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Emergency Medical Technician – Intermediate Protocols Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 1 of 45 TABLE OF CONTENTS INTRODUCTION ....................................................................................................... 3 DEVIATION FROM PROTOCOL ........................................................................ 3 COMMUNICATIONS ........................................................................................... 3 GENERAL HISTORY AND PATIENT PHYSICAL ASSESSMENT ...................... 4 STANDING ORDERS ................................................................................................ 5 ALLERGIC REACTION / ANAPHYLAXIS ............................................................. 6 BURNS ........................................................................................................................ 7 BURNS (continued) ..................................................................................................... 8 CHEST PAIN............................................................................................................... 9 CARDIAC ARREST .................................................................................................. 10 DIABETIC EMERGENCIES ..................................................................................... 11 DYSPNEA .................................................................................................................. 12 DYSPNEA (continued) ............................................................................................... 13 HEAT EMERGENCIES ............................................................................................. 14 HYPOTHERMIA ....................................................................................................... 15 INTRAVENOUS CATHETERIZATION .................................................................. 16 TRAUMA ....................................................................................................................17 TRAUMA (continued) .................................................................................................18 HEAD TRAUMA .................................................................................................. 18 OBSTETRIC EMERGENCIES .................................................................................. 19 OBSTETRIC EMERGENCIES (continued) ...............................................................20 OBSTETRIC EMERGENCIES (continued) ...............................................................21 OBSTETRIC EMERGENCIES (continued) ...............................................................22 OXYGEN THERAPY ................................................................................................ 23 OXYGEN THERAPY (continued) ............................................................................. 24 POISONING / TOXIN EXPOSURE / OVERDOSE ................................................. 25 POISONING / TOXIN EXPOSURE / OVERDOSE (continued) .............................. 26 SEIZURES / GENERAL MOTOR ............................................................................. 27 SHOCK ....................................................................................................................... 28 SHOCK (continued).................................................................................................... 29 UNRESPONSIVE PATIENT ..................................................................................... 30 PEDIATRICS ............................................................................................................. 31 PEDIATRIC DYSPNEA (continued) ......................................................................... 32 PEDIATRIC DYSPNEA (continued) ......................................................................... 33 PEDIATRIC DYSPNEA (continued) ......................................................................... 34 APPENDIX – APGAR ................................................................................................ 35 APPENDIX – GLASGOW COMA SCALE ................................................................36 APPENDIX – SEMI-AUTOMATED EXTERNAL DEFIBRILLATION ................. 37 APPENDIX – SAED (continued)................................................................................ 38 APPENDIX – PARAMEDIC INTERCEPT ............................................................... 39 APPENDIX – PRESUMPTION OF DEATH ............................................................. 40 APPENDIX – RULE OF NINES ................................................................................ 41 APPENDIX – D50W ADMINISTRATION ............................................................... 42 APPENDIX – COMBITUBE ................................................................................ 43-45 Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 2 of 45 INTRODUCTION The protocols listed here are intended to be guidelines for pre-hospital patient management. These protocols have been refined to meet the needs of the evolving EMTIntermediate curriculum and will replace the existing “Charlotte Hungerford Hospital’s Hospital EMT-IV Protocols”. These protocols should help the Intermediates understand what is expected of them while providing patient care. DEVIATION FROM PROTOCOL These protocols cannot be expanded upon except in extreme circumstances and with the full agreement and responsibility from the Medical Control Physician. Any deviation from protocol shall be documented in the Patient Care Report with an explanation of why it occurred. COMMUNICATIONS Medical Control will be obtained from any one of the Region Five Hospitals, depending on where the patient is being transported. If the patient is going to be transported to a hospital other than the above listed, then your sponsor Hospital will be utilized as Medical Control. Charlotte Hungerford Hospital can be reached by telephone at the following numbers: (860) 496-6650 (860) 496-6666 Emergency Department Hospital Operator Danbury Hospital can be reached by telephone at the following numbers: (203) 797-7100 (203) 797-7500 Emergency Department Hospital Operator New Milford Hospital can be reached by telephone at the following numbers: (860) 350-7222 (860) 355-2611 Emergency Department Hospital Operator St. Mary’s Hospital can be reached by telephone at the following numbers: (203) 574-6004 (203) 574-6000 Emergency Department Hospital Operator Sharon Hospital can be reached by telephone at the following numbers: (860) 364-4111 (860) 364-4141 Emergency Department Hospital Operator Waterbury Hospital can be reached by telephone at the following numbers: (203) 573-6290 (203) 573-6000 Emergency Department Hospital Operator Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 3 of 45 GENERAL HISTORY AND PATIENT ASSESSMENT Observation of the environment Mechanism of injuries Sex, age and weight Chief complaint HISTORY OF PRESENT ILLNESS Provoked-onset Quality Region Severity Quantity Aggravation-alleviation Associated complaints Attempts to modify symptoms PHYSICAL EXAMINATION Initial Assessment Focused History & Physical *Level of consciousness *Respirations (including lung sounds) *Pulse *Blood pressure *Skin (color-moisture-temperature) *Pupils *Neuro (movement of extremities-strength) *Glasgow Coma Scale SAMPLE *Symptoms *Allergies *Medications *Past medical history (appropriate to current chief complaint) *Last oral intake *Events leading up to Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 4 of 45 IV STANDING ORDERS Intravenous therapy may be initiated on standing orders by medically authorized Intermediates in the presence of life threatening situations under the following guidelines and circumstances: BURNS (>20% TBSA 2ND AND 3RD DEGREE) CARDIAC ARREST CARDIAC CHEST PAIN-sub-sternal, diaphoresis, dyspnea, with cardiac history DIABETIC EMERGENCIES (altered mental status with diabetic history) DYSPNEA: ANAPHYLAXIS-moderate to severe distress with wheezing and/or hypotension PULMONARY EDEMA-moderate to severe distress with rhales, diaphoresis and/or hypertension 6) TRAUMA-with signs of: DYSPNEA *SCENE TIME NO > THAN 10 MIN* TACHYCARDIA *IV STARTED ENROUTE* HYPOTENSION RIGID ABDOMEN SIGNIFICANT BLOOD LOSS 7) UNRESPONSIVE PATIENT 8) SHOCK: HYPOTENSION-systolic blood pressure <100 with signs and symptoms 1) 2) 3) 4) 5) *IV’S will be started only after a complete examination, including lung sounds *Intravenous fluid shall consist only of 0.9 sodium chloride (normal saline) *Whenever possible, IV’s shall be started while enroute to the E.D. or ALS intercept. *Documentation must include findings to support the standing order *IV will be run to K.V.O. unless fluid replacement is desired. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 5 of 45 ALLERGIC REACTION / ANAPHYLAXIS Allergic reaction: patient is stable (No airway compromise, No shock). Patient may have red-raised rash, c/o itchy skin, or reported contact/ingestion of allergic substance. Oxygen as per protocol Establish Medical Control Transport position of comfort Possible Physician Orders: Establish IV Paramedic Intercept Anaphylaxis: patient is unstable (Upper airway obstruction, Shock). Patient may have audible wheezes, altered mental status. Airway management as per protocol Oxygen per protocol Request Paramedic Intercept Establish Medical Control Transport to ED or Intercept location Establish IV while enroute Possible Physician Orders: Administration of Epi Pen or Epi Pen jr. Fluid Challenge patient, IV wide open Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 6 of 45 BURNS Thermal Stop the burning process and remove the patient from the source of injury if safe to do so. Consider respiratory insult due to possible toxic inhalation or from superheated atmosphere. Check airway for burns, blackness, or singed hair. Check for signs of dyspnea. If any of these are present, give the patient high flow O2. Leave clothing intact (unless burning). Remove jewelry from affected area. Do not remove any loose tissue or skin. Estimate the extent of burn to the total body surface area using the rule of nines. Palm Method-palm is equal to approx. 1% adult TBSA Apply sterile burn sheets to area (dry) for 3rd degree burns. If burns are 1st or 2nd degree and less than 15% TBSA, apply moistened sheets using normal saline. Use caution as this may precipitate hypothermia. Oxygen as per protocol. Monitor vital signs. Consider Paramedic Intercept for airway or pain control Establish IV per S.O. protocol Establish Medical Control Transport Possible Physician Orders: IV flow rate to maintain patient’s fluid balance Chemical: Stop the burning process and remove the patient from the source of injury if safe to do so. Remove affected clothing. Brush off all dry chemical-avoid inhalation and contamination of yourself. Try to obtain the name of the chemical for identification of side effects. If possible, obtain MSDS form for chemical. Flush with copious amounts of water/saline unless contraindicated. Oxygen as per protocol. Monitor vital signs. Consider Paramedic Intercept for airway or pain control Establish IV per S.O. protocol Establish Medical Control Transport Possible Physician Orders: IV flow rate to maintain patient’s fluid balance. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 7 of 45 BURNS (con’t) Electrical: If patient is responsive: Paramedic Intercept-patient needs cardiac monitoring Oxygen as per protocol. Monitor vital signs. Treat any thermal burns as per protocol. Transport Establish Medical Control Possible Physician Orders: Establish IV and flow rate. If patient is unresponsive: Request Paramedic Intercept Oxygen and airway as per protocol Transport to ED or Intercept location Establish IV enroute as per protocol. Establish Medical Control If patient is pulseless and apneic, follow cardiac arrest protocol. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 8 of 45 CHEST PAIN (possible acute myocardial ischemia) Initial assessment: Oxygen –high flow unless contraindicated Request Paramedic Intercept Establish IV access per S.O. protocol Establish Medical Control Transport to ED or Intercept Possible Physician Orders: Administration of Nitroglycerin Adjustment of IV and/or Oxygen flow rates Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 9 of 45 CARDIAC ARREST MEDICAL Assess patient (ABC’s) Request Paramedic Intercept Initiate CPR-D If indicated begin Semi-Automatic External Defibrillator sequence: 200J 300J 360J CPR x 1 Min 360J 360J 360J Airway Management: EOA if indicated Establish IV access Transport patient to ED or intercept. Patient may be reanalyzed while enroute Establish Medical Control TRAUMATIC Establish airway with C-spine control and stabilization. Begin CPR. Request Paramedic Intercept. Immobilize patient Transport to closest Trauma Center (Please refer to State wide Trauma Protocols). Establish IV access, Large Bore, wide open. YOU MAY START TWO LINES. Establish Medical Control-Trauma Alert Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 10 of 45 DIABETIC EMERGENCIES Initial assessment/routine care. Oxygen as per protocol. If available, check the patient’s Blood Sugar If patient is unresponsive (GCS < 10): Request Paramedic Intercept and refer to Unresponsive protocol Establish IV access as per S.O. protocol (#18 guage or larger) Establish Medical Control Possible Physician Orders: Administration of D50W If patient is responsive (GCS > 10): If patient has an intact gag reflex, and is able to comply, give 1 tube oral glucose. Possible Physician Orders: Paramedic Intercept Establish IV access and flow rate Repeat Oral Glucose Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 11 of 45 DYSPNEA – Excluding upper airway obstruction If respiratory distress is due to an allergen (i.e. :insect bite, etc.) proceed to the anaphylaxis protocol. Oxygen as per protocol. If moderate to severe respiratory distress, request Paramedic Intercept. Sit patient up on stretcher (if BP low recline to 45 degrees). Transport to ED or Intercept location. Establish Medical Control Possible Physician Orders: IV and flow rate (if moderate or severe, use S.O. protocol) Assist patient with their own Multi Dose inhaler Acute Cardiogenic Pulmonary Edema Protocols as above. Paramedic Intercept. Assist ventilations if necessary. Have patient sit up on stretcher to ease respiratory effort. STAT transport to ED or Intercept. Establish IV, Run to K.V.O. Establish Medical Control Asthma Any patient with a history of asthma or similar presentation experiencing moderate to severe distress who has not used their inhaler upon EMS arrival should be encouraged to use it in the manner prescribed by their private physician. PLEASE REMEMBER: A WHEEZE IS NOT ALWAYS ASTHMA Moderate to severe patients require a Paramedic Intercept. Oxygen as per protocol Assist ventilations if necessary. Have patient sit up on stretcher to respiratory effort. Establish Medical Control Possible Physician Orders: IV and flow rate (if moderate or severe, use S.O. protocol) Assist patient with their own Multi Dose inhaler Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 12 of 45 DYSPNEA- (con’t) COPD- with bronchospasm Any patient experiencing moderate to severe respiratory distress, who has not used their inhaler upon EMS arrival, should be encouraged to use it in the manner prescribed by their private physician. Moderate to severely distressed patients require Paramedic Intercept Assist ventilations if necessary. Have patient sit up on stretcher to ease respiratory effort. Transport to ED or Intercept point Establish Medical Control Possible Physician Orders: IV and flow rate (if moderate or severe, use S.O. protocol) Assist patient with their own Multi Dose inhaler Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 13 of 45 HEAT EMERGENCIES Elderly patients and children are more susceptible to heat emergencies Maintain airway, breathing and circulation. Remove patient from warm environment. Oxygen as per protocol. Shock protocol as needed. Begin gradual cooling measures. Rapid cooling can harm the patient. Obtain accurate history including rate of onset. Decide if Paramedic Intercept is needed. Transport to ED Establish Medical Control Possible Physician Orders: More aggressive cooling measures IV and flow rate Paramedic Intercept Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 14 of 45 HYPOTHERMIA The emphasis of this protocol is to perform only the absolutely essential ALS treatment on the scene and initiate rapid but careful transport. Maintain airway, breathing and circulation. Oxygen as per protocol. Assist ventilations as necessary. Handle all hypothermia patients with care. Rough handling may precipitate ventricular fibrillation. Do not presume death in the unresponsive, non-breathing, pulseless patient with suspected hypothermia. Patients are not dead until they are warm and dead. Initiate CPR as needed. Applying external heat may precipitate ventricular fibrillation. Remove all clothing and maintain the patient in a warm, draft-free environment. Cover the patient including the head, leaving the face exposed. Truly hypothermic patients require Paramedic Intercept for cardiac monitoring. Transport to ED or Intercept location. Establish Medical Control Possible Physician Orders: Warmed IV fluids and flow rate Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 15 of 45 INTRAVENOUS ACCESS Intravenous access may be initiated by standing order or after consultation with Medical Control using the following guidelines: ATTEMPTS - The Intermediate will not attempt IV access on any patient less than 12 years old Only one attempt will be made on scene. If the patient is in critical condition, one more attempt may be made by the Intermediate while enroute to the hospital or intercept point. Trauma patients require rapid transport to the ED, therefore, IV access shall only be initiated while enroute to the hospital. DETERMINATION OF SIZE - - All patients requiring IV access, but not fluid resuscitation shall have an IV established at a flow rate to K.V.O., and access shall be through an 18 guage catheter or smaller (except in cases of “diabetic emergency”) Any patients requiring fluid resuscitation shall have an IV established with an 18 guage catheter or larger whenever possible. FLUID RESUSCITATION - Lung sounds must be assessed prior to fluid resuscitation Patients without a cardiac and/or respiratory history, with clear lung sounds may be given an initial bolus of 250ml (Normal Saline). Patients with a cardiac and/or respiratory history, with clear lung sounds may be given and initial bolus of 100ml (Normal Saline). If the patient’s lungs are not clear, contact Medical Control. Please remember to reassess after each fluid bolus LOCATION - - Use of the Anticubital fossa (AC) shall be reserved for those patients in critical condition, or when previous attempts distal to the AC have failed. Please remember, if the vein is infiltrated, you may establish an IV proximal to the infiltrated site, but you may not make another attempt distal to that site. That is why we tell you to “start with the hands and work your way up to the AC”. DOCUMENTATION - Remember to document the number of attempts The location of the IV The guage of the catheter The solution (Normal Saline), and the flow rate Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 16 of 45 TRAUMA (Transport! Transport! Transport!) The following require Paramedic Intercept: Auto Vs Pedestrian Motorcycle Operators and Passengers Prolonged Extrications Death of the occupant in the same car Multi-System Trauma Initial Assessment Airway-cervical spine immobilization. Breathing-expose chest, check for adequate air exchange. Circulation-identify and control bleeding. Disability-brief neurological evaluation. Expose-do not palpate blindly. Focused History & Physical Exam Head-skull depressions/fluid from nose, ears or mouth/pupils Maxillo-facial Chest/Back-rib fx?, lung sounds, Sub. Emphysema, entrance or exit wounds Abdomen-rigid?, tender? Extremities-fractures?, bleeding? GLASGOW COMA SCALE – This will be done on ALL trauma patients and documented on the run-form. Treatment Is the scene safe? # of patients? Immobilize C-spine with C-collar, backboard with at least 3 sets of straps & CID. Oxygen as per protocol. Airway maintenance, CPR, and other life saving protocols for patient care should be initiated when the problem is identified. Transport to ED or Intercept location. Initiate shock protocol if necessary. IV per S.O. if patient presents with: Dyspnea Tachycardia Hypotension Rigid Abdomen Significant blood loss Possible Physician Orders: PASG Aggressive fluid resuscitation with multi-IV’s Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 17 of 45 TRAUMA – (con’t) HEAD TRAUMA Routine care-Glasgow Coma Scale Maintain airway while performing spinal immobilization Oxygen as per protocol If patient is unresponsive with respiratory compromise, secure airway and ventilate at normal or slightly increased rates. Paramedic Intercept for airway control If hypotensive, treat for shock. Establish Medical Control Possible Physician Orders: IV and fluid rate Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 18 of 45 OBSTETRIC EMERGENCIES Normal Delivery Routine patient care. Oxygen as per protocol. Determine if delivery is imminent, check for crowning. Other possible indications of imminent delivery: -Contractions 2-3 minutes apart, duration 1 minute. -Woman that has had multiple deliveries. -Amniotic sac has broken -Woman has the urge to “bear down” or move her bowels Prepare for delivery, allow delivery to progress, position the patient on her back and assemble OB kit. When the head emerges, support it and use bulb syringe to suction nose/mouth. Tear amniotic sac if not already torn (before delivery of shoulders and chest). If umbilical cord is around neck, gently slip it over the head. If unable to do so, place umbilical clamps 2 inches apart and cut cord between clamps (must have access to airway before clamping). Deliver anterior shoulder, then posterior shoulder. If umbilical cord is not already cut, place a clamp 6 inches from the infant’s navel, place second clamp 8 inches from the infant and cut between the clamps. Check both ends for bleeding/apply additional clamps if bleeding is present. Dry baby and wrap up to prevent hypothermia.-Cover the head Medical Terminology Gravida: the number of all of the woman’s current and past pregnancies Para: the number of pregnancies that have remained viable to delivery. Example: a woman that is pregnant for the fourth time, and has two children, is said to be gravida 4, para 2. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 19 of 45 OBSTETRIC EMERGENCIES (con’t) APGAR SCORE ACTIVITY LIMP SOME FLEXION ACTIVE, MUCH FLEXION 0 1 2 PULSE NONE <100 PER MINUTE >100 PER MINUTE 0 1 2 GRIMACE, REFLEX TO SUCTION NONE SOME GRIMACING SNEEZES, COUGH, OR CRIES 0 1 2 RESPIRATIONS NONE IRREG, INEFFECTIVE, BRADYPNEIC RHYTHMIC, EFFECTIVE, CRYING 0 1 2 Evaluate newborn based on APGAR score at 1 minute and 5 minutes. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 20 of 45 OBSTETRIC EMERGENCIES (con’t) Delivery of placenta should occur within 30 minutes. Once delivered, place placenta in a plastic bag and take to hospital. If placenta has not been delivered in 10 minutes, do not delay transport. If post-partum bleeding is excessive, massage lower abdomen firmly (uterine massage). If mother is going to breastfeed, assist her in putting baby to breast. Transport to ED or Intercept location. Establish Medical Control Possible Physician Orders: IV and flow rate COMPLICATIONS OF PREGNANCY AND DELIVERY Breech Presentation Proceed immediately to the Hospital Establish Medical Control Prepare mother for normal delivery. Allow buttocks and trunk to deliver spontaneously. Support the infant with the palm and volar surface of arm. If head does not deliver in 3 minutes, place gloved hand into the birth canal with the palm toward the baby’s face. Form a “V” with fingers on either side of the baby’s nose/mouth and push the vaginal wall away from the infant’s face to allow for ventilation. Transport the mother with the buttocks elevated on pillows and maintain the infant’s airway as described above. Prolapsed Cord Proceed immediately to the hospital. Place mother in supine position with hips elevated, (or knee-chest w/hips elevated). Place mother on high flow O2 Assess cord, if pulse can be felt, maintain mother’s position. If pulse cannot be felt when touching the cord, insert a gloved hand into the birth canal and attempt to gently elevate the presenting part off of the cord to relieve the compression to the cord, then reassess for return of pulsation to the cord. Maintain this position until relieved by Emergency or OB staff. Establish Medical Control Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 21 of 45 OBSTETRIC EMERGENCIES (con’t) Limb Presentation Place mother in Trendelenberg position (feet elevated). Transport immediately. Multiple Births This should not present a unique problem After delivery of the first infant, tie off the cord as for normal delivery. If second infant has not delivered within 10 minutes, transport immediately. If first infant out is a Breeched presentation that does not deliver the head within 2 minutes, begin rapid transport to the hospital. Antepartum Hemorrhage Treat as per shock protocol. Post Partum Hemorrhage Treat as per shock protocol. Uterine massage, put baby to breast (if mother is breast-feeding). Establish Medical Control Possible Physician Orders: Paramedic Intercept IV and flow rate Eclampsia: seizures Paramedic Intercept Reduce external stimulus-no lights and siren unless extremely necessary. Place patient on her left side to ease blood flow to the heart. Monitor blood pressure carefully. Look for hypertension. Beware of possible seizures and take precautions to minimize injury High flow O2 Establish Medical Control Possible Physician Orders: Paramedic Intercept IV and flow rate Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 22 of 45 OXYGEN EQUIPMENT FLOW RATE Nasal Cannula Non-Rebreather (NRB) Bag-Valve-Mask (BVM 1-5 L/Min 10-15 (fill reservoir bag) 15 L/Min Patient Respiratory Status Equipment / Flow Rate No Distress color pink skin warm and dry respirations full, effective, and unlabored None Mild Distress mild chest pain asthma/COPD with mild distress Cannula 1-2 L/Min Moderate Distress chest pain with dyspnea CVA major fractures head injuries (concussion) asthma/COPD with moderate distress multi-system trauma chest injuries NRB 10-15 L/MIN Severe Distress Shock head injuries (concussion) smoke inhalation CHF/pulmonary edema Near drowning Any sign of cyanosis NRB 15L/MIN, BVM Assist Respiratory Arrest BVM with Nasal or Oral Airway Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 23 of 45 OXYGEN (con’t) Special Considerations 1. COPD patients, gradually increase O2 if signs and symptoms persist. Be prepared to assist ventilations. DO NOT WITHHOLD O2 IF THE COPD PATIENT DISPLAYS SIGNS/SYMPTOMS OF RESPIRATORY DISTRESS. 2. Inadequate respirations need to be assisted with BVM. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 24 of 45 POISONING / TOXIN EXPOSURE / OVERDOSE Initiate routine care. Determine the following: What was ingested? When was it ingested? How was it ingested? How much was ingested? Did patient vomit after? Did patient eat before or after? Was alcohol involved? If possible, and safe, bring pill bottles or toxin container to ED with patient. When establishing medical control, provide the above answers to ED as well as the patient’s condition. Oxygen as per protocol. Support ventilations as needed. Paramedic Intercept if needed. Treat all life threatening situations as per appropriate protocol. Specific Treatment Ingestion If patient is unresponsive (GCS 3-10) – Paramedic Intercept If patient is responsive (GCS > 10): Establish Medical Control Possible Physician Orders: IV and flow rate Charcoal 25-50 Gms. PO (by mouth) Inhaled Exposure Remove patient from toxin if safe to do so. Oxygen and ventilation support as per protocol. Paramedic Intercept if needed. Transport to ED or Intercept location. Establish Medical Control Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 25 of 45 POISONING / TOXIN EXPOSURE / OVERDOSE (con’t) Topical Exposure Remove patient from the source of contamination if safe to do so. Remove any contaminated clothing if safe to do so. Remove any contaminant if safe to do so. If Solid: Brush away all solid contaminant if safe to do so. Establish Medical Control Possible Physician’s Orders: Irrigate with copious amounts of water if not contraindicated. If Liquid: Establish Medical Control Possible Physician’s Orders: Flush with copious amounts of water when not contraindicated. * Unless contraindicated, if the eye(s) have been exposed to a contaminant they should be flushed with 1000ml of 9% Normal Saline Solution (per eye). Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 26 of 45 SEIZURES / GRAND MAL Maintain airway / suction as needed. Seizure patients needed good airway management. Assist ventilations as needed. Oxygen as per protocol. Protect patient from injury. Paramedic Intercept If patient is unresponsive (GCS 3-10), IV as per SO protocol. Transport to ED or intercept point Establish Medical Control Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 27 of 45 SHOCK Defined as: If the patient’s systolic blood pressure is 80 mm or less. If the patient’s systolic blood pressure is 80-100 mm and the other signs/symptoms of shock are present. Signs: Altered Mental Status Tachycardia Tachypnea Pale, ashen, cyanotic skin Clammy, diaphoretic skin Cool, dry skin Hemmorrhagic/Hypovolemic Shock Paramedic Intercept Trendelenberg position unless contraindicated. Control obvious bleeding Oxygen as per protocol. Establish large bore IV line NaCl Initiate 250cc fluid bolus and reassess vital signs Transport to ED or Intercept point Establish Medical Control Possible Physician’s Orders: Second large bore IV NaCl Second 250cc fluid bolus IV at wide-open rate. Apply MAST unless contraindicated. Cardiogenic Shock Oxygen as per protocol. Transport in Trendelenberg position if possible. Paramedic Intercept Establish Medical Control Possible Physician’s Orders: IV and fluid rate 200cc Fluid bolus MAST Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 28 of 45 SHOCK – (con’t) Neurogenic Shock Routine care-GCS Neurodeficit to lower extremities or upper and lower extremities *Maintain airway while performing spinal immobilization* Oxygen as per protocol. Paramedic Intercept Establish IV as per SO protocol Transport to ED or Intercept point Establish Medical Control Possible Physician Orders: Apply & Inflate MAST Fluid rate Additional Note Consider other causes of shock: Tension pneumothorax Sepsis Metabolic Toxic Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 29 of 45 UNRESPONSIVE PATIENT Maintain airway and administer O2 as per protocol. Request Paramedic Intercept. Perform brief neurological exam to include Glasgow Coma Scale and pupil response. Monitor vital signs. Treat all underlying complications as per appropriate protocol. Determine from family/bystanders any pertinent history. Transport to ED or Intercept point Establish Medical Control Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 30 of 45 PEDIATRICS Special Note: The pediatric is not a small adult and therefore requires an “inverted pyramid” approach to interventions with a secure airway and adequate oxygenation being first and foremost. Almost all cardiac arrests are secondary to respiratory arrests. Drying, warming, positioning, suction, tactile stimulation Oxygen Bag-valve-mask ventilation Chest compressions Intubation Medications Normal Heart Rates by Age (beats per min.) Age Neonate Infant (6 months) Toddler Preschooler School-age child Adolescent Awake 100-180 100-160 80-110 70-110 65-110 60-90 Sleeping 80-160 75-160 60-90 60-90 60-90 50-90 Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 31 of 45 PEDIATRICS (cont.) Normal Systolic Blood Pressure by Age Age 0 to 1 month old 1 month old to 1 year old Older children Systolic Blood Pressure (mmHg) Greater than 60 Greater than 70 70 + (2 x age in years) Normal Respiratory Rates by Age Age Infant Toddler Preschooler School age Adolescent Breaths Per Minute 30-60 24-40 22-34 18-30 12-18 Signs of Respiratory Distress Nasal flaring Inspiratory retractions (sternal, supraclavicular, intercostal and substernal Tachypnea Head-bobbing See-saw respirations Restlessness Tachycardia Grunting Stridor Signs of Respiratory Failure Cyanosis Diminished breath sounds Decreased level of consciousness Poor skeletal muscle tone Inadequate respiratory rate, effort or chest excursion Tachycardia Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 32 of 45 PEDIATRICS (CON'T) Comparison of Croup and Epiglottitis Age Location Onset Organism Fever Signs and Symptoms Croup 3 months to 3 years Subglottic Gradual Viral 100-101F “Barking” cough Retractions Hoarse voice Harsh cough Loud stridor Epiglottits 3 to 7 years Supraglottic Sudden Bacterial 102-104F Drooling Retractions Muffled voice Usually no cough Prefers to sit up and lean forward to breathe (Tripod) General Statement In the prehospital setting it is very difficult to differentiate between croup and epiglottitis, therefore always assume the worst. Both conditions will be treated as follows: Do not attempt to visualize oropharynx. Cool air - air conditioning as necessary. Attempt to calm patient, anxiety and stress exacerbate the stridor. Do not attempt an I.V. This may increase patient's agitation and worsen their condition. Oxygen. Manually ventilate as necessary as this may still be possible when the patient is unable to move air on his own. External ventilation pressures are effective even when negative inspiratory pressures are not. Request Paramedic intercept - for airway control Transport immediately to ED or intercept point Signs and Symptoms may include: 1. Fever 2. Hoarse voice, "seal bark", cough, STRIDOR. 3. Tachypnea 4. Drooling - unable to manage (swallow) oral secretions. 5. Positioning to maintain airway, "Tripod" position 6. Accessory muscle usage Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 33 of 45 PEDIATRICS (CON'T) Asthma Oxygen Paramedic intercept Rapid transport Establish Medical Control PEDIATRIC TRAUMA Management of the pediatric trauma includes the same priorities as in the adult patient: Rapid assessment Initiate resuscitative measures Request Paramedic intercept Secondary survey GCS Initial stabilization Rapid transport Establish Medical Control Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 34 of 45 APPENDIX - APGAR SCORE ACTIVITY LIMP SOME FLEXION ACTIVE, MUCH FLEXION 0 1 2 PULSE NONE <100 PER MINUTE >100 PER MINUTE 0 1 2 GRIMACE, REFLEX TO SUCTION NONE SOME GRIMACING SNEEZES, COUGH, OR CRIES 0 1 2 RESPIRATIONS NONE IRREG, INEFFECTIVE, BRADYPNEIC RHYTHMIC, EFFECTIVE, CRYING 0 1 2 Evaluate newborn based on APGAR score at 1 minute and 5 minutes. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 35 of 45 APPENDIX - GLASCOW COMA SCALE All trauma patients will have a GCS calculated and documented on the run form. Any patient who has an altered level of consciousness will also have a GCS calculated and documented on the run form. EYE OPENING 4 3 2 1 Spontaneous To Voice To Pain None VERBAL RESPONSE 5 Oriented 4 Confused 3 Inappropriate Words 2 Incomprehensible Words 1 None ______________________________________________________ MOTOR RESPONSE 6 Obeys Commands 5 Localizes Pain 4 Withdraw (pain) 3 Flexion (pain) 2 Extension (pain) 1 None ______________________________________________________ Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 36 of 45 APPENDIX – SEMI AUTOMATED EXTERNAL DEFIBRILLATION There are a number of different types of Semi Automated External Defibrillators (SAED) on the market today. The guidelines for the use of these different defibrillators vary somewhat from unit to unit, however, all units function basically the same way. Each one will analyze the rhythm, charge to a pre programmed energy setting, and defibrillate. Most of our services are currently using the Medtronic Physio Control LIFEPAK 500. All medical Cardiac arrest patients will be treated as follows: A. Establish unresponsiveness, pulselessness, and apnea (ABC’S) B. Request Paramedic Intercept C. Determine if defibrillator application is appropriate The following is a list of cardiac arrest patients excluded: Cardiac Arrest due to trauma Patients less than eight years old Patients less than eighty pounds Patients in wet or hazardous surroundings D. Attach defibrillator electrodes to the patient in the prescribed manner. Delayed defibrillation decreases the patient’s chance of survival. Deferral of defibrillation should occur only to ensure safety of rescuers, bystanders and/or patient CPR should be undertaken before defibrillation only if: The defibrillator is not available. Defibrillation cannot safely be performed until the patient environment is safe. A sufficient number of trained persons are present so that CPR may be performed without delaying or impeding defibrillation attempts. E. Turn on the Defibrillator. F. Stop CPR, if in progress, cease any patient contact. G. Press Analyze. H. If the defibrillator indicates “shock advised” or begins charging: Check that everyone (including the operator) is clear of the patient. Deliver the first shock (preset to 200 joules). Press Analyze. If “shock advised”, clear all personnel as the unit charges, and deliver the second shock (preset to 300 joules). Press Analyze. If “shock advised”, clear all personnel as the unit charges, and deliver the third shock (preset to 360 joules). Check the patient for a carotid pulse, if the patient remains pulseless, begin CPR and continue for 1 minute. During this time, insert an O.P.A., or and advanced airway. After one minute of CPR, press Analyze. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 37 of 45 APPENDIX – S.A.E.D. (cont.) If “shock advised”, clear all personnel as the unit charges, and deliver the fourth shock (preset to 360 joules). Shocks may be delivered in 2 stacks of 3 shocks. If “no shock advised”, initiate CPR for one minute, then press Analyze. If two “no shock advised” messages occur, package the patient and intercept with the paramedic If the patient is revived and then returns to cardiac arrest, continue defibrillating at the preset energy settings. Two additional stacks of three shocks are allowed if the patient remains in a shockable rhythm. If, at any point, a patient regains a pulse, continue BLS then ALS supportive care(ABC’s, O2 therapy, assisting ventilations, IV therapy) and continuously reassess and monitor the patient. The S.A.E.D. should not be removed until the paramedic, RN or MD requests it’s removal. S.A.E.D. electrodes should be two to six inches away from pacemakers, A.I.C.D.s and nitro patches. A defibrillation report must be filled out along with the run form. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 38 of 45 APPENDIX – PARAMEDIC INTERCEPT A paramedic may be requested to respond to an incident location or to an intercept site along the route to the hospital. Paramedics should be requested as early as possible to avoid delay in further ALS care. When requesting paramedics, also obtain their ETA. If the EMT’s on the scene can safely package and transport the patient to the hospital before an intercept can be made, transport should not be delayed. If a patient is unstable and the benefit of stabilizing the patient prior to transport is critical a delay for paramedic level care is acceptable. IV access should be accomplished following standing orders and/or direct Medical Control consultation as needed. Once the paramedic has taken report on the patient(s), that paramedic is now in control of that patient(s) and the scene. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 39 of 45 APPENDIX – PRESUMPTION OF DEATH Any patient found by an EMT to be pulseless and apneic shall be presumed dead, and no resuscitation initiated if any or all of the following four criteria apply: Advanced decomposition Injury incompatible with life Decapitation Total body transection Body consumed by fire Massive head injury with exposed brain matter Rigor mortis with post mortem dependent lividity A valid DNR bracelet is present Bracelet approved by DPH/OEMS Bracelet affixed to the patient’s wrist or ankle Bracelet displays the patient’s & attending M.D.’s name Bracelet has not been cut or broken at any time In the absence of the above criteria, resuscitation efforts should be initiated immediately as per protocol. If CPR has been initiated by any first responder prior to EMS arrival, resuscitation efforts may be discontinued if the patient fits any of the above criteria and the termination of CPR would not have an adverse effect on the family or the public at scene. This decision will be made by the senior EMT or crew leader and direct Medical Control authorization. Special care must be taken with respect to suspected hypothermia patients, as they may present with signs of rigor mortis. You shall administer emergency care to such victims unless any of the other above criteria applies or Medical Control advises otherwise. Presumption of Death must be carefully documented and will include the following: Check respirations for not less than 30 seconds Check pulse for not less than 30 seconds Auscultate lung sounds for not less than 30 seconds Auscultate heart sounds for not less than 30 seconds Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 40 of 45 APPENDIX – RULE OF NINES Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 41 of 45 APPENDIX – D50W ADMINISTRATION Classification: Sugar in solution Action: Increases serum glucose levels. Indications: Hypoglycemia Contraindications: None Potential Side Effect: Hyperglycemia Dosage / Route: 1 premixed ampule (25 grams) given via IV only. Important Points: Obtain a finger stick blood glucose level prior to administration Be sure IV line is patent. If infiltrated, D50W will cause tissue necrosis Initial assessment/routine care. Oxygen as per protocol. If available, check the patient’s Blood Sugar If patient is unresponsive (GCS < 10): Request Paramedic Intercept and refer to Unresponsive protocol Establish IV access as per S.O. protocol (#18 guage or larger) Transport patient to the ED or intercept site after one failed IV att. Obtain a finger stick blood glucose level Establish Medical Control Request order for 1 amp (25 grams) D50W If the order is granted, administer the D50W via the IV line slowly (push over 1 minute). After the administration, run 10ml of saline to flush the line. Re check the patient’s blood glucose level Monitor the patient carefully for any adverse effects. Please remember, when documenting, include the name of the MD ordering D50W administration, the time and amount administered, the blood glucose levels before and after administration, and the EMT-I that administered the medication. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 42 of 45 APPENDIX – DUAL LUMEN AIRWAY – “COMBITUBE” Introduction: The Combitube airway is designed to provide a patent airway for arrested patients (respiratory / cardiac) when visualization of the airway or endotracheal intubation is not possible. It is designed to be inserted blindly. The double lumen design allows effective ventilations to be provided regardless of whether esophageal or tracheal placement is accomplished. The pharyngeal balloon fills the hypopharynx, eliminating the need for a mask seal, and the associated face/mask seal problems. If the Combitube is placed in the esophagus, the distal cuff will occlude the esophagus preventing aspiration of gastric content. Ventilations are then provided through the perforations at the pharyngeal site. If the device is place in the trachea, it functions as an endotracheal tube, with the distal cuff preventing aspiration. Indications: 1. Patients in irreversible respiratory arrest. (i.e. narcotic overdose, hypoglycemia) 2. Patients in cardiac arrest. 3. Unconscious patients without a gag reflex, in need of ventilatory support and can not be intubated. Contraindications: 1. 2. 3. 4. 5. 6. Intact gag reflex Patient height less than 48 inches. Conscious patient. Known esophageal disease. (cancer, verices) Caustic substance ingestion. (acid, lye) Allergy or sensitivity to latex Precautions: 1. Take universal precautions (BSI), including facial protection, as expulsion of stomach content can occur in esophageal placement. 2. May be used in trauma in a neutral position. (flexion or extension need not occur to facilitate placement) 3. Defibrillation should not be delayed to place Combitube. 4. Pulse oximetry may be unreliable in low perfusion states, such as cardiac arrest. Procedure: 1. Open the airway and suction mouth and oropharynx. 2. Perform assessment and record vital signs, level of consciousness, and oxygen saturation if available. 3. Insure there are no contraindications to this procedure. 4. Begin positive pressure ventilation with 100% oxygen and oral airway. Hyperventilate with each ventilation lasting at least 2 seconds. 5. Auscultate bilateral lung sounds to ensure air entry with BVM and rule out FBAO or pre-existing condition. Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 43 of 45 6. While patient is being hyperventilated, assemble Combitube as follows: a. Attach the large syringe with 100cc’s of air to the BLUE cuff #1. b. Attach the small syringe with 15cc’s of air to the WHITE cuff #2. c. Test the device by inflating both balloons, looking for leaks. d. Deflate all air from both cuffs, and leave syringes attached. e. Attach fluid detector to the shorter white tube. (#2) f. Lubricate tube tip and pharyngeal balloon with a water soluble lubricant. 7. With the head in a neutral position, grasp the mandible and tongue between the thumb and fingers. Place the Combitube into the midline of the mouth. 8. Slide the Combitube GENTLY along the palate and posterior surface of the oropharynx. Use a curving motion to guide the tube inward and downward. Advance the tube until the upper teeth or gums are between the two black rings. 9. DO NOT force the tube. If resistance is met, withdraw the tube, reposition the head and reattempt. 10. If unable to place the tube within 30 seconds, hyperventilate with 100% oxygen for 1-2 minutes before you reattempt. 11. Inflate large pharyngeal balloon (#1) with 100cc of air. - 85ml of air for 37 French size. 12. Inflate distal balloon (#2) with 15cc of air. (DO NOT over-inflate, serious damage may result.) - 12ml of air for 37 French size. 13. Begin ventilation through the longer blue connecting tube #1. 14. Confirm tube placement by auscultating both lungs and gastric area. If appropriate breath sounds are heard esophageal placement has occurred continue to ventilate and continuously monitor for change. 15. If no breath sounds are heard and gastric sounds are appreciated, remove fluid deflector from the white tube, attach BVM and begin ventilation through tube #2. 16. Confirm tube placement by auscultating both lungs and gastric area. If appropriate breath sounds are heard tracheal placement has occurred continue to ventilate and continuously monitor for changes. 17. If no breath sounds are heard and no gastric sounds are heard, the tube is placed to deep and occluding the tracheal opening. Deflate both balloons, and withdraw 2-3 centimeters. Re-inflate the balloons and attempt again beginning at step #13. 18. A maximum of two attempts at Combitube placement is permitted. 19. If the patient regains consciousness or gag reflex, the Combitube MUST be removed. - Balloon Deflation Procedure: a) Have working suction ready, and suction oropharynx. b) If not contraindicated, roll patient to recovery position. c) Deflate blue balloon #1. d) Deflate white balloon #2. e) Remove Combitube. Charting and Documentation: The following information must be charted on the patient care report form: 1. Patient’s presenting signs and symptoms, including vital signs, level of consciousness, and oxygen saturation if available. 2. Indications for Combitube use. 3. Number of endotracheal intubation attempts. 4. Size of Combitube 41 French or 37 French 5. Which connecting tube was used for ventilation. (blue or white) Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 44 of 45 6. 7. 8. 9. 10. Steps taken to verify tube placement. Number of attempts made at Combitube placement. Repeat assessment and vital signs every five minutes. Changes from baseline that may have occurred, if any. Signature and certification / license number of EMT performing insertion. Certification: 1. Attend lecture and demonstration of Combitube placement and evaluation. 2. Demonstrate an understanding of the indications, contraindications, and possible complications related to the use of the Combitube. 3. In a lab setting, demonstrate the proper insertion, removal, and use of the Combitube. 4. Pass a written examination. 5. Pass an oral examination incorporating practical scenarios. Continuing Certification: 1. Review class and repeat certification steps 1-5 2. Record review of all cases where this protocol has been used. 3. Recertification at the intermediate level will occur annually. Quality Assurance: 1. The following will be measured for continuos quality improvement. - Appropriateness of use - Adherence to protocol - Deviations from protocol - Corrective action taken 2. Biannual statistics will be forwarded to each department using the Combitube. 3. Completion of a “Combitube” form, for feedback in the following areas: - Ease of use - Effectiveness of ventilation - Complications of use - Suggestions for improvement Emergency Medical Technician - Intermediate Protocols – September, 2002 Page 45 of 45