CARROLL COUNTY AMBULANCE

Transcription

1 Introduction The purpose of protocols in the out-of-hospital setting is to assure safe and effective intervention during the out-of-hospital phase of patient care. In consideration of the unique resources, needs, population and geography of individual service programs, the physician medical director may choose to enhance or omit portions in accordance with Iowa Code, Chapter 147A. Medical directors are responsible to ensure that EMS personnel use protocols, have the training and skills required, and perform Continuous Quality Improvement (CQI) activities. Use of skills in the out of hospital setting are limited to the EMS provider s scope of practice and EMS service program level of authorization as approved by the physicians medical director. The service program medical director must determine what skills within the level of service authorization and provider scope of practice are to be included or not included for individual EMS services. The Iowa EMS Scope of Practice document, adopted by reference to the administrative rules outlines skills by certification level. It can be found on the Bureau of EMS website or by contacting the Bureau of EMS. Protocols are essential to assure education, training, and standards of care to meet the needs of patients. Ongoing review and update of protocols is necessary to keep pace with interventions known to be effective in out-of-hospital care. The challenge is for all EMS providers, to keep current with the protocols so the EMS continuum of care can effectively reduce suffering, disability, death and costs from life-threatening illness and injury. It is the intent of the Protocol Committee and the Iowa EMS Advisory Council that these protocols will serve as a standard throughout Iowa s EMS system. Approved current protocols shall be available on all authorized service vehicles. According to Iowa Administrative Code (2)(a) individual physician medical directors duties include developing, approving, and updating protocols to be used by service program personnel that meet or exceed the minimum standard protocols developed by the department. Additionally, according to (3)(b) service programs shall utilize department protocols as the standard of care. The service program medical director may make changes to the department protocols provided the changes are within the EMS provider s scope of practice and within acceptable medical practice. A copy of the changes shall be filed with the department. The following authorization page and any changes or revisions made by the EMS service medical director must be on file with the State of EMS Field Coordinator. The complete Iowa Statewide EMS Treatment Protocols, Adult & Pediatric is also available on the Iowa Department of Public Health website 1

2 PROTOCOLS AUTHORIZATION Authority: According to Iowa Code, Chapter l47a, emergency medical personnel may only deliver emergency medical care under the direction of a physician medical director who is licensed in Iowa. The medical practice of out-of-hospital personnel is an extension of the medical director's license. Protocols shall be approved, signed and dated by the EMS service medical director prior to implementation. Staff training must be documented & on file. Any changes must be on file with your EMS Field Coordinator. Skills must be within the level of service authorization and EMS provider scope of practice. THE SERVICE PHYSICIAN MEDICAL DIRECTOR MUST APPROVE THE PROTOCOL IN ACCORDANCE WITH THE AUTHORIZED LEVEL OF SERVICE CARROLL COUNTY AMBULANCE X Ambulance Non-transport A. Level of Authorization: First Responder/EMR EMT-B/EMT EMT-I AEMT EMT P EMT-PI CCT (attach protocol) PS/Paramedic PS I CCT (attach protocol) B. These protocols are to be considered a standing order. Radio communications are not required prior to performing any protocol action. EMT's/Paramedics should call in for further direction or confirmation of orders whenever the situation warrants. X YES NO C. The emergency medical care provider present with the highest level of certification (on the transporting service) shall determine, based upon patient care needs, the appropriate level of provider to attend the patient during transport. X YES NO D. Approval of Skills and Training Level (Physician Medical Director must approve skills based on providers scope of practice & service authorization level) Esophageal/treacheal Double-lumen airway IV maintenance Glucose Monitor Epinephrine Auto injector Gastric Tube Insertion Needle Thoracostomy NG Tube Insertion Intraosseous Infusion Needle Crichothyrotomy CPAP Nasotracheal Intubation Thrombolytics Assessment-based Spinal Immobilzation _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO 2

3 I understand I am responsible for providing appropriate medical direction and overall supervision or the medical aspects or the service program and I have reviewed this document and the Iowa EMS Scope of Practice which is defined by Iowa Administrative Code Physician Medical Director s Name Physician Medical Director s Signature Date (Please Print) 3

4 Authorized Drug List Basic Oxygen Aspirin Glucose Paste Patient Assisted Inhaler Epi Pen Patient Assisted Nitroglycerin Individual drug protocols are attached to the patient care protocols for additional guidance when choosing an appropriate medication. For situations not covered in the PC Protocols, the drug protocols will be considered valid treatment options. Paramedics may continue IV drip medications initiated in the hospital during an interfacility transfer. The Paramedic should familiarize himself/herself with the drug prior to transport, obtain the appropriate IV drip chart, and have knowledge of the operations of the IV pump being used. The paramedic may take additional medications from the hospital for administration during a transfer provided the paramedic has a written doctor s order for the drug. A stand-alone written doctor s order or a copy of the doctor s order for an inpatient will be accepted. The paramedic should himself/herself with the drug drug prior to transport. For Critical Care Transport, Carroll Co. Ambulance will utilize equipment from the sending hospital, with arrangements made prior to accepting the transport. Advanced Dextrose 5% in water (for drug gtts) Normal Saline Adenosine Amiodarone Albuterol Aspirin Atropine Calcium Gluconate Dextrose Diazepam (Valium) Diphenhydramine (Benadryl) Dopamine Epinephrine Etomidate Fentanyl Flumazenil (Romazicon) Furosemide (Lasix) Glucagon Glucose Haloperidol (Haldol) Ipratopium (Atrovent) Lactated Ringers Lidocaine Magnesium sulfate Metaprolol (Lopressor) Midazolam (Versed) Morphine Sulfate Naloxone (Narcan) Nitroglycerin Odansetron (Zofran) Oxytocin Sodium Bicarbonate Solu-Medrol Succinylcholine Thiamin Vasopressin 4

5 Drugs Carried on Ambulance: Adenosine Albuterol Amiodarone Aspirin Atropine Dextrose Diphenhydramine (Benadryl) Epinephrine Epinephrine Auto-Injector Fentanyl Glucagon Glucose Paste Haloperidol Lidocaine Midazolam (Versed) Morphine Naloxone (Narcan) Nitroglycerin Odansetron (Zofran) Solu-medrol Vasopressin CARROLL COUNTY AMBULANCE MEDICATION PROTOCOLS 2013 Related Protocols: Medication Assisted Intubation (non-paralytic) Intranasal Drug Administration Rectal Valium/Versed Administration (pediatric) PAIN Protocol Drip Charts Dobutamine Dopamine Heparin Nitro 5

6 ADENOSINE (ADENOCARD) Classification: Antiarrthymic Mechanism of Action: Adenosine slows conduction through the AV node and may also interrupt re-entry pathways in the AV node. Indications: Symptomatic Paroxysmal Supra-Ventricular Tachycardia Contraindications: Second or Third Degree Heart Blocks Sick Sinus Syndrome Known Hypersensitivity to Adenosine Patient taking Dipyridamole (Persantine) Precautions: Arrthymias, including blocks, are common at the time of conversion. Use with caution in patients with asthma. Dosage: ADULTS: 6 mg given rapid IV bolus over 1-3 seconds followed by 20 cc flush. If after 2 minutes, conversion does not occur, repeat with 12 mg rapid 20cc IV flush. PEDIATRICS: 0.1 mg/kg rapid IV or 10cc bolus (up to 6 mg) over 1-3 seconds. If after 2 minutes, conversion does not occur, repeat with 0.2 mg/kg rapid IV or 10 bolus (up to 12 mg Route: IV should be started with large bore catheter in antecubital vein and administered in medication port closest to IV site with rapid bolus of IV fluid after administration. Side Effects I Complications: Facial Flushing Headache Dizziness Shortness of Breath Nausea I Vomiting Sinus pause of 3-10 seconds is common 6

7 ALBUTEROL Classification: Sympathomimetic Mechanism of Action: Albuterol is an a2 - adrenergic (pulmonary) agonist. Albuterol causes bronchodilation and stimulates the central nervous system and the heart. Indications: Bronchial Asthma Reversible bronchospasm caused by COPD Pulmonary Edema I CHF if wheezing Contraindications: Known hypersensitivity to Albuterol. Precautions: Vital signs must be monitored, especially in those with history of hypertension. ADULT Dosage: 2.5 mg / 3ml (prepackaged) by nebulizer. PEDIATRIC Dosage: 2.5 mg I 3ml (prepackaged) by nebulizer. Route: Inhalation via nebulizer. Side Effects I Complications: None 7

8 AMIODARONE Classification: Antiarrthymic Mechanism of Action: Amiodarone prolongs myocardial action potential and effective refractory period and causes noncompetitive a and s adrenergic inhibition. Amiodarone suppresses ventricular ectopy (PSVT, VT, VF,) and slows conduction through the AV node (ventricular rate control; useful in WPW). Amiodarone also causes vasodilation resulting in reduced cardiac work. Indications: Shock refractory ventricular fibrillation and pulseless ventricular tachycardia Ventricular Tachycardia Wide-complex tachycardia of unknown type Contraindications: Cardiogenic shock Marked sinus bradycardia 2nd or 3rd degree heart block Hypersensivity to Amiodarone Precautions: May worsen existing or precipitate new dysrhythmias, including torsades de pointes and VF. Use with beta-blocking agents could increase risk of hypotension and bradycardia. Amiodarone inhibits atrioventricular conduction and decreases myocardial contractility, increasing the risk of AV block with verapamil or diltiazem or of hypotension with any calcium channel blocker Adult Dosage: VF and Pulse less VT: Give 300 mg IV/I0. Give additional 150 mg IV push in 3 to 5 min for refractory or recurrent VF/VT. VT with pulse: Give a rapid infusion of 150 mg over 10 minutes. Dilute 3mg of Amiodarone in a 7ml of saline, for a total of 10 ml. (15mg/cc) Pediatric Dosage: VF and Pulseless VT: Give 5 mg/kg IV/I0. (No subsequent doses) VT with pulse: give an infusion of 5mg/kg over 20 min. Dilute in normal saline according to Pediatric tape. Side Effects I Complications: Dizziness, headache, bradycardia, cardiac conduction abnormalities, CHF, dysrhythmias, hypotension, SA node dysfunction, sinus arrest, dyspnea, pulmonary inflammation 8

9 ASPIRIN Classification: Anti-Platelet Mechanism of Action: Blocks formation of thromboxane A2, which prevents platelet aggregation and arteriole constriction. Indications: All patients with pain suggestive of an AMI Confirmed AMI by 12 Lead EKG Contraindications: Known hypersensitivity to Aspirin History of active ulcer disease or asthma Use with females in last trimester of pregnancy History of blood coagulation defects or in conjunction with anticoagulation therapy. Precautions: Higher doses can interfere with prostacyclin products and interfere with positive effects. Dosage: 2 81 mg (162 mg) tablets for patients currently on an anti-coagulant/anti-platelet 4 81 mg (324 mg) tablets for patients not currently on an anticoagulant/anti-platelet Route: P.O. Side Effects I Complications: Dyspepsia Heartburn Anorexia Nausea Occult blood loss Epigastic discomfort 9

10 ATROPINE SULFATE Classification: Antiarrhythmic I Anticholinergic Mechanism of Action: Atropine competes with the neurotransmitter acetylcholine for receptor sites, blocks the parasympathetic fibers, which enhances the sinus node and atrioventricular conduction. Indications: Symptomatic Bradycardia Organophosphate Poisoning Contraindications: None when used in an emergent situation. Precautions: Maximum dosage of 0.04mg/kg should not be exceeded except in organophosphate poisonings. Tachycardia & Hypertension Use with caution in all patients with myocardial ischemia, Type II AV blocks, and third degree heart blocks with wide QRS. Pace if needed. Adult Dosage: Bradycardia: 0.5 mg - every 5 minutes to max dose. Organophosphate Poisoning: 2-5 mg Pediatric Dosage: Bradycardia: 0.02 mg/kg every 5 minutes to max dose. Maximum single dose - Child: 0.5 mg, Adolescent: 1 mg Maximum total dose - Child: 1 mg, Adolescent: 2mg Minimum dose mg IV Route: IV, IM, I0 Side Effects I Complications: Palpitations Tachycardia Headache I Dizziness Anxiety Dry Mouth Pupillary dilation I Blurred Vision Urinary retention 10

11 DEXTROSE 50% Classification: Carbohydrate Mechanism of Action: Rapidly elevates blood glucose level. Indications: Hypoglycemic Coma of unknown origin Contraindications: lntracranial hemorrhage. Increased intracranial pressure. Known or suspected CVA in the absence of hypoglycemia. Precautions: Blood glucose level should be checked prior to administration. Make sure IV is patent, extravasation of D50 make cause necrosis in the tissues. If giving with Thiamine, administer Thiamine first. Adult Dosage: 25 grams (50ml) Pediatric Dosage: Up to 8 years old: D25, 2-4 ml/kg ( g/kg), not to exceed 25 grams If D25 is not available, draw 1-2 ml/kg ( g/kg) of D50 into syringe and dilute with equal amount of normal saline prior to administration. For infants less than 1 month of age, dilute with four times the amount of normal saline. >8 years old: D50, 2-4 ml/kg ( g/kg), not to exceed 50 ml (25 grams) Route: Intravenous I/O Rectally Side Effects I Complications: Local venous irritation 11

12 DIPHENHYDRAMINE (Benadryl) Classification: Antihistamine Mechanism of Action: Competes for H1 receptors on effector cells thus blocking effects of histamine release. Some sedative effects Indications: Anaphylaxis Allergic Reactions Dystonic reactions due to Phenothiazine Contraindications: Acute Asthma Nursing mothers Precautions: Hypotension Adult Dosage: mg slow IV mg IM Pediatric Dosage: 1-2 mg/kg slow IV, IM, 10 Maximum single dose of 50 mg. Route: Intravenous Deep Intramuscular Intraosseous Side Effects I Complications: Sedation Dries bronchial secretions Blurred Vision Headache Palpitations 12

13 DOPAMINE Classification: Sympathomimetic Mechanism of Action: Increases cardiac contractility Causes peripheral vasoconstriction Indications: Hemodynamically significant hypotension in the absence of hypovolemia. Contraindications: Hypovolemic shock before fluid resuscitation has been completed. Ventricular Fibrillation I Ventricular Tachycardia Precautions: May be deactivated by alkaline solutions (Furosemide and Sodium Bicarb) Increases myocardial oxygen demand, therefore use with caution in patients in cardiogenic shock or CHF. Should not be administered in the presence of severe tachyarrhythmias. Ventricular irritability Dosage: 5-20 mcg/kg/min Mix 400mg in 250 ml of Normal Saline giving concentration of 1600 mcg/ml. Or use prepackaged drip (1600 mcg/ml). Route: IV drip only Side Effects I Complications: Vasoconstriction Ventricular tachyarrhythmias Hypertension 13

14 EPINEPHRINE 1:10,000 and 1:1000 Classification: Sympathomimetic Mechanism of Action: Increases cardiac contractility Increases heart rate Causes bronchodilation Indications: Cardiac Arrest Anaphylactic Shock Exacerbation of COPD Bronchial Asthma Contraindications: Underlying cardiovascular disease. Hypertension Pregnancy Tachyarrhythmias None in the cardiac arrest situation. Precautions: Should be protected from light Can be deactivated by alkaline solutions (Furosemide and Sodium Bicarb) Blood Pressure, Pulse, and ECG must be constantly monitored. Adult Dosage: Cardiac Arrest: 1 mg IV (1:10,000) every 3-5 minutes Severe Anaphylaxis: 0.1 mg IV repeat as needed to max dose of 0.5mg (1/10,000) or mg IM (1/1000) Pediatric Dosage: Cardiac Arrest: 0.01 mg/kg of 1:10,000 or 0.1 ml/kg Severe Anaphylaxis: 0.01 mg/kg of 1 :1000 IV or 10, or up to 0.3 mg IM Route: Intravenous Intraosseous Intramuscular Side Effects I Complications: Palpitations Tachyarrhythmias 14

15 FENTANYL Classification: Synthetic Opiod Agonist Mechanism of Action: Analgesic with short duration of action. Minimal histamine release, so less hemodynamic compromise. Indications: Pain control. Sedation for invasive procedures, premedication for cardioversion. Contraindications: Respiratory depression or insufficiency Uncorrected hypotension Allergy/sensitivity to Fentanyl Side Effects: Respiratory depression, bradycardia, hypotension or hypertension, nausea, vomiting Drug Interactions: Effects may be increased when given with other CNS depressants or skeletal muscle relaxants. Route: IV, I0, IM, IN Dosage: Adults mcg slow IV/I0/IM/IN every 5-15 minutes as needed to control pain. Max of 100 mcg Pediatrics 1-2 mcg/kg slow IV/ I0 /IM/ IN every 5-15 minutes as needed to control pain Special considerations: Pregnancy Category C - use only if potential benefits justify the risk Schedule II drug with potential for abuse. Use with caution in elderly patients and those with severe respiratory disorders, seizure disorders, or cardiac disorders. 15

16 GLUCAGON Classification: Hormone Mechanism of Action: Inhibits glycogen synthesis Causes breakdown of glycogen to glucose Increases blood glucose level Increases cardiac contractile force Increases heart rate Indications: Hypoglycemia Contraindications: Hypersensitivity to Glucagon Precautions: Blood glucose level should be checked prior to administration Only works if pt. has stores of glycogen in liver Use caution in patients with cardiovascular or renal disease Dosage: 1 mg IM Route: Intramuscular injection Side Effects I Complications: Tachycardia Hypertension Nausea and or vomiting 16

17 GLUCOSE Classification: Carbohydrate Mechanism of Action: Elevates blood glucose level. Indications: Hypoglycemic Contraindications: lntracranial hemorrhage. Increased intracranial pressure. Known or suspected CVA in the absence of hypoglycemia. Unconsciousness and I or pt. unable to maintain own airway Precautions: Blood glucose level should be checked prior to administration. Airway must carefully be maintained. In pt's with blood glucose of <40 mg/dl, IV Dextrose or Glucagon should be first line treatment. Dosage: 1 tube - approximately 25 grams Route: Orally Side Effects I Complications: None, if airway is maintained. 17

18 HALOPERIDOL (HALDOL) Classification: antipsychotic Mechanism of Action: Blocks the dopamine receptors in the brain associated with mood and behavior. It has strong antiemetic effects and it impairs central thermoregulation. It produces weak central anticholinergic effects and transient orthostatic hypotension. Indications: Acute psychotic disorder. Contraindications: Parkinson's disease Seizure disorders Coma Alcoholism Severe mental depression CNS depression Thyrotoxicosis Precautions: Pregnancy Category C Do not give if other sedatives have been given. Use with caution in elderly or debilitated patients. Use with caution in patients with urinary retention, glaucoma, and cardiovascular disorders. Use with caution in patients receiving anticonvulsant, anticoagulant, or lithium therapy. Dosage: Adults: 2-5 mg IM or IV, titrated to effect. Max of 10 mg Use low dose if patient is on lithium Route: Intramuscular injection Side Effects I Complications: Dystonia, akathisia Lethargy, fatigue, weakness Tremor Headache, confusion, vertigo Tachycardia, hypotension, ECG changes Laryngospasm, bronchospasm, increased depth of respirations 18

19 MIDAZOLAM (Versed) Classification: Benzodiazepine I Sedative I Hypnotic Mechanism of Action: Short acting CNS depressant 3-4 times more potent than Valium Produces sleepiness and relief of apprehension Diminished patient recall very effectively Indications: To produce sedation in conscious patients or high anxiety patients To impair memory of therapeutic procedures To provide muscle relaxation in patients with long bone fracture, used in conjunction with pain control medication To control seizure activity Contraindications: Acute narrow angle glaucoma Hypersensitivity to Versed Pregnancy Lactation Acute alcohol intoxication with depressed vital signs Precautions: Use with caution in elderly and patients with chronic diseases Increased risk of apnea Be alert for developing hypotension Adult Dosage: mg IV every 3-5 minutes, titrated to effect OR 2 mg IN every 2-5 minutes, titrated to effect, delivered via mucosa! atomizer device, with limit of 1 ml per nostril per dose. Pediatric dosage: 0.2 mg/kg IV, I0, IM, or IN delivered via mucosal atomizer device Route: Intravenous, lntraosseous, Intranasal, Intramuscular Side Effects I Complications: Apnea Airway obstructions Blurred vision Bradycardia Hypotension Nausea I vomiting Coma Arrhythmias Patient Wtg Intranasal (IN) Midazolam age (yr) (kg) volume in ml (assuming 5mg/ml concentration) and maximum dosage Neonate ml 0.6mg < ml 1.2 mg ml 2.0mg ml 2.8mg ml 3.2mg ml 3.6mg ml 4.0mg ml 4.4mg ml 4.8mg ml 5.2mg ml 5.6 mg ml 6.0mg ml 6.4mg ml 6.8mg Small teenager ml 8.0mg Adult or full grown teenager 50 or more 2.00ml 10.0 mg 19

20 MORPHINE Classification: Narcotic Mechanism of Action: CNS Depressant Peripheral vasodilator Decreases sensitivity to pain Indications: Severe Pain Pulmonary Edema Contraindications: Head Injury Volume depletion Patients with undiagnosed abdominal pain Patients with hypersensitivity to Morphine Precautions: Hypotension Respiratory depression Nausea I vomiting Adult Dosage: IV: 2-5 mg every 5 minutes until relief of pain, respiratory depression occurs, or until 10 mg is reached. IM: 2-5 mg based on patient's weight. Call med control to exceed 10 mg. Non STEMI MI 1-5 mg one time only Pediatric Dosage: IV: mg/kg every 5 minutes until relief of pain, respiratory depression occurs, or until 10 mg is reached. IM: mg/kg Route: Intravenous Intraosseous Intramuscular Side Effects I Complications: Respiratory depression Dizziness Hypotension Altered level of consciousness 20

21 NALOXONE (NARCAN) Classification: Narcotic Antagonist Mechanism of Action: Reverses effects of opiate narcotics Indications: Narcotic overdoses including the following: Codeine, Demerol, Dilaudid, Fentanyl, Heroin, Lortabs, Methadone, Morphine, Paregoric, Percodan, Tylox, Vicodin, and synthetic analgesics. Overdoses including the following: Darvon, Nubain, Stadol, Talwin, alcoholic coma To rule out narcotics in coma of unknown origin. Contraindications: Patients with hypersensitivity to Narcan Precautions: Use with caution in patients with narcotic dependence as this may cause withdrawal symptoms. Short-acting, should be augmented every 5 minutes Adult Dosage: 1-2 mg IV, given in increments to effect OR 2 mg IN, limit of 1 ml per nostril, administered via mucosal atomizer device Pediatric Dosage: <20 kg- 0.1 mg/kg, titrated to effect > 20 kg - 2 mg, titrated to effect Route: Intravenous Intraosseous Intramuscular Side Effects I Complications: None 21

22 NITROGLYCERIN Classification: Antianginal Mechanism of Action: Smooth muscle relaxant Decreases cardiac work load Dilates systemic and coronary arteries and veins Indications: Angina Pectoris Cardiac related chest pain Hypertensive crisis Contraindications: Children under 12 years of age Patients with Viagra or similar drug use in last 24 hours Hypotension Precautions: Constantly monitor blood pressure Protect from light Syncope Tablets will expire in 30 days once bottle is opened Dosage: 1 tablet (0.4 mg) every 3-5 minutes up to 3 times Up to 3 doses can be administered if blood pressure is above 90 Systolic Route: Sublingual Side Effects I Complications: Hypotension Headache Dizziness 22

23 ODANSETRON (ZOFRAN) Classification: Anti-Emetic Mechanism of Action: Selectively antagonizes serotonin 5-HT3 receptors. Indications: Nausea and vomiting Contraindications: Hypersensitivity to drug I class Impaired liver functions Precautions: Use with caution in patients with HTN, Diabetes, Seizure Disorder, and hypothyroidism. Use with caution in patients with Arrhythmias and Cardiovascular Disease. Adult Dosage: 4 mg slow IV push Pediatric Dosage: 0.1 mg/kg slow IV push Max dose 4mg Route: IV, IM Side Effects I Complications: Headache Fatigue Anaphylaxis Vertigo I Dizziness Diarrhea Seizure 23

24 SOLU-MEDROL Classification: Corticosteriod, anti-inflammatory Mechanism of Action: Used in management of allergic reactions and occasionally as an adjunctive agent in the management of shock Used for spinal cord injury in both Emergency Departments and pre-hospital settings Indications: Spinal cord injury Anaphylaxis Asthma Exacerbation of COPD Contraindications: None in the emergency setting Adult Dosage: Initial bolus of 30 mg/kg is administered IVP over a fifteen minute period, 45 minutes later follow with maintenance infusion of 5.4 mg/kg/hour Asthma/COPD/Allergic reactions 80 to 125 mg IVP or IM Pediatric Dosage: 2 mg/kg IV to a max of 125 mg Route: IV/IO IM Side Effects I Complications: Fluid retention CHF Hypertension Abdominal distention Vertigo Headache Nausea Malaise Hiccups Special Considerations: Single dose is all that should be given in the prehospital setting. Long term steroid therapy can cause GI bleeding, prolonged wound healing, and suppression of adrenocortical steriods 24

25 VASOPRESSIN Classification: Hormone Mechanism of Action: Potent peripheral vasoconstrictor Indications: May be used once in pulseless arrest patients in lieu of 2nd dose of epinephrine Contraindications: None when used in above emergency situation Dosage: 40 units IVP. May not be repeated Route: Intravenous Side Effects I Complications: None Special Considerations: Standard Epinephrine therapy may begin ten minutes after Vasopressin dose 25

26 MEDICATION ASSISTED INTUBATION INDICATIONS: A qualified EMS provider* may use this skill for the following: Uncontrolled, obstructed or inadequate airway secondary to trauma or overdose when further sedation is needed Decreased level of consciousness, combativeness or severe agitation secondary to trauma or suspected CV A Combative or uncontrollable head trauma patient that presents potential for injury to self or others CHF, COPD, or Asthma patient with hypoxia and/or respiratory exhaustion who cannot be nasotracheally intubated or easily orally intubated Burn patient with potential or existing respiratory compromise CONTRAINDICATIONS: Hypersensitivity to medications that would be used PROCEDURE: 1. Ensure all equipment is set up for intubation. 2. Ensure adequate spinal precautions are taken. 3. Pre-oxygenate with high flow oxygen by mask. Excessive manual ventilation may result in gastric distention with vomiting and aspiration. Be prepared to suction as needed. 4. If needed, sedate the patient with Valium/Versed mg IV (adult) or Valium/Versed mg/kg IV diluted 1: 1 in NS (peds), Wait for 1-2 minutes for sedative effect. May use repeat doses of 2.0 mg every 2-3 minutes as needed to titrate for effect. Maximum dose not to exceed 10 mg. 5. Once intubation is completed, confirm tube placement and secure the tube. 6. If bradycardia occurs associated with intubation, temporarily halt attempt and hyperventilate the patient with the BVM and 100o/o oxygen. If the patient remains bradycardic, consider Atropine 0.5 mg IV (adult) or Atropine 0.01 mg/kg IV (peds). 7. Consider use of Narcan 1-2 mg IV over 1-2 min for reversal of sedative effects. (May repeat in one minute. Max dose of 1.0 mg) *Qualified EMS provider: A certified EMT-P/PS who has the skills necessary to competently perform this procedure and the approval of the medical director. RECTAL VALIUM/VERSED ADMINISTRATION Administration of rectal Valium may be considered for pediatric seizure emergencies after the usual procedures to stabilize the patient are completed (ABC's management). 26

27 Procedure/Treatment: Draw up 0.4 mg/kg of Valium/Versed into syringe and remove needle. Lubricate end of feeding tube and insert approximately 2 inches into the rectum. Attach syringe to end of tube and push appropriate dose of Valium/Versed into tube. Clamp the tube and remove syringe. Pull back 2 cc's of air in syringe and reattach to tube. Unclamp the tube and push air into feeding tube, being sure the Valium/Versed is placed into the rectum. Repeat 4, 5 and 6 until Valium/Versed is fully into rectum. Remove the tube from rectum and hold buttocks together. 27

28 INTRANASAL MEDICATION ADMINISTRATION Indications Unable to initiate IV access. Administration of Midazolam for control for seizures or for sedation OR Administration of Fentanyl for pain control OR Administration of Naloxone for proven or probable narcotic overdose Procedure Inspect nostrils for significant amounts of blood or mucous discharge. Presence of these fluids will limit medication absorption. Suctioning the nasal passage prior to administration of the medication should be considered. Draw into a syringe the proper dose of medication per the drug protocol. Remove the needle from the syringe and attach the atomizer tip. Hold the forehead stable, place the tip of the atomizer 1.5 cm into the nostril aiming slightly up and outward. Briskly compress the syringe to administer half of the medication into the nostril. Remove and repeat into the other nostril until all the medication has been administered. NOTE: For the adult, volume should be limited to 1 ml per nostril. For children under 30 kg in weight, limit volume to 0.5 ml per nostril. 28

29 PAIN MANAGEMENT PROTOCOL INTRODUCTION: Pain is the most frequent symptom experienced by patients. The management of pain should be a priority. The purpose of this protocol is not to totally alleviate pain, but to safely decrease the intensity of the pain without causing physiologic compromise, delaying transport to definitive care or interfering with the patient's diagnostic workup following arrival at the emergency department. Indications: Acute myocardial infarction I Chest Pain Burns Isolated musculoskeletal injuries Other trauma with stable blood pressure (natural or with fluid bolus) Pain consistent with kidney stones Cancer pain Palliative care for DNR patients Non-traumatic back pain with history Contraindications: Head injury with suspected intracranial pressure Hypotension (SBP < 90 mmhg) Sensitivity or allergy to pain medication being used Altered level of consciousness due to overdose Pregnancy (Contact Medical Control) Respiratory depression DRUG OVERVIEW: DRUG Adult dose and routes Pediatric dose and routes Special considerations Fentanyl Morphine Midazolam mcg slow IV I IO I IM I IN every 5-15 minutes as needed to control pain Maximum dose 100 mcg IV I IO: 2-5 mg every 5 minutes until relief of pain, respiratory depression occurs. IM: 2-5 mg based on patient s weight Maximum dose 10 mg 1-5 mg IV or 10 every 1-2 minutes, titrated to effect OR 2 mg IN every 2-5 minutes, titrated to effect, delivered via mucosal atomizer device, with limit of l ml per nostril per dose. Maximum dose 10 mg 2-4 mcg/kg slow IV /IO/IM/IN every 5-15 minutes as needed to control pain IV I IO: mg/kg every 5 minutes until relief of pain, respiratory depression occurs, or until 10 mg is reached. IM: mg/kg 0.2 mg/kg IV, IO, IM, or IN delivered via mucosal atomizer device 29 May be given intranasally Drug of choice for abdominal pain, headache, and mutli-system trauma. See: Elderly Patients, Hypotensive Patients, Musculoskeletal injuries (for use of benzodiazepine with Fentanyl) Naloxone can be used to reverse effects of FentanvI if needed. DO NOT give intranasally. DO NOT give for abdominal pain or headache. See: Musculoskeletal injuries (for use of benzodiazepine with Fentanyl) Naloxone can be used to reverse effects of fentanvi if needed. May be given intranasally. May be beneficial in suspected long bone fractures for muscle spasm relief. Flumazenil can be used to reverse effects of Midazolam if needed.

30 Procedure: Obtain pain scale rating from patient using a 1-10 scale for adults and older children, and "faces" scale for young children. Except for chest pain, treatment of pain pharmacologically should be limited to pain rated at moderate or severe, or 4 or higher on a 1- l0 scale. If the patient can't rate the pain, the use of pain medication should be based on patient presentation. o Chest pain should be treated per "Acute Coronary Syndromes" protocol with a goal of complete relief of pain, within the limitations of the vital signs of the patient Verify and document any drug allergies the patient may have Document pain level prior to and after administration of analgesia Be sure to maintain adequate ventilation, oxygenation, and monitor cardiac rhythm I VS frequently. Consider premedicating patient with Odansetron 4 mg IVP to prevent nausea. Basic Pain Control Interventions: Splint, Elevate, Apply Cold Pak as appropriate Provide emotional support and I or distraction from pain Allow patient to remain in position of comfort unless contraindicated Paramedic Level Pain Control Interventions: Abdominal Pain o Fentanyl is the drug of choice for abdominal pain Limit total dose to no more than 100 mcg Contact Medical Control before administering to pediatric patient o Goal is to reduce pain level to tolerable, not to eliminate it o Be prepared to administer Zofran for nausea o Assess for referred pain, such as right shoulder pain indicative of cholecystitis o In patients over age 50, suspect and assess for possibility of AAA and do not administer pain medication if AAA is suspected. o Pain control for abdominal trauma is contraindicated o For epigastric pain, consider possibility of cardiac origin and treat accordingly Back pain (non-traumatic) o Fentanyl or Morphine may be used o Adding a benzodiazepine such as Midazolam or Diazepam may be considered for muscle relaxation effects o Assess amount and type of pain medication the patient is already taking. If the patient has been on long-term pain medications the dose may need to be increased. If short term and recent use, dose administered should be given onehalf dose at a time until effects are known. o If vital signs are stable and patient's pain is more severe with movement, consider pain control prior to moving patient o If pain is mid-thoracic or higher, consider possibility of cardiac or cardiovascular origin and treat accordingly. 30

31 Burns o o o o Fentanyl or Morphine may be used. Fentanyl has less hemodynamic effect, while Morphine may provide longer relief Large doses may be required; monitor VS every 5 minutes Be sure to provide oxygen as indicated Keep the patient warm Do not delay transport to initiate pain medication Chronic pain o For an increase in chronic pain to a severe state, in patients with chronic health conditions such as cancer, prior back injuries, and other conditions, use Fentanyl or Morphine o For analgesia during transport of hospice (or similar) patients with moderate to severe pain use Fentanyl or Morphine o Do not delay transport to initiate pain medication Headache o If acute onset without history, contact Medical Control. Musculoskeletal injuries o Fentanyl or Morphine may be used. Fentanyl is preferred for pediatric patients. o Consider Midazolam in conjunction with analgesia for relief of spasms of muscles when long bones are affected, especially femur fractures o If pain is severe, and splinting and/or moving will exert more pain on the patient, and the patient's VS are stable, analgesia may be considered prior to moving I transporting the patient Severe pain (other) o Follow drug protocols, contacting Medical Control for patients with questionable types of pain Multi-system trauma o Fentanyl is the drug of choice for pain. A combative patient cannot be safely secured, assessed or transported. Airway management is a priority.. o Monitor patient's blood pressure, administer fluid boluses as necessary. Considerations: Elderly patients (age 70 or older) o Administer pain medications in smaller increments and increase time between doses until the patient's reaction to the medication is displayed Fentanyl 0.5 mcg/kg for no more than single dose of 25 mcg Pediatric patients o Use drug protocols for pediatric doses o Consider intranasal administration o Consider initiation of IV after IN medication administration in case additional medications are needed, or to provide hemodynamic support in the event of hypotension developing 31

32 Hypotensive patients Analgesia medications should be provided in smaller increments when the patient's systolic blood pressure is between 100 and 120 mmhg Fentanyl 0.5 mcg/kg to be given cautiously to patients with borderline hypotension, to max single dose of 25 mcg IV fluids should be administered if blood pressure drops below I 00 mmhg after administration of analgesia in adults ml Normal Saline for adult patients Pediatric patients who show signs of hypoperfusion: 20 ml/kg Normal Saline Refusal of transport o If patients receive analgesia a refusal of transport should not be accepted Patients must be monitored for at least minutes after medication administration to observe for possible allergic reactions. o Administering analgesia en route will alleviate this problem 32

33 Bougie (Endotracheal Introducer) CONTRAINDICATIONS to use of Bougie Do not use on endotracheal tubes smaller than 6.0. Do not use for nasotracheal intubation. PROCEDURE 1. Holding the Bougie in your right hand and the angled tip pointing upward, gently advance the bougie anteriorly (under the epiglottis or over the posterior notch) to the glottic opening (cords). 2. Gently advance the device until resistance is encountered at the carina. 3. If no resistance is encountered and the entire length of the bougie is inserted, the device is in the esophagus. 4. The bougie is correctly placed when you see the device going through the cords, when you feel the washboard effect of the tip on the trachea, and/or when you meet resistance while advancing the bougie (bougie is at the carina). 5. Once positioned, withdraw the bougie until the black line mark is aligned with the lip and advance the lubricated ETT over the bougie and into the trachea. This indicates that the tip is well beyond the cords and the proximal end has enough length to slide the ETT over. 6. If resistance is encountered - caused by the ETT catching on the arytenoids or aryepiglottic folds - withdraw the ETT slightly, rotate 90 degrees and reattempt. If this is unsuccessful, use a smaller tube. 7. At no time should the ETT be forced as this may cause, or be caused by laryngospasm. 8. Once ETT is in position, while holding the tube, remove the bougie through the ETT. 33

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35 IOWA EMS TREATMENT PROTOCOLS Adult Treatment Initial Patient Care Protocol Abdominal Pain Acute Coronory Syndrome Airway Allergic Reaction Altered Mental Status Amputated Part Apparent Death Asthma Behavioral Emergencies Burns Cardiac Arrest Childbirth Congestive Heart Failure Frostbite Heat Illness Hypothermia Nausea & Vomiting Pain Control Poisoning Seizure Sexual Assault Stroke Trauma

36 Initial Patient Care Protocol 1. Scene Size Up a) Review the dispatch information b) As you approach the scene consider safety for yourself and your patient. c) Observe universal precautions d) After determining the number and location of patients, consider the need for additional resources d) Determine mechanism of injury and/or nature of illness e) Reassess the situation often 2. Primary Survey a) Obtain general impression of patient, chief complaint, and priority problems b) Determine responsiveness c) Assess airway d) Assess breathing e) Assess circulation 3. Initial Interventions a) Treat airway/breathing problems b) Treat circulation problems c) Establish IV/IO access if indicated d) Apply cardiac monitor if indicated e) Apply pulse oximetry or EtC02 monitor if available and indicated f) Treat pain or nausea if present 4. Secondary Survey a) Perform secondary assessment after initial interventions are completed b) Address problems identified in the secondary survey utilizing the appropriate protocol(s) c) Obtain vital signs, including blood glucose if available and indicated 5. Ongoing Assessment a) Repeated evaluation of patient Vitals every 5 minutes or as appropriate for unstable patients Vitals every 15 minutes or as appropriate for stable patients b) Assess effect of interventions 6. Transport/Contact Medical Control a) Patients should be transported as soon as feasible to an appropriate medical facility. Immediate transport with treatment en route is recommended for patients with significant trauma or unstable airways b) Tier with an appropriate service if level of care indicates or assistance is needed and can be accomplished in a timely manner c) Contact medical direction as soon as feasible in accordance with local protocol for further orders d) For seriously injured or critically ill patients, give a brief initial report from the scene when possible, with a more detailed report given to medical direction while en route 36

37 Abdominal Pain (non-traumatic) Follow Initial Care Protocol for all Patients a) Give nothing by mouth BASIC CARE GUIDELINES ADVANCED CARE GUIDELINES b) Consider a fluid bolus if indicated. c) Evaluate the need for pain and nausea control. d) Follow pain protocol 37

38 Acute Coronory Syndrome 1. Follow Initial Care Protocol for all Patients a. Place patient in position of comfort, loosen tight clothing and provide reassurance. If patient is complaining of shortness of breath, has signs of respiratory distress, or pulse oximetry of less than 94% then titrate oxygen to maintain a saturation of 94% or higher. b. If capability exists, obtain a 12-lead EKG and transmit to the receiving facility and/or medical control for interpretation as soon as possible c. If patient is alert and oriented and expresses no allergy to aspirin have patient chew (4) 81 mg non-enteric aspirin. d. An initial management goal should be to identify STEMI and transport the patient with cardiac symptoms to the facility most appropriate for their needs e. Contact medical direction for orders f. If the patient has been prescribed nitroglycerin (patient's nitro only) and systolic blood pressure is 90 mmhg or above, give one dose. If patient is taking erectile dysfunction drugs such as Viagra, contact medical direction prior to giving nitroglycerin g. Repeat one dose of nitroglycerin every 3-5 minutes if pain continues, systolic blood pressure is 90 mmhg or above and authorized by medical direction, up to a maximum of three doses h. If systolic blood pressure less than 90 mmhg or patient does not have prescribed nitroglycerin, transport promptly continuing assessment and supportive measures i. Further assess the patient and evaluate the nature of pain (unless other treatment priorities exist). j. If capability exists, obtain a 12-Lead EKG and transmit to the receiving facility and/or medical control for interpretation as soon as possible k. Establish IV access at TKO rate unless otherwise ordered or indicated l. Monitor EKG and treat dysrhythmias following appropriate protocols approved by the medical director, referencing AHA guidelines m. Administer nitroglycerin (tab or spray) 0.4 mg sublingually if systolic blood pressure 90 mmhg or above for symptoms of chest pain or atypical cardiac pain. Repeat every 3~ 5 minutes if pain continues and systolic blood pressure is greater than 90 mmhg or above. Morphine sulfate can be administered after 2 doses of nitro if no change in pain n. If pain continues after administration of nitroglycerin and systolic blood pressure remains above 90 mmhg administer morphine sulfate following the AHA ST Elevated Myocardial Infarction (STEMI) guidelines: BASIC CARE GUIDELINES ADVANCED CARE GUIDELINES STEMI - Morphine 2-4 mg IV may repeat 2-8 mg IV every 5 minutes titrated to pain relief and vitals remain stable OR NONSTEMI - Morphine 1-5 mg IV given once 38

39 Airway 1. Follow Initial Care Protocol for all Patients BASIC CARE GUIDELINES Breathing spontaneous on initial assessment and adequate ventilation present a) Maintain oxygenation with a cannula or mask if oxygen saturations are below 94% titrate to 94% or higher. Breathing spontaneous on initial assessment without adequate ventilation present a) Check airway for obstruction and clear if needed b) After airway is clear, assist ventilation with an appropriate adjunct and oxygen c) If adequate ventilation is not maintained, and no gag reflex present, proceed to an advanced airway Not breathing, pulse present on initial assessment a) Open airway with head tilt chin lift. If successful, assist ventilations at an adequate rate and depth then reassess b) If head tilt chin lift is not successful, check airway for obstruction and clear if needed c) After airway is clear, assist ventilation d) If adequate ventilation is not maintained, proceed to an advanced airway e) Assess for presence of pulse frequently and follow cardiac arrest protocol if needed ADVANCED CARE GUIDELINES a) Place advanced airway as needed to maintain patent airway. b) If airway is obstructed in an unresponsive or apneic patient, visualize with laryngoscope and use Magill forceps to remove obstruction if possible. c) If unable to clear the airway, perform needle cricothyrotomy as appropriate. 39

40 1) Follow Initial Patient Care Protocol Allergic Reaction BASIC CARE GUIDELINES a) Use Auto-Inject 0.3 mg Epinephrine pen and administer it if signs of anaphylaxis are present. ADVANCED CARE GUIDELINES b) Administer epinephrine 1:1,000 concentration 0.01 mg/kg IM, up to a maximum dose of 0.3 to 0.5 mg c) Administer diphenhydramine mg IV/IM d) Administer albuterol 2.5mg by nebulizer if respiratory distress, repeat as needed. e) For cases of severe anaphylaxis consider administration of mg (3-5 ml) epinephrine 1:10,000 slow IV/IO. f) Evaluate need for early intubation if severe anaphylaxis g) Contact medical control to repeat dose of Epi 40

41 1. Follow Initial Patient Care Protocol Altered Mental Status BASIC CARE GUIDELINES a) Obtain blood glucose b) If conscious & able to swallow, administer 1 tube glucose, up to 15 grams by mouth ADVANCED CARE GUIDELINES c) If blood sugar less than 60 mg/dl, and patient is not alert or able to swallow, administer D gm IV d) If blood sugar is less than 60 mg/dl, patient is not alert or able to swallow, and no vascular access, administer glucagon 1 mg IM e) Evaluate the need for naloxone 1 mg IV. If no response may repeat in 3 minutes. f) Evaluate the need for intubation 41

42 Amputated Part 1. Follow Initial Patient Care Protocol 2. Follow Trauma Protocol if indicated BASIC CARE GUIDELINES a) Locate amputated part if possible b) Wrap amputated part in saline moistened gauze c) Place wrapped amputated part in empty plastic bag d) Place the plastic bag with the amputated part in a water and ice mixture e) Do not use ice alone or dry ice f) Make sure the part is transported with the patient, if possible ADVANCED CARE GUIDELINES g) Follow pain protocol. 42

43 Apparent Death 1. Follow Initial Patient Care Protocol Apparent death indications are as follows: Signs of trauma are conclusively incompatible with life Physical decomposition of the body Rigor mortis and/or dependent lividity If apparent death is confirmed, continue as follows: BASIC AND ADVANCED CARE GUIDELINES a) The county Medical Examiner and law enforcement shall be contacted b) At least one EMS provider should remain at the scene until the appropriate authority is present c) Provide psychological support for grieving survivors d) Document the reason(s) no resuscitation was initiated e) Preserve the crime scene if present f) In all other circumstances (except where "NO CPR/DNR" protocol applies; full resuscitation must be initiated 43

44 Asthma 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) If patient has a physician prescribed hand-held metered dose inhaler: 1. Assist patient in administering a single dose if they have not done so already 2. Reassess patient and assist with second dose if necessary per medical direction ADVANCED CARE GUIDELINES b) Administer albuterol 2.5 mg via nebulizer, repeat as needed. c) Evaluate the need for epinephrine 1:1,000 concentration mg IM. d) Evaluate the need for CPAP, if available e) Evaluate the need for intubation f) Contact medical control to repeat dose of Epi 44

45 1. Follow Initial Patient Care Protocol Behavioral Emergencies a) If there is evidence of immediate danger, protect yourself and others by summoning law enforcement to help ensure safety BASIC CARE GUIDELINES b) Consider medical or traumatic causes of behavior problems c) Keep environment calm ADVANCED CARE GUIDELINES d) For severe anxiety, consider VERSED 2.5 mg IV or IM or 2.5mg to 5mg IM max of 10mg e) For excited delirium, consider administering haloperidol 1-5 mg IM/IV max of 10mg. 45

46 Burns 1. Follow Initial Patient Care Protocol Thermal Burns BASIC CARE GUIDELINES a) Initially stop the burning process with water or saline b) Perform primary survey with attention to airway and ventilation c) Estimate percent of body surface area injured and depth of injury d) If wound is less than 10 % Body Surface Area, cool down burn with Normal Saline e) Remove smoldering clothing and jewelry and expose area f) Continually monitor the airway for evidence of obstruction g) Cover the burned area with plastic wrap or a dry sterile dressing h) Do not break blisters i) Do not use any type of ointment, lotion, or antiseptic j) Keep patient warm ADVANCED CARE GUIDELINES k) Establish an IV of NS. Using the Parkland Burn Formula: 1. 4 ml x total body surface area sustaining 2nd/3rd/4th degree burns x person's weight in kilograms. 2. Infuse half of this volume over the first 8 hours from the time of the burn, with the remainder infused over the following 16 hrs. 3. Quick Calculation for the first hour: Patient's weight in kilograms x 20 ml= volume for the first hours. The total volume can be calculated when there is time l) Follow Pain Control protocol m) Transport to the most appropriate medical facility Chemical Burns BASIC CARE GUIDELINES a) Brush off powders prior to flushing. Lint roller may also be used to remove powders prior to flushing b) Immediately begin to flush with large amounts of water c) Continue flushing the contaminated area when en route to the receiving facility d) Do not contaminate uninjured areas while flushing e) Attempt to identify contaminant f) Transport to the most appropriate medical facility g) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness 46

47 h) Follow Pain Control protocol Toxin in Eye a) Flood eye(s) with lukewarm water and have patient blink frequently during irrigation. Use caution to not contaminate other body areas b) Attempt to identify contaminant c) Transport to the most appropriate medical facility d) Establish a large bore IV if indicated and infuse as patient condition warrants e) Follow Pain Control protocol Electrical Burns a) Treat soft tissue injuries associated with the bum with dry dressing b) Treat for shock if indicated c) Transport to the most appropriate medical facility d) Follow Pain Control protocol ADVANCED CARE GUIDELINES BASIC CARE GUIDELINES ADVANCED CARE GUIDELINES BASIC CARE GUIDELINES ADVANCED CARE GUIDELINES 47

48 1. Follow Initial Patient Care Protocol Cardiac Arrest BASIC CARE GUIDELINES a) All levels of providers should perform emergency cardiac care in accordance with protocols approved by the medical director, referencing AHA guidelines b) Autopulse device should be used for CPR chest compressions when available ADVANCED CARE GUIDELINES c ) All levels of providers should perform emergency cardiac care in accordance with protocols approved by the medical director, referencing AHA guidelines 48

49 Childbirth 1. Follow Initial Patient Care Protocol Normal Delivery a) If delivery is imminent with crowning, commit to delivery on site and contact medical control b) If the amniotic sac does not break, or has not broken, use a clamp to puncture the sac and push it away from the infant's head and mouth as they appear c) For newborn management, see newborn resuscitation protocol Breech delivery: (buttocks presentation) BASIC and ADVANCED CARE GUIDELINES a) Allow spontaneous delivery b) Support infant's body as it's delivered c) If head delivers spontaneously, proceed as in Section I (Normal Delivery) d) If head does not deliver within 3 minutes, insert gloved hand into the vagina, keeping your palm toward baby's face; form a "V" with your fingers and push wall of vagina away from baby's face, thereby creating an airway for baby e) Do not remove your hand until relieved by advanced EMS or hospital staff ADVANCED CARE GUIDELINES Care of mother: a) May establish IV access with NS and give fluid bolus. 49

50 Congestive Heart Failure 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Place patient in position of comfort, typically sitting up, loosen tight clothing and reassure b) Maintain oxygenation with cannula or mask if oxygen saturations are below 94% titrate to 94% or higher c) Transport immediately if the patient has any of the following: No history of cardiac problems Systolic blood pressure of less than 100. A history of cardiac problems, but does not have nitroglycerin d) If capability exists, obtain a 12-lead EKG and transmit it to the receiving facility and/or medical control for interpretation prior to patient's arrival e) Contact medical direction for orders f) If the patient has been prescribed nitroglycerin (patient's nitro only) and systolic blood pressure is 90 mrnhg or above, give one dose. If patient is taking erectile dysfunction drugs such as Viagra, contact medical direction prior to giving nitroglycerin g) Repeat one dose of nitroglycerin in 3-5 minutes if pain continues if systolic blood pressure is 90 mmhg or above and authorized by medical direction, up to a maximum of three doses h) Reassess patient and vital signs after each dose of nitroglycerin i) Further assess the patient and evaluate possible causes (unless other treatment priorities exist) ADVANCED CARE GUIDELINES j) If not already performed, obtain a 12-lead EKG and if possible transmit it to the receiving facility and/or medical control k) Establish IV access at TKO rate unless otherwise ordered or indicated l) Be prepared to intubate patient m) Monitor EKG and treat dysrhythmias following the appropriate protocol(s) n) If capability exists, apply CPAP o) Administer nitroglycerin (tab or spray) 0.4 mg sublingually if systolic blood pressure 90 mmhg or above. (Max of 3Nitro) 50

51 Frostbite 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Remove the patient from the cold environment b) Protect the cold injured extremity from further injury (manual stabilization) c) Remove wet or restrictive clothing d) Do not rub or massage e) Do not re-expose to the cold f) Remove jewelry g) Cover with dry clothing or dressings ADVANCED CARE GUIDELINES h) Establish IV access at a TKO rate. Use warmed IV fluid if possible i) Follow pain protocol 51

52 Heat Illness 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Remove from the hot environment and place in a cool environment (back of air conditioned response vehicle) b) Loosen or remove clothing c) Place in recovery position d) Initially cool patient by fanning e) Additionally cool patient with cold packs to neck, groin and axilla f) If alert, stable and not nauseated, you may have the patient slowly drink small sips of water g) If the patient is unresponsive or is vomiting, transport to an appropriate medical facility with patient on their left side ADVANCED CARE GUIDELINES h) Monitor EKG and treat dysrhythmias following the appropriate protocol(s) i) Administer IV fluids as appropriate/ consider Zofran for nausea. (4mg) 52

53 1. Follow Initial Patient Care Protocol a) Remove wet clothing b) If able, check core temperature c) Handle patient very gently d) Cover patient with blankets Hypothermia BASIC CARE GUIDELINES ADVANCED CARE GUIDELINES e) Administer warm IV fluids if available, do not administer cold fluids f) Follow AHA guidelines for treatment of Hypothermia. 53

54 Nausea & Vomiting 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Give nothing by mouth ADVANCED CARE GUIDELINES b) Consider fluid bolus IV/IO if evidence of hypervolemia and lung sounds are clear c) If patient nauseated or is vomiting, consider Ondansetron (Zofran) 4 mg IV d) Consider intubating patients with altered mental status who are vomiting and cannot protect their airway e) Consider blood sugar. 54

55 Pain Control 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) First, attempt to manage all painful conditions: Splint extremity injuries Place the patient in a position of comfort ADVANCED CARE GUIDELINES b) Follow Pain Protocol c) Monitor ECG and 02 saturations d) The patient must have vital signs taken prior to each dose of pain medication and be monitored closely. If at any time there is a decreased level of consciousness, decrease in oxygen saturation below 92%, or blood pressure drops to 90 mmhg or less, administration of narcotic medication must stop 55

56 Poisoning 1. Follow Initial Patient Care Protocol 2. Identify contaminate and call Poison Control and follow directions given to provide care: Contact Medical Direction as soon as possible with information given by Poison Control and care given BASIC CARE GUIDELINES Ingested poisons a) Identify and estimate amount of substance ingested Inhaled poisons: a) Remove patient to fresh air b) Administer high flow oxygen. c) Estimate duration of exposure to inhaled poison Absorbed poisons a) Identify contaminate! If it will be a hazard to you, use protective clothing and extreme caution Injected poisons a) Be alert for respiratory difficulty. Maintain airway and give high flow oxygen b) Check patient for marks, rashes, or welts c) Try to identify source of injected poison ADVANCED CARE GUIDELINES d) For drug specific overdoses of narcotics administer naloxone 0.4 mg - 2 mg IV /IO/IM, titrate to improve of respiratory rate and volume, to total of lo mg. 56

57 Seizure 1. Follow Initial Patient Care Protocol Active seizure BASIC CARE GUIDELINES a) Protect airway b) Check blood glucose level, if available, and treat hypoglycemia if present ADVANCED CARE GUIDELINES c) Administer midazolam in 2.5 mg doses IV push, until the seizure stops or until maximum dose of 10 mg is given OTHER ROUTES OF DRUG ADMINISTRATION ARE ACCEPTABLE. FOLLOW DRUG PROTOCOLS. Post seizure BASIC CARE GUIDELINES a) Protect airway b) Check blood sugar and treat hypoglycemia if present ADVANCED CARE GUIDELINES c) Treat hypoglycemia appropriately if present 57

58 Sexual Assault 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Identify yourself to the patient, assure patient that they are safe and in no further danger b) Do not burden patient with questions about the details of the crime; you are there to provide emergency medical care c) Be alert to immediate scene and document what you see. Touch only what you need to touch at the scene d) Do not disturb any evidence unless necessary for treatment of patient. (If necessary to disturb evidence, document why and how it was disturbed.) e) Preserve evidence; such as clothing you may have had to remove for treatment, and make sure that it is never left unattended at any time, to preserve "chain of evidence" Place in PAPER BAG f) Contact local law enforcement if not present g) Treat other injuries as indicated h) Treat for shock if indicated 58

59 Stroke A. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Perform a "FAST" Cincinnati Pre-hospital Stroke Scale - checking facial droop, arm drift, speech, and time of onset. Notify receiving facility as soon as possible if stroke is suspected b) If Stroke Screening is positive expedite transport to the hospital c) Check blood glucose, if available. If blood sugar is less than 60 mg/dl, and patient is conscious and able to swallow, administer one tube of oral glucose. ADVANCED CARE GUIDELINES d) If blood sugar less than 60 mg/dl administer D gm IV 1 ) If no vascular access, administer glucagon 1 mg IM f) Monitor patient's level of consciousness and blood pressure every five (5) minutes, and keep patient as calm as possible g) Follow AHA guidelines for Acute Stroke 59

60 Trauma 1. Follow Initial Patient Protocol for all patients 2. Follow the Out-of-Hospital Trauma Triage Destination Decision Protocol for the identification of time-critical injuries, method of transport and destination decision for treatment of those injuries 3. The goal should be to minimize scene time with time critical injuries, including establishing IVs en route. BASIC CARE GUIDELINES a) Hemorrhage Control Protocol Control bleeding with direct pressure. Large gaping wounds may need application of a bulky sterile gauze dressing and direct pressure by hand Consider application of tourniquet if unable to control hemorrhage with direct pressure ADVANCED CARE GUIDELINES b) Establish IV and infuse fluids to maintain a systolic pressure of 90 ~ 100 mmhg for shock. Chest Trauma BASIC CARE GUIDELINES a) Seal open chest wounds immediately. Use occlusive dressing taped down. If the breathing becomes worse, loosen one side of the dressing to release pressure and then reseal b) Impaled objects must be left in place and should be stabilized by building up around the object with multiple trauma dressings or other cushioning material c) Take care that the penetrating object is not allowed to do further damage ADVANCED CARE GUIDELINES d) Provide needle chest decompression if appropriate. Abdominal Trauma BASIC CARE GUIDELINES a) Control external bleeding. Dress open wounds to prevent further contamination b) Evisceration should be covered with a sterile saline soaked occlusive dressing c) Impaled objects should be stabilized with bulky dressings for transport Head and Neck Trauma 60

61 BASIC CARE GUIDELINES a) Establish and maintain manual spinal immobilization b) Place the head in a neutral in-line position unless the patient complains of pain or the head does not easily move into this position c) Apply cervical collar and maintain manual stabilization d) Closely monitor the airway. Provide suctioning of secretions or vomit as needed. Be prepared to log roll the patient if they vomit. Maintain manual spinal stabilization if patient is log rolled e) Impaled objects in the cheek may be removed if causing airway problems, or you are having trouble controlling bleeding. Use direct pressure on injury after removal to control any bleeding f) Reassess vitals and Glasgow Coma Score (GCS) frequently ADVANCED CARE GUIDELINES g) Consider intubation if airway cannot be maintained h) If patient is intubated or has an airway such as, King, LMA and C02 levels should be continually monitored and maintained at mmhg if available Extremity Injuries BASIC CARE GUIDELINES a) Assess extent of injury including presence or absence of pulse b) Establish and maintain manual stabilization of injured extremity by supporting above and below the injury c) Remove or cut away clothing and jewelry d) Cover open wounds with a sterile dressing e) Do not intentionally replace any protruding bones f) Apply cold pack to area of pain or swelling g) If severe deformity of the distal extremity is cyanotic or lacks pulses, align with gentle traction before splinting, and transport immediately ADVANCED CARE GUIDELINES h) Monitor EKG and treat dysrhythmias if indicated following the appropriate protocol i) Refer to Pain Control protocol 61

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63 IOWA EMS TREATMENT PROTOCOLS Pediatric Treatment Protocols Pediatric Initial Care Protocol Pediatric Airway Pediatric Allergic Reaction Pediatric Altered Mental Status Pediatric Apparent Death Pediatric Asthma Pediatric Burns Pediatric Cardiac Arrest Pediatric Nausea & Vomiting Pediatric Near Drowning Newborn Resuscitation & Care Pediatric Pain Control Pediatric Poisoning Pediatric Seizure Pediatric Shock Suspected Child Abuse Pediatric Trauma

64 Pediatric Initial Care Protocol 1. Scene Size Up a) Review the dispatch information b) As you approach the scene, be sure to consider safety for yourself and your patient c) Observe universal precautions d) After determining the number and location of patients, consider the need for additional resources e) Determine mechanism of injury and/or nature of illness f) Reassess the situation often 2. Primary Survey a) Obtain general impression of patient, chief complaint, and priority problems b) Determine responsiveness c) Assess airway d) Assess breathing e) Assess circulation f) Maintain cervical stabilization/immobilization if indicated 3. Initial Interventions a) Treat airway/breathing problems b) Treat circulation problems c) Establish IV access if indicated d) Treat pain or nausea e) Apply cardiac monitor 4. Secondary Survey a) Perform secondary assessment after initial interventions are completed b) Address problems identified in the secondary survey utilizing the appropriate protocol(s) c) Obtain vital signs, including blood glucose if available and indicated d) Assess pain 5. Ongoing Assessment a) Repeated evaluation of patient Vitals every 5 minutes or as appropriate for unstable patient Vitals every 15 minutes or as appropriate for stable patients b) Assess effect of interventions 6. Transport/Contact Medical Control a) Patients should be transported as soon as feasible to an appropriate medical facility. Immediate transport with treatment enroute is recommended for patients with significant trauma or unstable airways b) Tier with an appropriate service if level of care indicates or assistance is needed and can be accomplished in a timely manner c) Contact medical direction as soon as feasible in accordance with local protocol for further orders d) For seriously injured or critically ill patients, give a brief initial report from the scene when 64

65 possible, with a more detailed report given to medical direction while en route 65

66 Pediatric Airway l. Follow Initial Patient Care Protocol Breathing spontaneous on initial assessment with adequate ventilation BASIC CARE GUIDELINES a) Maintain oxygenation with cannula, mask, or blow-by if oxygen saturations are below 94%, titrate to 94% or higher Breathing without adequate ventilation or not breathing BASIC CARE GUIDELINES a) Open the airway b) Attempt assisted ventilation using an appropriate adjunct with high-flow 100% oxygen. If unable to ventilate, first reposition airway and attempt to ventilate again c) If ventilation still unsuccessful, check airway for obstruction and attempt to dislodge with age appropriate techniques ADVANCED CARE GUIDELINES d) If unsuccessful establish direct view of object and attempt to remove it with Magill forceps If obstruction cleared BASIC CARE GUIDELINES a) Assist ventilation and provide oxygen ADVANCED CARE GUIDELINES b) If adequate ventilation is NOT maintained proceed to an advanced airway as appropriate for patient size If obstruction not cleared ADVANCED CARE GUIDELINES a) Attempt endotracheal intubation and try to ventilate the patient b) If endotracheal intubation is not successful, perform needle Crichothyrotomy and needle insufflation 66

67 Pediatric Allergic Reaction 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Assess airway via Airway Protocol b) If signs of anaphylaxis are present, administer auto-injectable epinephrine: Pediatric epi-pen (0.15 mg) for children less than 66 lbs (30 kg) or Adult epi-pen (0.3 mg) for children 66 lbs (30 kg) or greater ADVANCED CARE GUIDELINES c) Administer epinephrine 1: 1,000 concentration 0.01 mg/kg IM, up to a maximum dose of 0. 5 mg d) Establish IV access e) Administer diphenhydramine at 1.0 mg/kg IV or deep IM, up to a maximum dose of 50 mg f) Administer epinephrine 1:10,000 concentration 0.01 mg/kg IV for profound shock, up to a maximum dose of 0.5 mg g) Administer albuterol 2.5 mg by nebulizer if in respiratory distress h) Contact medical control to repeat dose of Epi 67

68 Pediatric Altered Mental Status 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Follow Airway Protocol to ensure adequate ventilation b) Obtain blood glucose c) Patient conscious - give oral Glucose for children over 2 years of age. d) Establish IV I IO access If Hypoglycemic ADVANCED CARE GUIDELINES e) Patient unconscious; give Dextrose g/kg slowly IV up to 25 grams If less than 1 month of age, dilute D50 to concentration of 1:4, DSO:NS If 1 month - 8 yrs of age, dilute D50 to concentration of 1: 1, D50/NS If greater than 8 yrs of age, use 050 as supplied. f) Patient unconscious and no IV access; administer Glucagon mg/kg IM up to 1 mg maximum g) Monitor cardiac rhythm h) If no improvement in level of consciousness after glucose administration give Narcan 0.1 mg/kg IV up to maximum dose of2.0 mg per dose i) If there is evidence of shock or a history of dehydration, administer a fluid bolus of normal saline at 20 ml/kg over 10~15 minutes j) Reassess patient, if signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg 68

69 Pediatric Apparent Death l. Follow Initial Patient Care Protocol BASIC and ADVANCED CARE GUIDELINES Apparent death indications are as follows: Signs of trauma are conclusively incompatible with life Physical decomposition of the body Rigor mortis and/or dependent lividity If apparent death is confirmed, continue as follows: a) The county Medical Examiner and law enforcement shall be contacted b) Where possible contact Iowa Donor Network at c)at least one EMS provider should remain at the scene until the appropriate authority is present d) Provide psychological support for grieving survivors e) Document reason no resuscitation was initiated f) Preserve the crime scene if present g) In all other circumstances (except where "NO CPR/DNR" protocol applies) full resuscitation must be initiated 69

70 Pediatric Asthma 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Use Airway Protocol to evaluate the airway and adequacy of ventilation b) If patient has a physician prescribed, hand-held metered dose inhaler, contact medical direction for approval to give inhaler treatment c) Reassess patient and repeat second dose if necessary per medical direction ADVANCED CARE GUIDELINES d) Administer albuterol 2.5.mg via Nebulizer e) Administer epinephrine l:l,000 concentration 0.01 mg/ kg SC or IM up to a maximum dose of 0.5 mg f) For profound respiratory distress, may administer 1:10,000 epinephrine 0.01 mg per kg IV, to maximum dose of 0.5 mg. 70

71 Pediatric Burns 1. Follow Initial Patient Care Protocol Thermal burns BASIC CARE GUIDELINES a) Stop the burning process, initially with water or saline b) Remove smoldering clothing and jewelry c) Continually monitor the airway for evidence of obstruction d) Prevent further contamination of wounds e) Cover the burned area with a dry sterile dressing or plastic wrap f) Do not use any type of ointment, lotion, or antiseptic g) Do not break blisters h) Transport to the most appropriate medical facility i) Estimate percent of body surface area injured and estimate the depth of bum as superficial, partial thickness or full thickness j) Establish an IV of NS. Using the Parkland Bum Formula: 1. 4 ml x total body surface area sustaining 2 nd or 3 rd degree burns x person's weight in kilograms. 2. Infuse half of this volume over the first 8 hours from the time of the burn, with the remainder infused over the following 16 hrs. 3. Quick Calculation for the first hour: Patient's weight in kilograms x 20 ml= volume for the first hours. The total volume can be calculated when there is time k) Treat pain per pain protocol Chemical burns ADVANCED CARE GUIDELINES BASIC CARE GUIDELINES a) Brush off powders prior to flushing. Lint roller may also be used to remove powders prior to flushing b) Immediately begin to flush with large amounts of water. Continue flushing the contaminated area when en route to the receiving facility c) Do not contaminate uninjured areas while flushing d) Attempt to identify contaminant e) Transport to the most appropriate medical facility f) Estimate percent of body surface area injured and estimate the depth of bum as superficial, partial thickness or full thickness 71

72 ADVANCED CARE GUIDELINES g) Treat pain per pain control protocol Toxin in eye BASIC CARE GUIDELINES a) Flood eye(s) with lukewarm water and have patient blink frequently during irrigation. Use caution to not contaminate other body areas b) Continue irrigation until advanced personnel take over c) Attempt to identify contaminant d) Transport to the most appropriate medical facility ADVANCED CARE GUIDELINES e) Establish a large bore IV if indicated and infuse as patient condition warrants f) Treat pain per pain control protocol Electrical burns BASIC CARE GUIDELINES a) Treat soft tissue injuries associated with the burn with dry dressing b) Treat for shock if indicated c) Transport to the most appropriate medical facility d) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness e) Treat pain per pain control protocol ADVANCED CARE GUIDELINES 72

73 Pediatric Cardiac Arrest 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) All levels of providers should perform emergency cardiac care in accordance with protocols approved by the medical director, referencing AHA guidelines ADVANCED CARE GUIDELINES b) All levels of providers should perform emergency cardiac care in accordance with protocols approved by the medical director, referencing AHA guidelines 73

74 Pediatric Nausea & Vomiting 1. Follow Initial Patient Care Protocol ADVANCED CARE GUIDELINES a) Initiate IV access b) Consider fluid bolus if evidence of hypovolemia c) If patient nauseated or is vomiting administer anti-emetic medication such as Ondansetron (Zofran) 0.1 mg/kg IV up to 4 mg maximum d) Consider intubating patients with altered mental status who are vomiting and can't protect their airway 74

75 Pediatric Near Drowning 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Establish patient responsiveness b) If cervical spine trauma is suspected, manually stabilize the spine c) Assess airway for patency, protective reflexes and the possible need for advanced airway management. Look for signs of airway obstruction d) Open the airway using head tilt/chin lift if no spinal trauma is suspected, or modified jaw thrust if spinal trauma is suspected e) Suction as necessary f) Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway cannot be maintained with positioning and the patient is unconscious g) Assess breathing. Obtain pulse oximeter reading h) If breathing is inadequate, assist ventilation using an appropriate adjunct with high-flow, 100% concentration oxygen i) Assess circulation and perfusion j) If breathing is adequate, place the child in a position of comfort and maintain oxygenation with cannula, mask or blow-by if oxygen saturations are below 94% titrate to 94% or higher. k) Assess mental status l) If spinal trauma is suspected, continue manual stabilization, apply a rigid cervical collar, and immobilize the patient on a long backboard or similar device m) Expose the child only as necessary to perform further assessments. n) Maintain the child's body temperature throughout the examination o) If the child's condition is stable, perform focused history and detailed physical examination on the scene, then initiate transport p) If the child's condition is stable, perform focused history and detailed physical examination on the scene, then initiate transport ADVANCED CARE GUIDELINES q) If abdominal distention arises, consider placing a gastric tube to decompress the stomach if available r) If the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated s) Perform sedatives to aid with intubation as permitted by medical direction. Confirm placement of endotracheal tube using clinical assessment and end-tidal C02 monitoring as per medical direction t) Initiate cardiac monitoring and determine rhythm. Consult the appropriate protocol for treatment of specific dysrhythmias. Refer to AHA guidelines u) Obtain vascular access. Administer normal saline at a maintenance rate according to weight v) If the child's condition is critical or unstable, initiate transport as quickly as possible. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit 75

76 Newborn Resuscitation & Care 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Suction the airway using a bulb syringe as soon as the head is delivered and before delivery of the body. Suction the mouth first, then the nose b) Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the baby in a thermal blanket or dry towel. Cover the scalp to preserve warmth c) Open and position the airway. Suction the airway again using a bulb syringe. Suction the mouth first, then the nose d) Assess breathing and adequacy of ventilation e) Clamp cord in two places 6-8 inches from the infant, and cut, f) If ventilation is inadequate, stimulate by gently rubbing the back and flicking the soles of the feet g) If ventilation is still inadequate after brief stimulation, begin assisted ventilation at 40 to 60 breaths per minute using a bag-valve-mask device with room air. If no improvement after seconds, apply 100% oxygen to BVM and continue to ventilate infant. h) If ventilation is adequate and the infant displays central cyanosis, administer oxygen at 5 lpm via blow-by. Hold the tubing 1/2 to l inch from the nose. Check heart rate. i) If the heart rate is slower than 60 beats per minute after 30 seconds of assisted ventilation with high-flow, 100% concentration oxygen, initiate the following actions: Begin chest compressions at a combined rate of 120/minute (three compressions to each ventilation) ADVANCED CARE GUIDELINES j) If there is no improvement in heart rate after 30 seconds. Perform endotracheal intubation k) If there is no improvement in heart rate after intubation and ventilation, administer 1. epinephrine 1:1000 concentration at 0.1 mg/kg (maximum individual dose 10.0 mg) via endotracheal tube, 2. or epinephrine 1:10,000 concentration at 0.01 mg/kg (maximum individual dose 1.0 mg) IV/IO 3. Repeat epinephrine at the same dose every 3 to 5 minutes as needed l) Initiate transport. Reassess heart rate and respirations en route If the heart rate is between 60 and 80 beats per minute, initiate the following actions: Continue assisted ventilation with high-flow, 100% concentration oxygen. If there is no improvement in heart rate after 30 seconds, initiate management sequence described in step H above, beginning with chest compressions 76

77 Initiate transport. Reassess heart rate and respirations en route If the heart rate is between 80 and 100 beats per minute. initiate the following actions: Continue assisted ventilation with high-flow, 100% concentration oxygen. Stimulate as previously described Initiate transport. Reassess heart rate after 15 to 30 seconds If the heart rate is faster than 100 beats per minute, initiate the following actions: Assess skin color. If central cyanosis is still present, continue blow by oxygen. Initiate transport. Reassess heart rate and respirations en route If thick meconium is present Initiate endotracheal intubation before the infant takes a first breath. Suction the airway using an appropriate suction adapter while withdrawing the endotracheal tube. Repeat this procedure until the endotracheal tube is clear of meconium. If the infant's heart rate slows, discontinue suctioning immediately and provide ventilation until the infant recovers Note: If the infant is already breathing or crying, this step may be omitted 77

78 Pediatric Pain Control 1. Follow Initial Patient Care Protocol 2. First attempt to manage all painful conditions with basic care BASIC CARE GUIDELINES a) Splint extremity injuries b) Place the patient in a position of comfort ADVANCED CARE GUIDELINES c) Follow pain protocol d) Monitor ECG and 02 saturations e) The patient must have vital signs taken prior to each dose and be monitored closely. Administration of narcotic medication must stop if at any time there is a decreased level of consciousness, decrease in oxygen saturation below 92% blood pressure drops below normal values for age I weight of patient by 10 mmhg or more After drug administration, reassess the patient using the appropriate pain scale 78

79 Pediatric Poisoning 1. Follow Initial Patient Care Protocol 2. Identify contaminate and call Poison Control and follow directions given to provide care: l Contact Medical Direction as soon as possible with information given by Poison Control and care given BASIC CARE GUIDELINES Ingested Poisons a) Identify and estimate amount of substance ingested Inhaled Poisons: a) Remove patient to fresh air b) Administer high flow oxygen c) Estimate duration of exposure to inhaled poison Absorbed Poisons a) If it will be a hazard to you, use protective clothing and extreme caution Injected Poisons a) Be alert for respiratory difficulty. Maintain airway and give high flow oxygen b) Check patient for marks, rashes, or welts ADVANCED CARE GUIDELINES Follow drug protocols to treat drug-specific ingestion of narcotics (naloxone). 79

80 Pediatric Seizure 1. Follow Initial Patient Care Protocol Active Seizure BASIC CARE GUIDELINES a) Assess airway via Airway Protocol b) Check blood glucose, if available ADVANCED CARE GUIDELINES c) Establish IV access d) Administer IV Benzodiazepine to stop seizure. May repeat dose in 5 minutes if still seizing: Diazepam 0.l mg/kg IV /IO OR Midazolam 0.I5 mg/kg IV/IO/IN e) If blood glucose less than 60 mg/dl give IV glucose or glucagon if no IV access Post Seizure BASIC CARE GUIDELINES a) Protect airway b) Check blood glucose, if available. If blood glucose less than 60 mg/dl, and patient is conscious and able to swallow, give 1/2 to 1 tube oral glucose. ADVANCED CARE GUIDELINES c) Establish IV d) If blood glucose less than 60 mg/dl administer Dextrose 0.5 grams/kg slow IV up to 25 grams 80

81 Pediatric Shock 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Assess airway via Airway Protocol b) Assess circulation and perfusion c) Control external bleeding d) Assess mental status e) Expose the child only as necessary to perform further assessments. Maintain the child's body temperature throughout the examination f) Initiate transport. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit ADVANCED CARE GUIDELINES g) Initiate cardiac monitoring h) Establish IV access using an age-appropriate large-bore catheter with large-caliber tubing. If intravenous access cannot be obtained, proceed with Intraosseous access. Do not delay transport to obtain vascular access i) Administer a fluid bolus of normal saline at 20 ml/kg over 10 to 15 minutes. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg 81

82 Suspected Child Abuse 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) Approach child slowly to establish rapport (except in life-threatening situations), then perform exam b) Treat obvious injuries according to appropriate protocol c) Genital exam only if indicated in the presence of blood, known or obvious injury and or trauma d) Interview parents separate from child, if possible e) Transport if permitted by parents f) If parents do not allow transport, notify law enforcement for assistance g) Communicate vital information only - additional info can be given to attending RN and/or Physician on arrival h) Record observations and factual information on run report i) Report all suspected abuse to the National hotline at within 24 hours of your contact of the patient. This will be an oral report only j) Within 48 hours of oral reporting, you must submit a written report for all suspected abuse to the Department of Human Services 82

83 Pediatric Trauma l. Follow Initial Patient Care Protocol 2. Follow the Out-of-Hospital Trauma Triage Destination Decision Protocol for the identification of time critical injuries, method of transport and trauma facility resources necessary for treatment of those injuries 3. The goal should be to minimize scene time with time critical injuries, including establishing IVs en route. a) Follow Shock Protocol if shock is present Hemorrhage Control: BASIC CARE GUIDELINES BASIC CARE GUIDELINES b) Control bleeding with direct pressure. Large gaping wounds may need application of a bulky sterile gauze dressing and direct pressure by hand c) Elevation of extremity may be used to help control bleeding if no bone or joint injury evident d) If bleeding persists, consider appropriate arterial pressure points in upper and lower extremities e) If unable to control hemorrhage with direct pressure consider application of a tourniquet f) Establish large bore IV g) Cardiac monitor Chest Trauma: ADVANCED CARE GUIDELINES BASIC CARE GUIDELINES a) Seal open chest wounds immediately. Use occlusive dressing taped down. If the breathing becomes worse, loosen one side of the dressing to release pressure and then reseal b) Impaled objects must be left in place and should be stabilized by building up around the object with multiple trauma dressings or other cushioning material c) Take care that the penetrating object is not allowed to do further damage ADVANCED CARE GUIDELINES d) Perform needle chest decompression if appropriate. 83

84 Abdominal Trauma a) Control external bleeding. Dress open wounds to prevent further contamination b) Evisceration should be covered with a sterile saline soaked occlusive dressing c) Impaled objects should be stabilized with bulky dressings for transport Head and Neck Trauma Establish and maintain manual spinal immobilization a) Place the head in a neutral in-line position unless the patient complains of pain or the head does not easily move into this position b) Continue manual stabilization, apply a rigid cervical collar, and immobilize the patient on a long backboard or similar device c) Closely monitor the airway. Provide suctioning of secretions or vomit as needed. Be prepared to log roll the patient if they vomit. Maintain manual spinal stabilization if patient is log rolled d) Reassess vitals, GCS and pupillary response frequently 84

85 IOWA EMS TREATMENT PROTOCOLS EMS Out-of-Hospital Do-Not-Resusicate Protocol Out-of-Hospital Trauma Triage Destination Decision Protocol Physician on Scene Air Medical Transport Discontinuation of Resusitation Strategies for Reperfuson Therapy: Acute Stroke Simple Triage and Rapid Treatment Guidelines for Responding to a Patient with Special Needs EMS Approved Abbreviations Blood Glucose Testing Accessing Central Lines/Ports (PS Skill) Ventilators Accessing Implanted Port Monitoring Chest Tubes Morgan Lens Administration of Blood and Blood Components CPAP Port O2 Vent Operation Needle Cricothyrotomy External Jugular IV Insertion Gastric Tube Placement Maintenance of Non-Medicated IV s King LT/LTS-D Airway Needle Chest Decompression External Cardiac Pacing Tourniquet Application Taser Barb Removal Simple Triage and Rapid Treatment Jump START Pediatric MCI Triage Assessment Based Spinal Management

86 EMS OUT-Of-HOSPITAL DO-NOT-RESUSCITATE PROTOCOL Purpose: This protocol is intended to avoid unwarranted resuscitation by emergency care providers in the out-of-hospital setting for a qualified patient.' There must be a valid Out-Of- Hospital Do-Not Resuscitate (OOH DNR) order signed by the qualified patient's attending physician or the presence of the OOH DNR identifier indicating the existence of a valid OOH DNR order. No resuscitation: Means withholding any medical intervention that utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function, including but not limited to: 1. Chest compressions, 2. Defibrillation, 3. Esophageal/tracheal/double-lumen airway; endotracheal intubation, or 4. Emergency drugs to alter cardiac or respiratory function or otherwise sustain life. Patient criteria: The following patients are recognized as qualified patients to receive no resuscitation: l. The presence of the uniform OOH DNR order or uniform OOH DNR identifier, or 2. The presence of the attending physician to provide direct verbal orders for care of the patient. The presence of a signed physician order on a form other than the uniform OOH DNR order form approved by the department may be honored if approved by the service program EMS medical director. However, the immunities provided by law apply only in the presence of the uniform OOH DNR order or uniform OOH DNR identifier. When the uniform OOH DNR order or uniform OOH DNR identifier is not present contact must be made with on-line medical control and on-line medical control must concur that no resuscitation is appropriate. Revocation: An OOH DNR order is deemed revoked at any time that a patient, or an individual authorized to act on the patient's behalf as listed on the OOH DNR order, is able to communicate in any manner the intent that the order be revoked. The personal wishes of family members or other individuals who are not authorized in the order to act on the patient's behalf shall not supersede a valid OOH DNR order. Comfort Care : When a patient has met the criteria for no resuscitation under the foregoing information, the emergency care provider should continue to provide that care which is intended to make the patient comfortable (a.k.a. Comfort Care). Whether other types of care are indicated will depend upon individual circumstances for which medical control may be contacted by or through the responding ambulance service personnel. Comfort Care may include, but is not limited to: 1. Pain medication. 2. Fluid therapy. 3. Respiratory assistance (oxygen and suctioning). 86

87 Qualified Patient means an adult patient determined by an attending physician to be in a terminal condition for which the attending physician has issued an Out of Hospital DNR order in accordance with the law. Iowa Administrative Code I (I 44A) Definitions. 87

88 OUT OF HOSPITAL TRAUMA TRIAGE DESTINATION DECISION PROTOCOL ADULT IOWA'S TRAUMA SYSTEM ADULT The following criteria shall be utilized to assist the EMS provider in the identification of time critical injuries, method of transport and trauma care facility resources necessary for treatment of those injuries Step 1- Assess for Time Critical Injuries: Level of Consciousness a Vital Signs Glasgow Coma Score < 14 Respiratory diff./rate <10 or >29 Heart Rate > 120 Systolic B/P <90 If ground transport time to a Resource (Level I) or Regional (Level II) TCF is less than 30 minutes. Transport to the nearest Resource (Level 1) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes ground transport time to Resource (level I) or Regional (Level II) Transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 1 does not apply, move on to step 2 Step 2- Assess for Anatomy of an Injury All Penetrating injury to head, neck, torso, and extremities proximal to elbow and knee Partial or full thickness Burns > 10 /o TBSA or involving face/airway Amputation proximal to wrist or ankle Paralysis or Parasthesia Suspected two or more long bone fractures Suspected pelvic fracture EMS provider judgment for possible abdominal or thoracic injuries. Crushed, degloved, or mangled extremity Flail chest Any open long bone fracture Open or depressed skull fracture If ground transport time to a Resource (Level I) or Regional (Level II) TCF is less than 30 minutes. Transport to the nearest Resource (Level 1) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes ground transport time to Resource (Level I) or Regional (Level II), Transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program. If step 2 does not apply, move on to step 3 88

89 Step 3. Consider Mechanism of injury & High Energy Transfer Falls - Adult: > 20 ft. (1 story = 10 ft) Intrusion: > 12 in, occupant site; > 18 in, any site, High-risk auto crash: Ejection (partial or complete) from automobile Death in same passenger compartment, vehicle telemetry data consistent with high risk of injury Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact Motorcycle crash > 20 mph Rollover (unrestrained occupant) Bicyclist into handlebars Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If step 3 does not apply, move on to step 4 Step 4. Consider risk factors Age > 55 yrs (Risk of injury/death increases) Time-sensitive extremity injury EMS provider judgment Anticoagulation and bleeding disorders Pregnancy > 20 weeks Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If none of the criteria in the above 4 steps are met, follow local protocol for patient disposition. When in doubt, transport to nearest trauma care facility for evaluation. For all Transported Trauma Patients Contact receiving trauma care facility: 1. Give patient report to include: MOI, Injuries, Vital Signs & GCS, Treatment, Age, Gender and ETA 2. Obtain further orders from Medical Control as needed. 89

90 PHYSICIAN ON SCENE Your offer of assistance is appreciated. However, this EMS service, under law and in accordance with nationally recognized standards of care in Emergency Medicine, operates under the direct authority of a Physician Medical Director. Our Medical Director and physician designees have already established a physician-patient relationship with this patient. To ensure the best possible patient care, and to prevent inadvertent patient abandonment or interference with an established physician-patient relationship, please comply with our established protocols. Please review the following if you wish to assume responsibility for this patient: 1. You must be recognized or identify yourself as a qualified physician. 2. You must be able to provide proof of licensure and identify your specialty. 3. If requested, you must speak directly with the on-line medical control physician to verify transfer of responsibility for the patient from that physician to you. 4. EMS personnel, in accordance with state law, can only follow orders that are consistent with the approved protocols. 5. You must accompany this patient to the hospital, unless the on-line medical control physician agrees to re-assume responsibility for this patient prior to transport. 90

91 AIR MEDICAL TRANSPORT Utilization Guidelines for Scene Response These guidelines have been developed to assist with the decision making for use of air medical transport by the emergency medical services community. The goal is to match the patient's needs to the timely availability of resources in order to improve the care and outcome of the patient from injury or illness. CLINICAL INDICATORS: 1. Advanced level of care need (skills or medications) exists that could be made available more promptly with an air medical tier versus tiering with ground ALS service, and further delay would likely jeopardize the outcome of the patient 2. Transport time to definitive care hospital can be significantly reduced for a critically ill or injured patient where saving time is in the best interest of the patient 3. Multiple critically ill or injured patients at the scene where the needs exceed the means available 4. EMS Provider 'index of suspicion' based upon mechanism of injury and patient assessment DIFFICULT ACCESS SITUATIONS: 1. Wilderness or water rescue assistance needed 2. Road conditions impaired due to weather, traffic, or road construction I repair 3. Other locations difficult to access The local EMS provider must have a good understanding of regional EMS resources and strive to integrate resources to assure that ground and air services cooperate as efficiently and effectively as possible in the best interest of the patient. Medical directors for ambulance services should assure that EMS providers are aware of their own service's abilities and limitations given the level of care and geographic response area being served. Audits should be conducted on an ongoing basis to assure that utilization of regional resources (ground and air) is appropriate in order to provide the level of care needed on a timely basis. 91

92 DISCONTINUATION OF RESUSCITATION INDICATIONS TO CONSIDER TERMINATION OF RESUSCITATION: I. Patient is in full arrest with no signs of life present. 2. Patient is considered an adult. 3. Full ACLS has been instituted (Paramedic level) to include rhythm analysis and defibrillation if indicated, advanced airway management, and drugs given per protocol. 4. No return of circulation or shockable rhythm exists. 5. Correctable causes or special resuscitation circumstances have been considered and addressed. TERMINATION OF RESUSCITATION: 1. Patient meets all five criteria under 'indications' above, or patient is terminally ill/dnr where CPR was started prior to knowledge of resuscitation status. 2. Physician on-line medical direction is contacted (while ACLS continues) to discuss any further appropriate actions. 3. ACLS may be discontinued if physician on-line medical direction authorizes. OTHER CONSIDERATIONS: 1. Documentation must reflect that the decision to terminate resuscitation was determined by physician on-line medical direction. 2. An EMS/health care provider must attend the deceased until the appropriate authorities arrive. 3. All IVs, tubes, etc. should be left in place until the medical examiner authorizes their removal. 4. Implement survivor support plans related to coroner notification, funeral home transfer, leaving the body at the scene, and death notification/grief counseling for survivors. Physician on-line medical direction includes either of the following: 1. Hospital based physician contact via phone or radio. 2. Patient's primary care physician or on call physician contact via phone or radio. Special Considerations Patients with profound hypothermia or drug or toxin overdose may benefit from continued resuscitation. 92

93 STRATEGIES FOR REPERFUSION THERAPY: ACUTE STROKE Reperfusion Therapy Screening Not Limited to Paramedic Level This form should not be completed for patients suffering from Acute Coronary Syndromes. This tool will be used to triage patients to the appropriate receiving facility, and provide a template for passing information on to the receiving facility. Fibrinolytic screening may be done at the EMT-B level; however the decision to bypass a local hospital to transport to a Percutaneous Intervention (PCI) capable facility is reserved for the PS level. 1. If available, obtain 12 Lead EKG and transmit to receiving facility 2. EMT level Transport patent to closest appropriate facility. Contact medical control for decision on completing thrombolytic checklist. 3. PS Level Evaluate 12 Lead for evidence of STEMI. If STEMI is present, determine appropriate destination. If transport time to a facility capable of providing emergency PCI care is 60 minutes or less, it is recommended that all these patients be transported directly to the emergency PCI capable facility. If transport time to a facility capable of providing emergency PCI care is between minutes, transport to the PCI capable facility should be considered. If transport is initiated to a non-pci facility: 1. Complete fibrinolytic therapy checklist on next page. 2. If a local protocol for fibrinolytic therapy in the field has been established, then proceed with fibrinolytic protocol if: Authorized by voice contact with medical control, and The paramedic specialist has received training and has the approval of their physician medical director In all instances those patients requiring immediate hemodynamic or airway stabilization should be transported to the closet appropriate facility. If STEMI is not present, transport patient to closest appropriate facility. Note: See Fibrinolytic Checklist on the following page 93

94 STRATEGIES FOR REPERFUSION THERAPY: ACUTE STROKE If directed by medical control, complete fibrinolytic checklist below FIBRINOLYTIC CHECKLIST Any YES findings will be relayed to medical control. Absolute Contraindications preclude the use of fibrinolytic. Relative Contraindications require consultation with medical control. DATE: PATIENT AGE: MALE FEMALE INCIDENT/RECORD#: YES NO ABSOLUTE CONTRAINDICATIONS Any known intracranial hemorrhage? Known structural cerebral vascular lesion? Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours? Suspected aortic dissection? Active bleeding or bleeding diathesis (excluding menses)? Significant closed head trauma or facial trauma within 3 months? RELATIVE CONTRAINDICATIONS History of chronic, severe, poorly controlled hypertension? Severe, uncontrolled hypertension on presentation (S >180mmHg or D>110mmHg) History of prior ischemic stroke >3 months, dementia, or known intracranial pathology? Traumatic or prolonged (>ta min) CPR or major surgery (<3 weeks) Non-compressible vascular punctures? Pregnancy? Active peptic ulcer? Current use of anticoagulants? EMS Provider Print Name: Signature: 94

95 GUIDELINES FOR RESPONDING TO A PATIENT WITH SPECIAL NEEDS (This Protocol is not intended for interfacility transfers.) These guidelines should be used when an EMS provider, responding to a call, is confronted with a patient using specialized medical equipment that the EMS provider has not been trained to use, and the operation of that equipment is outside of the EMS provider's scope of practice. The EMS provider may treat and transport the patient, as long as the EMS provider doesn't monitor or operate the equipment in any way while providing care. When providing care to patients with special needs, EMS personnel should provide the level of care necessary, within their level of training and certification. When possible, the EMS provider should consider utilizing a family member or caregiver who has been using this equipment to help with monitoring and operating the special medical equipment if necessary during transport. Some examples of special medical devices: PCA (patient controlled analgesic) Chest Tube 95

96 EMS APPROVED ABBREVIATIONS a before Ix fracture ABC airway, breathing, GI gastrointestinal ALS circulation advanced life support gm gram AMI acute myocardial infarction gr grain amps ampules gt(t) drop(s) ASA aspirin h,hr hour AT atrial tachycardia hx history AV atrioventricular ICU intensive care unit bicarb sodium bicarbonate IM intramuscular BID twice a day IV intravenous BLS basic life support Kg kilogram BP blood pressure KVO keep vein open BS blood sugar L liter - c with LOC level of consciousness CAD coronary artery disease LR lactated ringers cc chief complaint Mgtt microdrip cc cubic centimeter MD medical doctor CCU coronary care unit meq mil1iequivalents CHB complete heart block mg milligram CHF congestive heart failure Ml myocardial infarction cm centimeter min minute CNS central nervous system ml milliliter c/o complains of mm millimeter co carbon monoxide MS morphine sulfate C02 carbon dioxide NaCl sodium chloride COPD chronic obstructive NaHC03 sodium bicarbonate pulmonary disease NG,N/G nasogastric CPR cardiopulmonary nitro nitroglycerine CSF resuscitation cerebral spinal fluid NPO nothing by mouth CVA cerebral vascular accident NS normal saline D/C discontinue NSR normal sinus rhythm DOA dead on arrival NTG nitroglycerine DSW 5% dextrose in water 02 oxygen Dx diagnoses OB obstetrics ED emergency department OD overdose EKG/ECG electrocardiogram OR operating room Epi epinephrine p pulse ER emergency room p after ET endotracheal PAC premature atrial contraction ETOH alcohol PAT paroxysmal atrial tachycardia fib fibrillation PCR patient care record physical exam, pulmonary fl fluid PE edema 96

97 EMS Approved Abbreviations pedi pediatric PERL pupils equal, reactive to light PJC premature junctional po by mouth pr per rectum prn whenever necessary, as needed PVC premature ventricular contraction q every QID four times a day R respirations R/0 rule out RN registered nurse Rx treatment s without SC subcutaneous Sec second SL sublingual SOB shortness of breath SQ subcutaneous STAT immediately s/s sign, symptoms SVT supraventricular tachycardia Sx symptoms TIA transient ischemic attack TIO three times a day TKO to keep open VF ventricular fibrillation w/s watt second setting x times y/o years old 97

98 BLOOD GLUCOSE TESTING Equipment Glucometer Test Strips 4x4s or 2X2s Disposable Lancet Alcohol Wipes Procedure Warm the fingers to increase blood flow. Let the patient's arm hang down at their side to allow blood to the fingertips. Grasp the finger just below the joint closest to the fingertip, and squeeze for 3 seconds. Wipe the side of the finger with an alcohol wipe and allow it to dry completely. Prepare lancet device according to manufacturer's instructions. Tum monitor ON. Check that the code number displayed matches code number on vial of test strips that you are using. When test strip symbol flashes on the display, monitor is ready to accept a test strip. Remove new test strip from vial. Replace the vial cap. Within 30 seconds, gently insert test strip (target area facing up) into test strip guide. Once the strip is correctly inserted, a blood symbol flashes on the display. Obtain a blood sample and briefly touch the drop of blood to the target area. When blood is applied correctly to a strip the machine will beep The blood glucose result is displayed & automatically recorded in the monitor's memory. Remove the test strip from the monitor and discard. When the test strip is removed, the strip symbol flashes indicating the monitor is ready to accept another strip. If you are done testing, tum the monitor OFF. Dispose of lancet in a sharps container. NOTES: If HI is displayed; your blood glucose result is higher than 600 mg/di. If this does not support the patient's history and clinical presentation, repeat the test with a new test strip. If LO is displayed, your blood glucose is lower than 20 mg/di. If this does not support the patient's history and clinical presentation, repeat the test with a new test strip. A. Very small amounts of blood may give you an error message or an inaccurate result. You will need to repeat the test using a new test strip. 98

99 ACCESSING CENTRAL LINES / PORTS (PS skill) Central venous access devices provide reliable short or long tern access for administration of fluids, TPN, chemotherapy, and blood sampling. Access only if true need exists. Tunneled Catheters: Groshong: The Groshong catheter is a central access device, which is surgically implanted by the physician and is tunneled under the skin. It has a smooth round tip with a slit valve that closes automatically when not in use. Because of this valve, the Groshong catheter does not require clamping or heparinization. Groshong catheters are flushed with I Orn! Normal Saline before and after NBP's or daily. Hickman: The Hickman catheter is blunt ended (like a straw) and us surgically inserted by the physician and is tunneled under the skin. Hickman catheters need to be heparinized when not in use. It is very important that this catheter be clamped when not in use to prevent blood loss or entrance of air. Hickman catheters are flushed with l Oml sterile Normal Saline before and after IVBP's followed by a heparin flush and once daily when not in use. Inserted Central Catheter (PICC): The PICC is inserted into the antecubital fossa. The distal tip may be a valve or open ended which determines how the catheter is managed. PICC lines are secured by using steri-strips and a dressing. Assessment of the site includes measuring the upper arm. A PICC may be used to administer blood, but may not be used for blood samples. Implantable Venous Access Port: The Infusaport is a venous access port implanted under the skin, which provides access to the vascular system. A Huber needle is used to access the Infusaport. ACCESSING EQUIPMENT: alcohol swabs Sterile 2 x 2 gauze 10 cc and 20 cc syringes Leurlock male adapter 25 gauge 5/8" needle, 22 gauge l" needle Sterile gloves Heparin flush (IOOu/cc) NaCl 0.9% solution, pump tuning and infusion pump Huber needle (lifeport) 20 gauge for blood transfusion, 22 gauge for fluid administration. Central line dressing kit PREPARATION: Obtain physician order to access device Explain procedure to patient providing instructions to keep hands away from the area. Wash hands and assemble equipment at the bedside. Drop kit supplies, syringes, 99

100 needles, and 2x2's onto sterile field. Remove caps from vials of saline and Heparin. Lay patient flat unless contraindicated, with head turned away from the catheter site Apply gloves and palpate site, isolating port between thumb and index finger. Cleanse skin over port connection with a Betadine swab, working from the center out 3" in a circular motion. Cover with a sterile 2 x 2, and allow to dry for a minimum of 2 minutes. NOTE: Hickman catheters are clamped with a slide clamp or a Quinton clamp discontinuing all IV flow. Groshong catheters do not require clamping. PROCEDURE: Apply sterile gloves. Using sterile technique, draw up 20 cc's of NaCl. Prime tubing of Huber needle, leave syringe attached and clamp tubing. If capping port, purge male adapter with Heparin flush using a I 0 cc syringe and 22 gauge needle. Pick up non-sterile areas of catheter hub with sterile 2 x 2's. Remove Leurlock tubing/male adapter plug from either the proximal or distal pigtail port. Discard male adapter plug or cover end of IV tubing with sterile needle. Hold the Huber needle by wings perpendicular to the port. Push needle through skin until resistance is met. Aspirate for blood return and flush with 20 cc's of NaCl or 30 cc's of TPN for infusing. BLOOD SAMPLING: Unclamp catheter and aspirate 5 cc's of blood (Peds 2-3 cc's). Clamp catheter; remove syringe and discard this specimen. Attach 10 cc syringe, unclamp catheter, and aspirate required amount of blood. Clamp catheter. Remove specimen syringe from port and place in appropriate vacuum tubes. Attach a 20 cc syringe of NaCl 0.9% solution to the catheter hub, unclamp catheter and flush port. For peds, flush with 2-5 cc's of NaCl 0.9% or amount ordered by physician until line clears. Clamp catheter and attach sterile Leurlock male adaptor plug primed with Heparin (Normal Saline for Groshong) or reattach IV infusion. Unclamp catheter and flush with Heparin IOOu/cc, Sec (Groshong final flush is with 5 cc Normal Saline). Amounts will be less for peds. Maintain positive pressure on syringe plunger while pulling catheter off needle. This prevents blood reflux. Resume all IV infusions. DOCUMENTATION: Document on the patient record the date, time, amount of blood sample, flush of Heparin or Normal Saline, size of Huber needle, IV solution and rate of administration. INITIALIZATION OF INFUSION: Connect Leurlock tubing, tum on pump and release clamp. CENTRAL LOCK: Attach sterile prefitted Leurlock male adapter to Huber needle and release clamp. Flush male adapter with Heparin flush, clamp during last 0.5 cc's of flush. 100

101 SITE DRESSING: Stabilize Huber needle by placing 2x2's under wings and secure wings with steristrips. Place 2x2 over Huber needle including wings and cover with a transparent dressing. 101

102 VENTILATORS INDICATIONS Interfaculty transport of patients that are apneic or exhibiting agonal respirations, or patients with respiratory compromise, requiring ventilator support, that have been nasally or orally intubated with endotraceal tube, with proper placement confirmed prior to transport. CONTRAINDICATIONS Patients with suspected pneumothorax/tension pnuemothorax. Patients with history of spontaneous Pneumothorax s. (Physician order to transport) EQUIPMENT Approved Automatic Transport Ventilator Oxygen source Bag valve device Intubation equipment End tidal CO2 detector (if patient has pulses) PROCEDURE 1. Determine need for Automatic Ventilator or assisted ventilations 2. Confirm security and proper placement of endotrachial tube, by using Bag-valve device auscultation and conventional assessment methods 3. End tidal CO2 detector shall be used if patient has a pulse, remove if patient has pulse 4. Assemble components of Auto Transport Vent and insure proper working order, including pressure limit alarm 5. Obtain pertinent Patient information and physicians order, including pressure limit alarm 6. Determine proper tidal volume for patient. (Use the following equation for adult and pediatric patients) 7. Set the tidal volume on the ventilator s control module accordingly 102

103 ACCESSING IMPLANTED PORT DEFINITION: The process of accessing implanted port for fluid or medication infusion. INDICATIONS: A qualified EMS provider* may use this skill for the following: 1. For emergency access for IV infusion of fluids and/or medications when other IV access is unavailable or otherwise not advised. 2. During life threatening injuries or illness when immediate IV access is necessary PROCEDURE: 1. Ensure all equipment is set up for port access 2. Prime tubing of Huber point needle with normal saline and close clamp, leaving syringe in place 3. Put on sterile gloves 4. Clean the skin with appropriate skin prep provided in VAP kit 5. Stabilize port with fingers after locating inner septum and push the needle until it contacts the back of the port. 6. Open clamp and flush with remaining sterile NS to confirm patency checking for blood return during flushing 7. Secure needle in place while supporting the 90 degree angled needle. Use gauze pad if needed. 8. Administer fluids or medication with even slow pressure. Drug administration should be less force than the force of the IV drip chamber. If the solution backs up in the drip chamber, the force is too great *Qualified EMS Provider: A certified EMT P/PS who has the skills necessary to competently perform this procedure and the approval of their medical director 103

104 MONITORING CHEST TUBES PURPOSE: To evacuate air and /or fluid from the pleural space or mediastinum To prevent air and/or fluid from re-accumulating in the pleural space or mediastinum To reestablish and maintain normal intrathoractic pressure gradients To facilitate complete lung re-expansion and restore normal mechanics of breathing EQUIPMENT: (As required) Pleur-evac chest drainage system Occlusive dressing Vaseline gauze Suction system (portable or wall mount) Sterile normal saline 1000 ml bottle Sterile gloves Felt-tip pen Patient care documentation sheets (run report) Accessing patient with chest drainage system PROCEDURE: 1. When performing a baseline assessment, assess the patient s chest drainage system according to the following guidelines 2. Check the system from the insertion site to the water-seal chamber and from the suction control chamber to the wall suction unit. Make sure all connections are tight and taped securely 3. Check to see that the dressing around the insertion site is dry and intact 4. Palpate for subcutaneous emphysema around the insertion site, and over the entire chest wall. If present mark the borders with a felt-tip pen and document the location in the run report 5. Auscultate breath sounds. Note any changes, being especially observant of the equality of breath sounds 6. Observe the fluid in the connecting tubing, noting its color and consistency. Note the fluid level in the collection chamber, mark the level and continually monitor fluid level in chamber, documenting level in run report 104

105 MORGAN LENS The Morgan Lens Eye Irrigation System will be used for continuous medication or lavage to the cornea, conjunctiva and entire cul-de-sac; ocular injuries due to acid burns or solvents, gasoline, detergents, etc. alkali burns; non-embedded foreign bodies; foreign body sensation with no visible foreign body; and severe infections. The Morgan Lens is not to be used with penetrating injuries, suspected or actual rupture of the globe, or to instill anesthetic agents with known allergies. Procedure: 1. Gather all equipment to be used including Morgan Lens, Tetracaine, irrigation solution and tubing, towels and tubs for fluid collection 2. Follow all guidelines for other emergency care 3. Prepare and explain procedure to patient 4. Instill two or three Tetracaine drops into the affected eye 5. Attach Morgan Lens to IV tubing 6. Prime tubing and lens with irrigation solution 7. Have patient look down, insert lens under upper lid 8. Have patient look up, retract lower lid and drop lens in place 9. Release lid over lens and adjust flow to desired rate 10. Tape tubing to patient s forehead 11. Direct and absorb outflow with towels and collection tubs 12. Irrigate with appropriate amount of fluid and do not stop irrigation flow unless recommended by Medical Control 13. To remove lens, continue flow, have patient look up, retract lower lid, hold position and slide lens out, terminate flow 14. Discard lens, irrigation solution and tubing in appropriate container 15. Document patient tolerance, amount of fluid instilled, outcome and visual acuity pre and post therapy 105

106 ADMINISTRATION OF BLOOD AND BLOOD COMPONENTS PURPOSE: To provide health care personnel with guidelines for the administration of blood and blood components INDICATIONS FOR TRANSFUSION OF BLOOD PRODUCTS: a) Red blood cells (RBC s) used for correction of red blood cell deficiencies including volume replacement in hemorrhagic shock b) Platelets used for treatment or prevention of coagulopathies and bleeding during massive blood transfusions. Also used to treat other conditions involving thrombocytopenia or inadequate platelet function c) Fresh frozen plasma used for replacement of clotting factors, and occasionally for emergency volume expansion EQUIPMENT: IV site with at least 20 gauge intravenous catheter adult, 22 gauge pediatric Appropriate blood product Appropriate blood tubing Standard IV tubing Normal saline Blood return bag Fenwal sampling site coupler (blood bag plug) Hospital documentation forms Blood reaction medications hives, elevated temperature, shortness of breath, etc. GUIDELINES AND PRECAUTIONS: a) Hospital Paramedics, Paramedic Specialists and Critical Care Paramedics are authorized to administer blood and blood born products during interfacility transfers, per Physicians orders b) Monitor for adverse reactions temperature, hives, shortness of breath, etc. 106

107 CPAP PORT O2 VENT OPERATION Indications: 1. Adult patients with respiratory distress 2. CHF/Pulmonary edema and 02 saturation of 90% or less 3. COPD and 02 saturation of 90% or less Contraindications: 1. Pneumothorax 2. Penetrating chest trauma 3. Hypotension (Systolic c 90mmHG) 4. Apnea 5. Decreased level of consciousness - unable to follow commands or protect airway 6. Facial injuries or abnormalities that prevent proper mask seal 7. Persistent, uncontrolled nausea/vomiting Considerations: 1. Patient must be spontaneously breathing 2. Not to be used in patient's less than 12 years old 3. Patient must not have decreased level of consciousness - must be able to protect airway 4. Signs of respiratory distress include: a. Use of accessory muscles b. Rapid, shallow respirations c. Anxiety d. Cyanosis e. Sp02 less than 90% f. Wheezing, rates, rhonchi, and absent/diminished lung sounds can be associated Procedure: 1. Assess patient and monitor vital signs and ECG as needed 2. Inform the patient of the need for and efficacy of CPAP therapy. Explain the procedure stating the need to breathe normally and allow machine to help patient. Reassure patient as needed. 3. Assemble circuit and equipment as follows: a. Attach appropriate mask to tubing b. Attach expiration filter to exhalation port c. Attach circuit tubing to Port 02 Vent ensuring prongs come to rest under flanges d. Attach head straps to one side of mask or place behind supine patient's head e. Attach nebulizer T-piece and reservoir between mask and circuit valve and connect oxygen tubing to oxygen source. (If indicated) 4. Ensure Port 02 Vent knob is started at Attach quick connect to portable oxygen tank or directly to wall in ambulance a. This will start the flow of oxygen and CPAP 6. Ensure a proper airtight seal 107

108 7. Observe Port 02 Vent pressure indicator for "tidaling" of needle 8. Increase flow by turning the knob clockwise to maintain needle in green area (0-1 OcmH20) of pressure indicator a. For severe distress increase flow to higher pressures (10 cmh20) b. For moderate distress increase flow to (7.5 cmh20) c. Use lower pressures if patient cannot tolerate procedure or if patient condition indicates use of lower CP AP pressures 9. Attach remaining straps of harness to mask ensuring a good seal. If patient cannot tolerate, allow patient to remain holding mask if seal is adequate 10. Monitor patient's vital signs and lung sounds throughout treatment 11. If patient condition worsens, or patient is no longer able to maintain airway, discontinue CPAP and provide appropriate airway control. Continue use of CPAP throughout transport and monitor patient as appropriate. Notify receiving facility of CPAP use. 108

109 NEEDLE CRICOTHYROTOMY INDICATIONS: Inability to gain airway access by other means Upper airway obstruction CONTRAINDICATIONS Pre-existing laryngeal pathology Anatomical barriers Anticoagulation therapy POSSIBLE COMPLICATIONS Injury to surrounding structures Hemorrhage Infection Edema Aspiration of blood Subcutaneous and mediastina emphysema PROCEDURE 1. Stabilize the patient's head in the neutral position. 2. Identify the cricothyroid membrane and prepare the skin. 3. Stabilize the cricoid and thyroid cartilages with the non-dominant hand. 4. Insert a 14 gauge over the needle catheter attached to a syringe into the membrane at a 45 degree angle caudally, aspirating during insertion. 5. Ability to aspirate air indicates entrance into trachea. 6. Remove the needle and ventilate through the catheter with a 3.0mm ETI end connected to the catheter hub. 7. Ventilate using demand valve at a rate of 12/min, allowing l second for insufflation and 4 seconds for exhalation. 109

110 EXTERNAL JUGULAR IV INSERTION INDICATIONS Establish an IV line in a patient on whom peripheral IV attempts has been unsuccessful and an IV line is necessary to administer fluids or medication. PROCEDURE Adult 1. Assemble equipment a) Appropriate size catheter: Ga. In most cases a larger catheter can be used and may facilitate a more steady insertion. b) Attach a syringe to the IV catheter. c) Appropriate IV fluid and tubing d) Tape 2. Place patient in supine, head-down position to fill the external jugular vein. Tum patient's head to opposite side from procedure. Locate vein, below the ear and behind the angle of the jaw. 3. Cleanse the area with alcohol prep 4. Align the cannula in the direction of the vein, with the point aimed toward the isobilateral shoulder (on the same side). 5. Make the venipuncture midway between the angle of the jaw and the mid-clavicular line "tourniqueting" the vein lightly with one finger above the clavicle. 6. Draw back on the syringe to confirm location, note blood return and advance catheter. 7. Withdraw needle; cover end of catheter with gloved finger. Be careful not to let air enter the catheter. 8. Attach IV tubing, assuring that all air has been cleared. 9. Secure tubing to patient's neck; do NOT put circumferential dressing around neck. Pediatric (above 3 years of age) 1. Assemble equipment a) Ga. catheter with 10cc saline-filled syringe attached b) Additional equipment as above 2. Place patient in a supine position so that both shoulders are touching a flat surface, and rotate the head 90 degrees. An assistant may be needed to help hold patient in position so that the head is extended 45 degrees. 3. Palpate the vein in a line from the angle of the jaw to the middle of the clavicle. This is usually visible on the surface of the skin. 4. Cleanse the area with Alcohol. 5. Attach the saline-filled syringe to the needle and flush air out of needle. Keep the syringe attached and draw back to assure constant negative pressure in order to 6. avoid air embolism. 7. Make venipuncture midway between the angle of the jaw and the midclavicular line and slowly advance until the jugular vein is entered and free blood return is obtained. 8. Gently advance the catheter over the needle into the vein and remove the needle 9. Quickly disconnect syringe and connect IV tubing assuring that all air has been cleared from the tubing. 10. Secure IV with tape. Do not use kling to secure dressing around the neck. 110

111 GASTRIC TUBE PLACEMENT INDICATIONS Respiratory compromise related to gastric distention Prevention of gastric distention during CPR Evacuation of ingested poisons Evacuation of blood in cases of GI hemorrhage CONTRAINDICATIONS Patients with severe facial trauma, especially those involving the nasal area Patients with suspected or possible epiglottitis or croup COMPLICATIONS Epistaxis Coiling of tube in posterior pharynx Placement of tube into trachea Retching in conscious patient Procedure Nasal 1. Mark the distance the tube should be inserted by measuring the distance from the ear lobe to the bridge of the nose, then from the bridge of the nose to the xyphoid process. 2. Examine the nose for septal deviation. 3. Select most patent nostril, place patient in semi-fowler position and flex head slightly forward. 4. Insert lubricated tube and pass carefully along nasal floor, instructing patient to swallow as tube enters oropharynx. 5. Pass the tube to desired point as marked on tube. 6. Check placement of tube by aspirating gastric contents or by auscultating over epigastrium while injecting 20-30cc of air. 7. Secure tube and perform evacuation as needed. Oral 1. Mark the distance the tube should be inserted by measuring the distance from the ear lobe to the comer of the mouth then from the comer of the mouth to the xiphoid process. 2. Insert lubricated (if needed) tube into mouth, instruct patient to swallow as tube enters Oropharynx. 3. Pass the tube to desired point as marked on tube. 4. Check placement by aspirating gastric contents or by auscultating over epigastrium while injecting 20-30cc of air. 5. Secure tube and perform evacuation as required. 111

112 MAINTENANCE OF NON-MEDICATED IV S DISCONTINUING AN IV: Procedure 1. Advise or receive orders from medical direction to discontinue IV 2. Take appropriate BS! precautions 3. Explain procedure to the patient and/or family members 4. Turn off IV fluid by closing pressure wheel on administrative tubing 5. Remove tape and other securing material from IV tubing and catheter 6. Remove IV catheter and administration tubing still connected 7. Cover the puncture site with an alcohol wipe, 2x2, or 4x4 and hold pressure until bleeding stops 8. Cover wound with appropriate dressing (Band-Aid) 9. Discard IV administration set, fluid, and catheter in an approved fashion 10. Document discontinuance of IV Rational During long distance transfers. Change of fluids by medical direction. Procedure 1. Check orders/authorization for change of IV fluids from medical direction. 2. Check for correct IV fluid. 3. Take appropriate BSI precautions. 4. Prepare new IV solution, remove covers. 5. Tum off IV flow rate by closing pressure wheel on administration tubing. 6. Invert IV container; remove the IV container to be changed from the administration set, maintaining a sterile environment. 7. Invert the new solution container and puncture the replacement solution container with spike of administration set. 8. Tum IV container over (upright). 9. Fill drip chamber of administration set to marked line if needed. 10. Adjust IV flow rate to desired amount. 11. Reassess IV site and flow. 12. Discard used IV container in an appropriate manner. 13. Document procedure. Precautions Do not allow an IV to "run dry". If the drip chamber is empty, you will need to "bleed" air from the tubing before adjusting the IV flow rate. 112

113 KING LT/LTS-D AIRWAY INDICATIONS A need to secure an airway and provide ventilations for patients who are unconscious, have no gag reflex and are over 4 feet tall This is a secondary device to be used when considerations to manage the airway with endotracheal intubation are unsuccessful or improbable. PROCEDURE 1. Choose the correct size airway, based on patient height. a) Size 3(yellow) 4-5 feet tall. b) Size 4(red) 5-6 feet tall. c) Size 5(purple) greater than 6 feet tall. 2. Test the cuff inflation system by injecting the maximum recommended volume of air into the cuffs. Remove all air from both cuffs prior to insertion. a) Size 3-60ml. b) Size 4-80ml. c) Size 5-90ml. 3. Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube taking care to avoid introduction of lubricant in or near the ventilatory openings. 4. Have a spare King LTS-D ready and prepared for immediate use. 5. Pre-oxygenate. 6. Ensure gag reflex is not intact. 7. Position the head. The ideal position is the "sniffing position". 8. Hold the airway at the connector with the dominant hand. With non-dominant hand, hold 9. Mouth open and apply chin lift. 10. Place the flat edge of the airways tip against the hard palate. The tube should be in the comer of the mouth with the tube rotated laterally (outward), when the tip passes under the tongue, rotate it medially to midline -: Continue until the proximal cuff is slightly visible in the posterior pharynx under the base of the tongue. (Never use force when positioning the airway). 11. Depth markings are provided at the proximal end of the airway which refers to the distance from the distal ventilatory opening. When properly placed, with the distal tip and cuff in the esophagus, and the ventilatory openings aligned with the opening to the larynx, the depth markings give an indication of the distance, in centimeters, from the vocal cords to the teeth. 12. Inflate the cuffs starting with ml. using a standard luer-tipped syringe. Use minimum amount of pressure necessary to seal the airway at, the peak ventilatory pressure employed.(see maximum amounts above.) 13. Check lung ventilation by auscultation, chest movement and verification of C02 by capnography. 14. If ventilation is not sufficient, gently advance or retract the airway to achieve optimal ventilation. Recheck for proper ventilation. 113

114 15. Secure the airway by fully inflating the cuff REMOVAL Removal should always be carried out with suction equipment and intubation equipment readily available for use. It is important that both cuffs are completely deflated before removal. CONTRAINDICATIONS Responsive patients with an intact gag reflex. Patients with known esophageal disease. Patients who have ingested caustic substances. Patients under 4 feet tall. CONSIDERATIONS The King LT does not protect the airway from the effects of regurgitation and aspiration. Intubation of the trachea cannot be ruled out as a potential complication. Lubricate only the posterior surface of the airway. It is important that both cuffs are completely deflated before removal. 114

115 NEEDLE CHEST DECOMPRESSION INDICATIONS The following is a list of possible patient presentations in which needle decompression should be considered: Respiratory Compromise associated with two or more of the following: Absent or greatly decreased breathe sounds over hemothorax area Trachea shift to the unaffected side Subcutaneous emphysema Multiple rib fractures Signs and symptoms of shock CONTRAINDICATIONS There are no contraindications when used in the setting of a tension pneumothorax. POSSIBLE COMPLICATIONS Puncture of the lung. Hemorrhage from the puncture of the intercostal vessels. Hemorrhage from puncture of a pulmonary vessel. PREPARATION Expose and cleanse anterior chest at level of 2nd intercostal space on the affected side. Find 2nd intercostal space midclavicular line with gloved finger. PROCEDURE 1. Using 14 gauge or larger over the needle catheter (at least 2 inches long) with syringe attached direct needle over the third rib into the 2nd intercostal space. 2. Apply enough pressure to push the needle through the intercostal muscle and into the pleural cavity. 3. You should pull back air in the syringe or if no syringe on the needle you should hear a rush of air, either of these should be considered positive placement. 4. Remove the needle leaving catheter in place and secure with tape or provided device. 5. If extended transport time, connect to one way valve. 115

116 EXTERNAL CARDIAC PACING INDICATIONS Thermodynamically unstable bradycardia (heart rate <60, blood pressure <90) and heart blocks that are unresponsive to Atropine. Some cases of bradyasystolic arrests, including post-defibulation asystole that are unresponsive to ACLS drug therapy. CONTRAINDICATIONS None when used in the emergency setting. PROCEDURE 1. Apply external pacing electrodes in the proper position and connect to Life Pak 15 via dual purpose cables. 2. The 4 lead monitoring patches must be on and the lead selector must be in Lead I, II or III. The pacer will not function if using fast patch system for monitoring in "paddles" mode. 3. Apply external pacing pads according to the instructions on the product. Ensure that all electrodes are making good contact with the patients skin and are not covering any part of the other electrodes. 4. If pacing a conscious patient, pain/discomfort from the pacing current may be excessive. 5. Consider VALIUM 2-10 mg slow IV push or VERSED 1-3 mg IVP if sedation is indicated 6. Tum selector switch to PACER. 7. Set PACER OUTPUT to 0 ma. If the unit has just been turned on, the PACER OUTPUT will automatically be set to 0 ma. 8. Set PACER RATE to a value bpm higher than patient=s intrinsic rate. If no intrinsic rate exists, use 80 bpm. 9. Increase PACER OUTPUT ma until stimulation is effective (capture) 10. Determine capture. Electrical capture is determined by the presence of a widened QRS complex, the loss of any underlying intrinsic rhythm, and the appearance of an extended, and sometimes enlarged T wave. Mechanical capture is assessed by palpation of peripheral pulse. In order to avoid mistaking muscular response to pacing stimuli for arterial pulsations the FEMORAL and RIGHT BRACHIAL or RADIAL arteries are the ONLY recommended locations for palpating pulse during pacing. 11. Determine optimum threshold. The ideal output current is lowest value that will maintain capture. This is usually about 10% above threshold. Location of pacing pads will affect the current required to obtain capture. 12. Constant monitoring for loss of capture should be performed. 116

117 TOURNIQUET APPLICATION INDICATIONS Extremity wounds where direct pressure with a sterile dressing does not control active bleeding. SUPPLIES Triangular bandage (may tie two together if needed for a large limb - pad the knot) Dowel (or similar object, ie: B/P cuff ) PROCEDURE 1. Leave dressings/bandages already used in place 2. Unfold the triangular bandage until it is at least 2" wide for upper extremity, or 4" wide for lower extremity 3. Place the band around the affected limb approximately two to four inches above the wound. 4. Place the dowel on top of the knot and tie another overhand knot over the dowel 5. Twist the dowel until bleeding has stopped. 6. Tie the ends of the triangular bandage around the limb to secure 7. Stabilize the dowel with bulky dressing and gauze as needed 8. Continuously monitor for bleeding and distal pulse. 9. If bleeding is not controlled apply direct pressure and tighten tourniquet 10. Record the time of application. 11. A verbal report will be given to the receiving hospital that a tourniquet is in place. SPECIAL CONSIDERATIONS Never remove or cover a tourniquet. Only use on an arm or leg. If extenuating circumstances result in a tourniquet being in place greater than 60 minutes, at the 60 minute time mark, loosen the tourniquet slightly to see if bleeding is controlled. If bleeding restarts reapply pressure. If bleeding does not restart, secure the tourniquet as loosened. Repeat every l 0 minutes until hospital arrival. 117

118 TASER BARB REMOVAL If requested by Law Enforcement to remove taser probes/barbs from a subject that has been arrested, the EMS provider should take the follow steps: 1. Assess the patient a. Assess the patient for secondary injuries that may have resulted from falls sustained after the Taser was deployed. Subjects should not be dazed or confused following Taser deployment. b. Confirm that the Taser has been shut off and the wires connecting the barbs to the device have been cut by law enforcement. c. Obtain vital signs. d. Evaluate the anatomical location of the barbs. High-risk sensitive zones will require transport to a hospital for removal. Do not attempt to remove the barbs if they are lodged in the eyes, ears, nose, mouth, face, neck, genitals or spine. 2. Remove the barbs a. Utilize PPE b. Remove one barb at a time. Stabilize the skin surrounding the Taser barb. Firmly grasp the barb and with one smooth hard pull, remove the barb from the skin. Use of a multi-tool grasping device may be used. c. Visually examine the barb tip to ensure it is fully intact. If any part of the barb remains in the subject, transport the patient to a medical facility for removal. d. The Taser barb is considered a sharp and EMS personnel should take all precautions to avoid accidental needle sticks when removing the barbs. e. Ensure the barb is returned to the law enforcement officer. f. Provide wound care by covering the affected area with an adhesive bandage or gauze and bandage. g. Inform subject of basic wound care and the need to seek additional care in the event signs of infection occur (redness, pain, drainage, swelling, fever). 118