EMR Medical Directives and Guidelines

Transcription

1 EMR Medical Directives and Guidelines Central East Prehospital Care Program, May 1, 2009 Section One 1

2 USE OF MEDICAL DIRECTIVES / GUIDELINES These medical directives and guidelines are not intended to be all encompassing of the complex medical and trauma situations that may be encountered in the field. Since patients do not always fit into a cook book approach, these medical directives and guidelines are not a substitute for good judgment. As a Firefighter / First Responder, it is your responsibility to assess the situation and use your knowledge and skills to benefit the patient while remaining within your scope of practice. We would strongly recommend that if you are involved in a situation that does not fall within a specific directive and/or guideline as outlined for your level of certification, that you contact the Central East Prehospital Care Program (CEPCP) as soon as possible. DELEGATION The Firefighter / First Responder is the extension of the physician in the field and provides care under the direction of the Base Hospital Medical Directors of the CEPCP. The Firefighter / First Responder receives delegation from the Medical Director through written medical directives. The Firefighter / First Responder does not receive delegation from an on-scene physician, nor should the Firefighter / First Responder delegate to another defibrillation provider or citizen. The medical directives that are associated with the use of a Semi-Automated External Defibrillator (SAED) fall under the auspices of delegation. RESPONSIBILITY With the development of SARS (Severe Acute Respiratory Syndrome), the Firefighter / First Responder must recognize their obligation to protect themselves and others while providing patient care. It is strongly recommended that the Firefighter / First Responder utilize all available personal protective equipment (PPE) precautions to limit personal exposure and disease transmission. It is important to note that not all victims of infectious respiratory illnesses are febrile, and some prehospital interventions may increase the risk of contamination. The Firefighter / First Responder must use their judgment and investigative skills to identify situations of risk and take appropriate protective steps. Central East Prehospital Care Program, May 1, 2009 Section One 2

3 CARDIAC ARREST GENERAL MEDICAL DIRECTIVE When the following indications and conditions exist, a Firefighter / First Responder may treat victims of cardiac arrest according to the following: Indications Conditions Patient is in cardiac arrest (Vital Signs Absent - VSA). Patient is 1 year old for application of an SAED. Contraindications Procedure 1. Patients who meet the criteria for obvious death. 2. Patients who have a valid and completed Ministry of Health (MOH) DNR Confirmation form or a York / Durham Base Hospital approved DNR form. 1. Confirm VSA by the absence of spontaneous respirations and palpable pulses. 2. Initiate airway management, oxygen, ventilation, and CPR. 3. Initiate therapy outlined in a directive according to the causative agent and based upon SAED prompts received. Central East Prehospital Care Program, July 1, 2009 Section One 3

4 MEDICAL CARDIAC ARREST MEDICAL DIRECTIVE Indication: Patient who is in a medical cardiac arrest Procedure: 1. Ensure Scene Safety 2. Establish Unresponsiveness (AVPU) 3. Open airway and check breathing for 3 6 seconds 4. If no breathing, insert an oral airway and ventilate x 2 with a BVM to ascertain airway patency 5. Check for signs of circulation including carotid pulse 6. If the arrest was unwitnessed, initiate 2 min of dedicated CPR. (If the arrest is witnessed, apply the cardiac monitor and proceed with an immediate analysis). 7. Attach the SAED and turn it on and follow the prompt to: Stop CPR and analyze Stand clear 8. a) If the rhythm is shockable, defibrillate according to the following chart Defibrillator standard AHA 2005 compliant # shocks delivered 1 CPR interval Reanalyze 2 minutes After 2 min of CPR b) If the rhythm is non-shockable, proceed to the next step. 9. Initiate 2 min of dedicated CPR followed by an assessment of signs of circulation and carotid pulse. 10. Continue the cycle of analysis defibrillation (if shockable) CPR circulation assessment. 11. Provide a report of patient care on arrival of EMS. Notes N/A Central East Prehospital Care Program, July 1, 2009 Section One 4

5 HYPOTHERMIA CARDIAC ARREST DIRECTIVE Indication: Patient who is in a medical cardiac arrest due to hypothermia. Procedure: 1. Ensure Scene Safety 2. Establish Unresponsiveness (AVPU) 3. Open airway and check breathing for 3 6 seconds 4. If no breathing, ventilate x 2 with a BVM to ascertain airway patency 5. Assess the patient s core temperature by feeling the abdomen 6. Check for signs of circulation including carotid pulse (minimum seconds) 7. If no pulse, initiate 2 minutes of dedicated CPR. 8. Attach the SAED and turn it on and follow the prompt to: Stop CPR and analyze Stand clear. 9. a) If the rhythm is shockable, defibrillate according to the following chart Defibrillator standard AHA 2005 compliant # shocks delivered 1 CPR interval Reanalyze b) If the rhythm is non-shockable, proceed to the next step. 2 minutes NONE 10. Initiate 2 min of dedicated CPR followed by an assessment of signs of circulation and carotid pulse. 11. Resume CPR and ignore subsequent defibrillator prompts to analyze. 12. Provide a report of patient care on arrival of EMS. Notes An oral airway should only be used if a patent airway cannot be maintained using manual airway management procedures. After the first analysis is complete, subsequent defibrillator prompts are to be ignored when following this directive. The Base Hospital recommends that you unplug your SAED pads if you have an SAED that analyzes automatically. Central East Prehospital Care Program, July 1, 2009 Section One 5

6 TRAUMA ARREST MEDICAL DIRECTIVE Indication: Patient is in cardiac arrest due to multiple system trauma: Procedure: 1. Ensure Scene Safety 2. Establish Unresponsiveness (AVPU) 3. Open airway and check breathing for 3 6 seconds 4. If no breathing, insert an oral airway and ventilate x 2 with a BVM to ascertain airway patency 5. Check for signs of circulation including carotid pulse 6. If no pulse, rapidly extricate the patient using C-spine precautions and initiate 2 minutes of CPR 7. a) If the cause of the cardiac arrest is PENETRATING trauma, continue to perform CPR until EMS arrives and DO NOT attach the SAED. b) If the cause of cardiac arrest is BLUNT trauma, attach the SAED and continue with the following steps; 8. Turn the SAED on and follow the prompt to: Stop CPR and analyze - Stand clear 9. a) If the rhythm is shockable, defibrillate according to the following chart Defibrillator standard AHA 2005 compliant # shocks delivered 1 CPR interval Reanalyze b) If the rhythm is non-shockable, proceed to the next step. 2 minutes NONE 10. Initiate 2 min of dedicated CPR followed by an assessment of signs of circulation and carotid pulse. 11. Resume CPR and ignore subsequent defibrillator prompts to analyze. 12. Provide a report of patient care on arrival of EMS. Notes If the cardiac arrest patient (regardless of cause) is trapped, or in a rescue situation where paramedics cannot safely enter, you should provide immediate extrication while attempting CPR for two minutes. Nothing should delay extrication, but if the patient is still trapped, or in a rescue situation after two minutes, then attempt to attach the SAED. If prompted, deliver one shock and upon completion of the shock all efforts should be put towards extricating the patient. After the first analysis is complete, subsequent defibrillator prompts are to be ignored when following this directive. The Base Hospital recommends that you unplug your SAED pads if you have an SAED that analyzes automatically. Central East Prehospital Care Program, July 1, 2009 Section One 6

7 NEONATAL RESUSCITATION MEDICAL DIRECTIVE When the following indications and conditions exist, a Firefighter / First Responder may treat pediatric victims of cardiac arrest/cardio-respiratory distress according to the following: Indications: Conditions: Patient is in cardiac arrest (Vital Signs Absent - VSA) or in severe cardio-respiratory distress. Patient is < 29 days of age Procedure: 1. Ensure Scene Safety 2. Establish level of responsiveness (AVPU). In the newly born: dry, warm, position, suction and stimulate as necessary 3. Open airway and check breathing for 3 6 seconds If not breathing: Insert an oral airway Ventilate x 2 with BVM to ascertain airway patency If breathing Administer blow-by oxygen (O 2 ) 4. Check for signs of circulation* including carotid/brachial pulse Assess the newly born using the APGAR scale If no pulse, start CPR: 120 compressions/min 3 compressions : 1 vent If pulse < 100 bpm: Secure the airway Ventilate with BVM at 40 breaths/min x 1 min 5. Reassess If no pulse and no breathing: Continue CPR If pulse < 60 bpm, start CPR: 120 compressions/min 3 compressions : 1 vent 6. Continue to reassess frequently 7. Provide a report of patient care on arrival of EMS. Notes If meconium is present in the airway of the newborn, the meconium must be suctioned prior to positive pressure ventilation. The mouth, nose and posterior (back) area of the oral cavity should be suctioned following delivery of head, or as soon as possible. *Signs of poor circulation include unresponsiveness, agonal or no breathing, cool skin temperature that is centrally cyanotic or mottled with delayed capillary refill. Central East Prehospital Care Program, July 1, 2009 Section One 7

8 RECOGNITION OF DEATH MEDICAL DIRECTIVE The medical directives for patients that have are Vital Signs Absent (VSA) should be followed, except in the following circumstances: 1. OBVIOUSLY DEAD The Firefighter / First Responder may presume death, and not initiate resuscitation, when one or more of the following gross signs of obvious death is present: Decapitation Transection Visible decomposition Putrefaction (smell) Otherwise (see below) Otherwise is delineated as: Grossly charred body Open head or torso wounds with gross outpouring of cranial or visceral contents Gross rigor mortis in a pulseless, apneic, warm patient In such cases, no treatment is required, but Central Communications contact is required to notify the Emergency Medical Services and the Police Department. Documentation Guidelines for the Firefighter / First Responder You need to complete a Medical Assist Report (MAR) for any cardiac arrest including: Date and time of the call Patient s name, address and date of birth Incident history, and assessment findings Names and/or I.D. numbers of EMS paramedics in attendance 2. EXPECTED DEATH DO NOT RESUSCITATE (DNR) Upon arrival at a scene a Firefighter / First Responder may be presented with a request NOT to initiate resuscitation. In order to consider the request, one of the following must be present: A. An appropriately completed Ministry of Health (MOH) DNR CONFIRMATION FORM (a sample is provided on page 12). OR B. A York/Durham Region recognized DO NOT RESUSCITATE MEDICAL DIRECTIVE AND FUNERAL HOME TRANSFER FORM order document clearly identifying the patient, the physician and any substitute decision-maker involved (a sample is provided on page 11). OR C. The attending physician is present and he/she indicates that he/she is the patient s physician and that resuscitation is not indicated. Central East Prehospital Care Program, July 1, 2009 Section One 8

9 If no physician is present, the Firefighter / First Responder will: Contact Central Communications: o stating the patient s condition o verifying the presence of valid documentation o ensure that Emergency Medical Services is responding o ensure that the Police department is responding Complete a MAR, leaving the white copy on-scene and retaining the others for distribution. Remain at the scene until EMS has arrived. If the family/attending physician is on scene, the Firefighter / First Responder will: Contact Central Communications: o stating the patient s condition o identifying the name of the physician on scene o ensure that Emergency Medical Services is responding Complete a MAR, leaving the white copy on scene and retaining the others for distribution. Documentation Guidelines for the Firefighter / First Responder Do NOT document anything on the DO NOT RESUSCITATE MEDICAL DIRECTIVE AND FUNERAL HOME TRANSFER FORM. You need to complete a MAR as for any other cardiac arrest including: NOTES Date and time of the call Patient s name, address and date of birth That the appropriate DNR was seen by responders Names of witnesses at the scene (person assuming responsibility for the victim or on-scene physician Names and / or numbers of EMS paramedics in attendance In the event of a disagreement on scene between family members regarding the resuscitation, the firefighter / first responder on scene will consider the DNR null and void and initiate a resuscitation, until otherwise directed by EMS. Central East Prehospital Care Program, July 1, 2009 Section One 9

10 DO NOT RESUSCITATE MEDICAL DIRECTIVE & FUNERAL HOME TRANSFER FORM I, have discussed and understand my health status and (Client s name-print) prognosis with my physician,. I request that, in the event my (Physician name-print) heart stops beating and/or my breathing stops, Emergency Medical Responders (Nurses, Paramedics, Police or Firefighters) shall not attempt to resuscitate me. In the event that the above named person is incapable of making, or understanding their own health care decisions, has been appointed as the substitute (Substitute Decision-makername-print) decision-maker and agrees to the preceding information. (Client s signature, date) (Client s name-print) (Substitute Decision-maker signature, date) (Relationship and/or Power of Attorney for Care) (Physician signature, date) (Alternate Physician name/ Physician Group) Tel # After Hr # Pager/cell (Physician contact no. in event of death) Tel # After Hr # Pager/cell (alternate Physician/Group contact no. in event of death) Pronounced at home on at (date) (time) by (Nurse/Paramedic) (Agency) Dr. notified at (Doctor s name) (date & time) Funeral Home contacted at (Funeral Home name) (date & time) Once death has been pronounced, this form will enable a funeral home to remove the deceased prior to signature of the Medical Certificate of Death. The Funeral director will arrange with the Attending Physician for completion of the Medical Certificate of Death. The Paramedics/Nurse or Coroner s agent will notify the Attending Physician as soon as possible. In the event that the Attending Physician is not immediately available, his/her Alternate will be contacted. It is requested, that a partially completed Medical Certificate of Death be left attached to this form (not yet completed and unsigned by physician). The Do Not Resuscitate Medical Directive and Funeral Home Transfer Form must be completed in full, and signed, to be acted upon by Emergency Responders This document has been authored conjointly by the Coroner s office, Palliative care Physician group, Durham Access To Care, Funeral Director s group and the Base Hospital Paramedic Program for York / Durham Region. Nov 2006 Central East Prehospital Care Program, July 1, 2009 Section One 10

11 Central East Prehospital Care Program, July 1, 2009 Section One 11

12 CARDIAC ARREST REFERENCE PAGE Witnessed refers to a cardiac arrest that occurs in front of the firefighter / first responder. Unwitnessed refers to the situation in which the firefighter / first responder arrives to find the patient in cardiac arrest. If effective CPR is being performed by a bystander upon your arrival, you may credit the bystander s CPR into your 2 minutes of CPR to be done before the SAED is applied. CPR should be performed according to the Heart and Stroke Foundation of Canada Guidelines for PATIENT AGE SINGLE RESCUER MULTIPLE RESCUERS COMPRESSION RATE Adult ( 8 years of age) Child/Infant (30 days to 8 years of age) Neonate (< 29 days of age) 30 : 2 30 : / min 30 : 2 15 : / min 3 : 1 3 : / min If the Firefighter / First Responder encounters a citizen with an SAED on scene, allow the citizen to complete the shock sequence safely. Once the citizen SAED prompts to commence CPR, the Firefighter / First Responder should switch over to their defibrillator and continue the resuscitation. Make sure that treatment provided by the citizen provider is reported to the EMS paramedic, as well as documented on the Medical Assist Report (MAR). It is the responsibility of the citizen responder to download the information from their SAED. The Firefighter / First Responder is only responsible for the information transfer from their own SAED. In the event of return of spontaneous circulation and then re-arrest, the rhythm should be reanalyzed immediately and the directive resumed (this may necessitate turning the defibrillator off and back on). If the SAED fails to operate, continue CPR. A second rescuer should attempt to trouble shoot the SAED problem (i.e. change battery, examine cables/pads, improve pad adherence to the chest etc.). You should update EMS of the situation and consider calling for a second SAED from your service if it will be faster than EMS. After the call is complete, you should remove the SAED from service and ensure it is flagged for maintenance. You should also document the SAED and details of your management of the patient and SAED situation on the MAR. Should exceptional conditions (water rescue, long distance difficult access, etc.) warrant the need for patient movement to facilitate a rendezvous with EMS, the patient may be moved as long as appropriate patient care is continued and safety precautions taken. Pad placement the preferred pad placement in cardiac arrest is the sternum apex position. In the event that the pads cannot be placed in this position without overlapping, as In the smaller patient, including the pediatric patient, the bi-axillary (armpit) position is next in order of preference. If due to curvature of the chest wall, this position cannot be used, the anterior posterior position may be used. Central East Prehospital Care Program, July 1, 2009 Section One 12

13 RAPID TRAUMA EXTRICATION GUIDELINE When the following indications and conditions exist, a Firefighter / First Responder may treat victims of cardiac arrest according to the following: Indications 1. Environmental situations that place the patient s life in imminent danger. 2. Primary Survey findings that place the victim s life in imminent danger: a) no breathing with the inability to ventilate in the position found, and/or b) no pulse with the inability to provide chest compressions in the position found and/or c) serious gross bleeding with the inability to control it in the position found Conditions N/A Contraindications Firefighter / First Responder safety is at risk Procedure 1. Maintain the patient s head and neck in neutral alignment. 2. Remove the patient to a safe place and reassess beginning with the primary survey. 3. If available, an appropriately sized cervical collar and a backboard may be applied to the patient. Notes Immobilization with a collar and backboard is typically undertaken under the direction of an EMS crew. Central East Prehospital Care Program, July 1, 2009 Section One 13

14 ADDITIONAL GUIDELINES FOR THE EMR IMMOBILIZATION When the following indications and conditions exist, an EMR firefighter may immobilize patients according to the following: Indications 1. Rescue situation that paramedics can t safely enter (e.g. high angle rescue or confined space, etc.) 2. Under the direction of an on-scene paramedic Conditions N/A Contraindications Procedure Notes: Firefighter / First Responder safety is at risk 1. Apply manual stabilization of the head & neck in a neutral position 2. Size and apply cervical collar 3. Log-roll patient supine onto backboard (using 3 rescuers) holding: a. The head b. The shoulder area c. The pelvic area 4. Apply head blocks on each side of head 5. Secure the head, chest and pelvis (straps and tape) to the backboard Always ensure ABCs are being assessed and treated. Example - oxygen 100% - ventilation - cardiac compression - AED - control severe bleeding Firefighters need to protect the neck and spine of stable patients by holding their head and preventing movement. Immobilization is typically undertaken under the direction of EMS. Central East Prehospital Care Program, July 1, 2009 Section One 14

15 ADDITIONAL GUIDELINES FOR THE EMR BURN TREATMENT When the following indications and conditions exist, an EMR firefighter may treat patients with burns according to the following: Indications Primary assessment indicates that the patient has been burned. This includes burns caused by thermal, chemical, radiation and electrical sources. Conditions N/A Contraindications Procedure Notes Firefighter / First Responder safety is at risk 1. Manage the scene safely, especially when removing the patient from the source of the burn. 2. Assess and manage the airway, ventilation and oxygenation. 3. Treat burn patients as trauma patients, and perform a rapid trauma assessment. 4. Properly cool thermal burns if you reach the patient early, but be careful not to induce hypothermia. 5. Initiate therapy according to the appropriate guideline (i.e. thermal, radiation, electrical and chemical). These guidelines are found on the next few pages. Patients do not die quickly from burns. It is the injuries and trauma that are associated with the burns (i.e. potential airway problems, altered levels of consciousness, major injuries) that cause rapid death. Therefore, manage the life threatening injuries before the burns. Remember that any victim exposed to smoke and/or fire should be assumed to have carbon monoxide poisoning, airway swelling and/or airway compromise due to the heat and smoke from the fire. The upper and lower airways could have burns that will not appear serious until the victim s condition suddenly changes. Physical findings to alert you are: Unresponsive or semi-responsive victim Facial burns Soot on face and/or in mouth Difficulty swallowing or talking Shortness of breath Use of accessory muscles to breathe (neck, shoulders, in-drawing of chest, JVD, etc.) Central East Prehospital Care Program, July 1, 2009 Section One 15

16 ADDITIONAL GUIDELINES FOR THE EMR THERMAL & RADIATION BURNS Procedure 1. Ensure the area is safe and you can remove the patient from the hazard safely. 2. Ensure airway, breathing and circulation is adequate. Provide oxygen (high concentration) and ventilation support if required. 3. If burns involve the face/airway, and the patient is unresponsive to pain, ensure an oropharyngeal airway is inserted. 4. Complete a rapid trauma assessment. 5. Remove burned clothing that is not stuck to the burn. 6. Remove rings, watches, or other jewelry if that area is involved (i.e. hands, wrists, or toes). 7. Cover partial thickness burns with a BSA (Body Surface Area) of less than 10% with clean/sterile dressings. You may cool with water/saline or use a manufactured dressing like a Water Jel if the blisters are not broken and the tissue is still hot. 8. Cover partial or full thickness burns with a BSA of 10% or greater with a dry sterile dressing only. Apply water only to extinguish fire/smoldering clothes or flesh. Central East Prehospital Care Program, July 1, 2009 Section One 16

17 ADDITIONAL GUIDELINES FOR THE EMR ELECTRICAL BURNS Procedure 1. Ensure the area is safe and you can remove the patient from the hazard safely. Special training is required to safely handle energized electrical equipment. Ensure appropriate personal protective equipment is worn to protect yourself. 2. Ensure airway and breathing are adequate. Provide oxygen (high concentration) and ventilation support if required. 3. Assess circulation. (A common result of electrical contact is ventricular fibrillation. Therefore, check cardiac status and ensure the SAED is readily available. Continue to monitor pulse. With high voltages and lightning strikes, assume spinal injuries as well.) 4. If burns involve the face/airway, and the patient is unresponsive to pain, ensure an oropharyngeal airway is inserted. 5. Complete a rapid trauma assessment 6. Remove burned clothing that is not stuck to the burn. 7. Remove rings, watches, or other jewelry if that area is involved (i.e. hands, wrists, or toes). 8. Cover partial thickness burns with a BSA of less than 10% with sterile dressings. You may cool with water/saline or use a manufactured dressing like a Water Jel if the blisters are not broken. 9. Cover partial or full thickness burns with a BSA of 10% or greater with a dry sterile dressing only. Apply water only to extinguish fire/smoldering clothes or flesh. 10. Additional information will be required by the treating hospital. If possible and without delaying patient transfer inquire about the following: a. The type and amount of current b. Path of current flow (through the body) c. How long the patient was in contact with the current 11. Industrial EMR should also ensure that the appropriate management supervisor follows up with any additional information on the nature of the electrical contact to the treating hospital. Notes N/A Central East Prehospital Care Program, July 1, 2009 Section One 17

18 ADDITIONAL GUIDELINES FOR THE EMR CHEMICAL BURNS Procedure 1. Identify the chemical. Ensure the area is safe and you can remove the patient from the hazard safely. Special training is required to safely handle hazardous materials like corrosive chemicals. Ensure appropriate personal protective equipment is worn. 2. Ensure the area is safe and you can remove the patient from the hazard safely. 3. Remove any contaminated clothing from the patient. This will protect both the patient and the responder from the chemical. Brush off any dry powder chemicals from the patient before flushing the burn area. Flush the affected area with water for 15 minutes. If it is a liquid chemical, flush immediately before removing the clothing and continue for 15 minutes. Remove the clothing from the liquid contaminated casualty while flushing. 4. Ensure airway, breathing and circulation is adequate. Provide ventilation support if required. 5. If burns involve the face/airway, and the patient is unresponsive to pain, ensure an oropharyngeal airway is inserted. 6. Complete a rapid trauma assessment. 7. Remove burned clothing that is not stuck to the burn. 8. Remove rings, watches, or other jewelry if that area is involved (i.e. hands, wrists, or toes). 9. Cover burns with a dry sterile dressing. 10. Industrial EMR should also ensure that the appropriate management supervisor follows up communicating any additional information on the chemical to the treating hospital. Notes In some circumstances, steps 3 and 4 may need to be completed at the same time as Step 2, but remember to protect yourself from the chemical. Central East Prehospital Care Program, July 1, 2009 Section One 18