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Contra Costa County Prehospital Care Manual January 2010 Table of Contents GENERAL NOTES SECTION ....................................................................................................1 Communications .........................................................................................................................................1 Radio Communications ............................................................................................................................1 Receiving Facility Report Format ............................................................................................................1 Notes on Dialysis Patients ..........................................................................................................................4 Load And Go Procedures ..........................................................................................................................5 Notes on Pain Assessment and Management ...........................................................................................5 OPQRST Mnemonic ................................................................................................................................6 Pain Assessment Tools .............................................................................................................................6 FACES PainScale.................................................................................................................................6 Numeric Pain Scale ..............................................................................................................................6 Pain Assessment In The Very Young ......................................................................................................7 Notes On Pediatric Patients.......................................................................................................................7 Initial Approach .......................................................................................................................................7 Age Definitions ........................................................................................................................................7 Vital Signs ................................................................................................................................................7 ALT-E ......................................................................................................................................................8 Notes On OB/Gyn Emergencies ................................................................................................................8 Vaginal Bleeding ......................................................................................................................................8 Sexual Assault ..........................................................................................................................................9 Childbirth .................................................................................................................................................9 Notes On Trauma .......................................................................................................................................9 Helmet Removal.......................................................................................................................................9 Cervical Collars ........................................................................................................................................9 Spinal Immobilization ............................................................................................................................10 Head Injury.............................................................................................................................................10 Amputations ...........................................................................................................................................11 Geriatric Patients ....................................................................................................................................11 Notes On Hypothermia ............................................................................................................................11 Notes On Geriatrics ..................................................................................................................................11 Notes On Burns ........................................................................................................................................12 Rule of Nines..........................................................................................................................................13 BLS NOTES SECTION.............................................................................................................15 EMT Scope of Practice ............................................................................................................................17 Contra Costa County Prehospital Care Manual – January 2010 Page i BLS Management of Patients Encountered Prior to Activation of 9-1-1 ...........................................18 Administration of Oral Glucose ..............................................................................................................18 Public Safety Defibrillation .....................................................................................................................19 Patient Assessment .................................................................................................................................19 Verbal Report .........................................................................................................................................19 Defibrillator Cables/Pads .......................................................................................................................19 Patient Care Data....................................................................................................................................19 Public Safety Defibrillation .....................................................................................................................20 Spinal Immobilization.............................................................................................................................. 21 ALS NOTES SECTION ............................................................................................................ 23 Paramedic Scope of Practice ...................................................................................................................25 Local Optional Scope of Practice ............................................................................................................26 ALS Skills List ..........................................................................................................................................27 Airway Management ................................................................................................................................ 28 ALS Procedures ........................................................................................................................................30 Oral Endotracheal Intubation .................................................................................................................30 Endotracheal Tube Introducer (Bougie).................................................................................................33 Esophageal Airway (King LTS-D) ........................................................................................................34 Tracheostomy Tube Replacement ..........................................................................................................36 Stomal Intubation ...................................................................................................................................37 ResQPOD ...............................................................................................................................................38 Continuous Positive Airway Pressure (CPAP) ......................................................................................39 Needle Thoracostomy ............................................................................................................................40 Intraosseous Infusion - Pediatric ............................................................................................................42 Saline Lock.............................................................................................................................................45 Pulse Oximetry .......................................................................................................................................47 Blood Glucose Testing ...........................................................................................................................48 External Cardiac Pacing .........................................................................................................................49 12-Lead Electrocardiography .................................................................................................................50 12-Lead Electrocardiography .................................................................................................................52 FIELD MANUAL/TREATMENT GUIDELINES ......................................................................... 55 Instructions For Use ............................................................................................................................... 58 ADULT ......................................................................................................................................................59 A1 - Adult Patient Care ..........................................................................................................................59 A2 – Chest Pain – Suspected Acute Coronary Syndrome .....................................................................60 A3 – Cardiac Arrest – Initial Care and CPR ..........................................................................................61 A4 – Ventricular Fibrillation – Pulseless Ventricular Tachycardia .......................................................62 A5 – Pulseless Electrical Activity - Asystole ........................................................................................63 Page ii Contra Costa County Prehospital Care Manual – January 2010 A6 – Symptomatic Bradycardia .............................................................................................................64 A7 – Ventricular Tachycardia with Pulses.............................................................................................65 A8 – Supraventricular Tachycardia .......................................................................................................66 A9 – Other Cardiac Dysrhythmias .........................................................................................................67 A10 - Shock............................................................................................................................................68 GENERAL ................................................................................................................................................69 G1 – Allergy/Anaphylaxis .....................................................................................................................69 G2 – Altered Level of Consciousness ....................................................................................................70 G3 – Behavioral Emergency ..................................................................................................................71 G4 - Burns ..............................................................................................................................................72 G5 – Childbirth – Routine or Complicated ............................................................................................73 G6 – Dystonic Reactions .......................................................................................................................74 G7 – Envenomations – Snake Bites, Insect Stings ................................................................................75 G8 – Heat Illness/Hyperthermia ............................................................................................................76 G9 - Hypothermia ..................................................................................................................................77 G10 – Pain Management (Non-Traumatic) ...........................................................................................78 G11 – Poisoning - Overdose ..................................................................................................................79 G12 – Respiratory Depression or Apnea ...............................................................................................80 G13 – Respiratory Distress ....................................................................................................................81 G14 – Seizure/Status Epilepticus ...........................................................................................................82 G15 - Stroke ...........................................................................................................................................83 - Cincinnati Stroke Scale ....................................................................................................................83 G16 - Trauma .......................................................................................................................................84 - Crush Injury Syndrome ....................................................................................................................84 PEDIATRIC .............................................................................................................................................85 P1 - Pediatric Patient Care .....................................................................................................................85 P2 – Cardiac Arrest – Initial Care and CPR ..........................................................................................86 P3 – Neonatal Care and Resuscitation ...................................................................................................87 P4 – Ventricular Fibrillation – Pulseless Ventricular Tachycardia .......................................................88 P5 – Pulseless Electrical Activity/Asystole ...........................................................................................89 P6 – Symptomatic Bradycardia .............................................................................................................90 P7 - Tachycardia ....................................................................................................................................91 P8 - Shock ..............................................................................................................................................92 PROCEDURES ........................................................................................................................................93 Indications For Spinal Immobilization...................................................................................................93 Vascular Access .....................................................................................................................................93 12-Lead Acquisition/Lead Placement ....................................................................................................94 - Localizing Site of Infarct .................................................................................................................94 STEMI Recognition and Destination .....................................................................................................95 STEMI Report ........................................................................................................................................95 Key ALS Procedures ..............................................................................................................................96 Pediatric Assessment ..............................................................................................................................97 Pediatric Vital Signs ...............................................................................................................................97 ABC Maneuvers .....................................................................................................................................98 POLICY SUMMARY - GENERAL INFORMATION ........................................................................99 Base Hospital Information .....................................................................................................................99 Contra Costa County Prehospital Care Manual – January 2010 Page iii Contra Costa Hospitals...........................................................................................................................99 Destination Determination ...................................................................................................................100 Basic Procedure....................................................................................................................................100 5150 and Obstetric ............................................................................................................................... 100 Trauma Triage Criteria .........................................................................................................................101 Trauma – Base Call-In Criteria ............................................................................................................101 Helicopter Transport Criteria ...............................................................................................................102 Restraints ..............................................................................................................................................102 Rule of Nines .......................................................................................................................................103 Burn Patient Destination ......................................................................................................................103 Burn Centers .......................................................................................................................................... 103 Declining Medical Care or Transport (AMA) .....................................................................................104 Determination of Death ........................................................................................................................104 Adult Drug Reference ..........................................................................................................................105 Dopamine Drip Rates ...........................................................................................................................107 Pediatric Drug Reference .....................................................................................................................108 PEDIATRIC DOSAGE CHARTS ........................................................................................................111 Gray – 3-5 kg .......................................................................................................................................111 Pink – 6-7 kg ........................................................................................................................................112 Red – 8-9 kg .........................................................................................................................................113 Purple – 10-11 kg .................................................................................................................................114 Yellow – 12-14 kg................................................................................................................................ 115 White – 15-18 kg..................................................................................................................................116 Blue – 19-22 kg ....................................................................................................................................117 Orange – 24-28 kg................................................................................................................................ 118 Green – 30-36 kg..................................................................................................................................119 40 kg .....................................................................................................................................................120 45 kg .....................................................................................................................................................121 Pain Evaluation/Treatment ...................................................................................................................122 PATIENT REPORTING GUIDELINES ................................................................................... 125 INDEX..................................................................................................................................... 131 Page iv Contra Costa County Prehospital Care Manual – January 2010 General Notes Section COMMUNICATIONS RADIO COMMUNICATIONS Four radio channels are designated for communications with hospitals in Contra Costa County. Receiving hospital communications are done via XCC EMS 2, whereas paramedic base hospital communications may occur via XCC EMS 2 or XCC EMS 3, depending on location. XCC EMS 1 (formerly L9) T: 491.4375 R: 488.4375 Use for Sheriff’s Dispatch-to-ambulance communication XCC EMS 2 (formerly L19) T: 491.9125 R: 488.9125 Primary channel for base contact for West County paramedic units. Also used county-wide for BLS and helicopter radio traffic XCC EMS 3 T: 491.6125 R: 488.6125 Primary channel for base contact for paramedic units operating south of Ygnacio Valley Road and west of I-680 along Highway 24 XCC EMS 4 T: 491.6625 R: 488.6625 Primary channel for base contact for paramedic units operating in East County and Central County north of Ygnacio Valley Road. Whenever possible, paramedic personnel should use the XCC EMS channel assigned to the area in which they are responding, for ambulance-to-base hospital communications. XCC EMS 2 is the countywide backup ALS channel and should be used if XCC EMS 3 or XCC EMS 4 is not available. Ambulance and helicopter personnel are to contact Sheriff’s Dispatch on XCC EMS 1 to request the use of XCC EMS 2 prior to utilizing the channel. The dispatcher shall be given unit identification and a description of current traffic (Code 2, Code 3 or trauma destination decision). No request for use is necessary for XCC EMS 3 or XCC EMS 4. However, each unit must monitor the channel prior to use to ensure that other units are not already using the channel. Radio identification procedures must be strictly followed, as more than one call may be occurring at the same time. If traffic is in progress on a XCC EMS channel, other ambulance personnel may either wait until current traffic is finished or find an alternate means of contacting the desired hospital. Any unit may, in cases such as trauma destination decisions, request that Sheriff’s Dispatch break into current traffic on XCC EMS 2 to request temporary use of the channel. Units using XCC EMS 3 or XCC EMS 4 may request use of the channel from a unit that is currently on that channel. When making base contact for trauma destination only, the initial transmission should make the purpose of the call clear. Cellular phones may also be used as a means of communication. RADIO CONTACT AND PATIENT HANDOFF GUIDELINES: SBAR Agency name & unit #. Situation What is the situation? Urgent Issues? State why calling: (eg: STEMI Alert, High Risk Criteria, ETA) Pt age and gender. Chief complaint. Urgent concerns & immediate needs up front. Contra Costa County Prehospital Care Manual – January 2010 Page 1 Background What happened up to this point? What past history would be important to others caring for the patient to know? Assessment How is the patient now? Improved or worse since on scene? Patient stable or unstable? RX/Recap What field care has been given? Was it effective? Repeat concerns as needed? Presenting complaint and symptoms. Pertinent past medical history. High risk medications. General impression. Pertinent Findings. Vital Signs. Pain Level. Prehospital treatments given & patient response. Restate concerns. Respond to questions. SBAR is a evidenced-based communication model developed in the military and is widely used in many industries including aviation and health care to make sure the right information gets to the right people in the shortest timeframe. It is currently the communication standard of care in many emergency departments in the United States because it has been so effective in improving communication between health care providers. These guidelines outline the priority information that needs to be related during patient care handoff to the receiving party so that information critical to patient care is not missed. The format emphasizes urgent concerns be brought to the forefront and empowers the EMS provider to advocate for the patient These guidelines are to be used in a flexible way that meets the needs of the situation encountered. Although the format is split into separate sections (Situation, Background, Assessment and Rx Recap) the information is relayed as a conversation. See addendum of PHCM for SBAR guidelines for trauma, STEMI, hospital contact & patient handoff. TRAUMA PATIENT REPORT FORMAT This report is for personnel calling the base hospital either for destination or to inform the base of a patient who is being transported to the trauma center (meets criteria for direct transport). Agency name & unit #. S State “Trauma Destination Decision” or patient meeting “High Risk” criteria. What is the situation? Urgent Issues? ETA to trauma center. Pt age and gender. Urgent concerns & immediate needs up front. If trauma destination request-state destination you believe is needed. Page 2 Contra Costa County Prehospital Care Manual – January 2010 Mechanism of Injury/Injuries Sustained B What happened up to this point? What past history would be important to others caring for the patient to know? Chief Complaint. State patient’s major injuries and LOC Basic scene information: Seatbelt or helmet use Airbag deployment Prolonged extrication Estimated MPH in known Primary Survey and pertinent positives: ABCD (can report as ABCD normal except….) Report if abnormal A How is the patient now? Improved or worse since on scene? Patient stable or unstable? Airway (if not patent) Breathing (labored, shallow, or rapid) Circulation (altered perfusion, shock) Estimated blood loss Disability: AVPU include any changes If pertinent VS, ALOC Treatment(s): R What field care has been given? Was it effective? Repeat concerns as needed? Prehospital treatments & patient response. Restate concerns as needed. Respond to questions. Request direct online MD consultation as needed. The following is a list of examples of positive findings on secondary survey that would be appropriate to report. This is not an exhaustive list and other important findings may need reporting: HEENT: Blood, swelling anywhere on head around eyes, ears, mouth, nose. Inability to open mouth. NECK: Midline tenderness to touch or crepitus. CHEST: Visible wounds, breath sounds unequal, pain upon compression. ABDOMEN: Visible wounds, tender to palpation, distention PELVIS: Pain on compression. Stable or unstable. EXTREMITIES: Deformity, tenderness, swelling. NEUROLOGICAL: Presence of numbness or tingling. Abnormal motor exam or extremities (if nontender/not splinted) SPINE: Tenderness or pain to palpation. TRAUMA PATIENT HANDOFF: MIVT The MIVT (Mechanism, Injuries, Vital Signs, Treatment) report is given at the trauma center upon arrival. MIVT works with SBAR to efficiently relate the most critical prehospital information to the trauma physician or ED physician in the trauma room in a time frame of 30 seconds or less. The MIVT report puts urgent concerns & immediate needs of the trauma patient needs up front. Contra Costa County Prehospital Care Manual – January 2010 Page 3 If there are major issues the paramedic feels are critical to the first minutes of care that needs to be relayed upfront. The paramedic should remain available to provide more detailed or additional information to the scribe in the trauma room. S Pt identification, age and gender & MR # (if known) What is the situation? Urgent Issues? (M) Mechanism of Injury: eg: MVA, rollover, ejection, GSW, blunt trauma B What happened up to this point? What past history would be important to others caring for the patient to know? (I) Injuries Sustained/Level of Consciousness Injuries: Major Anatomy involved, major patient complaints-does not have to be all inclusive Level of Consciousness: AVPU format. Should include changes noted on scene and en route. (V) Vital Signs. A R How is the patient now? Improved or worse since on scene? Patient stable or unstable? What field care has been given? Was it effective? Repeat concerns as needed? Blood Pressure: If known, otherwise quality/location of pulse Pulse: Rate and quality Respiratory Rate: Add abnormal lung sounds if noted ECG rhythm: if anything other than NSR or sinus tachycardia Pulse oximetry: If known (T) TREATMENT Patient response to treatment. Respond to questions. Repeat concern as needed. NOTES ON DIALYSIS PATIENTS Patients with advanced renal disease requiring dialysis have special medical needs that may deserve specific attention in the pre-hospital setting. Problems that may occur include fluid overload and electrolyte imbalances. Patients may be particularly prone to these problems if they should miss scheduled dialysis sessions. Fluid overload may lead to pulmonary edema. The initial treatment of this is similar to other patients with pulmonary edema, and may include oxygen, nitroglycerin and morphine. Definitive treatment at a center that provides acute dialysis capabilities is often necessary. The preferable transport destination for this type of patient is the hospital at which the patient has received dialysis care. Patients in extremis will need transport to the closest emergency department. Hyperkalemia is also common in renal failure patients, leading to arrhythmia or ventricular fibrillation. Treatment in the field may include sodium bicarbonate and calcium chloride. Page 4 Contra Costa County Prehospital Care Manual – January 2010 NOTES ON BARIATRIC PATIENTS Bariatric patients are morbidly obese individuals who weigh 100 pounds or more than their ideal body weight. Severe obesity can result in patients having difficulty with walking or moving and special equipment may be necessary to transport the patient. AMR has a bariatric unit in Contra Costa County which, when needed, should be requested as soon as possible. When the decision is made to transport the bariatric patient, notify the receiving facility as they need time to prepare equipment for the patient’s arrival. Obesity has many health care risks associated with it, including diabetes, cardiovascular respiratory and other problems. Special prehospital considerations are: Airway Management Obese patients are prone to respiratory insufficiency, airway obstruction and have difficult airways to intubate. Positioning to maintain their airway is very important. Obese patients should be transported in a seated position. CPAP may also be needed more often to support oxygenation and ventilation. Vascular Access Increased subcutaneous tissue makes it difficult to obtain regular IV access. The IO proximal tibia site may be difficult to access due to difficulty in finding appropriate landmarks. In these cases the distal tibia (media malleolus) is a preferred IO site. Proper Medication Dosage Obesity may create a need for increased medication due to the patient’s body weight. Increases in medication beyond what is listed in the PHCM should be requested through the Base as needed. LOAD AND GO PROCEDURES Patients with severe medical conditions or traumatic injuries often need to be transported without delay. Field treatment is to be minimized to essential stabilization and the emphasis is placed on prompt transport to an appropriate receiving facility. Conditions to be considered for "Load and Go" transport include: unmanageable airways in any patient; obstetrical emergencies including prolapsed cord, abnormal presentation, abnormal bleeding, or maternal seizures. patients in shock severe trauma, especially to the head, chest, or abdomen; for severe trauma, scene time should not exceed 15 minutes. Reasons for extended scene times should be documented on the patient care report NOTES ON PAIN ASSESSMENT AND MANAGEMENT Relief of pain and suffering is an important component of quality EMS field care. Pain assessment is the 5th vital sign and should be performed on each patient using an age appropriate pain scale. Pain is a subjective experience for the patient and should be treated following the appropriate pain treatment guideline. Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts should be made to alleviate pain using both pharmacologic (e.g, Contra Costa County Prehospital Care Manual – January 2010 Page 5 Morphine, Nitroglycerin for cardiac cases) and non-pharmacologic (e.g., splinting, immobilization) measures. Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5 minutes after every medication administration. Assess pain using the same pain scale before and after pain administration and document. Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved. Administer medication cautiously and monitor patient. Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional narcotic administration. OPQRST MNEMONIC Mnemonic Onset Provocation Description Document time when pain started and if suddenly worsening, when this occurred. Document what caused the pain and what makes it worse or better. Quality In patient’s own words, document description of what type of pain it is. If not able to describe it on their own, provide a list of different types of pain (e.g. heaviness, pressure, burning, tearing, dull , stabbing or needle-like). Radiation Document if pain travels to another part of the body. Severity Ask the patient to rate the pain using an age appropriate pain scale. Always reassess after medication is given to relieve pain. Time Document if patient states the pain is intermittent or is constant. PAIN ASSESSMENT TOOLS FACES Pain Rating Scale: (used in children older than 3 years and adults) Point to each face using the words to describe the pain intensity. Ask the patient to choose the face that best describes how they are feeling. A person does not have to be crying to have the worst pain. RATING English 0 No pain 1-2 3-4 5-6 7-8 Hurts a Hurts a Hurts even Hurts a lot little bit little more more Spanish No dolor Muy leve Leve Moderada Severa 0-10 Numeric Pain Rating Scale: (used in adults and children older than 9 years) 9-10 Hurts worst Muy severa Explain scale (0 means no pain and 10 is the most severe pain they have ever had). Ask patients what number on a scale of 0-10 they would give as the level of pain currently. Page 6 Contra Costa County Prehospital Care Manual – January 2010 PAIN ASSESSMENT IN THE VERY YOUNG, NON-VERBAL INFANT AND CHILD Pain assessment in infants, non-verbal young children or developmentally delayed children is more complex and presents special challenges. Despite this, pain medication should be considered in cases where the infant or child is in severe pain. This includes evidence of painful mechanisms such as burns, limb fractures or other events. Using pain medication in these children requires judgment and caution. Signs and symptoms of pain in non-verbal young or developmentally delayed children include: Inconsolable crying, screaming that cannot be distracted from by a caregiver High pitched crying Any pain face expression that is continual o Grimace o Quivering chin Constant tense/stiff body tone and/or guarding “Whatever is painful to adults, is painful to children until proven otherwise” NOTES ON PEDIATRIC PATIENTS The causes of catastrophic events, such as cardiac arrest are most often related to respiratory failure, shock or central nervous system injuries. Early treatment is critical in this population. INITIAL APPROACH Remain calm and confident as the child may pick up on any anxiety. DO NOT SEPARATE THE CHILD FROM THE PARENT unless absolutely necessary. Establish a rapport with the parents as well as the child, and encourage the parents to touch, hold or cuddle the child when appropriate. Go from least intrusive to most intrusive in your initial assessment. LOOK, then LISTEN, then FEEL Always explain what you are doing as you proceed. Avoid manipulating any area that appears to be painful until late in the examination, and always tell the child before you touch those potentially painful areas. PEDIATRIC AGE DEFINITIONS Neonate is 0-1 month Pediatric patient is less than 14 years old PEDIATRIC VITAL SIGNS Vital signs are valuable in the assessment of pediatric patients, but have significant limitations and can be dangerously misleading. Children can be in compensated shock with a normal blood pressure. However, they will exhibit signs of poor peripheral circulation. Blood pressure is maintained by increasing peripheral vascular resistance and heart rate. This will cause the skin to appear pale, dusky or mottled, and to feel cool, clammy or moist. Capillary refill may also be delayed. Capillary refill greater Contra Costa County Prehospital Care Manual – January 2010 Page 7 than 2 seconds is a sign of poor circulation. Capillary refill time of 5 seconds or greater indicates impending circulatory failure. Hypotension is a late and often sudden sign of cardiovascular decompensation. The systolic pressure may not drop until the patient has a decrease of 25-30% in blood volume. Relatively little blood loss in an infant or young child may cause decompensation and cardiopulmonary arrest. Tachycardia (heart rate greater than 100) will persist until cardiac reserve is depleted. Bradycardia (heart rate less than 60) in a distressed child is an ominous sign of impending cardiac arrest. APPARENT LIFE-THREATENING EVENT (ALTE) An Apparent Life-Threatening Event (ALTE) was formally known as a "near-miss SIDS" episode. This is an event that is frightening to the observer (may think the infant has died) and involves some combination of apnea, color change, marked change in muscle tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with symptoms described under 2 years of age may be considered an ALTE. Most patients have a normal physical exam when assessed by responding personnel. Approximately half of the cases have no known cause, but the other half do have a significant underlying cause such as infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS. Because of the high incidence of problems and the normal assessment usually seen, there is potential for significant problems if the child's symptoms are not seriously addressed. If an ALTE is suspected, the following should be done: 1. Obtain history, including duration and severity of event, whether patient awake or asleep at time of episode, and what resuscitative measures were done by the parent or caretaker 2. Obtain medical history, including history of chronic diseases, seizure activity, current or recent infections, gastroesophageal reflux, recent trauma, medication history. Obtain history with regard to mixing of formula 3. Perform comprehensive exam, including general appearance, skin color, interaction with environment, or evidence of trauma 4. Treat identifiable cause if appropriate 5. Transport 6. If treatment/transport is refused by parent or guardian, contact base hospital to consult prior to leaving patient. Document refusal of care. NOTES ON OB/GYN EMERGENCIES VAGINAL BLEEDING Vaginal bleeding that is not a result of direct trauma or a women's normal menstrual cycle may indicate a serious gynecological emergency. Determining the specific cause of the bleeding may be impossible, therefore, all women who have vaginal bleeding should be treated as though they have a potentially lifethreatening condition. This is especially true if the bleeding is associated with abdominal pain. The most serious complication of vaginal bleeding is hypovolemic shock due to blood loss. Page 8 Contra Costa County Prehospital Care Manual – January 2010 SEXUAL ASSAULT Care of the patient who has been sexually assaulted must include both medical and psychological considerations. The best approach is to be nonjudgmental and to maintain a professional but compassionate attitude. Examine the victim for injury that requires immediate stabilization. Though your responsibilities do not include law enforcement, try wherever possible to preserve evidence. Field personnel are required to notify law enforcement personnel in these cases. CHILDBIRTH Since childbirth is a natural process, the decision field personnel will need to make is whether there is time to transport the patient to the hospital or whether they should prepare for a field delivery. If delivery appears imminent, immediately prepare to assist the delivery. NOTES ON TRAUMA HELMET REMOVAL Patients wearing helmets present special management needs regarding airway maintenance and monitoring. There are generally two types of helmets, and the type of helmet determines how easily or difficult it may be to maintain or monitor the airway with the helmet in place: Sports Helmets (football, hockey, etc) - these helmets are generally open anteriorly and allow for easy airway access. The face mask should be removed to facilitate easy airway access. If spinal immobilization is required, the helmet should not be removed. If the helmet must be removed, the shoulder pads must also be removed to maintain neutral spinal alignment. Motorcycle Helmets - these helmets may have full face shields, which makes airway assessment and management very difficult. As a general guideline DO NOT REMOVE HELMETS, unless: The helmet interferes with airway management. The helmet has improper fit, which allows the head to move within the helmet. The helmet interferes with proper spinal immobilization. The patient is in cardiac arrest. CERVICAL COLLARS The primary purpose of a cervical collar is to protect the cervical spine from compression. Cervical collars are an important adjunct to immobilization but must always be used in conjunction with manual immobilization or with mechanical immobilization provided by a suitable spine immobilization device. The rigid anterior portion of the collar also provides a safe pathway for the lower head strap across the neck. Proper sizing of a cervical collar is critical. The key dimension on a patient is the distance between an imaginary line drawn across the top of the shoulders, where the collar will sit, and the bottom plane of the patient's chin. The key dimension on the collar is the distance between the black fastener and the lower edge of the rigid plastic encircling band, not the foam padding. When the patient is being held in a Contra Costa County Prehospital Care Manual – January 2010 Page 9 neutral position, measure the distance from the shoulder to the chin in finger widths. Then select the size collar that most closely matches the key dimensions of the patient. The tallest collar that does not hyperextend a patient should be used. The most important step in application is the proper positioning of the chin piece. Position the chin piece by sliding the collar up the chest wall. Be sure that the chin is well supported by the chin piece and that the chin extends far enough onto the chin piece to at least cover the central fastener. Difficulty in positioning the chin piece may indicate the need for a shorter collar. A cervical collar must NOT inhibit the patient's ability to open his mouth or your ability to open the patient's mouth if vomiting occurs. A cervical collar must not obstruct or hinder ventilation in any way. SPINAL IMMOBILIZATION Spinal immobilization is a critical procedure necessary in many, but not all patients suffering trauma. Proper evaluation, including assessment of the mechanism of injury, assessment of the patient (particularly with regard to neurologic function) and assessment of confounding factors (drugs, pain, etc.) are necessary in order to make a proper decision about spinal immobilization. One overriding principle is that if any doubt exists as to whether a patient has sustained a spinal injury, immobilization should be done. A poor neurologic outcome because immobilization was not performed far outweighs the discomfort of immobilization for those without injuries. A systematic approach will allow appropriate evaluation of patients with potential for spinal injury and application of immobilization techniques for those patients. Patients who do not meet criteria will avoid the discomfort, delay and additional unnecessary testing that often accompanies spinal immobilization. In all situations, airway and ventilation have the highest priority and must be addressed with minimal movement of the patient prior to full assessment. A wide variety of devices and methods exist for immobilizing a patient. The specific method and equipment to be used should be based upon the situation, the patient's condition and available resources. Regardless of the specific device the focus should be on the patient and their needs HEAD INJURY Priorities for treatment of head-injury patients include maintenance of adequate oxygenation and blood pressure as well as appropriate attention to possible cervical spine injury. Hyperventilation of headinjury patients should be avoided, as it may worsen delivery of oxygen to the brain. Patients with adequate ventilatory effort (10-12 breaths per minute in adults) should receive 100% oxygen by mask. Patients with poor ventilatory effort (either in terms of slow rate or shallow breathing) may need assisted ventilations at normal rate. Deeply comatose patients may require intubation to assure an adequate airway. Capnography and end-tidal CO2 levels should guide ventilation rate (levels of 35-45 mm Hg are optimal). Patients with a dilated pupil on one side, or who have decerebrate or decorticate posturing likely have severe brain injury and swelling that may lead to brain herniation. For these patients, an increase in respiratory rate of 2-4 per minute is appropriate to provide the small degree of increased ventilation advised for these most severe cases. Fluid administration should not be withheld in hypotensive head injury patients, as hypotension also worsens brain injury. Rapid transport of trauma patients is essential, and it is appropriate to obtain IV access and administer fluids during transport. Page 10 Contra Costa County Prehospital Care Manual – January 2010 AMPUTATIONS For partial amputations, splint in anatomic position and elevate the extremity. If the part is completely amputated, place the amputated part in a sterile, dry container or bag. Seal or tie off the bag, and place it in a second container or bag. Seal or tie off the second bag and place on ice. DO NOT PLACE THE AMPUTATED PART DIRECTLY ON ICE OR IN WATER. Elevate the extremity involved and dress with dry gauze. GERIATRIC PATIENTS Due to the physiologic changes of aging, a mechanism of injury that might be less damaging to a younger person can cause grave injury in the geriatric patient. Undertriage in the patient over 65 is three times greater than with younger patients. The decreased perception of pain can mask injury – they can have many injuries but rate their pain very low. The most common mechanisms of injury are motor vehicle crashes, falls, and auto vs. pedestrian. Falls are the most frequent mechanism in patients over age 75. Motor vehicle crashes are most common in the 65-75 range. Anticoagulant use (particularly Coumadin or warfarin) in the elderly is relatively common and may add risk. Aspirin and other anti-platelet agents are also very common. Direct pressure to hemorrhage is the best way to deal with control of bleeding. The elderly are also more prone to environmental thermal emergencies – avoid hypothermia. Field care for critical elderly trauma victims should follow basic trauma principles - rapid assessment, performing only necessary interventions on scene, and rapid transport. Necessary on-scene interventions include basic airway management, appropriate spinal immobilization, and bleeding control. Vascular access should not delay transport. NOTES ON HYPOTHERMIA Many patients seen in the prehospital setting may have predisposing factors that lead to hypothermia. Common medical conditions leading to hypothermia include hypoglycemia or stroke. Trauma with shock may also lead to hypothermia, and this can be worsened by exposure to a cold environment. Resuscitative efforts for these patients are less effective in the setting of hypothermia. Newborns and infants as well as the elderly have an increased predisposition to hypothermia, as do some persons with drug and alcohol abuse. For any patient with a predisposition to or suspected hypothermia, general treatment measures include removing wet clothing and drying the patient. Insulate against additional heat loss by covering the patient with a blanket. In newborns and infants, the head should also be covered to prevent heat loss. Patients should be removed from cold environments as soon as possible. Severe hypothermia leading to marked lowering of core body temperature is rare in our county. Severely hypothermic patients may have impaired speech, memory, judgment, and coordination. Hypotension may also be present. Gentle handling of these patients, general warming/treatment measures listed above, and prompt transport (in a warmed ambulance) is appropriate. NOTES ON GERIATRICS Contra Costa County Prehospital Care Manual – January 2010 Page 11 Geriatric patients (older than 65 years of age) have decline in organ function and physiologic changes which make their presentation and treatment different than younger patients. Older patients also more frequently have chronic medical problems and may be taking numerous medications for their illnesses. System Physiologic Changes/Prehospital Considerations Neurologic One of the first to deteriorate in illness. Elder patients with fever, MI, and sepsis may appear confused and have impaired balance and coordination. Short-term memory impairment, a decrease in the ability to perform psychomotor skills and slower reflex times are normal in the aging process. The patient’s baseline abilities are important for comparison to current findings Senses Sight problems (visual acuity and depth perception) as well as balance problems caused by the inner ear can make falls more likely. Changes in vision and hearing also may affect the rescuer’s interaction with the patient. Decreased function of sensory nerves also may increase chances of injury. Skin Connective and subcutaneous tissue loss makes skin more easily traumatized, less likely to stop bleeding spontaneously, and sensitive to pressure (ulcers can develop in 45 minutes or less). Musculoskeletal A decrease in muscle mass often results in less strength, and decreased bone density make fractures more likely. Posture changes can make immobilization of the geriatric patient more challenging. Cardiovascular Stiffer vessels are unable to compensate for an increase in demand on the cardiovascular system. The heart walls are less compliant and cardiac function slowly declines. Increase in heart rate may not be seen in elderly with blood loss and hypovolemia (as is typically seen in younger patient). Atypical presentations for MI may be seen (painless, presenting with weakness, fatigue, syncope or shortness of breath). Respiratory Changes in the lung result in a decreased ability to exchange oxygen and carbon dioxide. Pulse oximetry readings can be lower even in healthy individuals. The ability to cough is decreased because of loss of muscle mass and lower chest wall compliance, and increases the chance of infection, particularly pneumonia. Spinal curvature (kyphosis) additionally may compromise respiratory function. Gastrointestinal Saliva and gastric juices decrease, making chewing and digestion more difficult. The intestinal tract slows and may cause constipation or fecal impaction. Liver function decreases which makes it harder to detoxify the blood and eliminate substances (e.g. medications and alcohol). Abdominal pain may be less prominent when serious problems exist. Renal Renal function declines after age 50 because of decreased blood flow and filtration. Elimination of certain medications can be impaired, and along with electrolyte disturbances caused by decreased filtration, may often be the cause of altered mental status in older people. Illness in the geriatric patient can result in a “domino effect” where failure of one organ system leads to failure of others. Symptoms may be subtle, atypical, vague and easily dismissed as part of old age. Geriatric patients require a high index of suspicion. NOTES ON BURNS Page 12 Contra Costa County Prehospital Care Manual – January 2010 After the patient has been removed from direct contact with the source of the burn, and the acute burning process has been stopped, then the priorities for burned patients are the same as for any other type of injury or illness. In the case of chemical burns (other than dry chemicals that may become more harmful when wet), remove the patient's shoes, hose or shower over the clothes, and then remove the clothes. Remove potentially constricting jewelry. Do not remove clothing that has stuck to the skin as a result of the burning. Protection should be afforded to prehospital personnel during this process. Airway problems should be suspected whenever the patient was burned or otherwise exposed to smoke in an enclosed space, when there was exposure to toxic fumes, or when there are burns or evidence of soot or hair singing to the face and/or upper airway. Pulmonary complications are usually delayed; however, if early airway problems are evident or likely, apply oxygen and transport immediately to the nearest appropriate facility. Further care can be given en route. All patients exposed to smoke should be treated for possible carbon monoxide poisoning using high flow oxygen. Chronic lung patients will be more dramatically affected and should be more closely observed. Shock from burns is usually delayed. If the patient is in shock, consider other causes. Associated injuries are likely to be more acutely life threatening than the burn itself. If the burn has just occurred (less than 3 minutes prior), cool wet dressings should be used to stop the burning process and to limit the depth of injury. Dry dressings should then be placed on burns. If patients have large burns (more than 10% of total body surface area), cooling measures and exposure may lead to hypothermia. Those patients should be covered with blankets to preserve body heat (can be placed over wet dressings). Patients with other life threatening injuries may require stabilization at the closest appropriate receiving facility prior to transfer to a burn center. Transporting units may be directed past closer facilities by the base hospital physician, once it has been determined that the patient is stable enough and that the burn center is prepared to receive the patient. The following patients may be appropriate for initial transport to a Burn Center:: a. Partial thickness (2nd degree) greater than 20% TBSA b. Full thickness (3rd degree) greater than 10% c. Significant burns to face, hands, feet, genitalia, perineum, or circumferential burns of the torso or extremities d. Chemical or high voltage electrical burns e. Smoke inhalation with external burns Use the Rule-of-Nines to estimate the extent of the burn. Contra Costa County Prehospital Care Manual – January 2010 Page 13 BLS NOTES Section EMERGENCY MEDICAL TECHNICIAN (EMT) SCOPE OF PRACTICE "Emergency Medical Technician I" or "EMT-I" means a person who has successfully completed an EMT-I course which meets the requirements of this Chapter, has passed all required tests, and who has been certified by the EMT-I certifying authority. 100063. Scope of Practice of Emergency Medical Technician-I (EMT-I). a) During training, while at the scene of an emergency, during transport of the sick or injured, or during interfacility transfer, a supervised EMT-I student or certified EMT-I is authorized to do any of the following: 1) Evaluate the ill and injured. 2) Render basic life support, rescue and emergency medical care to patients. 3) Obtain diagnostic signs to include, but not be limited to the assessment of temperature, blood pressure, pulse and respiration rates, level of consciousness, and pupil status. 4) Perform cardiopulmonary resuscitation, including the use of mechanical adjuncts to basic cardiopulmonary resuscitation. 5) Use the following adjunctive airway breathing aids: A) oropharyngeal airway; B) nasopharyngeal airway; C) suction devices; D) basic oxygen delivery devices; and E) manual and mechanical ventilating devices designed for prehospital use. 6) Use various types of stretchers and body immobilization devices. 7) Provide initial prehospital emergency care of trauma. 8) Administer oral glucose or sugar solutions. 9) Extricate entrapped persons. 10) Perform field triage. 11) Transport patients. 12) Set up for ALS procedures, under the direction of an EMT-II or EMT-P. 13) Perform automated external defibrillation when authorized by an EMT AED service provider. 14) Assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices. b) In addition to the activities authorized by subdivision (a) of this section, the medical director of the local EMS agency may also establish policies and procedures to allow a certified EMT-I or a supervised EMT- I student in the prehospital setting and/or during interfacility transport to: 1) Monitor intravenous lines delivering glucose solutions or isotonic balanced salt solutions including Ringer’s lactate for volume replacement; Contra Costa County Prehospital Care Manual – January 2010 Page 17 2) Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow and turn off the flow of intravenous fluid; and 3) Transfer a patient who is deemed appropriate for transfer by the transferring physician, and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines; 4) Monitor preexisting vascular access devices and peripheral lines delivering intravenous fluids with additional medications pre-approved by the Director of the EMS Authority (not currently allowed in Contra Costa County). c) The scope of practice of an EMT-I shall not exceed those activities authorized in this Section, Section 100064, and Section 100064.1. BLS MANAGEMENT OF PATIENTS ENCOUNTERED PRIOR TO ACTIVATION OF 9-1-1 EMT-I's who encounter a patient where the 9-1-1 system has not been activated should assess the patient to determine whether the care needed by that patient is beyond their scope of practice. If it is determined that the patient may benefit from ALS level care, the 9-1-1 system should be activated. After assuring activation of the 9-1-1 system, EMT-I personnel should assess the patient and begin any care required that is allowed in the EMT-I Scope of Practice. If the EMT-I unit has transport capabilities, the personnel should determine if the ETA of the paramedic unit is greater than the transport time to the closest appropriate receiving facility. If so, the EMT-I unit should proceed with patient transport and cancel the ALS unit. If the ETA of the paramedic unit is less than the transport time to the closest appropriate receiving facility, remain on scene and turn the patient over to the paramedic unit upon their arrival. Documentation of the patients chief complaint, history of present illness, past medical history, medications, allergies, vital signs, findings from the physical exam, and a general assessment and any treatment initiated is to be completed. A copy of the patient documentation should be given to the transport unit prior to transport, if possible. ADMINISTRATION OF ORAL GLUCOSE EMT-Is may administer an approved oral glucose agent by utilizing the following procedure: 1. Confirm altered level of consciousness in a patient with a known history of diabetes, and that the patient is conscious and able to sit in an upright position. 2. Dispense up to 30 grams of the oral glucose solution into the patient's mouth. Optimally, the patient will self-administer the solution. 3. If the patient has difficulty swallowing the solution, discontinue the procedure. The first priority is keeping an open airway. 4. Record the administration of the oral glucose solution with the time given and any changes in the patients level of consciousness. Page 18 Contra Costa County Prehospital Care Manual – January 2010 PUBLIC SAFETY DEFIBRILLATION PATIENT ASSESSMENT All patients are to be assessed upon arrival for level of consciousness and the presence or absence of a pulse and respirations, even if CPR is being done. The results of this initial assessment are to be verbalized in the initial report. If the patient is an unwitnessed arrest or a witnessed arrest with no CPR for 5 minutes or more, two minutes of CPR shall be done prior to attaching the defibrillator for analysis. If the patient was a witnessed arrest with CPR or a downtime less than 5 minutes proceed to attach defibrillator and immediately initiate analysis. VERBAL REPORT Verbal reports are very important and should begin once the self-check for the AED has cleared the screen. The initial report should include the name of the person reporting, engine company designation, status of the defibrillator self-check (e.g., self-check ok), patient location, estimated patient age, patient sex, and findings from the initial assessment of the patient. Continue to verbally report events as they occur (e.g., attaching electrodes, analyzing rhythm, paramedics (unit number) on-scene at...). If a shock is advised, verify that everyone (including the operator) is clear of the patient, and verbalize that everyone is clear. DEFIBRILLATOR ELECTRODES Do not use the defibrillation electrode if the gel is torn, separated or split from the foil. This may cause arcing and patient burns. Peel the protective backing from the electrode slowly to prevent damage to the gel. Patients with implanted pacemakers or implantable defibrillators are treated just like any other patient. If possible, do not place the electrodes on the pulse generator of the pacemaker. EMS personnel may feel the shock from an implantable defibrillator as a slight "buzz", but it will not harm them. PATIENT CARE DATA Patient data should be downloaded and a patient care report completed and sent to the EMS Agency as soon as possible after the use of the AED. Contra Costa County Prehospital Care Manual – January 2010 Page 19 ► Public Safety Defibrillation NON-TRANSPORTING UNIT 1. CONFIRM: - unconscious, pulseless, and apneic or - unconscious, pulseless with agonal respirations - if 1-8 years of age, attach pediatric electrodes, if available. If not, attach adult electrodes if able to do so without electrodes touching IF TRAUMA: Prepare patient for immediate transport. As time permits, prior to transport unit arrival, initiate defibrillation protocol 2. If unwitnessed or there is a known down time of 5 minutes or greater with no effective CPR - CPR for 2 minutes - If patient remains unconscious, pulseless and apneic proceed to 3 If witnessed and the down time is less than 5 minutes proceed to 3 3. Attach Defibrillator and Initiate Analyze/Defibrillation Clear bystanders and crew Have machine analyze the patient’s rhythm 3.1 If the rhythm is shockable Clear bystanders and crew Deliver shock Resume CPR Machine will reanalyze rhythm as indicated by manufacturer protocol 3.2 If the rhythm is NOT shockable Resume CPR beginning with chest compressions Machine will reanalyze the rhythm as indicated by manufacturer protocol 4. If the patient begins breathing or becomes responsive: Maintain airway Assist ventilations as necessary Check blood pressure, if equipment is available If the patient again stops breathing or becomes unresponsive: Clear bystanders and crew Have the machine analyze the patient’s rhythm Proceed as in 3 above 5. If a paramedic unit arrives to transport the patient, turn the patient over to paramedic personnel when you reach the point where CPR is appropriate. If turnover is delayed, continue to provide care according to this protocol. If a BLS unit, without defibrillation capability, arrives to transport the patient, accompany the patient to the hospital providing care enroute. Deliver no more than nine (9) defibrillations onscene prior to beginning transport. Page 20 Contra Costa County Prehospital Care Manual – January 2010 ► Spinal Immobilization Spinal immobilization is a critical procedure necessary in many, but not all patients suffering trauma. Proper evaluation, including assessment of the mechanism of injury (high velocity motor vehicle crash, significant fall, penetrating trauma that may have potential spinal involvement, etc.), assessment of the patient (particularly with regard to neurologic function) and assessment of confounding factors (drugs, pain, etc.) are necessary in order to make a proper decision about spinal immobilization. If any doubt exists as to whether a patient has sustained a spinal injury, immobilization should be done. In all situations, airway and ventilation have the highest priority and must be addressed with minimal movement of the patient prior to full assessment. Indications Penetrating Injury (Trauma to head, neck or torso): o presence of neurologic complaint or deficit – paralysis, weakness, numbness, tingling, priapism or neurogenic shock, loss of consciousness o anatomic deformity of spine Blunt Injury (regardless of mechanism): o o o o altered level of consciousness (GCS less than 15) presence of spinal pain or tenderness anatomic deformity of spine presence of neurologic complaint or deficit – paralysis, weakness, numbness, tingling, priapism or neurogenic shock Blunt Injury (when mechanism of injury is concerning): o presence of alcohol or drugs or acute stress reaction/anxiety o distracting injury (e.g., long bone fracture, large laceration, crush or degloving injury, large burns) o inability to communicate (e.g., speech or hearing impaired, language gap, small children, developmental or psychiatric conditions) Concerning mechanisms of injury include but are not limited to: Violent impact to head, neck, torso or pelvis (e.g. assault, entrapment in structural collapse) Sudden acceleration, deceleration or lateral bending forces to neck or torso (e.g. moderate- to high-speed motor vehicle crash, pedestrian struck, explosion) Falls (especially in elderly patients) Ejection from motorized or other transportation device (e.g. scooter, skateboard, bicycle, motor vehicle, motorcycle, recreational vehicle, or horse) Victims of shallow-water diving incident Contra Costa County Prehospital Care Manual – January 2010 Page 21 Equipment - Rigid cervical collar - Long backboard - Straps (for torso immobilization) - Head immobilization device - Padding Procedure 1) Provide manual in-line immobilization immediately, moving the head into a proper in-line position, unless contraindicated*. Continue to support and immobilize the head without interruption. 2) Evaluate the patient's ABC's and provide any immediately required intervention. 3) Examine patient to determine if an indication for immobilization exists. Check motor and sensory function and circulation in all four extremities. 4) If patient meets criteria for spinal immobilization: a. Examine the neck and apply a properly fitting, effective cervical collar. b. Pick the immobilization device that you will use, and immobilize the torso to the device so that the torso cannot move up or down, left or right. c. Evaluate and pad behind the head as needed. d. After the torso straps have been tightened, immobilize the head, maintaining a neutral inline position. e. Tie the feet together and immobilize the legs so that they can not move anteriorly or laterally. f. Fasten the arms to the immobilization device. g. If patient is pregnant, elevate spine board on patient's right side to approximately 15 degree angle (left lateral recumbent) to promote venous return. h. Recheck the ABC's and motor, sensory, and circulation in all four extremities. * In-line movement should not be attempted if the patient's injuries are so severe that the head presents with such misalignment that it no longer appears to extend from the midline of the shoulders. Other contraindications would be if careful movement of the head and neck into a neutral in-line position results in neck muscle spasm, increased pain, the commencement or increase of a neurological deficit such as numbness, tingling or loss of motor ability, or compromise of the airway or ventilation. Page 22 Contra Costa County Prehospital Care Manual – January 2010 ALS Notes Section PARAMEDIC SCOPE OF PRACTICE California Code of Regulations, Title 22, Division 9, Chapter 4: 100145. Scope of Practice of Paramedic. a) A paramedic may perform any activity identified in the scope of practice of an EMT-I in Chapter 2 of the Division, or any activity identified in the scope of practice of an EMT-II in Chapter 3 of this Division. b) A paramedic shall be affiliated with an approved paramedic service provider in order to perform the scope of practice specified in this Chapter. c) A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a hospital as part of his/her training or continuing education under the direct supervision of a physician, registered nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during interfacility transfer, or while working in a small and rural hospital pursuant to section 1797.195 of the Health and Safety Code, may perform the following procedures or administer the following medications when such are approved by the medical director of the local EMS agency and are included in the written policies and procedures of the local EMS agency. 1) Basic Scope of Practice: A) Perform defibrillation and synchronized cardioversion. B) Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps. C) Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway, and adult endotracheal intubation. D) Institute intravenous (IV) catheters, heparin locks, saline locks, needles, or other cannulae (IV lines), in peripheral veins; and monitor and administer medications through pre-existing vascular access. E) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer's lactate solution. F) Obtain venous blood samples. G) Use glucose measuring device. H) Perform Valsalva maneuver. I) Perform needle cricothyroidotomy. (not currently used in Contra Costa County) J) Perform needle thoracostomy. K) Monitor thoracostomy tubes L) Monitor and adjust IV solutions containing potassium, equal to or less than 20 mEq/L. M) Administer approved medications by the following routes: intravenous, intramuscular, subcutaneous, inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or topical. N) Administer, using prepackaged products when available, the following medications: (1) 25% and 50% dextrose; (2) activated charcoal; (not currently used in Contra Costa County) (3) adenosine; (4) aerosolized or nebulized beta-2 specific bronchodilators; Contra Costa County Prehospital Care Manual – January 2010 Page 25 (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) aspirin; atropine sulfate; pralidoxime chloride; calcium chloride; diazepam; (not currently used in Contra Costa County) diphenhydramine hydrochloride; dopamine hydrochloride; epinephrine; furosemide; (not currently used in Contra Costa County) glucagon; midazolam lidocaine hydrochloride; morphine sulfate; naloxone hydrochloride; nitroglycerin preparations, except intravenous, unless permitted under (c)(2)(A) of this section; (20) sodium bicarbonate 2) Local Optional Scope of Practice: A) Perform or monitor other procedure(s) or administer any other medication(s) determined to be appropriate for paramedic use, in the professional judgment of the medical director of the local EMS agency, that have been approved by the Director of the Emergency Medical Services Authority when the paramedic has been trained and tested to demonstrate competence in performing the additional procedures and administering the additional medications. CONTRA COSTA LOCAL OPTIONAL SCOPE OF PRACTICE The following medications and procedures are approved for use in the Contra Costa County local optional scope of practice: Pediatric Endotracheal Intubation (limited to patients > 40 kg) Ipratropium (CCT-P Only) Midazolam Infusion (CCT-P Only) Intraosseous Infusion Blood/Blood Product Infusion (CCT-P Only) External Cardiac Pacing Amiodarone Glycoprotein IIb/IIIa Receptor Inhibitor Infusion (CCT-P Only) Esophageal Airway (King LTS-D) Morphine Sulfate Infusion (CCT-P Only) Heparin Infusion (CCT-P Only) Sodium Bicarbonate Infusion (CCT-P Only) Lidocaine Infusion (CCT-P Only) Nitroglycerin Infusion (CCT-P Only) Total Parenteral Nutrition (TPN) Infusion (CCT-P Only) KCL Infusion (CCT-P Only) Page 26 Contra Costa County Prehospital Care Manual – January 2010 ADVANCED LIFE SUPPORT SKILLS LIST The following skills may be performed by Contra Costa County paramedics following treatment guidelines or base hospital orders: 1. Adult oral endotracheal intubation 2. Esophageal Airway (King LTS-D)* 3. Removal of foreign body obstruction with magill forceps 4. Defibrillation 5. Cardioversion 6. Intravenous therapy 7. Drug therapy (see drug list) 8. Needle thoracostomy 9. Intraosseous infusion* 10. Pediatric oral endotracheal intubation* (limited to patients > 40 kg) 11. Use of pulse oximeter 12. End-tidal CO2 monitoring (ETCO2) 13. Glucose Testing 14. External Cardiac Pacing* 15. 12-Lead ECG 16. Continuous Positive Airway Pressure (CPAP) * Only paramedics who are currently accredited in Contra Costa County may perform these skills. Contra Costa County Prehospital Care Manual – January 2010 Page 27 AIRWAY MANAGEMENT The goal of airway management is to ensure adequate ventilation and oxygenation. Initial airway management should always begin with BLS maneuvers. BLS airway management is the preferred method in all patients who can be adequately ventilated (visible chest rise) using bag-mask ventilation. All cardiac arrest patients should have initial BLS airway management. Advanced airway management should not interfere with initial CPR and defibrillation efforts. Intubation should not be used in pediatric patients weighing less than 40 kg. Intubation should not be used in trauma patients (arrest or non-arrest) unless BLS airway management has failed to produce adequate ventilation. Initial BLS airway maneuvers are to include: Follow the “JAWS” pnemonic: J Use jaw thrust maneuvers to open airway A Use oral or nasal airway W Work together. Ventilation using a bag-valve mask is enhanced using two rescuers to manage airway S Slow and small ventilations Ventilation Rates (avoid hyperventilation): o Adults – 10/minute o Children – 20/minute o Infants (< 1 yr) – 30/minute Deliver ventilation over one second to produce visible chest rise and to avoid distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary based on patient size. Position the patient to optimize airway opening and facilitate ventilations: o Use “sniffing” position – head extended (A) and neck flexed forward (B) – unless suspected spinal injury. o Position with head/shoulders elevated – anterior ear at same horizontal level as sternal notch (C). This is especially advantageous in larger or morbidly obese patients. C Page 28 Contra Costa County Prehospital Care Manual – January 2010 Avoid prolonged / multiple interruptions in ventilation: - Interrupt ventilation for no more than two periods of up to 30 seconds during laryngoscopy or intubation attempt - No more than two (2) endotracheal intubation attempts should be made - Endotracheal Tube Introducer (ETI / bougie) may be helpful on first or second attempt - Oxygenate using BLS techniques for 60 seconds (if possible) between attempts (ET or Rescue Airway) Initial BLS Maneuvers BLS Airway Management Adequate ventilation Patient apneic or unable to maintain BLS airway Prepare intubation equipment, including ETI (bougie) and rescue airway Laryngoscopy – Consider initial ETI use if difficult airway anticipated ET Attempt #1: Pass tube and check tube position Cords visualized Cords not visualized Correct position verified Secure Tube Correct position not verified Resume BLS Airway Management Consider ETI for second attempt Laryngoscopy not possible or likely futile If second ET attempt omitted ET Attempt #2: Pass ETI / tube, check tube position Correct position verified Correct position not verified Resume BLS Airway Management Rescue Airway Placement (maximum 2 attempts) Correct position verified Correct position not verified BLS Airway Management Tube verification / monitoring: Check end-tidal CO2 initially (colorimetric or capnography) If ETCO2 is negative, use Esophageal Detector Device (EDD) with endotracheal tubes View chest rise / listen for lung sounds and gastric sounds All intubated patients require continuous ETCO2 monitoring until transfer of patient care at hospital Documentation of findings is critical Contra Costa County Prehospital Care Manual – January 2010 Page 29 ALS PROCEDURES Oral Endotracheal Intubation Indications Patient with decreased sensorium (GCS less than or equal to 8) and apneic (adults) Patient with decreased sensorium (GCS less than or equal to 8), ventilation unable to be maintained with BLS airway Contraindications Pediatric patients under 40 kg Suspected hypoglycemia or narcotic overdose Maxillo-facial trauma with unrecognizable facial landmarks Patients experiencing seizures Patients with an active gag reflex Ventilation should be interrupted for no more than two periods of up to 30 seconds during laryngoscopy or intubation attempts and patients should be ventilated with 100% oxygen for 1 minute via bag-valve mask between attempts. No more than two attempts at endotracheal intubation should be done (an intubation attempt is defined as the laryngoscopy and passing of an ET tube beyond the teeth with the intent of placing the endotracheal tube). Use of rescue airway or return to BLS maneuvers may occur at any time (neither require repeated advanced airway attempts before use). Base hospital physician consultation is recommended if there is any question concerning the need to intubate a patient. The base hospital physician may also approve extubation of a patient in the field. Nasotracheal intubation is not an approved skill in Contra Costa County. Procedure 1) Assure an adequate BLS airway. 2) Oxygenate with 100% oxygen using a bag-valve-mask. 3) Select appropriate ET tube. If appropriate tube has a cuff, check cuff to ensure that it does not leak; note the amount of air needed to inflate. Deflate tube cuff. Leave syringe attached. a. Insert appropriate stylet, making sure that it is recessed at least one cm. from the distal opening of the ET tube. Lubricate the tip of the tube. b. Prepare endotracheal tube introducer (bougie) and rescue airway for possible use. 4) Assure c-spine immobilization with suspected trauma. 5) Insert laryngoscope and visualize the vocal cords. If unable to identify cords, resume BLS aiway management and utilize endotracheal tube introducer in next attempt. 6) Suction if necessary and remove any loose or obstructing foreign bodies. 7) CAREFULLY pass the endotracheal tube tip past the vocal cords; remove the stylet ; advance the ET tube until the cuff is just beyond the vocal cords 8) Inflate the cuff with 5-7ml of air. For uncuffed pediatric tubes, advance tube no more than 2.5 cm beyond vocal cords (use vocal cord marker line if present on tube). 9) Immediately assess tube placement with capnography or colorimetric end-tidal CO2 indicator and/or esophageal detector bulb (see tube confirmation procedure): 10) Following successful confirmation of intubation, auscultation of lungs, epigastrium, and observation of chest rise should be done. If chest does not rise, extubate and reintubate. Endotracheal tube introducer (bougie) should be considered for second attempt. 11) Secure the tube with tape or ET holder and ventilate. Mark the TUBE at the level of the lips. Page 30 Contra Costa County Prehospital Care Manual – January 2010 Confirmation of Tube Placement / Post-Intubation Monitoring Every patient intubated with an endotracheal tube or esophageal airway requires initial evaluation of tube placement and ongoing tube monitoring until patient turnover or until resuscitative efforts cease. Physical findings (chest rise, lung and abdominal sounds, and vital signs, if present) must be assessed and documented in all intubated patients. End-tidal carbon dioxide (ETCO2) measurement must be utilized in all intubated patients. Electronic waveform capnography (with numerical ETCO2 readout) should be utilized from the earliest moment possible after every tube placement to continuously verify placement as well as to guide ventilation rates. Colorimetric ETCO2 indicators may be useful if electronic monitoring is not immediately available, but should be replaced with waveform monitoring as soon as possible. Documentation of ETCO2 measurement in the patient care record is required in all intubations. Electronic data upload or attachment of a code summary from the monitor-defibrillator to the record should be done in all cases. The esophageal detector bulb is useful only in cardiac arrest situations in which no ETCO2 is detected, and should only be used with endotracheal tubes (not with King Airway). When ETCO2 is not detected in the setting of King Airway use, physical exam remains as the key method to assess functionality of the airway. Procedure 1) Following tube placement and cuff inflation, attach waveform capnography unit (or colorimetric ETCO2 indicator if waveform not immediately available). a. If exhaled ETCO2 is detected, the tube should be secured. Waveform capnography should be used continuously until patient turnover or cessation of resuscitative efforts. Physical exam reassessment should also be utilized after any patient movement. b. If exhaled ETCO2 is not detected: 1. In a patient with pulses, the tube should be removed and reintubation attempted. 2. In a patient without pulses: a. Endotracheal tube: use esophageal bulb detector. b. King Airway: use physical examination findings (chest rise, lung sounds present, abdominal sounds absent) should be used to verify placement. c. Reassessment should occur after any patient movement, and in pulseless patients may include re-use of the esophageal detector bulb. d. In all patients, ETCO2 monitoring should be continued as it may be the initial indicator when there is return of spontaneous circulation. Contra Costa County Prehospital Care Manual – January 2010 Page 31 SIGNIFICANCE OF END-TIDAL CO2WAVEFORM / CHANGES AFTER INTUBATION Loss of previous waveform with Endotracheal tube disconnected, dislodged, kinked or ETCO2 near zero obstructed Loss of circulatory function Decreasing ETCO2 with loss of Endotracheal tube cuff leak or deflation plateau Endotracheal tube located in hypopharynx Partial obstruction Sudden increase in ETCO2 Return of spontaneous circulation Gradual increase in ETCO2 If elevated above normal levels, need for increased ventilation From low levels, improvement in perfusion Gradual decrease in ETCO2 Effects of hyperventilation Worsening of perfusion “Sharkfin” waveform Asthma or COPD Normal capnography: ET Tube disconnected, displaced, or patient develops cardiac arrest: ET Tube in hypopharynx (above cords), partly obstructed, or cuff leak: Sudden Increase in ETCO2 (return of spontaneous circulation): “Shark-Fin” waveform (asthma or COPD): (Source: Medtronic Physio-Control Capnography Educational Series 2002) ESOPHAGEAL DETECTOR BULB FINDINGS AND ACTIONS Finding Action Rapid inflation of bulb Tracheal placement – Secure tube Slow inflation or no inflation Likely esophageal placement – remove tube and reattempt intubation. If second attempt, remove tube and use King Airway or BLS airway management Visualize airway directly via laryngoscopy Alternative – rotate tube 90 degrees, suction, and recheck with bulb Remove tube if any question If paramedic confident of tube placement (false findings more common with excessive secretions, CHF, or obesity) Page 32 Contra Costa County Prehospital Care Manual – January 2010 ► Endotracheal Tube Introducer (Bougie) The flexible endotracheal tube introducer is a useful adjunct which can be used on any intubation. It is particularly helpful when vocal cord visualization is anticipated to be difficult (e.g. short neck, limited neck mobility, spinal immobilization). A two-person or a one-person technique can be used. Do not force introducer as it can potentially cause tracheal or pharyngeal perforation. The introducer cannot be used in endotracheal tubes smaller than 6.0. 1. Two-Person Technique (recommended when visualization is less than ideal) a. Using laryngoscope, visualize as well as possible b. Place stylet just behind the epiglottis with the bent tip anterior and midline c. Gently advance the tip through the cords, maintaining anterior contact d. Use stylet to feel for tracheal rings e. Advance stylet black mark past teeth to feel for the carina. If no stop felt, remove as stylet is in esophagus, and retry. f. Withdraw the stylet to align the black mark with the teeth. g. Have assistant load and advance ETT tip to the black mark h. Have assistant grasp and hold steady the straight end of stylet i. Advance endotracheal tube while maintaining laryngoscope position j. At glottic opening turn endotracheal tube 90 degrees counterclockwise to assist passage over arytenoids k. Advance endotracheal tube to appropriate position l. Maintaining endotracheal tube position, withdraw stylet 2. One-Person Technique or Pre-loaded technique (recommended when visualization better but cords too anterior to pass tube). Can be used, by paramedic choice, for any intubation. a. Load stylet into endotracheal tube with bent end approximately 10 cm past distal end of tube b. Pinch the endotracheal tube against the stylet c. With bent tip anterior, visualize cords and advance stylet through cords d. Maintain laryngoscope position e. When black mark on stylet is at the teeth, ease grip to allow tube to slide over the stylet. If available, have an assistant stabilize the stylet. f. At glottic opening, turn endotracheal tube 90 degrees counter-clockwise to assist passage over the arytenoids. g. Advance endotracheal tube to appropriate position h. Maintaining endotracheal tube position, withdraw stylet Contra Costa County Prehospital Care Manual – January 2010 Page 33 ► Esophageal Airway (King LTS-D) The Esophageal Airway, or King LTS-D, is a single-use device intended for airway management. It can be used as a rescue airway device when other airway management techniques have failed, or as a primary device when advanced airway management is required in order to provide adequate ventilation. The esophageal airway does not require direct visualization of the airway or significant manipulation of the neck. Its main use is in cardiac arrest situations (pulseless and apneic patients). In some patients it may be preferable to use initially (e.g. patients who are obese or with short necks, patients with limited neck mobility, difficult visualization due to access to the patient, or blood or emesis in the airway). It is not necessary to attempt endotracheal intubation before opting for the esophageal airway. Because it is not tolerated well in patients with airway reflexes, it should not be used in patients with perfusing pulses unless all other methods of ventilation have failed. Two intubation attempts with the esophageal airway are permissible. Ventilations should be interrupted no more than 30 seconds per attempt. Between attempts, patients should be ventilated with 100% oxygen for one minute via bag-valve mask device. The King LTS-D is available in three sizes and cuff inflation varies by model: - Size 3 – Patient between 4 and 5 feet tall (55 ml air) - Size 4 – Patient between 5 and 6 feet tall (70 ml air) - Size 5 – Patient over 6 feet tall (80 ml air) Indications Cardiac arrest (of any cause) Inability to ventilate non-arrest patient (with BLS airway maneuvers) in a setting in which endotracheal intubation is not successful or unable to be done Contraindications Presence of gag reflex Caustic ingestion Known esophageal disease (e.g. cancer, varices, stricture, others) Laryngectomy with stoma (can place ET tube in stoma) Height less than 4 feet Note: Airway deformity due to prior surgery or trauma may limit the ability to adequately ventilate with this device (may not get adequate seal from pharyngeal cuff) Equipment Suction King LTS-D Kit (Size 3, 4, or 5) Bag-Valve-Mask Page 34 Stethoscope End-tidal CO2 detection device Contra Costa County Prehospital Care Manual – January 2010 Insertion of LTS-D King Tube (Source: King LTS-D Manufacturer’s Instructions for use) Source: Source: King LT(S)-D: Manufacturers Instructions for Use Procedure 1) 2) 3) Assure an adequate BLS airway (if possible). Select appropriately sized esophageal airway. Test cuff inflation by injecting recommended amount of air for tube size into the cuffs. Remove all air from cuffs prior to insertion. 4) Apply water-based lubricant to the beveled distal tip and posterior aspect of tube, taking care to avoid introduction of lubricant in or near ventilatory openings. 5) Have a spare esophageal airway available for immediate use. 6) Oxygenate with 100% oxygen. 7) Position the head. The ideal head position for insertion is the “sniffing position.” A neutral position can also be used (e.g. spinal injury concerns). 8) Hold mouth open and apply chin lift unless contraindicated by cervical spine injury or patient position. 9) With tube rotated laterally 45-90 degrees such that the blue orientation stripe is touching the corner of the mouth, introduce tip into mouth and advance behind base of tongue. Never force the tube into position. 10) As the tube tip passes under tongue, rotate tube back to midline (blue orientation stripe faces chin). 11) Without exerting excessive force, advance tube until base of connector aligns with teeth or gums. 12) Inflate cuff to required volume. 13) Attach bag-valve to airway. While gently bagging the patient to assess ventilation, simultaneously withdraw the airway until ventilation is easy and free flowing. 14) Confirm proper position by auscultation, chest movement, and verification of CO2 by capnography. Do not use esophageal detector device with esophageal airway. 15) Secure the tube. Note depth marking on tube. 16) Continue to monitor the patient for proper tube placement throughout prehospital treatment and transport. Capnography should be done in all cases. 17) Document airway placement and results of monitoring throughout treatment and transport. Troubleshooting: If placement is unsuccessful, remove tube, ventilate with BVM and repeat sequence of steps. If unsuccessful on second attempt, BLS airway management should be resumed. Additional Information: The key to insertion is to get the distal tip of the airway around the corner in the posterior pharynx, under the base of the tongue. It is important that the tip of the device is maintained at the midline. If the tip is placed or deflected laterally, it may enter the piriform fossa and cause the tube to appear to “bounce back” upon full insertion and release. Contra Costa County Prehospital Care Manual – January 2010 Page 35 ► Tracheostomy Tube Replacement Establishing a patent airway in a patient with a tracheostomy may be accomplished by suctioning or by replacement of an old tracheostomy tube when suctioning is not successful. Tracheostomy tube replacement may only be performed when patient has a new replacement tracheostomy tube available. If tracheostomy tube is not available, or placement of a new tube is unsuccessful, use of an endotracheal tube (stomal intubation) or BVM ventilation is appropriate. Indications: Contraindications: Dislodged tracheostomy tube (decannulation) Tracheostomy tube obstruction not resolved by suction Recent tracheostomy surgery (less than 1 month) Inadequately sized tract or stoma for insertion of new tube (use endotracheal tube instead) Procedure: 1) Remove old tracheostomy tube if obstructed a. Hyperextend head to extent possible to expose tracheostomy site b. Apply oxygen over mouth and nose and occlude stoma or tracheostomy tube c. If existing tube has a cuff, deflate with 5-10 ml syringe (do not cut balloon) d. Cut or untie cloth ties holding tube in place e. Withdraw tube using a slow and steady outward and downward motion f. Assess airway for patency and adequate ventilation g. Provide oxygen through stoma as needed 2) Replace tracheostomy tube a. If tube has obturator, place in tube. If tube has outer and inner cannula, use the outer cannula and obturator for placement. b. Moisten or lubricate tip of tube and obturator with water, saline, or a water-soluble lubricant c. Hold device by flange (wings) or actual tube like a pencil d. Gently insert tube with arching motion (follow curvature of tube) posteriorly and then downward. Slight traction on skin above and below stoma may help. e. Once tube is in place, remove obturator, attach BVM and attempt to ventilate. If tube uses inner cannula, insert to allow ventilation with BVM. f. Check for proper placement by observing bilateral chest rise, listening for equal breath sounds, and general patient assessment. Signs of improper placement include lack of chest rise, unusual resistance to assisted ventilation, air in surrounding tissues, or lack of patient improvement. g. If tube cannot be inserted, withdraw, administer oxygen, and ventilate as needed. h. If insertion not successful, consider use of smaller tracheostomy tube (if available) or endotracheal tube placement. i. An additional aid in placement may be use of a suction catheter as a guide (without applying suction) for tube placement. Remove obturator and slide tube along suction catheter into stoma. Remove suction catheter after placement and assess. Page 36 Contra Costa County Prehospital Care Manual – January 2010 j. If still unsuccessful and patient requires ventilation, consider endotracheal intubation or BVM ventilation through newborn mask or via nose and mouth with stoma occluded. 3) After proper placement, place tracheostomy ties through openings on flanges and tie around neck, allowing room for a little finger to pass between ties and neck. Possible Complications Creation of false lumen Subcutaneous air Pneumothorax or pneumomediastinum Bleeding at insertion site or through tube ► Stomal Intubation For patients with existing tracheostomy without tube (mature stoma): 1. Assure an adequate BLS airway. 2. Oxygenate with 100% oxygen using a bag-valve-mask. 3. Select the largest endotracheal tube that will fit through the stoma without force (it should not be necessary to lubricate the tube). 4. Check cuff, if applicable. 5. Do not use a stylet. 6. Pass endotracheal tube until the cuff is just past the stoma. Right mainstem bronchus intubation may occur if the tube is placed further since the distance from tracheostomy to carina is less than 10 cm. The tube will protrude from the neck by several inches. 7. Inflate the cuff 8. Immediately assess tube placement with colorimetric end-tidal CO2 indicator (see confirmation of tube/post-intubation procedure). 9. Auscultate the chest for air entry on the right and left sides equally. Look for symmetric chest wall rise. Check neck for subcutaneous emphysema, which indicates false passage of tube. If the chest DOES NOT RISE, extubate and repeat steps 2-7. 10. Secure the tube with tape and ventilate. Note: Do not attempt to reinsert a dislodged pre-existing tracheostomy tube. Contra Costa County Prehospital Care Manual – January 2010 Page 37 ► ResQPOD ResQPOD impedance threshold device is a novel circulatory enhancement device that is intended to be an adjunct for intubated adult patients with cardiac arrest. It should not be used on patients with perfusing pulses or spontaneous breathing or on patients with history of traumatic cardiac arrest due to blunt chest trauma. The ResQPOD is not required equipment. Indications Patients ≥ 9 years of age in cardiac arrest Contraindications Patients under the age of nine (9) Patients with a perfusing pulse or spontaneous breathing Patients with history of traumatic cardiac arrest due to blunt chest trauma Patients with flail chest Procedure 1. Secure advanced airway (because less CPR interruption occurs, King Airway is the ideal advanced airway to use early in cardiac arrest to facilitate ResQPOD use). 2. Attach bottom of ResQPOD directly to the airway adjunct. Assure tight fit, being sure to avoid movement of airway. 3. Attach ventilation bag to the ResQPOD. 4. Remove clear tab and slide red timing assist light switch on. 5. Place end-tidal CO2 measurement device between bag and ResQPOD (not between tube and ResQPOD). 6. Administer 10 breaths per minute. (Timing light flash rate is 10/minute) Do Not Hyperventilate. If spontaneous respiration resumes, ResQPOD should be immediately discontinued. The ResQPOD is to be used for a single patient. If secretions are encountered, clear the device by shaking it. Page 38 Contra Costa County Prehospital Care Manual – January 2010 ► Continuous Positive Airway Pressure (CPAP) The purpose of CPAP is to improve ventilation and oxygenation and avoid intubation in patients with congestive heart failure (CHF) with acute pulmonary edema or other causes of severe respiratory distress. Indications Patients 14 years and older in severe respiratory distress who are: Awake and able to follow commands Able to maintain a patent airway Exhibit two or more of the following: o Respiratory rate > 25 o Pulse oximetry < 94% o Use of accessory muscles during respiration Conditions in which CPAP may be helpful include suspected: CHF with pulmonary edema Acute exacerbation of COPD or asthma Pneumonia Near drowning Absolute Contraindications: (Do NOT Use) Respiratory or cardiac arrest or agonal respirations Tracheostomy Signs and symptoms of pneumothorax Major facial, head or chest trauma Vomiting Procedure 1) 2) 3) 4) 5) Place patient in a seated position Monitor ECG, Vital signs (BP, HR, RR, SPO2) Set up the CPAP system (per manufacturers recommendation) with pressure set at 7.5 cm H2O Explain to the patient what you will be doing Apply mask while reassuring patient – encourage patient to breathe normally (may have a tendency to hyperventilate) 6) Reevaluate the patient every 5 minutes – normally the patient will improve in the first 5 minutes with CPAP as evidenced by: Decreased heart rate Decreased respiratory rate Decreased blood pressure Increased SPO2 BVM ventilation or endotracheal intubation may be considered, when indicated, if the patient fails to show improvement. Contra Costa County Prehospital Care Manual – January 2010 Page 39 ► Needle Thoracostomy Needle thoracostomy may be performed to relieve a tension pneumothorax. Indications Signs and symptoms of tension pneumothorax, including: o o o o o o o altered level of consciousness decreased B/P; increased pulse and respirations absent breath sounds on the affected side hyperresonance to percussion on the affected side jugular vein distension increased dyspnea or difficulty ventilating tracheal shift away from the affected side (often difficult to assess) Contraindications Any condition other than tension pneumothorax Equipment 12 – 14 gauge 2 – 3” angiocath One-way valve Betadine and alcohol swabs Occlusive dressing/vaseline gauze Procedure 10-30 ml syringe Rubber connecting tubing Sterile gauze pads Tape 1) Locate the 2nd ICS in the midclavicular line on the same side as the pneumothorax (An alternate site is the fourth or fifth intercostal space, in the mid-axillary line). 2) Prep site 3) Attach syringe to 10 - 14 gauge angiocath. 4) Make insertion on top of lower rib at a 90o angle. 5) Advance slightly superior to clear rib, then back to 90o angle, to make "Z" track puncture. 6) A "give" will be felt upon entering the pleural space. Air and/or blood should push the syringe plunger back. 7) Advance catheter superiorly, remove needle and allow pressure to be relieved. 8) Attach one-way valve. 9) Apply vaseline gauze/occlusive dressing to site and cover with dressing. 10) Secure catheter and one-way valve. a. criss-cross taping for catheter. b. tape down to prevent leakage. c. tape one-way valve in dependent position. Reassess - expect rapid improvement in clinical condition and breath sounds. Page 40 Contra Costa County Prehospital Care Manual – January 2010 ► Vascular Access General Indications Emergent administration of intravenous medication or fluid bolus Anticipated emergent need to administer intravenous medications or fluid bolus General Contraindications Situations in which an IV is “precautionary” – without need or anticipated emergent need for use for medications or fluids. External jugular and intraosseous access are contraindicated in stable patients. Other Considerations In difficult access situations (e.g. history IV drug use, dialysis patient), IM alternatives (e.g. glucagon, naloxone, morphine, midazolam) are generally appropriate if intravenous fluid is not required. For critical trauma patients, IV access should occur en route to the hospital or helispot. Timely transport is important in a number of conditions (e.g. stroke, STEMI, and pulmonary edema) and vascular access attempts should not unduly delay scene departure. In patients with potential need only, no more than two attempts should be made. Access Site / Type Saline Lock Upper Extremity IV (available vein) Antecubital IV Intraosseous Access (IO) External Jugular IV Indication / Comments Indicated for vascular access in upper extremity when medication alone is being administered or a potential need for medication is anticipated. Indicated when fluids and / or medications are needed, and patient not in shock or arrest. Indicated in arrest, shock or when adenosine (rapid IV bolus) is required In arrest, use intraosseous access if rapid peripheral access cannot be obtained within 30-60 seconds Appropriate if other peripheral sites not available and medication or fluids indicated Indicated in cardiac arrest, profound shock, or unstable dysrhythmia when peripheral IV access cannot be accomplished or a suitable vein cannot be rapidly found Should be done only when medication or fluid bolus is being administered, not for prophylactic vascular access Not indicated when other routes for medications available (IM, IN) Not indicated in alert or stable patients IO infusion is PAINFUL! In non-arrest patients, use lidocaine for pain control PRIOR to giving fluid or medication Indicated only when unstable patient requires vascular access for emergent IV medication or fluids, no peripheral site is available and patient not appropriate for IO access (e.g., when patient is alert) Use intraosseous access in arrest situations (does not disrupt CPR) Use alternative routes for medications when possible rather than EJ o Patients requiring treatment of hypoglycemia should receive IM glucagon – monitoring for 10-15 minutes is appropriate before EJ considered o Use intranasal or IM route for naloxone in respiratory depression Contra Costa County Prehospital Care Manual – January 2010 Page 41 ► Intraosseous Infusion (Pediatric and Adult) Intraosseous infusion may be performed by EMT-P’s who have successfully completed a Contra Costa County EMS approved training course. Indications After evaluation of potential IV sites, it is determined that an IV attempt would not be successful; One of the following conditions exists: o cardiac or respiratory arrest, impending arrest, or unstable dysrhythmia o shock or evolving shock, regardless of cause Absolute Contraindications Fracture or suspected vascular compromise of the selected tibia Inability to locate anatomical landmarks for insertion Relative Contraindications Skin infection or burn overlying the area of insertion Equipment Povodine-based prep solution IV of NS attached to 500ml bag in pediatric patients IV NS 1 liter in adult patients 10/12 ml syringe filled with normal saline Sterile gloves Pressure bag for IV fluid administration Intraosseous needle (suitable to age 8) - OR Automated IO insertion device (EZ-IO PD) up to 40 kg Automated IO insertion device (EZ-IO AD) if over 40 kg Lidocaine 2% for injection Procedure 1) Locate and prep the insertion site. For children, place supine with a rolled towel under the knee, restrain if necessary. Select extremity (if applicable) without evidence of trauma or infection. 2) Put on gloves and thoroughly prep the area with the antiseptic solution. 3) Locate insertion site: a. In small children (3-12 kg), the tibial tuberosity cannot be palpated as a landmark, so the insertion site is two finger-breadths below the patella in the flat aspect of the medial tibia. b. In larger children (13-39 kg), the insertion site is located on the flat aspect of the medial tibia one finger-breadth below the level of the tibial tuberosity. If tibial tuberosity not palpable, insert two finger-breadths below the patella in the flat aspect of the medial tibia. c. For adults, proximal or distal tibial sites may be utilized. i. The proximal tibial site is one finger-breadth medial to the tibial tuberosity. ii. The distal tibial site is 2 finger-breadths above the medial malleolus (inside aspect of ankle) in the midline of the shaft of the tibia. 4) Introduce the intraosseous needle at a 90° angle, to the flat surface of the tibia. 5) For manual insertion, pierce the bony cortex using a firm rotary or drilling motion (do not move needle side to side or up and down). A distinct change in resistance will be felt upon entry into the medullary space. 6) Remove the stylet and confirm intramedullary placement by injecting, without marked resistance, 10 ml normal saline. Page 42 Contra Costa County Prehospital Care Manual – January 2010 7) Attach IV tubing to the intraosseous hub. 8) Anchor needle to overlying skin with tape. 9) If unable to establish on first attempt, make one attempt on opposite leg, no more than two (2) attempts total. 10) Monitor pulses distal to area of placement 11) Monitor leg for signs of swelling or cool temperature which may indicate infiltration of fluids into surrounding tissue. 12) For adult patients who awaken and have pain related to infusion, slowly administer LIDOCAINE 20 mg IO. May repeat dose once. 13) For pediatric patients with pain related to infusion, slowly administer LIDOCAINE 0.5 mg/kg IO (max dose 20 mg). Possible Complications Local infiltration of fluids/drugs into the subcutaneous tissue due to improper needle placement Cessation of the infusion due to clotting in the needle, or the bevel of the needle being lodged against the posterior cortex Osteomyelitis or sepsis Fluid overload Fat or bone emboli Fracture Contra Costa County Prehospital Care Manual – January 2010 Page 43 ► External Jugular Vein Cannulation Indications For intravenous access when meeting both of the following criteria: Contraindications (Relative) Arrest or profound shock. Intraosseous access is more reliably obtained. Suspected coagulopathy (e.g. advanced liver disease or taking coumadin) Contraindications (Absolute) Emergent need for fluid bolus or intravenous medication and no peripheral access is available; No alternative route is available for administration or treatment (i.e. glucagon IM for hypoglycemia or naloxone IM or intranasally). Inability to tolerate supine position Stable patient Procedure 1) Place patient in trendelenburg (preferred) or supine position. 2) Elevate shoulders on rolled towel or sheet 3) Turn head 45 to 60 degrees to side opposite of intended venipuncture site. 4) Palpate to assure no pulsatile quality to vessel. 5) Cleanse venipuncture site with appropriate solution. 6) “Tourniquet” vein by placing finger just above clavicle near midclavicular line. 7) Stabilize skin over vein with thumb. 8) Point needle toward shoulder in direction of vein, and puncture vein midway between jaw and clavicle over belly of sternocleidomastoid muscle. 9) Maintain compression of vein at clavicle area until needle withdrawn and IV tubing has been connected in order to prevent air from entering vein. 10) Secure IV site. Possible Complications Page 44 Air embolism Hematoma requiring compression of neck Extravasation of fluid or medication, infection, thrombosis Contra Costa County Prehospital Care Manual – January 2010 ► Saline Lock A saline lock is used to provide IV access in patients who do not require continuous infusion of solutions and administration of multiple medications is not anticipated. If a saline lock is in place, it may be used to administer one to two medications in an emergent situation, prior to connecting a primed IV line. Indications Any patient where placement of a prophylactic IV line is appropriate Contraindications Patient presentations which may require IV fluid replacement or multiple IV medication administrations Patients requiring administration of D50 Equipment IV start pak or equivalent Intravenous catheter of appropriate gauge (not to be used with 24 gauge catheters). Saline lock catheter plug with short extension 3ml syringe Sterile normal saline (3-5ml) Procedure 1) Explain the procedure to the patient. 2) Remove catheter plug and attached extension set from package and prime with normal saline. 3) Prepare the site for venipuncture. 4) After venipuncture, secure extension set to hub of catheter and affix to patient's skin. 5) Prep rubber stopper on saline lock, insert needle, and slowly flush with at least 3ml of normal saline while observing for signs of infiltration. 6) While injecting the last .2ml of normal saline, continue exerting pressure on the syringe plunger while withdrawing the needle from the saline lock. 7) If a medication is administered via the saline lock, flush with at least 3ml of normal saline following administration of the medication. NOTE: If the patient requires fluid bolus or administration of multiple medications, remove saline lock and secure primed IV tubing to catheter. Contra Costa County Prehospital Care Manual – January 2010 Page 45 ► Intranasal Administration of Naloxone Indications Patients with altered mental status who have respiratory rate of less than 12 and in whom an opiate overdose is suspected. Contraindications Patients do not meet criteria for naloxone administration Patients in whom vascular access has already been established for other reasons Patients with increased upper respiratory secretions (e.g., due to bleeding or URI) Patients with shock and signs of poor perfusion Equipment Mucosal Atomizer Device (MAD) Naloxone 2 mg/ml Procedure 1) Assess ABC’s and support ventilation as needed. 2) Load syringe with naloxone 2 mg and attach MAD to syringe. 3) Place atomizer in nostril. 4) Administer 1 mg (one-half of dose) in each nostril 5) Continue to support respirations as needed. 6) Consider use of IM or IV naloxone if no response and opiate overdose is suspected. Note Intranasal administration may also be less effective in patients with pre-existing nasal mucosa damage. Page 46 Contra Costa County Prehospital Care Manual – January 2010 ► Pulse Oximetry Pulse oximetry is a method of detecting hypoxia in patients. A pulse oximeter measures arterial blood oxygen saturation and provides a reading as a percent of hemoglobin saturated with oxygen. (% SpO2) A normal pulse oximetry reading for a person breathing room air is in the high 90s. A SpO2 reading of less than 95% may indicate hypoxia and should be investigated. While the pulse oximeter is a sensitive device that may detect hypoxia long before overt signs and symptoms of hypoxia are present, it is very important to remember that the pulse oximeter is just one tool used in assessment of the patient. The reading must be used in conjunction with other assessment findings to make a determination of whether the patient is hypoxic or not. In addition to indicating hypoxia, the pulse oximeter is a good tool for monitoring the effectiveness of airway management and oxygen therapy and to detect if the patient is deteriorating or improving. Indications: When the patient’s oxygen status is a concern When hypoxia is suspected Limitations: The pulse oximeter needs pulsatile arterial blood flow to determine an accurate reading. Any condition that interferes with the blood flow in the area where the probe is attached may produce an erroneous reading. The following conditions may produce no reading or inaccurate readings: Shock or hypoperfusion states associated with blood loss or poor perfusion Hypothermia or cold injury to the extremities Excessive movement of the patient During some types of seizures Nail polish if the finger probe is used Carbon monoxide poisoning Anemia Equipment: Pulse Oximeter Probes (pedi/adult) Procedure: 1) If possible, apply the pulse oximeter prior to administration of oxygen. Do not delay administration of oxygen in a suspected hypoxic patient. 2) Choose a site that is well perfused and least restricts a conscious patient’s movement. 3) Clean and dry site prior to sensor placement. 4) Apply appropriate sensor for patient. 5) Monitor and document the SpO2 as a sixth vital sign. 6) Continue to assess the respiratory status, include rate and tidal volume. Contra Costa County Prehospital Care Manual – January 2010 Page 47 ► Blood Glucose Testing Glucose testing is to be done on all patients presenting with an altered level of consciousness from either medical or traumatic causes. Patients with known diabetes and suspected hypoglycemia (e.g., diaphoresis, weakness) should also be tested. Testing may be done from a digit blood sample or a venous sample. Indications Any patient with an altered level of consciousness Any patient with signs or symptoms suggestive of hypoglycemia Equipment Alcohol Swabs Finger lancets (for digit samples) Cotton Balls/sterile gauze pads Glucose Testing device and strips Procedure 1) If obtaining blood sample via finger stick: a. Cleanse finger with alcohol swab. b. Puncture finger tip with lancet. c. Place drop of blood on glucose test strip per manufacturer's instructions. d. Place gauze/cotton ball on puncture site with pressure to stop bleeding. e. Use glucose testing device per manufacturer's instructions. f. If blood sugar is less than or equal to 60mg/dl, give Dextrose as specified in field treatment guidelines. 2) If obtaining blood sample via venipuncture (e.g., at IV start), follow steps c-f above. Page 48 Contra Costa County Prehospital Care Manual – January 2010 ► External Cardiac Pacing External cardiac pacing may be performed for the treatment of symptomatic bradycardia. This procedure is required for transport providers and optionally available for first-responder paramedic providers. Indications Symptomatic bradycardia (heart rate less than 60 and one or more signs or symptoms below) Signs and symptoms: o Blood pressure less than 90 systolic; o Shock—Signs of poor perfusion, evidenced by: decreased level of consciousness or decreased sensorium; prolonged capillary refill; cool extremities or cyanosis; o Chest pain, diaphoresis; o CHF or acute shortness of breath. Contraindications Patients with asymptomatic bradycardia (pacing equipment should be immediately available) Asystole Brady-asystolic cardiac arrest Hypothermia (relative contraindication) – patient warming measures have precedence Children less than 14 years old (hypoxia/respiratory problems are most likely causes of bradycardia in children and should be addressed.) Equipment Cardiac monitor/defibrillator with pacing capability Pacing electrodes Procedure 1) Patient assessment and treatment per Symptomatic Bradycardia treatment guideline. 2) Explain procedure to the patient. 3) Place pacing electrodes and attach pacing cable to pacing device per manufacturer's recommendations. 4) Set pacing mode to demand mode, pacing rate to 80 BPM, and current at 10 mA. 5) As possible/if required, provide patient sedation/pain relief with midazolam or morphine sulfate IV or IM. Patients with profound shock and markedly altered level of consciousness may not require sedation/pain relief initially. 6) Activate pacing device and increase the current in 10 mA increments until capture is achieved (pacemaker produces pulse with each paced QRS complex). 7) Assess patient for mechanical capture and clinical improvement (BP, pulses, skin signs, LOC). 8) Continue monitoring. Contact base for further orders if patient symptoms are not resolving (consideration for dopamine, further alteration of pacer settings) or if further sedation /pain control orders required. Contra Costa County Prehospital Care Manual – January 2010 Page 49 ► 12-Lead Electrocardiography Indications Contraindications (relative) Uncooperative patient Any other condition in which delay to obtain ECG would compromise care of the patient (e.g., arrhythmia requiring immediate shock or pacing) Equipment Chest pain/Acute Coronary Syndrome o Includes patients with atypical symptoms or anginal equivalents such as shortness of breath, syncope, dizziness, weakness, diaphoresis, nausea/vomiting, or altered level of consciousness. Elderly patients, females and diabetics are more likely to present atypically. Arrhythmias (both pre- and post-conversion) if patient stable or not in extremis Suspected cardiogenic shock Consider in pulmonary edema if patient not in extremis (may be presentation in ischemia) Consider in cardiac arrest patients with return of spontaneous circulation Monitor-defibrillator with 12-lead ECG capability Electrodes for limb leads and chest leads Clippers, scissors, or razor for chest hair removal Gauze or commercially available skin prep for electrode placement Sheet or blanket to cover patient as necessary while obtaining ECG Procedure 1. Expose Chest. Remove excess hair. Prep skin. 2. Place electrodes on chest and limbs. (See 12-lead placement) 3. Acquire ECG tracing as per manufacturer’s direction. ECG should be done prior to administration of nitroglycerin (NTG). 4. If baseline artifact or other artifact is noted, repeat ECG as machine readout may be incorrect 5. Patient destination should be promptly determined per STEMI Triage and Destination Policy if machine notes ***Acute MI*** (Zoll) or; ***Acute MI Suspected*** (Lifepak-12); or ***Meets ST-Elevation MI Criteria (Lifepak-15) and no significant artifact is noted. 6. Perform V4R in patients who have inferior MI infarct pattern noted (ST-segment elevation in leads II, III and aVF). Label ECG to note V4R (machine will not mark lead). Page 50 Contra Costa County Prehospital Care Manual – January 2010 7. Perform repeat ECG’s if any question about quality of ECG or if intial ECG does not show STelevation and syspected cardiac symptoms continue. 8. Leave electrodes in place unless defibrillation, cardioversion, or pacing is required 9. Deliver copy of ECG to hospital personnel caring for the patient upon arrival in the Emergency Department. 10. A copy of 12-lead ECG shall be forwarded with the PCR to the appropriate personnel at the provider agency. 12-Lead Placement 1. Limb leads should be placed on distal extremities if possible. May be moved to proximal if needed. 2. Chest leads should be placed: V1 – 4th intercostal space at the right sternal border V2 – 4th intercostal space at the left sternal border V3 – Directly between V2 and V4 V4 – 5th intercostal space at left midclavicular line V5 – Level of V4 at left anterior axillary line V6 – Level of V4 at left mid-axillary line V4R – Place in 5th intercostal space at right midclavicular line V4R Documentation Required documentation includes: 1. The performance of the 12-lead ECG procedure(s); 2. Findings of the 12-lead ECG; 3. Confirmation of a STEMI Alert (if applicable); 4. Electronic attachment of ECG data to the PCR. STEMI Alert The STEMI Receiving Center should receive a STEMI Alert as soon as possible after an ECG indicates STEMI (based on the listed messages noted above) and the machine interpretation is felt to be correct (e.g., no significant artifact). The alert should follow SBAR format in accordance with the STEMI Triage and Destination Policy. Contra Costa County Prehospital Care Manual – January 2010 Page 51 ► LUCAS Chest Compression System The LUCAS Chest Compression System is designed to perform external chest compressions on adult patients. It is a safe and efficient tool that standardizes chest compressions in accordance with the latest scientific guidelines. Indications Adult patients with medical cardiac arrest Cases where manual chest compression would be used Contraindications Do NOT use LUCAS Chest Compression System in the following cases: Adult patient too small: The pad within the suction cup does not touch patient’s chest when it is lowered as far as possible. Adult patient too large: The support legs of the LUCAS cannot be locked to the back plate without compressing the patient. Patient < 18 years old Traumatic arrest Pregnant patients Equipment LUCAS Chest Compression System Air Tanks (2) with LUCAS regulator preattached Procedure 1) Arrival at the patient: a. Confirm cardiac arrest by determining level of consciousness, breathing and pulse. b. If the patient has suffered a cardiac arrest, establish a team leader and commence manual CPR. If CPR already being done when you arrive, assess patient and take over CPR from bystander(s). 2) CPR or Defibrillation a. For unwitnessed arrests or witnessed arrests with 5 minutes or more time elapsed without CPR before arrival of first responders, provide 2 minutes or 5 cycles of CPR. b. For all other witnessed arrest, provide CPR until defibrillator available. c. Prepare LUCAS device. Minimize interruptions in CPR. 3) Connecting the Air: a. Confirm that the ON/OFF knob is in the Adjust (1) position. b. If not already connected, attach the air hose to the connector. c. Attach the connector to a portable air cylinder. Page 52 Contra Costa County Prehospital Care Manual – January 2010 d. If using a pressure regulator, open the air valve. 4) When initial CPR or Defibrillation is complete - Assemble the LUCAS: a. Take the back plate out of the bag b. At the direction of the team leader - Interrupt CPR c. Place the back plate under body below patient’s armpits – use two people to lift patient – supporting head. d. Resume manual CPR e. Attach compressor – extend legs with claw locks open Connecting to back plate – listen for click f. Pull up once to ensure attachment g. Position suction cup – the lower edge of the cup should be positioned immediately above the end of the sternum – the suction cup should be centered over the sternum h. Lower suction cup until the pressure pad inside the suction cup touches the patient’s chest without compressing the chest. Adjust as needed - It is critical that the pad is correctly positioned to prevent unwarranted injuries. Mark the chest at the edge of the suction cup using the permanent marker 5) Start Compressions using the LUCAS a. b. c. d. e. When the position of the suction cup is correct Turn the ON/OFF knob to Engage (3) (Active) Check that the device is working as it should Apply the stabilization strap Secure the patient’s arms with the straps on the support legs. Turn ON/OFF knob to Lock (2) to pause compressions for: a. Ventilations when doing bag-mask ventilation b. Analysis using an AED and c. Rhythm check using a manual monitor defibrillator. LUCAS may be used continuously with intubated patients. NOTE: LUCAS is only intended for temporary use. LUCAS is only intended for use in the prehospital setting. LUCAS will be attended by a trained first responder at all times and the first responder will remain with the device until transfer of care to the emergency room personnel can be done. Contra Costa County Prehospital Care Manual – January 2010 Page 53 Field Manual (Treatment Guidelines) TABLE OF CONTENTS Adult Treatment Guidelines A1 – Adult Patient Care A2 – Chest Pain / Suspected ACS A3 – Cardiac Arrest – Initial Care and CPR A4 – Ventricular Fibrillation / V. Tachycardia A5 – PEA / Asystole A6 – Symptomatic Bradycardia A7 – Ventricular Tachycardia with Pulses A8 – Supraventricular Tachycardia A9 – Other Dysrhythmias A10 – Shock Pediatric Treatment Guidelines P1 – Pediatric Patient Care P2 – Cardiac Arrest – Initial Care and CPR P3 – Neonatal Resuscitation P4 – Ventricular Fibrillation / V. Tachycardia P5 – PEA / Asystole P6 – Symptomatic Bradycardia P7 – Tachycardia P8 – Shock Procedures and Patient Care References Spinal Immobilization Vascular Access 12-Lead ECG and STEMI Key Paramedic Procedures Pediatric Assessment Pediatric Vital Signs and GCS Scoring ABC Maneuvers for Adults, Children and Infants Contra Costa County Prehospital Care Manual – January 2010 General Treatment Guidelines (All Patients) G1 – Allergy and Anaphylaxis G2 – Altered Level of Consciousness G3 – Behavioral Emergency G4 – Burns G5 – Childbirth G6 – Dystonic Reaction G7 – Envenomation G8 – Heat Illness / Hyperthermia G9 – Hypothermia G10 – Pain Management G11 – Poisoning / Overdose G12 – Respiratory Depression or Apnea G13 – Respiratory Distress G14 – Seizure G15 – Stroke G16 – Trauma Policy Summaries / Hospital References Base Hospital and Receiving Facilities Destination Determination Destination - 5150 and Obstetric Patients Trauma Triage Criteria Trauma Base Call-In Criteria Helicopter Transport Criteria Rule of Nines (Burn Surface Area) Burn Patient Destination Burn Centers Declining Medical Care or Transport (AMA) Determination of Death Restraints Drug References Adult Drug Reference Dopamine Drip Chart Pediatric Drug Reference Pediatric Drug Dosage Charts Page 57 INSTRUCTIONS FOR USE This field manual is intended to provide Contra Costa EMS prehospital personnel with quick reference to treatment guidelines and other critical reference materials for patient treatment. The Contra Costa Prehospital Care Manual includes the contents of this field manual as well as additional reference materials not in this manual. The entire Prehospital Care Manual can be accessed at www.cccems.org. Updates and corrections to this manual may also be posted at this website. Treatment Guidelines are divided into three main groupings: Adult, Pediatric, and General Guidelines. The General Guidelines include treatment guidelines that pertain to both adult and pediatric treatments. Treatment Guidelines A1 (Adult General Care) and P1 (Pediatric General Care) address basic concepts of care that are pertinent to all patients. This information is not repeated in other treatment guidelines. Policy summaries reflect critical information for field personnel. For full policies, please refer to www.cccems.org. Page 58 Contra Costa County Prehospital Care Manual – January 2010 A1 ADULT ADULT PATIENT CARE These basic concepts should be addressed for all adult patients (age 15 and over) Scene Safety Body Substance Isolation Use universal blood and body fluid precautions at all times Assure open and adequate airway. Management of ABC’s is a priority. Place patient in position of comfort unless condition mandates other position (e.g. shock, coma) Consider spinal immobilization if history or possibility of traumatic injury exists Apply appropriate field treatment guideline(s) Explain procedures to patient and family as appropriate Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines are considered Use SBAR to communicate with base Transport Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure Transport patient medications or current list of patient medications to the hospital Give report to receiving facility using SBAR Document Document patient assessment and care per policy Systematic Assessment Determine Primary Impression Base Contact Contra Costa County Prehospital Care Manual – January 2010 Page 59 A2 ADULT OXYGEN PRECAUTION Nitroglycerin CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME Low flow Caution: Do not administer or allow patient to take Nitroglycerin if patient has taken erectile dysfunction meds Viagra or Levitra within 24 hrs or Cialis within 36 hrs. In these situations, severe hypotension may occur as a result of NTG administration. BLS Personnel: Allow patient to take own if BP greater than 90 CARDIAC MONITOR 12 – LEAD ECG ASPIRIN IV NITROGLYCERIN STEMI Alert if appropriate. Perform right-sided lead (V4R) if inferior MI noted. Repeat ECGs are encouraged. 325 mg po to be chewed by patient – DO NOT administer if patient has allergies to aspirin or salicylates or has apparent active gastrointestinal bleeding TKO 0.4 mg sl if systolic BP above 90. May repeat every 5 minutes until pain subsides, maximum 6 doses or BP less than 90 systolic. Do not administer Nitroglycerin if Right Ventricular MI suspected 2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90 and NTG not effective. Consider earlier administration to patients in severe distress from pain. Consider MORPHINE SULFATE Consider FLUID BOLUS Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. If persistent pain, continue NITROGLYCERIN to maximum of 6 doses. Do not administer Morphine Sulfate if Right Ventricular MI suspected 250 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May repeat X 1. Patients with Right Ventricular MI may require multiple fluid boluses. Key Treatment Considerations Page 60 Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm, nausea, diaphoresis, dyspnea, anxiety Diabetic, female or elderly patients frequently present atypically Atypical symptoms can include syncope, weakness or sudden onset fatigue Rapid identification of STEMI to speed intervention is the goal of 12-lead ECG 12-lead ECG should be acquired as soon as possible after arrival (ideally within 5 minutes) 12-lead ECG should be acquired before initial NTG administration Minimize scene time in STEMI patients If STEMI noted and ST elevation is noted in inferior distribution (leads II, III, and aVF), the possibility for right ventricular MI (RVMI) exists o Perform ECG with right-sided lead (V4R) mirrored in the same orientation as V4. RVMI should be suspected if ST elevation of 1 mm or greater in V4R. o Patients with RVMI may present with shock or poor perfusion in the presence of clear lungs and may have JVD. o Nitroglycerin and Morphine should not be administered in the setting of RVMI. Trendelenburg positioning and fluid bolus is appropriate treatment for shock in this setting. If STEMI noted and ST elevation is noted in anterior distribution (V1-V4), patient is at higher risk for pump failure and CHF on presentation Many STEMI’s evolve during prehospital period and are not noted during first ECG, so repeat 12-lead ECGs are encouraged (avoid artifact by patient or vehicle movement) IV placement prior to NTG recommended in patients who have not taken NTG previously Contra Costa County Prehospital Care Manual – January 2010 A3 ADULT AIRWAY VENTILATIONS COMPRESSIONS CARDIAC ARREST – INITIAL CARE AND CPR Open airway and utilize BLS airway for initial management If ResQPOD available, King Airway should be used as soon as possible but should not interfere with compressions - keep interruption less than 10 seconds Ventilations: Give 2 breaths initially Administer each breath over 1 second and observe for chest rise CPR for 2 minutes or 5 cycles before rhythm analysis if: Witnessed arrests with 5 minutes or more time elapsed without CPR Unwitnessed arrests CPR until defibrillator available for rhythm analysis for all other witnessed arrests Compressions: Depth - 1.5-2 inches in adults – allow full recoil of chest Rate - 100/minute Compression/ventilation ratio - 30:2 Rotate compressors every 2 minutes if manual compression used Apply mechanical compression device (if available) after first 2-minute cycle of CPR To minimize CPR interruptions: Perform CPR during charging of defibrillator Resume CPR immediately after shock (do not stop for pulse or rhythm check) CARDIAC MONITOR IV / IO ACCESS Determine cardiac rhythm and follow specific treatment guideline Preferred IV site - antecubital vein If antecubital access not apparent or if unsuccessful, use IO access IO access is preferable to external jugular Hand veins and other smaller veins should be avoided in cardiac arrest Advanced airway management is not essential early in resuscitation and should not interfere with resuscitation in the first 2-3 CPR cycles (two minutes per cycle) ADVANCED AIRWAY TREATMENT ON SCENE Exception: If ResQPOD used, early use of King Airway is appropriate King Airway may be inserted more rapidly and causes less CPR interruption than endotracheal intubation efforts Placement of King Airway or endotracheal tube should not interrupt compressions for more than 10 seconds For endotracheal intubation, position and visualize airway prior to cessation of compressions for tube passage Ventilation rate with advanced airway – 8-10 breaths/minute Provide initial and continuous confirmation of tube placement with end-tidal carbon dioxide monitoring Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions, which may be detrimental to patient outcome Provide resuscitative efforts on scene up to 30 minutes to maximize chances of return of spontaneous circulation (ROSC) If resuscitation efforts do not attain ROSC, consider cessation of efforts per policy Contra Costa County Prehospital Care Manual – January 2010 Page 61 A4 ADULT INITIAL CARE DEFIBRILLATION CPR VENTILATION/AIRWAY VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA See Cardiac Arrest – Initial Care and CPR (A3) 200 joules (low energy 120 joules) For 2 minutes or 5 cycles between rhythm check and shock If ResQPOD available, utilize King Airway early If no ResQPOD available, use BLS airway in first 2-3 cycles of CPR o Defer advanced airway unless BLS airway inadequate TKO. Should not delay shock or interrupt CPR 300 joules (low energy 150 joules) 1:10,000 - 1 mg IV or IO every 3-5 minutes For 2 minutes or 5 cycles between rhythm check and shock 360 joules (low energy 200 joules) 300 mg IV or IO For 2 minutes or 5 cycles between rhythm check and shock 360 joules (low energy 200 joules) as indicated after every CPR cycle Should not interfere with first 2-3 CPR cycles – minimize interruptions IV or IO DEFIBRILLATION EPINEPHRINE CPR DEFIBRILLATION AMIODARONE CPR DEFIBRILLATION ADVANCED AIRWAY Consider repeat If rhythm persists, 150 mg IV or IO, 3-5 minutes after initial dose AMIODARONE TRANSPORT If indicated Consider SODIUM 1 mEq/kg IV or IO for suspected hyperkalemia, profound acidosis or prolonged BICARBONATE down time with return of circulation If Return of Spontaneous Circulation, see Symptomatic Bradycardia (A6), Shock (A10) if treatment indicated Key Treatment Considerations Page 62 Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications. To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second. If advanced airway placed, perform CPR continuously without pauses for ventilation If available, ResQPOD impedance threshold device may be used Place King Airway to utilize ResQPOD early in CPR If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage. Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement and continuously monitor Prepare drugs before rhythm check and administer during CPR Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) Follow each drug with 20 ml NS flush Sodium bicarbonate should only be given for listed indications, and should not be given if ventilation ineffective Contra Costa County Prehospital Care Manual – January 2010 A5 ADULT PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3) VENTILATION/AIRWAY IV or IO TKO EPINEPHRINE 1:10,000 1 mg IV or IO every 3-5 minutes If ResQPOD available, utilize King Airway early If no ResQPOD available, use BLS airway in first 2-3 cycles of CPR o Defer advanced airway unless BLS airway inadequate Asystole or PEA with rate less than 60: 1 mg IV or IO. Repeat every 3-5 minutes to total dose of 3 mg Consider treatable causes – treat if applicable: Consider 500 ml NS IV or IO for hypovolemia FLUID BOLUS VENTILATION Ensure adequate ventilation (8-10 breaths per minute) for hypoxia. ATROPINE Consider SODIUM BICARBONATE Consider CALCIUM CHLORIDE 1 mEq/kg IV or IO for hydrogen ion (acidosis), tricyclic antidepressant or aspirin overdose, or hyperkalemia 500 mg IV or IO – may repeat in 5-10 minutes for hyperkalemia or calcium channel blocker overdose WARMING MEASURES For hypothermia Consider NEEDLE For tension pneumothorax THORACOSTOMY If Return of Spontaneous Circulation, see Symptomatic Bradycardia (A6), Shock (A10) if treatment indicated Key Treatment Considerations Uninterrupted CPR is the key to successful resuscitation. Its performance takes precedence over advanced airway management and administration of medications. Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second If advanced airway placed, perform CPR continuously without pauses for ventilation If available, ResQPOD impedance threshold device may be used Place King Airway to utilize ResQPOD early in CPR If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage. Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement and continuously monitor Prepare drugs before rhythm check and administer during CPR Follow each drug with 20 ml NS flush Acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or if suspected diabetic ketoacidosis Contra Costa County Prehospital Care Manual – January 2010 Page 63 A6 ADULT SYMPTOMATIC BRADYCARDIA - Heart rate less than 60 with signs or symptoms of poor perfusion (e.g., acute altered mental status, hypotension, other signs of shock) OXYGEN High flow. Be prepared to support ventilation as needed CARDIAC MONITOR 12-LEAD ECG Consider pre- and post-treatment if condition permits TKO. If not promptly available, proceed to external cardiac pacing. Consider IO IV ACCESS if patient in extremis and unconscious or not responsive to painful stimuli. TRANSCUTANEOUS Set rate at 80 PACING Start at 10 mA, and increase in 10 mA increments until capture is achieved If pacing urgently needed, sedate after pacing initiated. Consider MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg increments SEDATION (maximum dose 5 mg), and/or MORPHINE SULFATE 1-5 mg IV or IO in 1 mg increments for pain relief if BP 90 systolic or greater 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective Consider Consider repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3 mg ATROPINE Use with caution in patients with suspected ongoing cardiac ischemia. Atropine should not be used in wide-QRS second- and third-degree blocks. TRANSPORT Consider 250-500 ml NS if clear lung sounds and no respiratory distress FLUID BOLUS Consider DOPAMINE Begin infusion at 5 mcg/kg/min if not responsive to pacing or atropine (see table) Key Treatment Considerations Page 64 Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor / observe) Sedation prior to starting pacing is not required. Patients with urgent need should be paced first. The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness. Patients who are in need of pacing are unstable and sedation should be done with great caution. Monitor respiratory status closely and support ventilation as needed Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in these patients) Patients with wide-QRS second- and third-degree blocks will not have a response to atropine because these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur. Contra Costa County Prehospital Care Manual – January 2010 A7 ADULT VENTRICULAR TACHYCARDIA WITH PULSES Widened QRS Complex (greater than or equal to 0.12 sec) – generally regular rhythm INITIAL THERAPY OXYGEN High flow. Be prepared to support ventilation as needed. CARDIAC MONITOR 12-LEAD ECG Consider pre- and post treatment if condition permits IV TKO AMIODARONE 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min) Consider repeat AMIODARONE If rhythm persists and patient remains stable, 150 mg IV over 10 minutes STABLE VENTRICULAR TACHYCARDIA UNSTABLE VENTRICULAR TACHYCARDIA Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF Consider Prepare for CARDIOVERSION: If awake and aware, sedate with SEDATION MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) SYNCHRONIZED CARDIOVERSION 100 joules (low energy setting – 75 W/S) 200 joules (low energy setting – 120 W/S) 300 joules (low energy setting – 150 W/S) 360 joules (low energy setting – 200 W/S) If VT recurs, use lowest energy level previously successful Key Treatment Considerations Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on recorded strip, not monitor screen Be prepared for previously stable patient to become unstable Give AMIODARONE via Infusion or slow IV push only Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly. AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should be considered unstable and should not receive AMIODARONE. If sedation done for cardioversion, monitor respiratory status closely and support ventilations as needed Contra Costa County Prehospital Care Manual – January 2010 Page 65 A8 ADULT SUPRAVENTRICULAR TACHYCARDIA Heart rate greater than 150 beats per minute – regular rhythm usually with narrow QRS complex INITIAL THERAPY OXYGEN High flow. Be prepared to support ventilation as needed. CARDIAC MONITOR 12-LEAD ECG IV Consider pre- and post-treatment if condition permits TKO STABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) May have mild chest discomfort VALSALVA Consider ADENOSINE 6 mg rapid IV - followed by 20 ml normal saline flush If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once. UNSTABLE SVT May need immediate synchronized cardioversion Signs of poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF If rhythm not regular, SVT unlikely If wide QRS complex, consider ventricular tachycardia Consider ADENOSINE Consider SEDATION SYNCHRONIZED CARDIOVERSION 6 mg rapid IV - followed by 20 ml normal saline flush. If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once. Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) 50 joules (low energy setting – 50 W/S) 100 joules (low energy setting – 75 W/S) 200 joules (low energy setting – 120 W/S) 300 joules (low energy setting – 150 W/S) 360 joules (low energy setting – 200 W/S) Key Treatment Considerations Page 66 Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on recorded strip, not monitor screen Be prepared for previously stable patient to become unstable Proceed to cardioversion if patient becomes unstable Do not administer Adenosine if poison - or drug-induced tachycardia If sedation done for cardioversion, monitor respiratory status closely and support ventilation as needed Contra Costa County Prehospital Care Manual – January 2010 A9 ADULT OTHER CARDIAC DYSRHYTHMIAS SINUS TACHYCARDIA – Heart rate 100-160, regular ATRIAL FIBRILLATION – Heart rate highly variable, irregular ATRIAL FLUTTER – Variable rate depending on block. Atrial rate 250-350, “saw-tooth” pattern INITIAL THERAPY OXYGEN Low flow. High flow if unstable. CARDIAC MONITOR Consider 12-LEAD ECG Consider IV 12-lead ECG pre- and post-treatment if patient symptomatic and condition permits TKO UNSTABLE ATRIAL FIBRILLATION OR ATRIAL FLUTTER Ventricular rate greater than 150, and: BP less than 80, or unconsciousness / obtundation, or severe chest pain or dyspnea OXYGEN High flow. Be prepared to support ventilation. Consider Prepare for CARDIOVERSION. If awake and aware, sedate with SEDATION MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) Atrial Flutter Only - Initial Level: 50 joules (low energy setting – 50 joules) SYNCHRONIZED CARDIOVERSION Atrial Flutter and Atrial Fibrillation: 100 joules (low energy setting – 75 joules) 200 joules (low energy setting – 120 joules) 300 joules (low energy setting – 150 joules) 360 joules (low energy setting – 200 joules) Key Treatment Considerations Sinus tachycardia commonly present because of pain, fever, hypovolemia Atrial fibrillation may be well-tolerated with moderately rapid rates (150-170) and often requires no specific treatment other than observation (oxygen, monitoring and transport) If sedation done for cardioversion, monitor respiratory status closely and support ventilation as needed Computerized rhythm analysis on 12-lead ECG is frequently incorrect and requires review of the ECG to verify rhythm Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI*** or ***Acute MI Suspected*** message encountered, the patient’s heart rate is important information to relate to the STEMI center at time of activation. Contra Costa County Prehospital Care Manual – January 2010 Page 67 A10 ADULT SHOCK HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with dry lungs, flat neck veins May have poor skin turgor, history of GI bleeding, vomiting or diarrhea May be warm and flushed, febrile May have history of high fever (sepsis) SHOCK (NOT CARDIOGENIC) OXYGEN High flow. Be prepared to support ventilations as needed. Keep patient warm CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline EARLY TRANSPORT CODE 3 IV or IO FLUID BOLUS 250-500 ml NS Recheck vitals every 250 ml to a maximum of 1 liter BLOOD GLUCOSE Check and treat if indicated Consider DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table) Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12) CARDIOGENIC SHOCK Signs and symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema OXYGEN High flow. Be prepared to support ventilations as needed. Keep patient warm CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline EARLY TRANSPORT CODE 3 IV or IO TKO BLOOD GLUCOSE Check and treat if indicated Consider DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table) 12–LEAD ECG Perform if time and condition permits Related guideline: Altered Level of Consciousness (G2) Page 68 Contra Costa County Prehospital Care Manual – January 2010 G1 GENERAL ALLERGY / ANAPHYLAXIS Serious reactions involve upper or lower respiratory tract - dyspnea, stridor, wheezing, anxiety, tachycardia, tightness in chest Some reactions involve only skin (hives, itching) Marked, sudden swelling of head, face neck and airway represents a serious systemic reaction (angioedema) OXYGEN High flow. Be prepared to support ventilations. EPI-PEN May assist with administration of patient’s auto-injector CARDIAC MONITOR Treat dysrhythmias per specific treatment guidelines If upper or lower respiratory tract symptoms or hypotension: EPINEPHRINE Adult – 0.3-0.5 mg IM (use 0.3 mg in elderly, small patients or mild symptoms) 1:1000 IM Pediatric – 0.01 mg/kg IM – maximum dose 0.3 mg ALBUTEROL Adult and pediatric - 5 mg/6 ml saline via nebulizer – may repeat as needed IV TKO If itching or hives, consider: Adult - 50 mg slow IV or IM Consider 25 mg if patient has taken po diphenhydramine DIPHENHYDRAMINE Pediatric – 1 mg/kg IV or IM (maximum dose 50 mg) Consider 0.5 mg/kg dose if patient has taken po diphenhydramine MONITOR PATIENT Carefully monitor vital signs, respiratory status, and response to treatments If serious progression of symptoms after treatment with IM epinephrine: Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis, severe respiratory distress or respiratory arrest. In pediatric patients, hypotension is late sign of shock. Consider IO If IV access not immediately available FLUID BOLUS Adult - wide open NS. Recheck vitals after every 250 ml Pediatric - 20 ml/kg NS bolus, may repeat X 2 If patient not responsive to IM epinephrine treatment: Consider EPINEPHRINE 1:10,000 IV Adult - titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg. Use extreme caution with patients with cardiac history, angina, hypertension. Pediatric - titrate in up to 0.1 mg doses slow IV or IO to a maximum of 0.01 mg/kg Key Treatment Considerations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 Page 69 G2 GENERAL ALTERED LEVEL OF CONSCIOUSNESS Glasgow Coma Scale less than 15 – uncertain etiology. Consider AEIOU/TIPPS OXYGEN High flow. Be prepared to support ventilations as needed. SPINAL IMMOBILIZATION Consider need for spinal precautions ORAL GLUCOSE Consider if known diabetic, conscious, able to sit upright, able to self-administer Adult - 30 g po Pediatric – 15-30 g po CARDIAC MONITOR BLOOD GLUCOSE Check level IV TKO If glucose 60 or less: Adult – DEXTROSE 50% 25 g IV Pediatric – DEXTROSE 10% 0.5 g/kg IV (5 ml/kg) If unable to establish IV: Adult – 1 mg IM Pediatric - 24 kg or more – 1 mg IM Pediatric - Less than 24 kg – 0.5 mg IM Recheck if symptoms not resolved DEXTROSE GLUCAGON BLOOD GLUCOSE DEXTROSE Repeat initial IV dose if glucose remains 60 or less Related guideline: Respiratory Depression or Apnea (G12) Key Treatment Considerations Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 12 breaths per minute) Patients with hypoglycemia as a result of oral diabetic medications are at higher risk of recurrent hypoglycemia and transport is highly recommended in these patients With prolonged hypoglycemia and in many elderly patients, increase in level of consciousness after dextrose given may not be as rapid as in others. Recheck glucose before considering repeat treatment. In patients with starvation, poor oral intake, or alcohol intoxication/alcoholism, glucagon may not be effective because of poor glycogen stores in liver Glucagon may take 10-20 minutes or longer to increase glucose level (peak effects in 45-60 minutes). Recheck glucose before considering additional treatment. Consider transport earlier in patients with poor vascular access who are not responding to glucagon or have reasons listed above for possible impaired response to glucagon Page 70 Most patients with hypoglycemia have diabetes. Other causes of hypoglycemia include renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses and sulfa drugs. Hypoglycemia may also occur rarely following gastric surgery for weight loss. Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 G3 GENERAL BEHAVIORAL EMERGENCY A behavioral emergency is defined as combative or irrational behavior not caused by medical illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated states or other conditions Combative or irrational behavior may be caused by psychiatric or other behavioral disorder History of event and past history are important in patient evaluation Past history of psychiatric condition does not eliminate need to assess for other illnesses SCENE SAFETY Many patients merit a weapons search by law enforcement Physical restraints may be needed if patient exhibits behavior that presents a danger to him/herself or others ASSESS PATIENT Assess for evidence of hypoxia, hypoglycemia, trauma Consider other medical causes for behavioral symptoms VITAL SIGNS Obtain vital signs as possible Consider OXYGEN Provide as possible if there is question of hypoxia or other medical condition CARDIAC MONITOR Place as possible / safe Consider BLOOD GLUCOSE Obtain as possible / safe Consider CHEMICAL RESTRAINT BASE ORDER REQUIRED Despite verbal de-escalation and physical restraint, if adult patient (15 years or older) remains extremely combative and struggling against restraints, consider: MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small patients (under 50 kg) MIDAZOLAM 1-5 IV mg in 1 mg increments if IV established and patent MONITOR PATIENT Monitor closely for respiratory compromise. Assess and document mental status, vital signs, and extremity exams (if restrained) at least every 15 minutes. Related guidelines: Altered Level of Consciousness (G2), Trauma (G16) Key Treatment Considerations Calming measures may be effective and may preclude need for restraint in some circumstances Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if possible, but maintain contact with other personnel and ability to exit rapidly. Avoid violating patient’s personal space, making direct eye contact or sudden movements. Frequent reassurance and calm demeanor of personnel are important. Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position. Assure adequate resources available to manage patient’s needs. Restraint may require up to five persons to safely control patient. Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior In pediatric patients, consider child’s developmental level when providing care Sedation with Midazolam intended for adult patients only (age 15 and over) Not all patients will respond to Midazolam. Repeat dosage is not recommended. Contra Costa County Prehospital Care Manual – January 2010 Page 71 G4 GENERAL BURNS Damage to the skin caused by contact with caustic material, electricity, or fire Second or third degree burns involving 20% of the body surface area, or those associated with respiratory involvement are considered major burns Move patient to safe area Stop the burning process OXYGEN Protect the burned area Remove contact with agent, unless adhered to skin Brush off chemical powders Flush with water to stop burning process or to decontaminate High flow. Be prepared to support ventilation as needed. Do not break blisters, cover with clean dressings or sheets. Remove restrictive clothing/jewelry if possible. Assess for associated injuries Consider IV or IO TKO Consider MORPHINE SULFATE IV For pain relief in the absence of hypotension (systolic BP less than 90), significant other trauma, altered level of consciousness: Adult – 2-20 mg IV or IO, titrated in 2 - 4 mg increments Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart Consider MORPHINE SULFATE IM If IV or IO access not available: Adult – 5-20 mg IM Pediatric – 0.1 mg/kg IM – See Pediatric drug chart Key Treatment Considerations Page 72 Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or edematous mucosa in mouth are clues) Transport to closest receiving facility for advanced airway management if time permits Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia. Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 G5 GENERAL CHILDBIRTH – ROUTINE OR COMPLICATED IMMINENT DELIVERY - Regular contractions, bloody show, low back pain, feels like bearing down, crowning Prepare for Delivery Reassure mother, instruct during delivery Consider IV Deliver Infant Clamp/Cut Cord Warming Measures TKO if time allows As head is delivered, apply gentle pressure to prevent rapid delivery of the infant Gently suction baby's mouth, then nose, keeping the head dependent If cord is wrapped around neck and can't be slipped over the infant's head, double-clamp and cut between clamps Immediately double-clamp cord 6-8 inches from baby and cut between clamps (if not done before delivery) Dry baby and keep warm, placing baby on mother's abdomen or breast Placenta Delivery If placenta delivers, save it and bring to the hospital with mother and child. DO NOT PULL ON UMBILICAL CORD TO DELIVER PLACENTA. Post-Delivery Observation Observe mother and infant frequently for complications. To decrease post-partum hemorrhage, perform firm fundal massage, put baby to mother's breast. Transport Prepare mother and infant for transport. Neonatal care or resuscitation as indicated. COMPLICATED DELIVERY BREECH DELIVERY – Presentation of buttocks or feet Allow delivery to proceed passively until the baby's waist appears Rotate baby to face down position (DO NOT PULL) Delivery If the head does not readily deliver in 4-6 minutes, insert a gloved hand into the vagina to create an air passage for the infant Transport Early transport if available – notify receiving hospital as soon as possible PROLAPSED CORD - Cord presents first and is compressed, compromising infant circulation Insert gloved hand into vagina and gently push presenting part off of the cord Manage Cord Do not attempt to reposition the cord Cover cord with saline soaked gauze Position Patient Place mother in trendelenburg position with hips elevated Transport Early transport if available – notify receiving hospital as soon as possible Contra Costa County Prehospital Care Manual – January 2010 Page 73 G6 GENERAL DYSTONIC REACTIONS History of ingestion of phenothiazine or related compounds, primarily anti-psychotic and antiemetic medications (for nausea/vomiting). Symptoms include restlessness, muscle spasms of the neck, jaw, and back, oculogyric crisis. OXYGEN High flow. Be prepared to support ventilations as needed. IV TKO DIPHENHYDRAMINE Adult - 25-50 mg IV or 50 mg IM if unable to establish IV access Pediatric – 1 mg/kg IV or 1 mg/kg IM if unable to establish IV access Key Treatment Considerations Common drugs implicated in dystonic reactions include many anti-emetics and anti-psychotic medications Prochlorperazine (Compazine) Haloperidol (Haldol) Metoclopromide (Reglan) Phenergan (Promethazine) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) Many other antipsychotic and anti-depressant drugs Rarely benzodiazepine drugs have been implicated as a cause of dystonic reaction Page 74 Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 G7 ENVENOMATIONS Snake Bites, Insect Stings GENERAL SNAKE BITES If the snake is positively identified as non-poisonous, treat with basic wound care INSECT STINGS Symptoms of stings usually occur at the site of injury and have no specific treatment Allergic reactions can be severe, and may cause anaphylactic shock Keep patient calm Address constricting items Remove rings, bracelets or other constricting items from affected extremity WOUND MANAGEMENT Snake bite: Splint extremity and keep at level of heart Insect Stings: Flick stinger off – do not squeeze stinger. Apply cold pack. OXYGEN High flow If signs of shock or allergic reaction Be prepared to support ventilations Monitor vital signs Consider CARDIAC MONITOR Consider if patient potentially unstable Consider IV TKO Related Guidelines: Shock (A10, P8), Allergy / Anaphylaxis (G1) Contra Costa County Prehospital Care Manual – January 2010 Page 75 G8 GENERAL HEAT ILLNESS / HYPERTHERMIA HEAT EXHAUSTION Presentation: Flu-like symptoms, cramps, normal mental status HEAT STROKE Presentation: Altered level of consciousness, absence of sweating, tachycardia, and hypotension Low flow for heat exhaustion OXYGEN High flow if altered level of consciousness / suspected heat stroke Move patient to cool environment Promote cooling by fanning COOLING MEASURES Remove clothing and splash / sponge with water Place cold packs on neck, in axillary and inguinal areas IV TKO. Perform if heat stroke or marked symptoms with heat exhaustion. Consider FLUID BOLUS If hypotensive or suspected heat stroke: Adult – 500 ml NS bolus May repeat X 1 Pediatric – 20 ml/kg NS bolus. May repeat X 1 Consider Check level if altered level of consciousness, treat as indicated BLOOD GLUCOSE Consider For adult patients only if hypotension persists despite fluid boluses DOPAMINE Begin at 5 mcg/kg/min (see table) Related guidelines: Altered Level of Consciousness (G2), Seizure (G14) Key Treatment Considerations Page 76 Seizures may occur with heat stroke – treat as per treatment guideline for seizure Increasing symptoms merit more aggressive cooling measures. With mild symptoms of heat exhaustion, movement to cooler environment and fanning may suffice. Conditions that may lead to or worsen hyperthermia include: o Psychiatric Disorders o Heart Disease o Diabetes o Alcohol o Medications o Fever o Fatigue o Obesity o Pre-existent dehydration o Extremes of age (Elderly and pediatric) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 G9 GENERAL HYPOTHERMIA MODERATE HYPOTHERMIA Conscious and shivering but lethargic, skin pale and cold SEVERE HYPOTHERMIA Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations Severe hypothermia patients may appear dead. When in doubt, begin resuscitation Low flow. High flow if decreased level of consciousness (warm humidified OXYGEN oxygen if available). Be prepared to support ventilations. SPINAL For patients with possible trauma or submersion PRECAUTIONS Gently move to sheltered area (warm environment) WARMING MEASURES Minimize physical exertion or movement of the patient Cut away wet clothing and cover patient with warm, dry sheets or blankets CARDIAC MONITOR Consider Do not delay transport if patient unconscious EARLY TRANSPORT IV TKO BLOOD GLUCOSE Check and treat if indicated Consider If respiratory rate less than 12 and narcotic overdose suspected NALOXONE Consider Only if unable to ventilate using BVM ADVANCED AIRWAY Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Considerations Avoidance of excess stimuli important in severe hypothermia as the heart is sensitive and interventions may induce arrhythmias. Needed interventions should be done as gently as possible. o Check for pulselessness for 30-45 seconds to avoid unnecessary chest compressions o Defer ACLS medications until patient warmed o If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, shock X 1 and defer further shocks Patients with prolonged hypoglycemia often become hypothermic – blood glucose check essential Patients with narcotic overdose may develop hypothermia Contra Costa County Prehospital Care Manual – January 2010 Page 77 G10 GENERAL PAIN MANAGEMENT (NON-TRAUMATIC) All patients expressing verbal or behavioral indicators of pain shall have an appropriate assessment and management of pain Morphine should be given in sufficient amount to manage pain but not necessarily to eliminate it Consider Low flow OXYGEN IV TKO ASSESS PAIN Assess and document the intensity of the pain using the visual analog scale Reassess and document the intensity of the pain after any intervention that could affect pain intensity PAIN RELIEF MEASURES Psychologic measures and BLS measures, including cold packs, repositioning, splinting, elevation, and/or traction splints, are important considerations for patients with pain Consider MORPHINE SULFATE IV See contraindications and cautions below: For pain relief: Adult – 2-20 mg IV, titrated in 2-5 mg increments to pain relief Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart Consider MORPHINE SULFATE IM If no IV access: Adult - 5-10 mg IM Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart Contraindications and Cautions for Morphine Sulfate Contraindications for Morphine: Closed head injury Hypotension o Adults - Systolic BP less than 90 Altered level of consciousness o Pediatric - Hypotension or impaired perfusion (e.g. Headache capillary refill > 2 seconds) Respiratory failure or worsening Infants 1mo-1yr systolic BP < 60 mmHg respiratory status Toddler 1-4 yrs systolic BP < 75 mmHg Childbirth or suspected active labor School age 5-13 yrs systolic BP < 85 mmHg Adolescent >13 yrs systolic BP < 90 mmHg Cautions for Morphine: Use with caution in patients with suspected drug or alcohol ingestion or with suspected hypovolemia Have Naloxone available to reverse respiratory depression should it occur Preferred route of administration for Morphine Sulfate is IV Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Key Treatment Considerations Page 78 Contra Costa County Prehospital Care Manual – January 2010 G11 GENERAL POISONING - OVERDOSE If possible, determine substance, amount ingested, time of ingestion. Bring in container or label. Be careful not to contaminate yourself and others DECONTAMINATION Remove contaminated clothing, brush off powders, wash off liquids. Irrigate eyes if affected. OXYGEN Low flow. Be prepared to support ventilations. CARDIAC MONITOR Consider IV TKO if unstable patient or suspected serious ingestion Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2), Seizures (G14), Shock (A10, P8) TRICYCLIC ANTIDEPRESSANT OVERDOSE Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes and associated ventricular arrhythmias are generally signs of a life-threatening ingestion. SODIUM BICARBONATE For adults only: For life-threatening hemodynamically significant dysrhythmias, 1 mEq/kg slow IV or IO ORGANOPHOSPHATE POISONING Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness, small/pinpoint pupils, muscle twitching, and/or seizures may occur ATROPINE For adults only: 1-2 mg IV Repeat every 3-5 minutes as necessary until relief of symptoms Large doses of Atropine may be required HYDROFLUORIC ACID EXPOSURE CALCIUM CHLORIDE For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10% solution) Consider MORPHINE SULFATE IV For adults only: In the absence of hypotension, significant other trauma or altered level of consciousness: 2-20 mg IV titrated in 2-5 mg increments to pain relief Consider MORPHINE SULFATE IM For adults only: If no IV access, 5-10 mg IM Key Treatment Considerations Few overdoses have specific antidotes. Supportive care is the mainstay of treatment. Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium Channel Blocker overdose) Poison Control Center can offer information but cannot provide medical direction to EMS Contra Costa County Prehospital Care Manual – January 2010 Page 79 G12 RESPIRATORY DEPRESSION OR APNEA GENERAL Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest BVM VENTILATION Assist ventilation or provide ventilation if no spontaneous respirations OXYGEN High flow CARDIAC MONITOR NALOXONE INTRANASAL or IM Consider IV NALOXONE IV Repeat NALOXONE Titration of Diluted NALOXONE IV ADVANCED AIRWAY Adult not in shock: 2 mg IN (intranasal) if narcotic overdose suspected Adult not in shock but unsuitable for IN (copious secretions): 1-2 mg IM Pediatric – 0.1 mg/kg IM – maximum dose 2 mg TKO if intravenous treatment indicated If patient in shock, if IN or IM routes ineffective (within 3 minutes), or if IV access already available for another reason: Adult – 1-2 mg IV Pediatric – 0.1 mg/kg IV – maximum dose 2 mg IV or IM if no response and narcotic overdose suspected – maximum dose 10 mg Consider for patients with chronic narcotic use for terminal disease or chronic pain: Dilute 1:10 with normal saline and administer in 0.1 mg (1 ml) increments – titrate to increased respiratory rate Consider when indicated - only if naloxone ineffective and BVM ventilation not adequate Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13) Key Treatment Considerations SAFETY WARNING! Naloxone will cause acute withdrawal symptoms in patients who are habituated users of narcotics (whether prescribed or from abuse) Page 80 Use of diluted Naloxone IV and titration with small increments may help decrease adverse effects of naloxone in patients who have chronic narcotic usage for terminal disease or pain relief Naloxone treatment should only be given to patients with respiratory depression (rate less than 12) Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%) Older patients are at higher risk for cardiovascular complications Be prepared for patient agitation or combativeness after naloxone reversal of narcotic overdose Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 G13 GENERAL RESPIRATORY DISTRESS Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema Rales may be present in pneumonia, pulmonary edema, and many other conditions INITIAL THERAPY OXYGEN CARDIAC MONITOR Consider CPAP Consider IV Low flow – increase as indicated. Be prepared to support ventilation. ALBUTEROL Adult and Pediatric – 5 mg in 6 ml NS via nebulizer. Repeat as needed. If respiratory rate greater than 25, accessory muscle use, pulse ox less than 94% TKO. Do not delay transport for vascular access if in extremis. ASTHMA Consider EPINEPHRINE 1:1000 SC (subcutaneously) EPINEPHRINE 1:1000 IM For use in asthma only: Use only if respiratory status deteriorating despite repeat treatment with Albuterol and transport time more than 10 minutes. Do not use in patients with history of coronary artery disease or hypertension. Adult - 0.3 mg SC Pediatric - 0.01 mg/kg SC - max dose 0.3 mg Never give Epinephrine 1:1000 intravenously! If respiratory arrest from asthma or bronchospasm: Adult - 0.3 mg IM Pediatric - 0.01 mg/kg IM - max dose 0.3 mg COPD EXACERBATION ALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed. SUSPECTED PULMONARY EDEMA (ADULTS ONLY) 0.4 mg sublingual if systolic BP between 90 and 149 0.8 mg sublingual if systolic BP 150 or greater Repeat every 5 minutes until symptoms improve NITROGLYCERIN Maximum dose 4.8 mg (12 - 0.4 mg doses) Discontinue if hypotension develops Caution: Do not administer if patient has taken erectile dysfunction medications Viagra or Levitra within prior 24 hours or Cialis within 36 hours Consider 2-5 mg IV in 1-2 mg increments for relief of anxiety. Do not administer if BP less MORPHINE SULFATE than 90, if patient has altered mental status or decreased respiratory effort. Related guidelines – Chest pain / Suspected ACS (A2), Shock (A10) Key Treatment Considerations CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of respiration will need assistance with BVM. Patients with potential respiratory failure should be transported emergently. Patients requiring advanced airway management in these situations are best handled in the hospital setting and CPAP may be a valuable “bridge” in care to potentially delay need for emergent intubation. IV access should not delay transport. For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg. If cardiac ischemia suspected in addition to pulmonary edema, treat as per chest pain protocol (Aspirin, 12-lead ECG if possible). Consider cardiac etiology for diabetic patients with respiratory distress Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 Page 81 G14 GENERAL SEIZURE / STATUS EPILEPTICUS Tonic, clonic movements followed by a period of unconsciousness (post-ictal period) A continuous or recurrent seizure is defined as seizure activity greater than 10 minutes or recurrent seizures without patient regaining consciousness OXYGEN High flow. Be prepared to support ventilations. Protect patient Do not forcibly restrain but protect from injuring self CARDIAC MONITOR Consider IV TKO BLOOD GLUCOSE Check and treat if indicated For continuous or recurrent seizures: Consider Adult – initial dose 1 mg IV - titrate in 1-2 mg increments – max. dose 5 mg MIDAZOLAM IV Pediatric – titrate in up to 1 mg IV increments – up to 0.1 mg/kg If IV access unavailable: Consider Adult – 0.2 mg/kg IM - maximum dose 10 mg MIDAZOLAM IM Pediatric – 0.2 mg/kg IM - maximum dose 10 mg MONITOR PATIENT Carefully observe vital signs, respiratory status – support ventilations as needed Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) SAFETY WARNING: Use caution when treating with Midazolam in pediatric patients previously treated by family or caretaker with rectal diazepam (Valium, Diastat) as a higher incidence of respiratory depression may occur. Wait five (5) minutes after last rectal dose to determine effect and need for treatment. Consider using reduced dosage of Midazolam. Key Treatment Considerations Page 82 Most seizures are self-limiting and do not require prehospital medication Seizures may appear frightening to observers. Provide reassurance to parents/family. Consider spinal immobilization if history of fall or trauma Febrile seizures in children are generally self-limiting For febrile patients, remove or loosen clothing, remove blankets to address cooling measures Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 G15 GENERAL STROKE Sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit, may be associated with headache Determination of time of onset of symptoms is the most crucial historical information needed If patient awoke with symptoms, time patient last seen normal is the time that should be noted OXYGEN High flow. Be prepared to support ventilations as needed. CARDIAC MONITOR STROKE SCALE Note findings of stroke scale and time of onset of symptoms TRANSPORT Minimize scene time BLOOD GLUCOSE Check and treat if indicated IV TKO. Perform enroute Consider 250-500 ml if hypotensive or poor perfusion – reassess FLUID BOLUS CONTACT RECEIVING Report time of symptom onset (time last seen normal), ETA, physical exam and HOSPITAL findings of Cincinnati Stroke Scale using SBAR format Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12), Seizure (G14) CINCINNATI STROKE SCALE If any one of the three tests are abnormal and is a new finding, the Stroke Scale is abnormal and may indicate an acute stroke Finding Facial Droop Patient Activity Ask patient to smile and show teeth or grimace Interpretation Normal: Symmetrical smile or face Abnormal: Asymmetry (one side droops or does not move) Normal: Both arms move symmetrically or do not move Arm Weakness Speech Abnormality Ask patient to close both eyes and extend both arms out straight for 10 seconds Have the patient say the words, “The sky is blue in Cincinnati” Abnormal: One arm drifts down or arms move asymmetrically Testing with patient holding palms upward is most sensitive way to check. Patients with arm weakness will tend to pronate (turn from palms up to sideways or palms down). Normal: The correct words are used and no slurring of words is noted Abnormal: If the patient slurs words, uses the wrong words, or is unable to speak (aphasia) Contra Costa County Prehospital Care Manual – January 2010 Page 83 G16 GENERAL TRAUMA SPINAL IMMOBILIZATION OXYGEN EARLY TRANSPORT WOUND / GENERAL CARE Consider NEEDLE THORACOSTOMY IV Consider FLUID BOLUS BLOOD GLUCOSE CARDIAC MONITOR As indicated High flow. Be prepared to support ventilations. Limit scene time to less than 10 minutes when possible. Load and go if high risk. Place splints, cold packs, dressings and pressure on bleeding sites as needed. Keep patient warm – minimize exposure after assessment Evaluate for and treat tension pneumothorax if indicated TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS. Start two (2) large bore IV’s en route when possible. If stable, single IV acceptable. If markedly hypotensive (absent peripheral pulses or BP less than 90), Adult – 250-500 ml NS, recheck vitals. Titrate to presence of peripheral pulses Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2 Test if GCS less than 15. See Altered Level of Consciousness (G2). See indications and precautions below: Adult – 2-20 mg IV in 2-5 mg increments. Titrate to pain relief and systolic BP greater than 100. See precautions below. Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug chart When IV access not available (non-critical patients only): Adult – 5-10 mg IM Pediatric – 0.1 mg/kg IM – See Pediatric Drug chart MORPHINE SULFATE IV MORPHINE SULFATE IM INDICATIONS AND PRECAUTIONS FOR MORPHINE USE Morphine may be used for relief of extremity pain in the absence of head or torso trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in patients with drug or alcohol intoxication. Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Considerations ALS procedures in the field (IV and advanced airway) do not improve outcome in critical patients. o IV starts should be done en route on these patients o Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers Repeated IV attempts in non-critical pediatric patients should be avoided Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. CRUSH INJURY SYNDROME (ADULTS ONLY) Caused by muscle crush injury and cell death. Most patients have an extensive area of involvement such as a large muscle mass in a lower extremity and/or pelvis. May develop after one hour in severe crush, but usually requires at least 4 hours of compression Hypovolemia and hyperkalemia may occur, particularly in extended entrapments Hyperkalemia should be suspected if ECG monitor reveals peaked ‘T’ waves, absent ‘P’ waves or widened QRS complexes FLUID BOLUS 20 ml/kg NS prior to release of compression IF ECG CHANGES SUGGEST HYPERKALEMIA: Page 84 ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer CALCIUM CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after administration of calcium chloride to avoid precipitation with sodium bicarbonate. SODIUM BICARBONATE - 1 mEq/kg IV. Additionally, consider 1 mEq/kg added to IV 1L NS - use second IV line as other medications may not be compatible Contra Costa County Prehospital Care Manual – January 2010 P1 PEDIATRIC PEDIATRIC PATIENT CARE Pediatric patient is defined as age 14 or less. Neonate is 0-1 month These basic treatment concepts should be considered in all pediatric patients Scene Safety Body Substance Isolation Systematic Assessment Determine Primary Impression Base Contact Transport Document Use universal blood and body fluid precautions at all times Management and support of ABC’s are a priority Identify pre-arrest states Assure open and adequate airway Place in position of comfort unless condition mandates other position Consider spinal immobilization if history or possibility of traumatic injury exists Assess environment to consider possibility of intentional injury or maltreatment Apply appropriate field treatment guidelines Explain procedures to family and patient as appropriate Provide appropriate family support on scene Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines is considered Use SBAR to communicate with base Minimize scene time in pre-arrest patient, critical trauma, shock or respiratory failure Transport patient medications or current list of patient medications to the hospital Give report to receiving facility using SBAR Document patient assessment and care per policy Key Treatment Considerations – Apparent Life-Threatening Event (ALTE) An Apparent Life-Threatening Event (ALTE) Is an event that is frightening to the observer (may think the infant has died) and involves some combination of apnea, color change, marked change in muscle tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with symptoms described under 2 years of age may be considered an ALTE. Most patients have a normal physical exam when assessed by responding personnel. Approximately half of the cases have no known cause, but the remainder of cases have a significant underlying cause such as infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS. Because of the high incidence of problems and the normal assessment usually seen, there is potential for significant problems if the child's symptoms are not seriously addressed. OBTAIN DETAILED HISTORY Obtain history of event, including duration and severity, whether patient awake or asleep at time of episode, and what resuscitative measures were done by the parent or caretaker. Obtain past medical history, including history of chronic diseases, seizure activity, current or recent infections, gastroesophageal reflux, recent trauma, medication history. Obtain history with regard to mixing of formula if applicable. ASSESSMENT Perform comprehensive exam, including general appearance, skin color, interaction with environment, or evidence of trauma TREATMENT Treat identifiable cause if appropriate TRANSPORT If treatment/transport is refused by parent or guardian, contact base hospital to consult prior to leaving patient. Document refusal of care. Contra Costa County Prehospital Care Manual – January 2010 Page 85 P2 PEDIATRIC AIRWAY VENTILATIONS CARDIAC ARREST – INITIAL CARE AND CPR Open airway and utilize BLS airway for initial management Ventilations: Give 2 breaths initially Administer each breath over 1 second and observe for chest rise Check pulse - If no pulse or if heart rate less than 60 with poor perfusion, begin CPR CPR For 2 minutes or 5 cycles before rhythm analysis if unwitnessed arrest Until monitor/defibrillator available for rhythm analysis if witnessed arrest COMPRESSIONS CARDIAC MONITOR IV / IO ACCESS Compressions: Depth – one-third to one-half depth of chest – allow full recoil of chest Rate - 100/minute Compression/ventilation ratio - 30:2 for one rescuer, 15:2 for two rescuers Rotate compressors every 2 minutes To minimize CPR interruptions: Perform CPR during charging of defibrillator Resume CPR immediately after shock (do not stop for pulse or rhythm check) Determine cardiac rhythm and follow specific treatment guideline If IV access not apparent or unsuccessful, use IO access Use length-based tape to determine weight if not known o If child is obese and length-based tape used to determine weight, use next highest color to determine appropriate equipment and drug dosing See Pediatric Drug Chart for medication dose and defibrillation energy levels MEDICATIONS AND DEFIBRILLATION Page 86 BLOOD GLUCOSE Treat if indicated. Glucose may be rapidly depleted in pediatric arrest. PREVENT HYPOTHERMIA Move to warm environment and avoid unnecessary exposure Pediatric arrest victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids TRANSPORT Consider rapid transport to definitive care Contra Costa County Prehospital Care Manual – January 2010 P3 PEDIATRIC NEONATAL CARE AND RESUSCITATION WARM PATIENT Provide warmth – move to warm environment immediately CLEAR AIRWAY If needed, position airway or suction. Rapidly suction secretions from mouth or nares. DRY AND STIMULATE Dry child thoroughly, stimulate, reposition if needed, place hat on infant EVALUATE RESPIRATIONS, HEART RATE AND COLOR REASSESS / BEGIN CPR IF INDICATED If breathing, heart rate above 100 and pink, observational care only If breathing, heart rate above 100 and central cyanosis – OXYGEN 100% by mask – reassess in 30 seconds o If cyanosis resolves (skin pink) – observational care only o If persistent central cyanosis after oxygen, initiate bag mask ventilation at rate of 40-60/minute If apneic, gasping, or heart rate below 100 – initiate bag mask ventilation at a rate of 40-60/minute with OXYGEN 100% – reassess in 30 seconds o If heart rate increases to above 100 and patient ventilating adequately, discontinue bag mask ventilation and continue close observation o If heart rate persists below 100 continue bag mask ventilation If heart rate less than 60 despite ventilation with oxygen for 30 seconds, begin CPR (3:1 ratio – 90 compressions and 30 ventilations/minute). Reassess in 30 seconds. If heart rate remains less than 60 despite adequate ventilation and chest compressions: IV/IO TKO. 100-500 ml NS bag (use care to avoid inadvertent fluid administration). Do not delay transport for IV or IO access. EPINEPHRINE 1:10,000, 0.01 mg/kg IV or IO. Repeat every 3-5 minutes if heart rate remains below 60. Consider FLUID BOLUS 10 ml/kg NS IV or IO. May repeat once if needed. Consider NALOXONE 0.1 mg/kg IV or IO if depressed respiratory status despite efforts. Avoid use if long term use of opioids during pregnancy known or suspected. Key Treatment Considerations For uncomplicated deliveries, treatment priorities are to warm, dry, and stimulate the infant Anticipate complex resuscitation if not term gestation, amniotic fluid not clear, if newborn is not breathing or crying or if newborn does not have good muscle tone Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 Page 87 P4 PEDIATRIC VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA INITIAL CARE See Cardiac Arrest - Initial Care and CPR (P3) DEFIBRILLATION 2 joules/kg AED can be used if patient over 1 year and pediatric electrodes available (age 1-8) or if adult electrodes can be applied without touching each other Use infant paddles and manual defibrillator up to 1 year of age or 10 kg CPR For 2 minutes or 5 cycles between rhythm check and shock BVM VENTILATION Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate IV or IO TKO. Should not delay defibrillation or interrupt CPR DEFIBRILLATION EPINEPHRINE CPR DEFIBRILLATION 4 joules/kg 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes - See Pediatric Drug Chart For 2 minutes or 5 cycles between rhythm check and shock 4 joules/kg AMIODARONE 5 mg/kg IV or IO (see Pediatric Drug Chart for dosage) CPR For 2 minutes or 5 cycles between rhythm check and shock TRANSPORT If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated Key Treatment Considerations Page 88 Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications. To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) Avoid hyperventilation with BLS airway management, which may cause gastric distention and limit chest expansion. Provide breaths over one second, with movement of chest wall as guide for volume needed. If advanced airway placed (40 kg and over), perform CPR continuously without pauses for ventilation Prepare drugs before rhythm check and administer during CPR Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for medication dose and defibrillation energy levels. Contra Costa County Prehospital Care Manual – January 2010 P5 PEDIATRIC PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE INITIAL CARE See Cardiac Arrest – Initial Care and CPR (P3) BVM VENTILATION Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate IV or IO TKO EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes Consider treatable causes – treat if applicable: Consider 20 ml/kg NS – may repeat X 2 for hypovolemia FLUID BOLUS VENTILATION WARMING MEASURES Consider NEEDLE THORACOSTOMY Ensure adequate ventilation (8-10 breaths per minute) for hypoxia For hypothermia For tension pneumothorax To determine treatment for other identified potentially treatable causes - Hydrogen Ion (Acidosis), Hyperkalemia, Toxins Safety Warning: Unlike adult resuscitation, atropine is not used in treatment of asystole or PEA in the pediatric patient If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated BASE CONTACT Key Treatment Considerations Uninterrupted CPR is key to successful resuscitation. This takes precedence over advanced airway management and administration of medications. If advanced airway placed in patients 40 kg and over, perform CPR continuously without pauses for ventilation Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second. Prepare drugs before rhythm check and administer during CPR Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 Page 89 P6 PEDIATRIC SYMPTOMATIC BRADYCARDIA 90% of pediatric bradycardias are related to respiratory depression and respond to support of ventilation Only unstable, severe bradycardia causing cardiorespiratory compromise will require further treatment Signs of severe cardiorespiratory compromise are poor perfusion, delayed capillary refill, hypotension, respiratory difficulty, altered level of consciousness OXYGEN High flow. Be prepared to support ventilation. IV or IO Consider CPR EPINEPHRINE TKO. Use IO only if patient unstable and requires medication. Use 100-500 ml NS bag. If heart rate remains less than 60 with poor perfusion despite oxygenation and ventilation, perform CPR. 1:10,000 - 0.01 mg/kg IV or IO. Repeat every 3-5 minutes. SAFETY WARNING: Atropine should be considered only after adequate oxygenation/ventilation has been assured 0.02 mg/kg IV, IO (0.1 mg minimum dose) Consider ATROPINE Child (1-8 years): Maximum single dose 0.5 mg. Maximum total dose 1 mg Adolescent (9-14 years): Maximum single dose 1 mg. Maximum total dose 2 mg. If continued heart rate less than 60, repeat 0.02 mg/kg IV or IO Key Treatment Considerations Page 90 Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 P7 PEDIATRIC TACHYCARDIA Sinus tachycardia is by far the most common pediatric rhythm disturbance UNSTABLE SINUS TACHYCARDIA (narrow QRS less than 0.08) ‘P’ waves present/normal, variable R-R interval with constant P-R interval Unstable sinus tachycardia is usually associated with shock and may be pre-arrest UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less than 0.08) ‘P’ waves absent/abnormal, heart rate not variable History generally vague, non-specific and/or history of abrupt heart rate changes Infants’ rate usually greater than 220 bpm, Children (ages 1 – 8) rate usually greater than 180 bpm UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA - Wide QRS (greater than 0.08 sec) In some cases, wide QRS can represent supraventricular rhythm INITIAL THERAPY – ALL TACHYCARDIA RHYTHMS OXYGEN CHECK PULSE AND PERFUSION CARDIAC MONITOR IV or IO FLUID BOLUS Low flow. If increased work of breathing – high flow. Be prepared to support ventilation. Determine stability: Stable - Normal perfusion: Palpable pulses, normal LOC, normal capillary refill, and normal BP for age Unstable - Poor perfusion: ALOC, abnormal pulses, delayed cap. refill, difficult/unable to palpate BP. If unstable, transport early and treat as below. Run strip to evaluate QRS Duration TKO. Use 100-500 ml bag NS 20 ml/kg NS if hypovolemia suspected. May repeat X 1. UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (narrow QRS less than 0.08) VAGAL MANEUVERS BASE CONTACT Consider if will not result in treatment delays. ICE PACK to face of infant/child. For all treatments listed below: ADENOSINE 0.1 mg/kg rapid IV push followed by 10-20 ml NS flush (maximum dose 6 mg) If not converted, 0.2 mg/kg rapid IV push followed by 10-20 ml NS flush (maximum dose 12 mg) SYNCHRONIZED CARDIOVERSION If unable to obtain IV access, prepare for Synchronized Cardioversion. Do NOT delay cardioversion to obtain IV or IO access or sedation. Consider SEDATION Consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) SYNCHRONIZED CARDIOVERSION 0.5-1 joule/kg. If not effective, repeat at 2 joules/kg. UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA ( Wide QRS greater than 0.08 sec) BASE CONTACT SYNCHRONIZED CARDIOVERION Consider SEDATION SYNCHRONIZED CARDIOVERSION For all treatments listed below: Prepare for CARDIOVERSION while attempting IV/IO access, but do not unduly delay care for IV access or medications If IV/IO access has been obtained, consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) 0.5-1 joule/kg. If not effective, repeat at 2 joules/kg. Early transport appropriate in unstable patients Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 Page 91 P8 PEDIATRIC SHOCK Altered level of consciousness; cool, clammy, mottled skin; capillary refill greater than 2 seconds; tachycardia; blood pressure less than 70 systolic Listless infant or child with poor skin turgor, dry mucous membranes, history of fever may indicate sepsis, meningitis OXYGEN High flow. Be prepared to support ventilations as needed. Keep patient warm CARDIAC MONITOR EARLY TRANSPORT CODE 3 IV or IO FLUID BOLUS 20 ml/kg NS – may repeat X 2 BLOOD GLUCOSE Check and treat if indicated PREVENT HYPOTHERMIA Move to warm environment. Avoid unnecessary exposure. Related guidelines: Altered level of consciousness (G2), Tachycardia (P7) Key Treatment Considerations Successful pediatric resuscitation relies on early identification of the pre-arrest state Normal blood pressure, delayed capillary refill, diminished peripheral pulses and tachycardia indicates compensated shock in children Hypotension and delayed capillary refill > 4 seconds indicates impending circulatory failure Systolic blood pressure in children may not drop until the patient is 25-30% volume depleted. This may occur through dehydration, blood loss or an increase in vascular capacity (e.g. anaphylaxis). Decompensated shock (Hypotension with > 5 seconds capillary refill) may present as PEA in children Sinus tachycardia is the most common cardiac rhythm encountered Supraventricular tachycardia should be suspected if heart rate greater than 180 in children (ages 1-8) or greater than 220 in infants Hypoglycemia may be found in pediatric shock, especially in infants Pediatric shock victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids Page 92 Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual – January 2010 INDICATIONS FOR SPINAL IMMOBILIZATION Presence of neurologic complaint or deficit – paralysis, weakness, numbness, tingling, priapism or neurogenic shock, loss of consciousness Anatomic deformity of spine Altered level of consciousness (GCS < 15) Blunt Injury Presence of spinal pain or tenderness (Regardless of Anatomic deformity of spine mechanism) Presence of neurologic complaint or deficit – paralysis, weakness, numbness, tingling, priapism or neurogenic shock Presence of alcohol or drugs or acute stress reaction / anxiety Blunt Injury Distracting injury (e.g. long bone fracture, large laceration, crush or degloving (When mechanism of injury, large burns) injury is concerning) Inability to communicate (e.g. speech or hearing impaired, language gap, small children, developmental or psychiatric conditions) Concerning mechanisms of injury include but are not limited to: Violent impact to head, neck, torso, or pelvis (e.g. assault, entrapment in structural collapse) Sudden acceleration, deceleration or lateral bending forces to neck or torso (e.g., moderate- to highspeed MVC, pedestrian struck, explosion) Falls (especially in elderly patients) Ejection from motorized or other transportation device (e.g. scooter, skateboard, bicycle, motor vehicle, motorcycle, recreational vehicle, or horse) Victims of shallow-water diving incident Penetrating Injury (Trauma to head, neck or torso) *** USE CLINICAL JUDGMENT – IF IN DOUBT, IMMOBILIZE *** VASCULAR ACCESS Saline Lock Upper Extremity IV Indicated for vascular access in upper extremity when medication alone is being administered or a potential need for medication is anticipated Indicated when fluids and / or medications are needed, and patient not in shock or arrest Antecubital IV Intraosseous Access (IO) External Jugular IV Indicated in arrest, shock or when adenosine (rapid IV bolus) is required o In arrest, use intraosseous access if rapid peripheral access cannot be obtained within 30-60 seconds Appropriate if other peripheral sites not available and medication or fluids indicated Indicated in cardiac arrest, profound shock, or unstable dysrhythmia when peripheral IV access cannot be accomplished or a suitable vein cannot be rapidly found Should be done only when medication or fluid bolus is being administered, not for prophylactic vascular access Not indicated when other routes for medications available (IM, IN) Not indicated in alert or stable patients IO infusion is PAINFUL! In non-arrest patients, use lidocaine for pain control PRIOR to giving fluid or medication Indicated only when unstable patient requires vascular access for emergent intravenous medication or fluids, no peripheral site is available, and patient not appropriate for IO access (e.g., when patient is alert) Use intraosseous access in arrest situations (IO does not disrupt CPR, higher success rate) Use alternative routes for medications when possible rather than EJ o Patients requiring treatment of hypoglycemia should receive IM glucagon – monitoring for 10-15 minutes is appropriate before EJ considered o Use intranasal or IM route for naloxone in respiratory depression Contra Costa County Prehospital Care Manual – January 2010 Page 93 12-LEAD ACQUISITION AND LEAD PLACEMENT Limb Lead Placement: Place limb leads on distal extremities if possible Confirm correct lead placement for each limb May be moved to proximal if needed (if motion artifact) Chest Lead Placement: To begin placement of chest leads, locate sternal angle (2nd ribs are adjacent) then count down to 4th interspace (below 4th rib) Sternal angle V1 – 4th intercostal space at the right sternal border V2 – 4th intercostal space at the left sternal border V4 – 5th intercostal space at left midclavicular line Note: Place V4 lead first to aid in correct placement of V3 V3 – Directly between V2 and V4 V5 – Level of V4 at left anterior axillary line V6 – Level of V4 at left mid-axillary line V4R V4R – (to detect Right Ventricular Infarct) – mirrors V4 on right side of chest – move V4 lead across Do V4R if Inferior MI noted (elevation in II, III, avF) Label ECG for V4R Note: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG LOCALIZING SITE OF INFARCT Page 94 Localization of an infarct pattern adds to the accuracy of ECG interpretation A STEMI will have 1 mm or more ST-segment elevation in two or more contiguous leads (which means findings noted in the same anatomical location of the infarct) o Contiguous leads for inferior infarction include II, III, and aVF o Contiguous leads for anterior infarction include V1-V4 (V1-V2 elevation also called septal infarction) o Contiguous leads for lateral myocardial infarction include Leads I, aVL, V5, and V6 o Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or inferolateral) In patients with an inferior infarct pattern (Leads II, III, aVF), a separate ECG with V4R should be obtained A 1 mm ST-segment elevation in V4R when inferior infarction noted indicates right ventricular infarct I – LATERAL aVR V1 – SEPTAL or ANTERIOR V4 – ANTERIOR II - INFERIOR aVL – LATERAL V2 – SEPTAL or ANTERIOR V5 – LATERAL III – INFERIOR aVF - INFERIOR V3 – ANTERIOR V6 – LATERAL (V4R – RVMI) Contra Costa County Prehospital Care Manual – January 2010 STEMI RECOGNITION AND DESTINATION STEMI Recognition Patients who have ECGs of acceptable quality with the following messages are candidates for transport to STEMI Receiving Centers: o ***Acute MI*** (Zoll) o ***Acute MI Suspected*** (LIFEPAK 12) o ***Meets ST-Elevation MI Criteria*** (LIFEPAK15) The 12-lead ECG should be inspected prior to initiation of a STEMI Alert – a steady baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation Causes of artifact include patient motion or tremor, poor lead contact, or electrical interference Good skin preparation is essential for optimal lead contact and clear 12-lead tracings If artifact is noted the ECG should be repeated Paced rhythms may cause false readings – the pacemaker spike is not always detected by the computer algorithm. Inform facility if patient has a pacemaker during report. STEMI Report If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon as possible following completion of the ECG Destination Policy Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC) Patients shall be transported to the closest SRC unless they request another facility A SRC that is not the closest facility is an acceptable destination if estimated additional transport time does not exceed 15 minutes Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after arrest shall be transported to the closest SRC Patients with unmanageable airway en route shall be transported to the closest available emergency department STEMI REPORT A patient with a computer interpretation of ***Acute MI*** (Zoll) or ***Acute MI Suspected*** (LP-12) or ***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have significant baseline artifact or other deficit before initiating a STEMI Alert Identify the call as a “STEMI Alert” Estimated time of arrival (ETA) in minutes Patient age and gender SITUATION Report ECG computer interpretation has a STEMI message (as listed above) Report if subsequent ECG findings are variable or if ECG quality not optimal (e.g., if no ***Acute MI*** findings noted in tracings without significant artifact) BACKGROUND Presenting chief complaint and symptoms Pertinent past cardiac history History of pacemaker (important – paced rhythms may give false ECG interpretations) ASSESSMENT General assessment Pertinent vitals (especially heart rate and BP) and physical exam Cardiac rhythm Pain level RX – RECAP Prehospital treatments given Patient response to prehospital treatments Contra Costa County Prehospital Care Manual – January 2010 Page 95 KEY PARAMEDIC PROCEDURES Skill External Cardiac Pacing Continuous Positive Airway Pressure (CPAP) Indication Contraindication Symptomatic bradycardia Cardiac arrest Hypothermia Pediatric Patients Pt. has 2 of more findings: Unconscious or unable to follow commands Respiratory arrest / apnea Pneumothorax Vomiting Major head, facial or chest trauma Cardiac arrest from blunt chest trauma Any condition other than cardiac arrest RR >25 Pulse ox <94% Use of accessory muscles and patient is awake, able to maintain airway & follow commands ResQPOD Cardiac Arrest Waveform Capnography (ETCO2) All intubated patients (King or Endotracheal Tube) King Airway Endotracheal Intubation Page 96 None Presence of gag reflex Caustic ingestion Known esophageal disease (e.g. cancer, varices, stricture) Laryngectomy with stoma (place ET tube in stoma) Height less than 4 feet Cardiac arrest Inability to ventilate non-arrest patient (with BLS airway maneuvers) in a setting in which endotracheal intubation is not successful or unable to be done Patient with decreased sensorium (GCS less than or equal to 8) and apneic (adults) Patient with decreased sensorium (GCS less than or equal to 8) and ventilation unable to be maintained with BLS airway Pediatric patients under 40 kg Suspected hypoglycemia or narcotic overdose Maxillo-facial trauma with unrecognizable facial landmarks Seizures Patients with an active gag reflex Comment Careful titration of midazolam or morphine if required for relief of discomfort Increased pulse oximetry is not necessarily indicative of patient improvement – follow respiratory rate and level of distress Optional equipment Use King Airway early to facilitate use Essential for ongoing verification of ET tube placement. Use as guide to ventilation rate in perfusing patients. Ideal advanced airway device in cardiac arrest – less CPR interruption Patients with perfusing pulses (e.g. trauma or respiratory insufficiency) should be managed with BLS airways unless unable to successfully ventilate Patients with perfusing pulses (e.g. trauma or respiratory insufficiency) should be managed with BLS airways unless unable to successfully ventilate No more than 2 interruptions of ventilation lasting up to 30 seconds during laryngoscopy or intubation attempts Contra Costa County Prehospital Care Manual – January 2010 PEDIATRIC ASSESSMENT PEDIATRIC ASSESSMENT TRIANGLE - GENERAL VISUAL ASSESSMENT Appearance Work of Breathing Circulation Assessment Assess TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry Abnormal Any Abnormal Increased or decreased effort or abnormal sounds Abnormal skin color or external bleeding Assess effort Assess for skin color PREHOSPITAL PRIMARY ASSESSMENT Assessment Assess patency Assess respiratory rate and effort, air movement, airway and breath sounds, pulse oximetry Signs of Life-Threatening Condition Complete or severe airway obstruction Circulation Assess heart rate, pulses, capillary refill, skin color and temperature, blood pressure Tachycardia, bradycardia, absence of detectable pulses, poor blood flow (increased capillary refill, pallor, mottling, or cyanosis), hypotension Disability Assess AVPU response, pupil size and reaction to light, blood glucose Decreased response or abnormal motor response (posturing) to pain, unresponsiveness Exposure Assess skin for rash or trauma Hypothermia, rash (petichiae/purpura) consistent with septic shock, significant bleeding, abdominal distention Airway Breathing Apnea, slow respiratory rate, very fast respiratory rate or significant work of breathing BEGIN INTERVENTIONS IMMEDIATELY AND TRANSPORT PROMPTLY IF LIFE-THREATENING CONDITIONS ARE IDENTIFIED IN GENERAL VISUAL ASSESSMENT OR PRIMARY ASSESSMENT VITAL SIGNS / GLASGOW COMA SCALE IN CHILDREN Age Term Neonate Infant (<1 yr) Toddler (1-3 yr) Preschooler (4-5 yr) School Age (6-12yr) Adolescent (13-18 yr) Pediatric GCS Motor Response Verbal Response Eye Response Normal RR Normal HR 30-60 30-60 24-40 22-34 18-30 12-20 100-205 100-190 90-150 80-140 70-120 60-100 Infant Spontaneous movements Withdraws to touch Withdraws to pain Flexion Extension No response Coos and babbles Irritable cry Cries to pain Moans to pain No response Opens spontaneously Opens to speech Opens to pain No response Contra Costa County Prehospital Care Manual – January 2010 Hypotension by systolic blood pressure Neonate: Less than 60 mmHg or weak pulses Infant: Less than 70 mmHg or weak pulses 1-10 yrs: Less than 70 mmHg + (age in yrs x 2) Over 10: Less than 90 mmHg Score 6 5 4 3 2 1 5 4 3 2 1 4 3 2 1 Child Obeys commands Localizes Withdraws Flexion Extension No response Oriented Confused Inappropriate Incomprehensible No response Opens spontaneously Opens to speech Opens to pain No response Score 6 5 4 3 2 1 5 4 3 2 1 4 3 2 1 Page 97 ABC MANEUVERS FOR ADULTS, CHILDREN AND INFANTS INTERVENTION BREATHING AIRWAY INITIAL BREATHS RESCUE BREATHING - NO COMPRESSIONS WITH CPR AND ADVANCED AIRWAY FOREIGN BODY OBSTRUCTION COMPRESSIONS PULSE CHECK (10 seconds or less) LANDMARKS Page 98 METHOD DEPTH INFANT Under 1 year Head tilt – chin lift. If trauma suspected, use jaw thrust. 2 effective breaths (make chest rise) - 1 second per breath 10 – 12 breaths/ minute 12-20 breaths / minute 1 breath every 5-6 seconds 1 breath every 3-5 seconds 8-10 breaths/minute 1 breath every 6-8 seconds Up to 5 back slaps Abdominal thrusts and 5 chest thrusts Perform laryngoscopy and use Magill forceps if BLS efforts unsuccessful Carotid Brachial or femoral Lower half of the sternum between the nipples Heel of one hand, other hand on top 1.5 to 2 inches RATE COMPRESSION / VENTILATION RATIO CHILD 1 year adolescent ADULT Just below nipple line 2 or 3 fingers, or Heel of one hand, 2 thumbs encircling or same as adult (with two rescuers) One-third to one-half depth of chest 100 per minute 30:2 30:2 (one rescuer) 2 minutes = 5 cycles 15:2 (two rescuers) 2 minutes = 8-10 cycles Contra Costa County Prehospital Care Manual – January 2010 Contra Costa County Base Hospital Hospital John Muir Medical Center – Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA 94598 Base Phone ED Phone Taped: (925) 939-5804 Receiving Facility Notification: (925) 947-3379 XCC EMS 2 Alert Code 14524 ED: 939-5800 Contra Costa County Hospitals (Receiving Facilities) Hospital Services ED Phone XCC EMS 2 Alert Code Contra Costa Regional Medical Center 2500 Alhambra Avenue Martinez CA 94553 Basic ED OB/Neonatal (925) 370-5971 14574 Doctor’s Medical Center – San Pablo 2000 Vale Road San Pablo CA 94806 Basic ED STEMI Center (510) 234-6010 13613 Basic ED STEMI Center (925) 689-0553 14214 Basic ED OB/Neonatal Trauma Center STEMI Center Receiving Facility Notification: (925) 947-3379 ED: (925) 939-5800 14524 John Muir Medical Center – Concord Campus 2540 East Street Concord CA 94520 John Muir Medical Center – Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA 94598 Kaiser Medical Center – Antioch 5001 Deer Valley Road Antioch CA 94531 Basic ED OB/Neonatal (925) 813-6880 (switchboard) 14564 Kaiser Medical Center – Richmond 901 Nevin Avenue Richmond CA 94504 Basic ED (510) 307-1758 13653 Kaiser Medical Center – Walnut Creek 1425 South Main Street Walnut Creek CA 94596 Basic ED OB/Neonatal STEMI Center (925) 939-1788 14284 San Ramon Regional Medical Center 6001 Norris Canyon Road San Ramon CA 94583 Basic ED OB/Neonatal STEMI Center (925) 275-8338 13623 Sutter/Delta Medical Center 3901 Lone Tree Way Antioch CA 94509 Basic ED OB/Neonatal STEMI Center (925) 779-7273 14294 Contra Costa County Prehospital Care Manual – January 2010 Page 99 DESTINATION DETERMINATION – BASIC PROCEDURE Field personnel shall assess a patient to determine if the patient is unstable or stable Patient stability must be considered along with a number of additional factors in making destination and transport code decisions FACTORS TO CONSIDER UNSTABLE PATIENTS Patient or family’s choice of receiving hospital and ETA to that facility Recommendations from a physician familiar with the patient’s current condition Patient’s regular source of hospitalization or health care Ability of field personnel to provide field stabilization or emergency intervention ETA to the closest basic emergency department Traffic conditions Hospitals with special resources Hospital diversion status Usually transported to the closest appropriate acute care hospital emergency department or specialized care centers if indicated If the patient or family requests, or if other factors exist which indicate that another facility be considered, field personnel are to contact the base hospital and present their findings, including ETAs to both facilities. Base personnel will assess the benefits of each destination and may direct field personnel to a facility other than the closest. STABLE PATIENTS Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient’s/family preference If a patient does not express a preference, the hospital where the patient normally receives health care or the closest ED is to be considered DESTINATION – 5150 and OBSTETRIC PATIENTS A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable. Patients on 5150 Holds Obstetric Patients Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center Unstable patients on 5150 holds shall be transported to the closest acute care hospital: A patient with a current history of overdose of medications is to be considered unstable A patient with history of ingestion of alcohol / illicit street drugs is considered unstable if: o Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or o Significantly abnormal vital signs; or o Any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis A patient is considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or more. Obstetric patients should be transported to hospitals with in-patient OB services in the following circumstances: Patients in labor Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy Injured patients who do not meet trauma criteria or guidelines Obstetric patients with impending delivery or unstable conditions where imminent treatment appears necessary to preserve the mother’s life should be transported to the nearest basic emergency department Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy Page 100 Contra Costa County Prehospital Care Manual – January 2010 TRAUMA TRIAGE CRITERIA Unmanageable airway or arrest not meeting field Closest receiving facility determination of death The following meet high-risk criteria and merit direct transport to the trauma center: Physiologic Criteria BP < 90 in adults GCS 13 or below if not pre-existing Anatomic Criteria Penetrating injury to head, neck, torso, groin, pelvis or buttocks Fracture of femur Fracture of long bone(s) resulting from penetrating trauma Traumatic Paralysis Amputation above wrist or ankle Major burns associated with trauma Motor vehicle crash with: Note: In the absence of o Extrication > 20 minutes significant symptoms or o Fatalities in the same vehicle physical findings with o Ejection these mechanisms, Unrestrained motor vehicle crash with: call base hospital for o Head on mechanism > 40 mph destination determination o Extrication required Fall 15 feet or greater Motorcycle crash with: o Abdominal or chest tenderness o Observed loss of consciousness Unrestrained motor vehicle crash with abdominal tenderness Mechanism Criteria Combined Criteria (combined mechanism and physical findings) TRAUMA – BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA) Base Hospital Destination Decision Required Prior to Transport Precaution with Elderly Patients Additional Considerations: Evidence of high-energy dissipation or rapid deceleration which may include: o vehicle rollover with unrestrained occupant o intrusion of passenger space by 1 foot or greater o impact of 40 mph or greater (restrained) o persons requiring disentanglement from a vehicle Adult hit by vehicle traveling faster than 15 mph Child (under 15) or elderly patient (65 years and over) struck by a vehicle Persons ejected from a moving object (motorcycle, horse, etc.) Significant blunt force to the head, neck, thorax (chest/back), abdomen or pelvis Penetrating injury to extremities (above knee or elbow) without apparent fracture Patients 65 years of age and older may sustain significant injuries with less forceful mechanisms, and may merit call-in for less significant mechanisms (e.g. ground level fall with new alteration of mental status) Base contact should be made if a patient meets call-in criteria and it is believed trauma center services may be needed, even in the event that the trauma has occurred several hours prior to EMS response If no significant symptoms or physical findings noted despite above mechanism(s), call-in not required and patient may be transported to hospital of choice or to closest facility Contra Costa County Prehospital Care Manual – January 2010 Page 101 HELICOPTER TRANSPORT CRITERIA USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET Time Criteria Clinical Criteria Use and Cancellation Helicopter transport generally should be used only when it provides a time advantage. Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally 20-25 minutes in most cases Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter arrival Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when time criteria not met Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except for: o Stable patients with isolated extremity trauma o Patients with mechanism but no significant physical exam findings Trauma patients who do not meet high-risk criteria but by evaluation of mechanism and physical exam findings, appear to have potential significant injuries that merit rapid transport Patients with specialized needs available only at a remote facility such as burn victims/critical pediatric Critically ill or injured patients whose conditions may be aggravated or endangered by ground transport (e.g. limited access via ground ambulance or unsafe roadway) The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not met, helicopter should be cancelled. Considerations for IC: Patient need Estimated ground transport time versus air response and transport Proximity of a helispot or need for a helicopter/ambulance rendezvous site ETA of the helicopter RESTRAINTS Restraint Types Restraint Issues Law Enforcement Role Transport Issues Page 102 Leather or soft restraints may be used during transport Handcuffs may only be used during transport if law enforcement accompanies the patient in the ambulance. Patients may not be handcuffed to the gurney. Chemical restraint requires a base hospital order Patients shall be placed in Fowler’s or Semi-Fowler’s position Patients shall not be restrained in hogtied or prone position Method of restraint should allow for monitoring of vital signs and respiratory effort and should not restrict the patient or rescuer’s ability to protect the airway should vomiting occur Restrained extremities should be monitored for circulation, motor and sensory function every 15 minutes Law enforcement agencies are responsible for capture and/or restraint of assaultive or potentially assaultive patients Law enforcement agencies retain responsibility for safe transport of patients under arrest or on 5150 holds Patients under arrest or 5150 hold should undergo a weapons search by law enforcement personnel Patients under arrest must be accompanied by law enforcement personnel If an unrestrained patient becomes assaultive during transport, ambulance personnel shall request law enforcement assistance, and make reasonable efforts to calm and reassure the patient If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. Ambulance personnel are to remain on scene until law enforcement arrives to take control of the situation. Contra Costa County Prehospital Care Manual – January 2010 RULE OF NINES – BURN SURFACE AREA BURN PATIENT DESTINATION General Destination Principles Patient Selection for Initial Transport to Burn Center Procedure for Burn Center Destination Burned patients with unmanageable airways should be transported to the closest basic ED Patients with minor burns and moderate burns can be cared for at any acute care hospital Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma center The following patients may be appropriate for initial transport to a Burn Center: Partial thickness (2nd degree) greater than 20% TBSA Full thickness (3rd degree) greater than 10% Significant burns to face, hands, feet, genitalia, perineum, or circumferential burns of the torso or extremities Chemical or high voltage electrical burns Smoke inhalation with external burns Contact Burn Center prior to transport to confirm bed availability Consult base hospital if any questions regarding destination decision BURN CENTERS Hospital Services Phone Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose CA Adult and Pediatric Burn Center 408-885-6666 UC Davis Medical Center Regional Burn Center 2315 Stockton Blvd. Sacramento CA Adult and Pediatric Burn Center 916-734-3636 St. Francis Burn Center 900 Hyde Street San Francisco CA Adult and Pediatric Burn Center (No Helipad available) 415-353-6255 Contra Costa County Prehospital Care Manual – January 2010 Page 103 DECLINING MEDICAL CARE OR TRANSPORT (AMA) All qualified persons are permitted to make decisions affecting care, including the ability to decline care Patient Competency Qualified Person Base Contact Requirements Any person encountered by EMS personnel who demonstrates any known or suspected illness or injury OR is involved in an event with significant mechanism that could cause illness or injury OR who requests care or evaluation The ability to understand and to demonstrate an understanding of the nature of the illness/injury and the consequence of declining medical care A competent person making decision for him/herself or another qualified by: An adult patient defined as a person who is at least 18 years old; A minor (under 18 years old) who qualifies based on one of the following conditions: o A legally married minor; o A minor on active duty with the armed forces; o A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault; o A minor, 12 years of age or older, seeking treatment of contact with an infectious, contagious or communicable disease or sexually transmitted disease; o A self-sufficient minor at least 15 years of age, living apart from parents and managing his/her own financial affairs; o An emancipated minor (must show proof); OR The parent of a minor child or a legal representative of the patient (of any age). Spouses or relatives cannot consent to or decline care for the patient unless they are legally designated representatives. When, in the field personnel’s opinion, patient’s decision to decline care poses a threat to his/her well being If the patient’s competency status is unclear (neither competent nor clearly incompetent) and treatment or transport is felt to be appropriate Any other situation in which, in the field personnel’s opinion, that base contact would be beneficial in resolving treatment or transport issues DETERMINATION OF DEATH Obvious Death Medical Arrest Traumatic Arrest Page 104 Pulseless, non-breathing patients with any of the following: Decapitation, Total incineration, Decomposition Total destruction of the heart, lungs, or brain, or separation of these organs from the body Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or poisoning. In patients with rigor mortis or post-mortem lividity: o Attempt to open airway, assess for breathing for at least 30 seconds; assess pulse for 15 seconds o Rigor, if present, should be noted in jaw and/or upper extremities o If any doubt exists, place cardiac monitor to document asystole in two leads for one minute Mass casualty situations Definition: Cardiac arrest with total absence of observers or witness information; or cardiac arrest in which witness information states arrest occurred greater than 15 minutes prior to arrival of prehospital personnel and no resuscitative measures have been done Procedure: BLS personnel – Follow Public Safety defibrillation guideline ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole in two leads for one minute Definition: Blunt or penetrating traumatic arrest Procedure: BLS personnel – Follow Public Safety defibrillation guideline ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole or wide-complex pulseless electrical activity (PEA) at rate of 40 or less Contra Costa County Prehospital Care Manual – January 2010 ADULT DRUG REFERENCE Drug Indication Adult Dosage 1st Dose – 6 mg rapid IV ADENOSINE Paroxysmal SVT 2nd & 3rd Doses – 12 mg rapid IV push Follow each dose with rapid bolus of 20 ml NS Bronchospasm 5 mg in 6 ml NS nebulized Crush Injury – Hyperkalemia 5 mg in 6 ml NS nebulized continuously Ventricular Fibrillation or Pulseless VT 300 mg IV or IO bolus, repeat 150 mg bolus if rhythm persists Stable Ventricular Tachycardia 150 mg IV infusion or slow IV push over 10 minutes (15 mg/minute) Chest Pain – Suspected ACS 4 – 81 mg tabs – chewed ALBUTEROL AMIODARONE ASPIRIN Asystole ATROPINE PEA rate under 60 1 mg IV or IO every 3-5 minutes up to max. 3 mg Symptomatic Bradycardia 0.5 mg IV or IO every 3-5 minutes up to max. 3 mg Organophosphate poisoning 1-2 mg IV or IO – repeat every 3-5 min. as needed to decrease symptoms Hyperkalemia – Arrest CALCIUM CHLORIDE DEXTROSE 50% Hyperkalemia – Crush Injury Hydrofluoric Acid Toxicity Hypoglycemia 500 mg IV or IO slowly May repeat in 5-10 minutes 1 gm IV or IO slowly over 60 seconds Precautions / Comments May cause transient heart block or asystole. Side effects include chest pressure/pain, palpitations, hypotension, dyspnea, or feeling of impending doom. Use caution when patient is taking carmbamazepine, dipyramidole, or methylxanthines. Do not administer if drugs or poisons are suspected cause of tachycardia. Repeat as need for bronchospasm. Use with caution in patients taking MAO inhibitors (antidepressants Nardil and Parnate). In patient with pulses, may cause hypotension. Do not administer if patient hypotensive. When creating infusion, careful mixing needed to avoid foaming of medication (do not use filter needle). Do not administer if patient has a history of allergy to aspirin or salicylates Atropine can dilate pupils, aggravate glaucoma, cause urinary retention, confusion, and dysrhythmias, including V-tach and Vfib. Doses less than 0.5 mg can cause paradoxical bradycardia. Increases myocardial oxygen consumption. Remove clothing of victim of organophosphate poisonings, and flush skin to remove traces of poison. Use cautiously or not at all in patients on digitalis. Avoid extravasation 500 mg IV or IO slowly Rapid administration can cause dysrhythmias or arrest 25 g IV – repeat if needed Recheck glucose after administration Contra Costa County Prehospital Care Manual – January 2010 Page 105 ADULT DRUG REFERENCE Drug DIPHENHYDRAMINE Indication Allergy – Hives / Itching Adult Dosage 25-50 mg IV or IM Dystonic Reaction Shock Starting dose (see chart) 5 mcg/kg/min IV or IO DOPAMINE Symptomatic Bradycardia Cardiac Arrest EPINEPHRINE 1:10,000 Anaphylactic Shock Maximum dose 20 mcg/kg/min IV or IO 1 mg IV or IO every 3-5 minutes 0.1 mg increments IV or IO up to 0.5 mg IV total dose Precautions / Comments For allergy, consider lower dose if patient has already taken po dose in past two hours for symptoms Alpha & beta sympathomimetic. May cause serious dysrhythmias and exacerbate angina. Avoid extravasation. Avoid exposure to light. Alpha & beta sympathomimetic. May cause serious dysrhythmias and exacerbate angina. Use only if IM treatment ineffective Allergy/ Anaphylactic Shock 0.3-0.5 mg IM Use lower dose in smaller, older patients Asthma 0.3 mg subcutaneously 0.3 mg IM if respiratory arrest from asthma or bronchospasm GLUCAGON Hypoglycemia 1 mg IM Effect may be delayed 5–20 minutes - if patient responds, give po sugar LIDOCAINE IO Pain 20-40 mg IO Not needed in arrest situations EPINEPHRINE 1:1000 Seizure MIDAZOLAM Sedation for pacing or cardioversion Behavioral Emergency Pain Control MORPHINE Trauma, Burn or Non-Traumatic Pain Sedation – Pacing Pulmonary Edema Page 106 Titrate 1-5 mg IV in 1-2 mg increments 0.2 mg/kg IM (max. dose 10 mg IM) Titrate 1-5 mg IV in 1-2 mg increments 5 mg IM 1-5 mg IV in 1 mg increments if IV available 2-20 mg IV (2-5 mg increments) 5-20 mg IM (max single dose 10 mg) 1-5 mg IV in 1 mg increments 2-5 mg IV in 1-2 mg increments Never administer intravenously! Do not use in asthma patients with a history of hypertension or coronary artery disease. May cause serious dysrhythmias and exacerbate angina. With IV dosing, begin with 1 mg dose. IV increments should not exceed 2 mg Observe respiratory status Use with caution in patients over age 60 Base order required for behavioral emergency indication Can cause hypotension and respiratory depression. Recheck VS between each dose. Hypotension more common in patients with low cardiac output or volume depletion. Nausea is a frequent side effect. Respiratory depression reversible with naloxone. Contra Costa County Prehospital Care Manual – January 2010 ADULT DRUG REFERENCE Drug NALOXONE NITROGLYCERIN SODIUM BICARBONATE Indication (Respiratory rate less than 12) For careful titration in chronic pain or terminal patients, dilute 1:10 and give 0.1 mg increments Precautions / Comments Intranasal administration preferred unless patient in shock or has copious secretion/blood in nares. IM route if copious secretions or blood. Use IV route in shock. Shorter duration of action than that of most narcotics. May not reverse vascular effects of narcotics. Abrupt withdrawal symptoms and combative behavior may occur. Chest Pain – Suspected ACS 0.4 mg sl or spray up to 6 doses 0.4 mg sl or spray if systolic BP 90-149 Can cause hypotension and headache. Do not give if BP less than 90 systolic. Do not give if right ventricular MI detected. 0.8 mg sl or spray if systolic BP 150 or over Max.dose 4.8 mg Do not give if Viagra or Levitra taken within 24 hours or if Cialis taken within 36 hours Cardiac arrest 1 mEq/kg IV or IO Tricyclic Antidepressant Overdose For crush injury, consider additional 1 mEq/kg added to 1L NS using second IV line Assure adequate ventilation. Can precipitate or inactivate other drugs. In cardiac arrest, indicated for treatment of suspected hyperkalemia (history of renal failure or diabetes). Respiratory Depression or Apnea Pulmonary Edema Crush injury Adult Dosage 2 mg intranasally (IN) 1-2 mg IV or IM Higher doses may sometimes be necessary DOPAMINE DRIP RATES Dopamine concentration = 1600 mcg/ml solution = 400 mg in 250 ml D5W or NS Drops per minute based on microdrip tubing (60 gtt/ml) Patient Weight 5 10 15 20 (kg) mcg / kg / min mcg / kg / min mcg / kg / min mcg / kg / min 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 8 8 9 10 11 12 13 14 15 16 17 18 19 20 21 15 17 19 21 23 24 26 28 30 32 34 36 38 39 41 Contra Costa County Prehospital Care Manual – January 2010 23 25 28 31 34 37 39 42 45 48 51 53 56 59 62 30 34 38 41 45 49 53 56 60 64 68 71 75 79 83 Page 107 PEDIATRIC DRUG REFERENCE Drug ADENOSINE Indication Paroxysmal SVT Pediatric Dosage Precautions / Comments 1st Dose – 0.1 mg/kg rapid IV (max. 6 mg) Base Order Required: May cause transient heart block or asystole. Side effects include chest pressure/pain, palpitations, hypotension, dyspnea, or feeling of impending doom. Do not administer if drugs or poisons are suspected cause of tachycardia. 2nd Dose – 0.2 mg/kg rapid IV (max 12 mg) Follow each dose with rapid 10-20 ml NS bolus ALBUTEROL Bronchospasm 5 mg in 6 ml NS nebulized AMIODARONE Ventricular Fibrillation or Pulseless VT 5 mg/kg IV or IO bolus Maximum dose 300 mg 0.02 mg/kg IV or IO Minimum dose 0.1 mg ATROPINE Child (1-8 years): Single dose max 0.5 mg Total dose 1 mg Bradycardia in pediatric patients primarily related to respiratory issue – assure adequate ventilation first Adolescent (9-14 years): Single Dose max 1 mg Total Dose 2 mg Atropine is not used in asystole in pediatric patients DEXTROSE 10% Hypoglycemia 0.5 g/kg IV (5 ml/kg) Maximum 250 ml Recheck glucose after administration DIPHENHYDRAMINE Allergy - Hives / Itching 1 mg/kg IV or IM Maximum dose 50 mg Consider lower dose (0.5 mg/kg) if patient has already taken po dose in the past two hours for symptoms Cardiac Arrest 0.01 mg/kg IV or IO every 3-5 minutes Max dose 1 mg Anaphylactic Shock Titrate in up to 0.1 mg increments slow IV or IO to a max. of 0.01 mg/kg Allergy/ Anaphylactic Shock 0.01 mg/kg IM Max single dose 0.3 mg Never administer intravenously! Asthma 0.01 mg/kg subcutaneously Maximum dose 0.3 mg If respiratory arrest from asthma or bronchospasm, administer IM Hypoglycemia Weight less than 24 kg: 0.5 mg IM Weight 24 kg or more: 1 mg IM Effect may be delayed 5–20 minutes - if patient responds, give po sugar EPINEPHRINE 1:10,000 EPINEPHRINE 1:1000 GLUCAGON Page 108 Symptomatic Bradycardia Repeat as needed In anaphylactic shock, IM epinephrine 1:1000 should be administered first and epinephrine 1:10,000 IV should only be used if IM is ineffective Contra Costa County Prehospital Care Manual – January 2010 PEDIATRIC DRUG REFERENCE Drug LIDOCAINE Indication IO Pain Seizure MIDAZOLAM Sedation for Cardioversion MORPHINE NALOXONE Pain Control – Trauma, Burn or Non-Traumatic Pain Respiratory Depression or Apnea Pediatric Dosage 0.5 mg/kg IO Maximum dose 20 mg Titrate in up to 1 mg increments IV up to 0.1 mg/kg 0.2 mg/kg IM Maximum dose 10 mg IM 0.1 mg/kg IV or IO titrated in 1 mg increments Maximum dose 5 mg See pain management drug chart for dosage. Use IV increments of up to 2 mg. 0.1 mg/kg IM 0.1 mg/kg IM or IV Maximum dose 2 mg May repeat as needed Contra Costa County Prehospital Care Manual – January 2010 Precautions / Comments Not needed in arrest situations Observe respiratory status carefully Sedation and cardioversion only with base hospital order Can cause hypotension and respiratory depression. Hypotension is more common in patients with volume depletion. Nausea is a frequent side effect. Recheck VS between each dose. Respiratory depression reversible with naloxone. Use IM route initially unless shock present. Shorter duration of action than that of most narcotics. May not reverse vascular effects of narcotics. Page 109 LENGTH-BASED TAPE COLOR – GRAY Weight Range: 3-5 kg (6-11 lbs) Defibrillation Doses: 8 J (1st) / 16 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.13 ml IV Adenosine – 1st dose 3 mg / ml 0.4 mg 0.27 ml IV Adenosine – 2nd dose 3 mg / ml 0.8 mg 1 ml IV Atropine 0.1 mg / ml 0.1 mg 20 ml IV Dextrose 10% 0.1 gm / ml 2g 0.08 ml IV or IM Diphenhydramine 50 mg / ml 4 mg 0.04 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.04 mg 0.4 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.04 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.16 ml IM Midazolam IM 5 mg / ml 0.8 mg 0.08 ml IV Midazolam IV 5 mg / ml 0.4 mg 0.4 ml IM or IV Naloxone 1 mg/ml 0.4 mg 80 ml IV Normal Saline Bolus Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Contra Costa County Prehospital Care Manual – January 2010 Page 111 LENGTH-BASED TAPE COLOR – PINK Weight Range: 6-7 kg (13-15 lbs) Defibrillation Doses: 13 J (1st) / 26 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.22 ml IV Adenosine – 1st dose 3 mg / ml 0.65 mg 0.43 ml IV Adenosine – 2nd dose 3 mg / ml 1.3 mg 0.64 ml IV Amiodarone 50 mg / ml 32 mg 1.3 ml IV Atropine 0.1 mg / ml 0.13 mg 33 ml IV Dextrose 10% 0.1 gm / ml 3.25 g 0.13 ml IM or IV Diphenhydramine 50 mg / ml 6.5 mg 0.06 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.065 mg 0.65 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.065 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.16 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 3.3 mg 0.25 ml IM Midazolam IM 5 mg / ml 1.25 mg 0.1 ml IV – initial 0.13 ml - max Midazolam IV 5 mg / ml 0.65 mg (max.) 0.65 ml IM or IV Naloxone 1 mg/ml 0.65 mg 130 ml IV Normal Saline Bolus Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Page 112 Contra Costa County Prehospital Care Manual – January 2010 LENGTH-BASED TAPE COLOR – RED Weight Range: 8-9 kg (17-19 lbs) Defibrillation Doses: 17 J (1st) / 34 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.28 ml IV Adenosine – 1st dose 3 mg / ml 0.85 mg 0.56 ml IV Adenosine – 2nd dose 3 mg / ml 1.7 mg 0.84 ml IV Amiodarone 50 mg / ml 42 mg 1.7 ml IV Atropine 0.1 mg / ml 0.17 mg 43 ml IV Dextrose 10% 0.1 gm / ml 4.25 g 0.16 ml IM or IV Diphenhydramine 50 mg / ml 8.5 mg 0.08 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.085 mg 0.85 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.085 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.21 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 4.25 mg 0.34 ml IM Midazolam IM 5 mg / ml 1.7 mg 0.1 ml IV – initial 0.17 ml - max Midazolam IV 5 mg / ml 0.85 mg (max.) 0.85 ml IM or IV Naloxone 1 mg/ml 0.85 mg 170 ml IV Normal Saline Bolus Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Contra Costa County Prehospital Care Manual – January 2010 Page 113 LENGTH-BASED TAPE COLOR – PURPLE Weight Range: 10-11 kg (22-25 lbs) Defibrillation Doses: 20 J (1st) / 40 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.33 ml IV Adenosine – 1st dose 3 mg / ml 1 mg 0.7 ml IV Adenosine – 2nd dose 3 mg / ml 2.1 mg 1 ml IV Amiodarone 50 mg / ml 52 mg 2.1 ml IV Atropine 0.1 mg / ml 0.21 mg 53 ml IV Dextrose 10% 0.1 gm / ml 5.25 g 0.2 ml IM or IV Diphenhydramine 50 mg / ml 10 mg 0.1 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.1 mg 1 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.1 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.26 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 5.25 mg 0.4 ml IM Midazolam IM 5 mg / ml 2 mg 0.1 ml IV – initial 0.2 ml IV - max Midazolam IV 5 mg / ml 1 mg (max.) 1 ml IM or IV Naloxone 1 mg/ml 1 mg 210 ml IV Normal Saline Bolus Standard Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Page 114 Contra Costa County Prehospital Care Manual – January 2010 LENGTH-BASED TAPE COLOR – YELLOW Weight Range: 12-14 kg (27-32 lbs) Defibrillation Doses: 26 J (1st) / 52 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.43 ml IV Adenosine – 1st dose 3 mg / ml 1.3 mg 0.9 ml IV Adenosine – 2nd dose 3 mg / ml 2.6 mg 1.3 ml IV Amiodarone 50 mg / ml 65 mg 2.6 ml IV Atropine 0.1 mg / ml 0.26 mg 65 ml IV Dextrose 10% 0.1 gm / ml 6.5 g 0.3 ml IM or IV Diphenhydramine 50 mg / ml 13 mg 0.13 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.13 mg 1.3 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.13 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.33 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 6.5 mg 0.5 ml IM Midazolam IM 5 mg / ml 2.6 mg 0.2 ml IV - initial 0.26 ml IV – max Midazolam IV 5 mg / ml 1.3 mg (max.) 1.3 ml IM or IV Naloxone 1 mg/ml 1.3 mg 260 ml IV Normal Saline Bolus Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Contra Costa County Prehospital Care Manual – January 2010 Page 115 LENGTH-BASED TAPE COLOR – WHITE Weight Range: 15-18 kg (34-41 lbs) Defibrillation Doses: 33 J (1st) / 66 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.6 ml IV Adenosine – 1st dose 3 mg / ml 1.7 mg 1.1 ml IV Adenosine – 2nd dose 3 mg / ml 3.3 mg 1.6 ml IV Amiodarone 50 mg / ml 80 mg 3.3 ml IV Atropine 0.1 mg / ml 0.33 mg 83 ml IV Dextrose 10% 0.1 gm / ml 8.25 g 0.34 ml IM or IV Diphenhydramine 50 mg / ml 17 mg 0.17 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.17 mg 1.7 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.17 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.43 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 8.5 mg 0.7 ml IM Midazolam IM 5 mg / ml 3.4 mg 0.2 ml IV - initial 0.34 ml IV – max Midazolam IV 5 mg / ml 1.7 mg (max.) 1.6 ml IM or IV Naloxone 1 mg/ml 1.6 mg 325 ml IV Normal Saline Bolus Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Page 116 Contra Costa County Prehospital Care Manual – January 2010 LENGTH-BASED TAPE COLOR – BLUE Weight Range: 19-22 kg (42-49 lbs) Defibrillation Doses: 40 J (1st) / 80 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.7 ml IV Adenosine – 1st dose 3 mg / ml 2.1 mg 1.4 ml IV Adenosine – 2nd dose 3 mg / ml 4.2 mg 2.1 ml IV Amiodarone 50 mg / ml 105 mg 4.2 ml IV Atropine 0.1 mg / ml 0.42 mg 105 ml IV Dextrose 10% 0.1 gm / ml 10.5 g 0.4 ml IM or IV Diphenhydramine 50 mg / ml 21 mg 0.21 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.21 mg 2.1 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.21 mg 1 ml IM Glucagon 1 mg / ml 1 mg 0.5 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 10.5 mg 0.8 ml IM Midazolam IM 5 mg / ml 4 mg 0.2 ml IV - initial 0.4 ml IV – max Midazolam IV - Titrate 5 mg / ml 2 mg (max.) 2 ml IM or IV Naloxone 1 mg/ml 2 mg 420 ml IV Normal Saline Bolus Standard in 0.2 ml (1 mg) increments Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Contra Costa County Prehospital Care Manual – January 2010 Page 117 LENGTH-BASED TAPE COLOR – ORANGE Weight Range: 24-28 kg (54-64 lbs) Defibrillation Doses: 53 J (1st) / 106 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 0.9 ml IV Adenosine – 1st dose 3 mg / ml 2.7 mg 1.8 ml IV Adenosine – 2nd dose 3 mg / ml 5.4 mg 2.6 ml IV Amiodarone 50 mg / ml 130 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 135 ml IV Dextrose 10% 0.1 gm / ml 13.5 g 0.5 ml IM or IV Diphenhydramine 50 mg / ml 27 mg 0.27 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.27 mg 2.7 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.27 mg 1 ml IM Glucagon 1 mg / ml 1 mg 0.7 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 13.5 mg 1 ml IM Midazolam IM 5 mg / ml 5.4 mg 0.2 ml IV - initial 0.5 ml IV – max Midazolam IV - Titrate 5 mg / ml 2.7 mg (max.) 2 ml IM or IV Naloxone 1 mg/ml 2 mg 500 ml IV Normal Saline Bolus in 0.2 ml (1 mg) increments Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Page 118 Contra Costa County Prehospital Care Manual – January 2010 LENGTH-BASED TAPE COLOR – GREEN Weight Range: 30-36 kg (65-80 lbs) Defibrillation Doses: 66 J (1st) / 132 J (2nd) ADMINISTER MEDICATION CONCENTRATION DOSE 1.1 ml IV Adenosine – 1st dose 3 mg / ml 3.3 mg 2.2 ml IV Adenosine – 2nd dose 3 mg / ml 6.6 mg 3.3 ml IV Amiodarone 50 mg / ml 165 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 165 ml IV Dextrose 10% 0.1 gm / ml 16.5 g 0.7 ml IM or IV Diphenhydramine 50 mg / ml 33 mg 0.3 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.3 mg 3.3 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.33 mg 1 ml IM Glucagon 1 mg / ml 1 mg 0.8 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 16.5 mg 1.3 ml IM Midazolam IM 5 mg / ml 6.6 mg 0.2 ml IV - initial 0.7 ml IV – max Midazolam IV - Titrate 5 mg / ml 3.3 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 500 ml IV Normal Saline Bolus in 0.2 ml (1 mg) increments Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Contra Costa County Prehospital Care Manual – January 2010 Page 119 For Pediatric Patients Beyond Length-Based Tape PEDIATRIC DOSAGE – 40 kg (90 lbs) ADMINISTER MEDICATION CONCENTRATION DOSE 1.3 ml IV Adenosine – 1st dose 3 mg / ml 4 mg 2.7 ml IV Adenosine – 2nd dose 3 mg / ml 8 mg 4 ml IV Amiodarone 50 mg / ml 200 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 200 ml IV Dextrose 10% 0.1 gm / ml 20 g 0.8 ml IM or IV Diphenhydramine 50 mg / ml 40 mg 0.3 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.3 mg 4 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.4 mg 1 ml IM Glucagon 1 mg / ml 1 mg 1 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 20 mg 1.6 ml IM Midazolam IM 5 mg / ml 8 mg 0.2 ml IV - initial 0.8 ml IV – max Midazolam IV - Titrate 5 mg / ml 4 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 500 ml IV Normal Saline Bolus in 0.2 ml (1 mg) increments Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Page 120 Contra Costa County Prehospital Care Manual – January 2010 For Pediatric Patients Beyond Length-Based Tape PEDIATRIC DOSAGE – 45 kg (101 lbs.) ADMINISTER MEDICATION CONCENTRATION DOSE 1.5 ml IV Adenosine – 1st dose 3 mg / ml 4.5 mg 3 ml IV Adenosine – 2nd dose 3 mg / ml 9 mg 4.5 ml IV Amiodarone 50 mg / ml 225 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 225 ml IV Dextrose 10% 0.1 gm / ml 22.5 g 0.9 ml IM or IV Diphenhydramine 50 mg / ml 45 mg 0.3 ml SC or IM Epinephrine 1:1000 1 mg / ml 0.3 mg 4.5 ml IV Epinephrine 1:10,000 0.1 mg / ml 0.45 mg 1 ml IM Glucagon 1 mg / ml 1 mg 1 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 20 mg 1.8 ml IM Midazolam IM 5 mg / ml 9 mg 0.2 ml IV - initial 0.9 ml IV – max Midazolam IV - Titrate 5 mg / ml 4.5 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 500 ml IV Normal Saline Bolus in 0.2 ml (1 mg) increments Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Contra Costa County Prehospital Care Manual – January 2010 Page 121 Pain Evaluation and Treatment IM MORPHINE 10 mg/ml concentration COLOR / WEIGHT IM DOSE (0.1 mg/kg) GRAY (3-5 kg) Not Given PINK (6-7 kg) 0.06 ml IM (0.6 mg) RED (8-9 kg) 0.08 ml IM (0.8 mg) PURPLE (10-11 kg) 0.1 ml IM YELLOW (12-14 kg) 0.13 ml IM (1.3 mg) WHITE (15-18 kg) 0.17 ml IM (1.7 mg) BLUE (19-22 kg) 0.2 ml IM ORANGE (24-28 kg) 0.25 ml IM (2.5 mg) GREEN (30-36 kg) 0.35 ml IM (3.5 mg) 40 kg 0.4 ml IM 45 kg 0.45 ml IM (1 mg) (2 mg) (4 mg) (4.5 mg) To assure accuracy, be sure the designated concentration is used. Page 122 Contra Costa County Prehospital Care Manual – January 2010 Pain Evaluation and Treatment IV MORPHINE 10 mg/ml concentration 0.05 – 0.1 mg/kg is used in children up to 18 kg. Titrate up to 10 mg as needed in patients > 18 kg. COLOR / WEIGHT FIRST DOSE IV MAXIMUM TOTAL IV DOSE * GRAY (3-5 kg) Not Given Not Given PINK (6-7 kg) 0.03 ml IV (0.3 mg) 0.06 ml IV (0.6 mg) RED (8-9 kg) 0.04 ml IV (0.4 mg) 0.08 ml IV (0.8 mg) PURPLE (10-11 kg) 0.05 ml IV (0.5 mg) 0.1 ml IV YELLOW (12-14 kg) 0.07 ml IV (0.7 mg) 0.13 ml IV (1.3 mg) WHITE (15-18 kg) 0.08 ml IV (0.8 mg) 0.17 ml IV (1.7 mg) BLUE (19-22 kg) 0.1 ml IV (1 mg) 1 ml (10 mg) ORANGE (24-28 kg) 0.1-0.2 ml IV (1-2 mg) 1 ml (10 mg) GREEN (30-36 kg) 0.1-0.2 ml IV (1-2 mg) 1 ml (10 mg) 40 kg 0.1-0.2 ml IV (1-2 mg) 1 ml (10 mg) 45 kg 0.1-0.2 ml IV (1-2 mg) 1 ml (10 mg) (1 mg) * Base contact required for higher doses than maximum listed. Careful titration should be done with repeat dosages. To assure accuracy, be sure the designated concentration is used. Contra Costa County Prehospital Care Manual – January 2010 Page 123 Appendix A Patient Reporting (Handoff) Guidelines Contra Costa County Prehospital Care Manual – January 2010 Page 125 INDEX INDEX 5 5150 hold ............................................... 100, 102 A abdominal pain .................................................. 9 activated charcoal ............................................ 25 acute pulmonary edema ................................... 39 adenosine ............................................. 25, 41, 93 adolescent ........................................................ 98 airway obstruction ....................................... 5, 97 albuterol............................... 69, 81, 84, 105, 108 allergies ..................................................... 18, 60 aloc ........................................................ 3, 84, 91 als procedures ......................................... ii, iii, 30 ALS procedures ............................................... 17 ALT-E ............................................................... 8 altered level of consciousness 18, 21, 40, 48, 49, 50, 70, 72, 76, 79, 90 ambulance ........................................... 1, 12, 102 anaphylactic shock .................................. 75, 108 anaphylaxis ...................................................... 92 angina ...................................................... 69, 106 apnea ....................................... 8, 68, 85, 96, 104 assessment .... 5, 6, 7, 8, 9, 10, 11, 17, 18, 19, 21, 36, 47, 49, 59, 78, 84, 85, 95 asystole .................................... 89, 104, 105, 108 atropine .............. 26, 63, 64, 79, 89, 90, 105, 108 B base hospital 1, 2, 8, 13, 27, 30, 59, 85, 100, 102, 103, 109 benzodiazepine ................................................ 74 bleeding ......... 5, 8, 11, 12, 46, 48, 60, 68, 84, 97 blood pressure .... 6, 7, 10, 17, 20, 39, 65, 66, 81, 92, 97 bougie .......................................................... ii, 33 bradycardia ...................... 49, 64, 90, 96, 97, 105 bronchospasm .................... 79, 81, 105, 106, 108 burn center ....................................................... 13 burns .............. 7, 13, 19, 21, 39, 72, 93, 101, 103 C calcium chloride ................ 4, 26, 63, 79, 84, 105 capillary refill .................... 49, 78, 90, 91, 92, 97 carbon dioxide ......................... 12, 31, 61, 62, 63 Contra Costa County Prehospital Care Manual – January 2010 carbon monoxide ..............................................13 cardiac arrest ...7, 8, 9, 28, 31, 32, 34, 38, 39, 41, 49, 50, 52, 61, 79, 80, 93, 95, 96, 104, 107 cardiogenic shock.............................................50 cardiopulmonary arrest ......................................8 cervical collar .........................................9, 10, 22 cervical spine .........................................9, 10, 35 chemical burns .................................................13 chest pain ...................65, 66, 67, 68, 80, 81, 100 chief complaint...................................18, 95, 100 child abuse ...................................................8, 85 childbirth ............................................................9 choking .........................................................8, 85 circulatory failure .........................................8, 92 clammy .........................................................7, 92 co2 ................................10, 27, 30, 34, 35, 37, 38 CO2 ............................................................30, 37 communications .................................................1 congestive heart failure (CHF).........................39 cool .......................................7, 13, 43, 49, 76, 92 copd ......................................................32, 39, 81 critical trauma ......................................41, 59, 85 cyanosis ..........................................49, 69, 87, 97 D decorticate posturing ........................................10 defibrillation ...17, 19, 20, 25, 28, 51, 86, 88, 104 determination of death ...................................101 dextrose 50% ............................................70, 105 diabetes ....................................5, 18, 48, 70, 107 documentation ........................................8, 18, 51 dopamine ..................26, 49, 64, 68, 76, 106, 107 dusky ..................................................................7 dysrhythmia..........................................41, 42, 93 E edema .............................4, 39, 41, 50, 68, 80, 81 EMT-I ..................................................17, 18, 25 endotracheal intubation .....25, 27, 30, 34, 37, 39, 61, 96 extubation .........................................................30 eyes ........................................................3, 79, 83 F foreign body obstruction ..................................27 Page 131 G N glucagon .................. 26, 41, 44, 70, 93, 106, 108 naloxone 26, 41, 44, 46, 70, 78, 80, 93, 106, 109, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121 needle thoracostomy ........................................25 H heart rate ... 6, 7, 8, 12, 39, 49, 64, 67, 86, 87, 90, 91, 92, 95, 97 heat stroke ....................................................... 76 helicopter ................................................... 1, 102 heparin locks ............................................. 18, 25 history... 2, 3, 4, 8, 18, 38, 41, 59, 68, 69, 71, 81, 82, 85, 91, 92, 95, 100, 105, 106, 107 hyperresonance ................................................ 40 hyperventilation................. 28, 32, 62, 63, 88, 89 hypotension .... 11, 60, 64, 65, 68, 69, 72, 76, 79, 81, 84, 90, 97, 100, 105, 106, 107, 108, 109 hypothermia... 11, 13, 63, 72, 77, 86, 89, 92, 104 hypovolemic shock........................................ 5, 9 hypoxia .................................... 47, 49, 63, 71, 89 I ice .................................................................... 11 immobilization ... 6, 9, 10, 11, 12, 17, 21, 22, 30, 33, 59, 82, 85 implantable defibrillators ................................ 19 infant ......................... 7, 8, 73, 85, 87, 88, 91, 92 inhalation ........................................... 13, 25, 103 J John Muir Medical Center .............................. 99 jugular vein distension .................................... 40 L laryngoscope ........................... 25, 30, 33, 62, 63 level of consciousness 17, 18, 19, 21, 40, 48, 49, 50, 52, 64, 68, 70, 72, 76, 77, 78, 79, 80, 90, 92, 93 lidocaine ........................ 26, 41, 43, 93, 106, 109 M magill forceps .................................................. 27 mechanism of injury...................... 10, 11, 21, 93 medical director ................................... 17, 25, 26 medications 2, 12, 17, 18, 25, 26, 41, 45, 59, 62, 63, 70, 74, 77, 81, 84, 85, 88, 89, 91, 93, 100 midazolam 26, 41, 49, 64, 65, 66, 67, 71, 82, 91, 96, 106, 109 moist .................................................................. 7 morphine sulfate .... 26, 49, 60, 64, 72, 78, 79, 81 mottled ........................................................ 7, 92 Page 132 O oral glucose ................................................17, 18 organophosphate poisoning .................................. 105 oropharyngeal airway ......................................17 overdose ...............30, 46, 63, 77, 79, 80, 96, 100 oxygen ...4, 10, 12, 13, 17, 30, 34, 35, 36, 37, 47, 67, 77, 87, 105 P pacemakers .......................................................19 pale ............................................................... 7, 77 past medical history ............................... 2, 18, 85 pediatric patients .....7, 28, 42, 43, 69, 71, 79, 82, 84, 85, 103, 108 peripheral vascular resistance ............................7 pneumothorax .......................... 39, 40, 63, 84, 89 pre-existing vascular access .............................25 pregnancy .........................................87, 100, 104 prolapsed cord ....................................................5 pulmonary edema ................. 4, 39, 41, 50, 80, 81 pulse oximetry......................................47, 96, 97 R radio channels ....................................................1 report ............................2, 3, 5, 19, 51, 59, 85, 95 respiratory arrest .................. 42, 69, 81, 106, 108 respiratory distress ......................... 39, 64, 69, 81 resqpod .............................................................38 restraints ...................................................71, 102 S saline lock ..................................................25, 45 San Ramon Regional Medical Center ..............99 seizure .............................................. 8, 76, 82, 85 sepsis ........................................ 12, 43, 68, 70, 92 sexual assault .............................................9, 104 shock .....3, 5, 7, 9, 11, 13, 19, 20, 21, 41, 42, 44, 46, 49, 50, 59, 60, 61, 62, 64, 68, 69, 71, 75, 77, 80, 85, 86, 88, 91, 92, 93, 97, 107, 108, 109 sinus tachycardia ..........................................4, 91 skin signs..........................................................49 spinal immobilization ...9, 10, 11, 21, 22, 33, 59, 82, 85 Contra Costa County Prehospital Care Manual – January 2010 Spinal immobilization ............................... 10, 21 stable ....... 2, 3, 4, 13, 41, 50, 65, 66, 84, 93, 100 stridor .............................................................. 69 stroke ....................................... 11, 41, 59, 76, 83 suctioning ........................................................ 36 synchronized cardioversion ....................... 25, 66 triage ........................................................17, 102 T V tachycardia ..... 4, 66, 67, 69, 76, 79, 91, 92, 105, 108 tension pneumothorax ................... 40, 63, 84, 89 tracheal shift .................................................... 40 tracheostomy ............................. ii, 18, 36, 37, 39 traction....................................................... 36, 78 trauma . 1, 2, 3, 4, 5, 8, 10, 11, 17, 21, 28, 30, 34, 38, 39, 41, 42, 59, 71, 72, 77, 79, 82, 84, 85, 96, 97, 98, 100, 101, 102, 103 trauma center ........................... 2, 3, 21, 101, 103 trauma destination ......................................... 1, 2 trauma destination decision ............................... 1 vaginal bleeding .................................................8 ventricular fibrillation ........................................4 vital signs .......7, 18, 31, 69, 71, 75, 82, 100, 102 Contra Costa County Prehospital Care Manual – January 2010 U unmanageable airways ...............................5, 103 unstable .....2, 3, 4, 41, 42, 64, 65, 66, 67, 75, 79, 90, 91, 93, 100 W wheezing ..........................................................69 X XCC EMS 1 .......................................................1 XCC EMS 2 .................................................1, 99 XCC EMS 3 .......................................................1 XCC EMS 4 .......................................................1 Page 133
