 2 mg dose for patients greater than 90 pounds (>40kg) Follow local HAZMAT protocols for decontamination and use of personal protective equipment For patients with major symptoms, there is no limit for atropine dosing Carefully evaluate patients to ensure they have not been exposure to another agent (e.g., narcotics, vesicants, etc.) Each Mark 1 kit contains 600 mg of pralidoxime (2-PAM) and 2 mg of atropine If the presence of a nerve agent is suspected by presentation of symptoms of large numbers of patients, personnel should immediately contact dispatch to notify other responding units and command staff The patient and/or crew must be decontaminated prior to transport. DO NOT transport a contaminated patient to a treatment facility SLUDGEM: Salivation, Lacrimination, Urination, Defication, Gastrointestinal upset, Emesis, Muscle twitching When the nerve agent has been ingested, exposure may continue for some time due to slow absorption from the lower bowel, and fatal relapses have been reported after initial improvement If dermal exposure has occurred, decontamination is critical and should be done with standard decontamination procedures; patient monitoring should be directed to the same signs and symptoms as with all nerve or organophosphate exposures Continued medical monitoring and transport is mandatory Atropine must be given first, do not give anything else until the effects of atropine become Apparent.only when the effects of the atropine have been seen can you then give 2 - PAM CL Pralidoxime (2-PAM CL) is most effective if administered immediately after the poisoning but not before atropine, especially for severe exposures 41

349 NERVE AGENT EXPOSURE - MARK 1 KIT SPECIAL OPERATIONS ENSURE SCENE SAFETY AND PROPER PPE B EMT B A Advanced A M MED CONTROL M MINOR SYMPTOMS: Salivation Lacrimation Visual Disturbances ATROPINE 2 mg IV/IM q5 minutes until symptoms resolve UNIVERSAL PATIENT CARE PROTOCOL Obtain history of exposure Observe for specific toxidromes Initiate triage and/or decontamination as indicated Assess for presence of major or minor symptoms MAJOR SYMPTOMS: Altered LOC Seizures SOB Respiratory Arrest MARK 1 KIT x 3, IM Rapidly PRALIDOXIME 2 grams (15 25 mg/kg for PEDS) IV over 30 minutes If Seizures: VALIUM 5-10 mg IV/IM Monitor for appearance of major symptoms ATROPINE 2 mg IV/IM q 5 minutes until symptoms resolve CONTACT MEDICAL CONTROL TRANSPORT 42

350 SPECIAL OPERATIONS TASERED PATIENT ALL PATIENTS SUBJECTED TO TASER USE MUST BE TRANSPORTED TO THE HOSPITAL FOR MEDICAL EVALUATION INDICATIONS Any patient that was subjected to taser use B EMT B A Advanced A PROCEDURE Follow Universal Patient Care Protocol Confer with Law Enforcement Officer regarding the patient s behavior prior to EMS arrival Refer to the appropriate medical protocol if the patient has a life-threatening injury or medical illness or continues to be combative Determine the location of the Taser probes, do not remove probes unless they interfere with patient care Perform a 12-Lead EKG and continuously monitor the patient s EKG, if the patient has a dysrhythmia, refer to the appropriate protocol. KEY POINTS With the increased use and deployment of TASERs by our area s local law enforcement agencies, EMS providers must be aware of the appropriate medical assessment of the tasered patient. The TASER is designed to transmit electrical impulses that temporarily disrupt the body's central nervous system. Its Electro-Muscular Disruption (EMD) Technology causes an uncontrollable contraction of the muscle tissue, allowing the TASER to physically debilitate a target regardless of pain tolerance or mental focus. All patients subjected to taser use must be assessed for trauma and medical causes for the combative behavior Always apply the cardiac monitor and obtain a strip for patients with irregular / abnormal pulse, elderly, pacer, AICD, known CAD, and excited delirium The patient s vital signs must be reassessed every 5 minutes Determine if the patient used any mind altering stimulants, has a cardiac history, and the date of their last Tetanus shot The cord or wire may be cut, but leave the probes embedded in the patient Removal of the probe if necessary: (Remove one at a time) Stabilize the skin surrounding the puncture site by placing one hand by where the probe is embedded. Pull the probe straight out from the puncture site in one fluid motion. TASER barbs that do penetrate the skin and are removed in the field are to be treated as contaminated sharps and are to be placed in an appropriate red box sharps container. Use small single use containers as law enforcement may wish to hold custody of the barbs after removal. 43

351 OTHER OPERATIONS INFECTIOUS EXPOSURE o University Hospitals has established a Pre-Hospital Providers Exposure to Infectious Disease(s) Policy. o It is designed to provide you with guidelines that must be followed in the event of an exposure. The Policy states: Any pre-hospital provider who believes he/she has suffered a significant exposure through contact with a patient may submit a written request for the notification of the presence of a contagious or infectious disease in the patient and/or results of any test performed on the patient to determine the presence of a contagious or infectious disease. Infection Control or designee will notify any prehospital provider who has been identified as having been exposed to a contagious or infectious disease. As required by Ohio Revised Code , any UH system hospital will respond to a prehospital provider s written request for notification of the presence of a contagious or infectious disease or the results of any test performed on the patient to determine the presence of a contagious or infectious disease in a patient received by UH. Go to our website to print off the policy and forms that you will need to fill out if you have an exposure. 44

352 OTHER OPERATIONS BLOOD COLLECTION FOR EVIDENCE (OHIO SENATE BILL 58) Ohio Senate Bill 58 became Law in September The Law includes provisions for EMS providers to withdraw blood for the purpose of evidence collection in cases involving allegations of operating watercraft or vehicles under the influence. The language of the bill states that drawing blood may not shall be done for evidence collection in the course of providing emergency medical treatment. o You CANNOT be dispatched or called by the police for the sole purpose of performing phlebotomy when the person does not require emergency medical treatment. o The Medic/EMTI in charge can refuse law enforcements request to draw the blood if doing so would interfere with life saving patient care or outcome. o The patient must consent to the collection of blood for evidence purposes. (If unconscious, Implied Consent applies) o The Police Officer making the request must be present at all times during the draw and must provide the Medic/EMTI with the evidence collection kit. o EMS Providers MUST use the evidence kit provided by law enforcement to obtain the blood samples for evidence. 45