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CENTRAL NEW YORK EMS MIDSTATE EMS NORTH COUNTRY EMS Serving Cayuga, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence & Tompkins Counties Collaborative Protocol Handbook 2013 CENTRAL NEW YORK EMS PROGRAM AGENCY STAFF Regional Medical Director Daniel J. Olsson, DO FACOEP-D MIDSTATE EMS PROGRAM AGENCY STAFF Regional Medical Director John J. DeTraglia, MD Executive Director Susie Surprenant, NREMT-P EMS Program Director Daniel Broedel, NREMT-P Clinical Consultant Kevin Carver, EMT-P EMS Clinical Coordinator Vinny Faraone, EMT-P Clinical Consultant William McGarrity, EMT-P Administrative Assistant Christina Buda Clinical Consultant Colleen Price, RN, EMT-P Administrative Assistant Tamara Eckstadt NORTH COUNTRY EMS PROGRAM AGENCY STAFF Regional Medical Director Sarah DelaneyRowland, MD Director James Stockman, EMT-P Secretary Mysti Putnam REGIONAL EMERGENCY MEDICAL ADVISORY COMMITTEES CENTRAL NEW YORY EMS REMAC PHYSICIANS Daniel J. Olsson, DO, FACOEP-D Chairman and Regional Medical Director Tom-meka Archinard, MD Michael Jorolemon,DO James Ciaccio, MD Jeremy Joslin, MD Derek Cooney, MD Drew Koch, DO Norma Cooney, MD David Landsberg, MD Mary DiRubbo, MD Joseph Markham, MD Jerry Emmons, MD Daniel Olsson, DO Christopher Fullagar, MD Cupid Gascon, MD Patsy Iannolo, MD Naveen Seth, MD David Thomson, MD David Wirtz, MD Central New York EMS 50 Presidential Plaza Jefferson Tower, Suite LL1 Syracuse, New York 13202 (315) 701-5707 (315) 701-5709 Fax http://www.cnyems.org MIDSTATE EMS NORTH COUNTRY EMS REMAC PHYSICIANS REMAC PHYSICIANS John J. DeTraglia, Sarah DelaneyMD-FACS Rowland, MD Chairman and Chairman and Regional Medical Regional Medical Director Director Lingappa Amernath, MD Harriet Burris, MD Andrew Bushnell, MD Troy Johnson, MD Dan Horth, MD Maja Lundborg-Gray,MD John Rubin, DO Rosemarie Heisse, MD Naveen Seth, MD Todd Howland, MD Michael Thomas, MD Matt Maynard, DO George Snicer, MD Midstate EMS North Country EMS 1705 Burrstone Road 34 Cornell Drive WH 027 New Hartford, New York 13413 Canton, NY 13617 (315) 738-8351 (315) 379-3977 (315) 738-8981 Fax (315) 379-3979 Fax http://midstateems.org http://www.canton.edu/ncems/ Content Copyright © 2013 by Central New York EMS, Midstate EMS and North Country EMS. 2 INDEX INTRODUCTION PEDIATRIC PROTOCOLS (continued…) 4 Medical Control Agreement 43 Altered Mental Status 5 Responsibilities of Providers 44 Asystole / PEA ADULT PROTOCOLS 45 Facilitated Intubation 6 Routine Medical Care 46 Fluid Challenge 7 Routine Trauma Care 47 IV / IO Therapy 8 Acute Coronary Syndrome 48 Neonatal Resuscitation 9 12 Lead ECG 49 Neonatal Resuscitation - continued 10 Acute Resp. Distress Asthma/COPD 50 Pain Management 11 Airway Management 51 Percutaneous Airway 12 Airway Obstruction 52 Poisoning / Overdose 13 Allergic Reaction / Anaphylaxis 53 Seizures 14 Altered Mental Status 54 Symptomatic Bradycardia 15 Antiemesis 55 Tachycardia - Stable 16 Asystole / PEA 56 Tachycardia - Unstable 17 Burns 57 Tension Pneumothorax 18 Facilitated Intubation 58 V. Fib and Pulseless V. Tach 19 Fluid Challenge SPECIAL PROTOCOLS 20 Hypoperfusion / Cardiogenic Shock 59 Air Medical Protocol 21 IV / IO Therapy 60 Continuous Positive Airway Pressure 22 OB Complications / Emer. Childbirth 61 Do Not Resuscitate / MOLST 23 Pain Management 62 Interfacility Transfers 24 Patient Restraint 63 Left Ventricular Assist Device (LVAD) 25 Percutaneous Airway 64 Left Ventricular Assist Device -continued 26 Poisoning / Overdose 65 Physician On Scene 27 Post Cardiac Arrest Hypothermia 66 Physician On Scene Card 28 Pulmonary Edema 67 Radio Failure 29 Rapid Sequence Intubation (RSI) 68 Patient Refusals Against Medical Advice 30 Seizures 69 Termination of Resuscitation 31 Stroke 70 Transfer of Care 32 Symptomatic Bradycardia 71 Trauma Triage Criteria 33 Tachycardia - Stable CHARTS 34 Tachycardia - Unstable 72 Adult Protocol Drug Chart 35 Tension Pneumothorax 73 Adult Protocol Drug Chart - continued 36 V. Fib and Pulseless V. Tach 74 Adult IV Drip & Pediatric Drug Charts PEDIATRIC PROTOCOLS 75 APGAR & Abnormal Pediatric Vital Signs 37 Routine Medical Care 76 Glasgow Coma & Cincinnati Stroke 38 Routine Trauma Care 77 Cranial Nerve Exam & Visual Pain Scale 39 Acute Resp. Distress 78 Rule of Nines Chart 40 Airway Management 79 Hospital Telephone & Fax Numbers 41 Airway Obstruction 80 Hospital Telephone & Fax Numbers 42 Allergic Reaction / Anaphylaxis 81 Notes 3 All MEDICAL CONTROL AGREEMENT These protocols are intended to result in improved patient care by pre-hospital Providers. They reflect the American Heart Association, Basic, Advanced and Pediatric Care standards. These protocols are not intended to be absolute treatment documents, rather as principals and directives which are sufficiently flexible to accommodate the complexity of patient management. THESE PROTOCOLS ARE NOT A SUBSTITUTE FOR GOOD CLINCAL JUDGEMENT The goal of pre-hospital care is to provide the best definitive care in a timely and safe manner. As an Advanced Provider in the Central New York, Midstate and North Country Regional EMS Systems you agree to: Membership in a regionally approved Advanced Life Support Agency. Maintain registration in the Regional EMS Program including all REMAC approved required documents. Successful completion of the appropriate level Protocol Exam. Participation in the Regional Continuing Medical Education and skills maintenance programs. Participation in the Regional Quality Assurance Program. In turn, the Central New York, Midstate and North Country REMACs agree to authorize you to practice in their respective system of medical control at the level at which you are currently certified. If you deviate from the protocols in such a manner as to endanger, potentially endanger a patient or employ a skill improperly, you may be subject to suspension of privileges by the respective Regional Medical Director. If your privileges are suspended (or practice limited), you will be given the opportunity for a REMAC hearing. If you have any questions or concerns please contact your Program Agency for assistance. 4 RESPONSIBILITIES OF PREHOSPITAL PATIENT CARE PROVIDERS AND COORDINATION OF SERVICES The provision of patient care is a responsibility given to certified and licensed individuals who have completed a medical training and evaluation program specified by the NYS Public Health or Education Laws and related to regulations or policy. Pre-hospital Providers are required to practice the standards of the certifying agency (DOH) and the medical protocols authorized by the local REMAC. Patient care takes place in many settings, some of which are hazardous or dangerous. The equipment and techniques used in these situations are the responsibility of the locally designated, specially trained and qualified personnel. Emergency incident scenes may be under the control of designated incident commanders who are not emergency care providers. These individuals are generally responsible for scene administration, safe entry to a scene or decontamination of patients or responders. Pursuant to the provisions of Public Health Law, the individual having the highest level of pre-hospital certification, and who is responding with authority (duty to act) is responsible for providing and or directing the emergency medical care and the transportation of a patient. Such care and direction shall be in accordance with all NYS standards of training, applicable State and Regional protocols and may be provided under medical control. The Governor’s Executive order No. 26 of March 5, 1996, establishes the National Incident Management System (NIMS) as the standard of command and control system for emergency operations in New York’s State. The Incident Command System (ICS) does not define who is in charge, but rather defines an operational framework to manage many types of emergency situations. One essential component of ICS is Unified Command. Unified Command is used to manage situations involving multiple jurisdictions, multiple agencies or multiple situations involving multiple jurisdictions, multiple agencies or technical needs. The specific issues of direction, provision of patient care, and the associated communications among responders must be integrated into each single or unified command structure and assigned to the appropriately trained personnel to carry out. 5 ROUTINE MEDICAL CARE INTERMEDIATE The following procedures will be performed on medical emergencies requiring Advanced Life Support: Assure scene safety Bring ALS equipment to the patient and utilize as indicated: o AED, Pulse oximetry, Oxygen, Suction o Advanced airway equipment, Continuous waveform capnography o IV access, Glucometer (Agencies with Regional approval) o Capability for field to hospital communications Initial patient assessment and vital signs; blood pressure, pulse, and respirations every 5- 15 minutes and after every treatment (first BP manually) Reassurance and proper positioning Medical Control notification as soon as reasonable INTERMEDIATE STOP CRITICAL CARE Bring ALS equipment to the patient and utilize as indicated: o Monitor/defibrillator o Medications o Obtain 12 Lead ECG if appropriate CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Multiple Patient Procedures: If a potential MCI exists, contact 911 center and medical control ASAP. The medical control physician may authorize standing orders during the MCI. Document incident commander’s name and affiliated agency. Upon completion of patient assessment and identification of need for ALS, ILS transporting units need to request and then rendezvous with ALS units or transport to hospital, whichever is closer. 6 ROUTINE TRAUMA CARE INTERMEDIATE Establish large bore Normal Saline IV or IO Intercept with ALS INTERMEDIATE STOP CRITICAL CARE Apply & Monitor ECG If indicated consider Fluid Challenge If in traumatic cardiac arrest consider bilateral chest decompression CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Patients meeting Trauma Triage Criteria will be transported to a designated Trauma Center, unless one of the following conditions exists transport to nearest hospital: o Patient in Cardiac Arrest o Unmanageable Airway o Directed by Medical Control 7 ACUTE CORONARY SYNDROME INTERMEDIATE Routine Medical Care Aspirin 325 mg PO INTERMEDIATE STOP ADVANCED EMT Nitroglycerin 0.4 mg SL tablet or 1 spray. May repeat every 5 min. maintaining systolic BP > 100 mmHg. OR Nitroglycerin Paste 1 inch (if systolic BP is > 100 mmHg) ADVANCED EMT STOP CRITICAL CARE Obtain 12 Lead ECG For confirmed STEMI: Strongly recommend transport to facility capable of primary angioplasty if transport time is less than one hour Notify receiving hospital as soon as possible to discuss transport options if patient requests facility not capable of primary angioplasty Consider use of air-medical if transport time is greater than one hour CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Morphine Sulfate up to 4 mg IV. May repeat every 5 min. up to 10 mg OR Fentanyl 50 mcg slow IV or IM Key Points/Considerations Nitroglycerin, in any form, is not to be administered to patients that have taken erectile dysfunction medications within the last 72 hours 4 Baby Aspirin (324 mg total) PO is an acceptable substitute for Aspirin 325 mg PO Revised Revised 2014 2014 8 12 LEAD ECG Criteria: Classic Angina Chest Pain Atypical Chest Pain Chest Pressure Chest Palpitations Consider 12 Lead ECG, for patients >55 years old with hypertension ( >140 systolic) or hypertension history or vascular history that present with one of the following criteria: o Dyspnea o Syncope or Dizziness o Fatigue or Weakness o Nausea/Vomiting Frequency: Initially with vital signs, where patient is found In ambulance, before leaving scene-if not done initially where patient was found OR if abnormalities found on initial 12 Lead If abnormalities noted, repeat with vital signs (every 5-10 minutes) Considerations For Suspected Acute Myocardial Infarction: Consider Second IV access enroute - same arm Consider continued Nitroglycerin as per protocol every 5 minutes even without pain; If systolic BP > 100 V1 V2 V3 V4 V5 V6 4th intercostal space @ R sternum edge 4th intercostal space @ L sternum edge Between V2 & V4 5th intercostal space, midclavicular line Level with V4, L anterior axillary line Level with V5, L mid axillary line I aVR II AVL Lateral Inferior Lateral III AVF Inferior Inferior V1 V4 Septal Anterior V2 Septal V3 V5 Anterior Lateral V6 Lateral Key Points/Considerations Radio report (and FAX, if capable) on ALL suspected AMIs Document note on PCR if patient was NOT lying flat Copies of 12 Leads to hospital AND Agency Consider silent MI 9 ACUTE RESPIRATORY DISTRESS ASTHMA OR COPD INTERMEDIATE Routine Medical Care Asthma Patients Only: o Albuterol Sulfate 2.5 mg in 3ml NS via nebulizer Repeat x 2 (total of 3 unit doses can be given); If agency approved. (Critical Care and Paramedic medication administration begins at the Critical Care line.) INTERMEDIATE STOP ADVANCED EMT Albuterol Sulfate 2.5 mg in 3ml NS via nebulizer rate of 6 lpm O2 Consider CPAP if: o Patient is and remains alert; No active vomiting o Is able to follow commands o No history of pneumothorax ADVANCED EMT STOP CRITICAL CARE Albuterol Sulfate 2.5 mg in 3ml NS mixed with Ipratropium Bromide 0.5 mg (one unit dose) via nebulizer at flow rate of 6 lpm O2 If no relief: Methylprednisolone 125 mg IV Albuterol Sulfate 2.5 mg in 3ml NS via nebulizer; Repeat x 2 Consider 12 Lead ECG CRITICAL CARE STOP PARAMEDIC Epinephrine 1:1000 (0.3 mg IM) PARAMEDIC STOP MEDICAL CONTROL ORDER Advanced EMT and Critical Care Technician: Epinephrine 1:1000 (0.3 mg IM) Critical Care Technician and Paramedic: Albuterol Sulfate 2.5mg in 3ml NS (4th dose and higher) via nebulizer Terbutaline 0.25 mg IM should be administered prior to Epinephrine for patients 51 years and older Key Points/Considerations Revised 2014 10 AIRWAY MANAGEMENT INTERMEDIATE Manually open the airway Suction as needed Insert oropharyngeal or nasopharyngeal airway Ventilate patient with Bag-Valve Mask and 100% oxygen May place appropriate alternative rescue airway device for patients in respiratory or cardiac arrest. INTERMEDIATE STOP ADVANCED EMT ADVANCED EMT STOP CRITICAL CARE May perform endotracheal intubation up to a total of 3 attempts on patients in respiratory or cardiac arrest. Consider using GumBougie. (If unsuccessful place appropriate alternative rescue airway device) May attempt endotracheal intubation if patient has an altered mental status, respiratory rate < 10, and tolerates an oropharyngeal airway. CRITICAL CARE STOP PARAMEDIC May attempt endotracheal intubation on patients requiring definitive airway management. If direct laryngoscopy is impossible, digital intubation may be attempted. If abdominal distention occurs, pass an Orogastric Tube. PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations In trauma, manual stabilization is required. Confirm and monitor airway device with continuous End-Tidal CO2 waveform capnography. If capnography unsuccessful, confirm position with EDD or End-Tidal CO2 Detector. Revised 2014 11 AIRWAY OBSTRUCTION INTERMEDIATE Follow NYS BLS Protocols Routine Medical or Trauma Care INTERMEDIATE STOP CRITICAL CARE If BLS maneuvers are unsuccessful: Use direct laryngoscopy and Magill forceps If unsuccessful, insert an ET tube in attempt to push through the obstruction or push it into the lower airway If unsuccessful, continue efforts and transport CRITICAL CARE STOP PARAMEDIC If unable to adequately ventilate with BLS/ALS techniques, perform Needle Cricothyroidotomy. Refer to Percutaneous Airway Protocol. PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Upon completion of patient assessment and identification of need for ALS, BLS and ILS transporting units need to request and then rendezvous with ALS units or transport to hospital, whichever is closer. 12 ALLERGIC REACTION / ANAPHYLAXIS INTERMEDIATE Routine Medical Care Epi-Pen Autoinjector per NYS BLS Protocols. (AEMT, Critical Care and Paramedic medication administration begins at the AEMT line.) If systolic BP < 90 mmHg with no signs and symptoms of pulmonary edema, perform Fluid Challenge INTERMEDIATE STOP ADVANCED EMT Inadequate perfusion with respiratory distress, stridor, wheezing, hypotension, altered level of consciousness, throat tightness, or shock: Epinephrine 1:1000 (0.3 mg IM) Albuterol Sulfate 2.5 mg in 3 ml NS via nebulizer may repeat as needed ADVANCED EMT STOP CRITICAL CARE Adequate Perfusion with hives and no respiratory compromise: Diphenhydramine 50 mg slow IV; IM Inadequate perfusion with respiratory distress, stridor, wheezing, hypotension, altered level of consciousness, throat tightness, or shock: Diphenhydramine 50 mg slow IV; IM Methylprednisolone 125 mg slow IV; IM CRITICAL CARE STOP PARAMEDIC Repeat Epinephrine 1:1000 (0.3 mg IM) if no improvement PARAMEDIC STOP MEDICAL CONTROL ORDER Advanced EMT and Critical Care Technician: o Epinephrine 1:1000 (0.3mg IM) for repeat dose Critical Care Technician and Paramedic: o Diphenhydramine 50 mg IV or IM for repeat dose o Glucagon 1mg IM for patients on beta-blockers o Consider Epinephrine 1:10,000 (0.5 mg IV) Paramedic: o Dopamine Drip 5 -10 mcg/kg/min; Titrate to BP > 100mmHg systolic Key Points/Considerations Revised 2014 13 ALTERED MENTAL STATUS INTERMEDIATE Routine Medical Care Assess Blood Glucose INTERMEDIATE STOP ADVANCED EMT Hypoglycemia: If Blood Glucose < 60 mg/dL: Dextrose 50% 50 ml IV If repeat Blood Glucose < 60 mg/dL: Consider 2nd Dose of Dextrose 50% 50ml IV If no IV access: Glucagon 1mg IM Signs and symptoms of opiate overdose with respiratory distress or apnea: o Naloxone 0.4 mg IV; IM or IN; May repeat every 5 minutes until respiratory effort improves. ADVANCED EMT STOP CRITICAL CARE o Hyperglycemia: If Blood Glucose > 300 mg/dL and patient is without signs and symptoms of pulmonary edema, consider Fluid Challenge CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Suspected Sympathomimetic OD - (Cocaine or Amphetamines) o Benzodiazepines Suspected Tricyclic OD o Sodium Bicarbonate Suspected Beta Blocker OD Glucagon ** Doses to be determined by Medical Control** Key Points/Considerations Consider other etiologies if no response: o Poisoning o Head Injury o Stroke Revised 2014 14 ANTIEMESIS INTERMEDIATE Routine Medical Care INTERMEDIATE STOP CRITICAL CARE Obtain 12 Lead ECG Ondansetron 4 mg IV or IM or PO or ODT Repeat once after 5 minutes as needed CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Contact Medical Control for additional doses Key Points/Considerations Prevention and treatment of severe nausea and vomiting 15 ASYSTOLE and PULSELESS ELECTRICAL ACTIVITY (PEA) INTERMEDIATE CPR AED Routine Medical Care Consider Advanced Airway INTERMEDIATE STOP ADVANCED EMT Epinephrine 1:10,000 (1 mg IV or IO) Repeat every 3-5 min. during arrest. ADVANCED EMT STOP CRITICAL CARE Confirm Asystole in 2 Leads Epinephrine 1:10,000 (1 mg IV or IO) Repeat every 3-5 min. during arrest. OR Vasopressin 40 units IV or IO (as replacement for first or second dose of Epinephrine). CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Sodium Bicarbonate 1 meq/kg IV or IO Key Points/Considerations If witnessed Asystole, immediate Transcutaneous Pacing (TCP) if available. Consider ET medication administration. Search for and treat contributing factors: o Hypovolemia, Hypoxia, Hydrogen Ion (Acidosis), Hypo/Hyperkalemia, Hypoglycemia, Hypothermia o Toxins, Tamponade, Tension Pneumothorax, Thrombosis, Trauma Revised 2014 16 BURNS INTERMEDIATE Routine Trauma Care INTERMEDIATE STOP CRITICAL CARE Consider Airway Management Consider Fluid Challenge for partial/full thickness burns > 15% BSA Consider Pain Management Protocol CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Contact Medical Control as soon as possible for possible referral to burn center. If airway compromise, transport immediately to nearest facility. Phosphorous burns should not be irrigated with water. Brush chemical off thoroughly. Hydrofluoric Acid burns be aware of cardiac implications. 17 FACILITATED INTUBATION PARAMEDIC Spray hypopharynx with topical anesthetic spray (optional) Etomidate 20 mg IV over 30 to 60 seconds If needed, repeat Etomidate 20mg IV over 30 to 60 seconds After successful intubation, consider medical control option for continued sedation If unsuccessful place appropriate secondary advanced airway device PARAMEDIC STOP MEDICAL CONTROL ORDER For continued sedation, Midazolam 5 mg IV Midazolam 5 mg IV in place of Etomidate o If Intubation unsuccessful, may repeat Midazolam 5 mg IV Key Points/Considerations Indicated for airway control in combative patients or patients who have a gag reflex. SPO2 monitoring is required during intubation attempts. Continuous End-Tidal CO2 waveform capnography is required. Confirm and document proper ETT placement . Confirm and monitor airway device with continuous End-Tidal CO2 waveform capnography. If capnography unsuccessful, confirm position with EDD or End-Tidal CO2 Detector. 18 FLUID CHALLENGE INTERMEDIATE Routine Medical / Trauma Care Infuse 500 ml Normal Saline rapidly Reassess and reconfirm indications Infuse 500 ml Normal Saline rapidly INTERMEDIATE STOP CRITICAL CARE CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Paramedic: o Consider additional fluid o Dopamine Drip 5 -10 mcg/kg/min; Titrate to BP > 100mmHg systolic Key Points/Considerations Indicated for patients in cardiac arrest or profound hypovolemia with alteration in mental status Reassess lung sounds Up to 1000 ml Normal Saline may be administered 19 HYPOPERFUSION / CARDIOGENIC SHOCK INTERMEDIATE Routine Medical Care Systolic BP less than 100 mmHg (if no pulmonary edema) o Normal Saline bolus 250 ml - 500 ml o Repeat bolus if lung sounds are clear Serial lung sounds assessment INTERMEDIATE STOP CRITICAL CARE Obtain 12 Lead ECG Waveform Capnography Advanced airway if indicated CRITICAL CARE STOP PARAMEDIC For systolic BP less than 100 mmHg: o Dopamine Drip 5 -10 mcg/kg/min; Titrate to BP > 100 mmHg systolic PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Search for and treat contributing factors: o Hypovolemia, Hypoxia, Hydrogen Ion (Acidosis), Hypo/Hyperkalemia, Hypoglycemia, Hypothermia o Toxins, Tamponade, Tension Pneumothorax, Thrombosis, Trauma Contact Medical Control early if patient remains hypotensive 20 IV / IO THERAPY INTERMEDIATE Patients 16 years and older: May establish Normal Saline IV IO access for patients in cardiac arrest or profound hypovolemia with alteration in mental status INTERMEDIATE STOP CRITICAL CARE External jugular access for critical patients when no other access is available CRITICAL CARE STOP PARAMEDIC Patients any age: IV access PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Normal Saline Lock or Normal Saline IV with macro drip Critical Patients no more than 90 seconds to obtain IV if available consider IO Critical Care Technician and Paramedic: o Consider use of EJV in unresponsive patients o Any vascular access device with an external hub (example: PICC or Central Line) for patients in cardiac arrest or profound hypoperfusion with alteration in mental status. 21 OBSTETRICAL COMPLICATIONS and EMERGENCY CHILDBIRTH INTERMEDIATE Routine Medical Care APGAR score at 1 and 5 minutes Support fetus Gentle delivery Provide airway to fetus Normal Delivery: o Follow NYS BLS Protocol Umbilical Cord Prolapse: o DO NOT GRAB CORD o Place mother face up with hips elevated o Gently displace fetus off cord Breach Presentation: o DO NOT TUG OR PULL ON FETUS INTERMEDIATE STOP CRITICAL CARE Postpartum hemorrhage - Follow Hypoperfusion Protocol Eclampsia: Magnesium Sulfate 4gm in 50 ml NS IV over 15min. CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Pre-eclampsia o Magnesium Sulfate 4gm in 50 ml NS IV over 15 min OR o If unable to establish an IV, administer Magnesium Sulfate in 2 doses of 1 gram each in 2ml NS in the buttocks. Administer 1 dose IM in each buttock. Key Points/Considerations 22 PAIN MANAGEMENT INTERMEDIATE Routine Medical Care INTERMEDIATE STOP CRITICAL CARE Standing Order Indications: Patients with pain secondary to: o Severe burns without hemodynamic compromise o Suspected extremity fractures or dislocations with severe pain o Amputations Medications: Morphine Sulfate 4 - 5 mg IV; Dose may be repeated once in 5 minutes as needed OR Fentanyl 50 mcg slow IV or IM OR Nitrous Oxide if available CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Presence of any Contraindication (for standing order) or the need for additional pain control requires a medical control order. Painful conditions not listed under “Standing Order Indications”. Ketorolac 30 mg IV or 60 mg IM 66 years and older Ketorolac 15 mg IV or 30 mg IM Key Points/Considerations 23 PATIENT RESTRAINT INTERMEDIATE Routine Medical Care Assess Blood Glucose Physical Restraint: o Appropriate physical restraints can be used but must be capable of IMMEDIATE RELEASE o Patient restraint must be in a manner to continuously monitor airway and vital signs o Restrain in supine position o Medical Control MUST be contacted and advised of patient condition INTERMEDIATE STOP CRITICAL CARE Chemical Restraint: o Haloperidol 5mg slow IV or IM o Medical Control MUST be contacted to advise of patient condition o Diphenhydramine 50mg IV or IM if dystonic reactions occur CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician and Paramedic: Midazolam 5 mg IV or IM Key Points/Considerations Emergency personnel should involve law enforcement as early as possible. The above may be used for hemodynamically stable patients with a psychosocial condition exhibiting extreme anxiety and/or combative/ violent behavior, if the patient presents a substantial risk of bodily harm or injury to themselves. 24 PERCUTANEOUS AIRWAY PARAMEDIC Routine Trauma Care Confirm indications for Percutaneous Airway Percutaneous airway device or surgical airway if trained and equipped PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations This procedure applies to situations in which standard endotracheal intubations cannot be performed. This procedure is to be used as a last resort and may not provide adequate oxygenation for long periods of time. Rapid transport to the closet hospital is required for definitive airway management. Use slow ventilations with extended exhalation periods. 25 POISONING / OVERDOSE INTERMEDIATE Routine Medical Care Assess Blood Glucose INTERMEDIATE STOP ADVANCED EMT If appropriate, Naloxone 0.4 mg IV or IM or IN for respiratory depressions or apnea; May repeat every 5 minutes until respiratory effort improves. ADVANCED EMT STOP CRITICAL CARE CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Tricyclic Antidepressants: o Sodium Bicarbonate 1 mEq/kg IV Beta Blockers: o Glucagon 0.1 mg/kg IV or IM, up to 2 mg maximum Organophosphate insecticides/cholinesterase inhibitors (ingested, absorbed, or inhaled): o Atropine 0.02 – 0.05 mg/kg IV or IN Key Points/Considerations Consider scene safety first Field decontaminate as indicated Identify substance and quantity Revised 2014 26 POST CARDIAC ARREST INDUCED HYPOTHERMIA INTERMEDIATE Routine Medical Care INTERMEDIATE STOP CRITICAL CARE Obtain 12 Lead ECG Infuse NS @ 4 degrees Celsius. Maximum 30 ml/kg not to exceed 2 liters Apply ice packs CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Consider potential causes: o Hypovolemia o Hypoxia o Hydrogen Ion (acidosis) o Hypo / Hyperkalemia o Hypoglycemia o Hypothermia o Toxins o Tamponade, cardiac o Tension Pneumothorax o Thrombosis o Trauma 27 PULMONARY EDEMA INTERMEDIATE Routine Medical Care INTERMEDIATE STOP ADVANCED EMT Nitroglycerin 0.4 mg SL tablet or 1 spray. May repeat every 5 min. maintaining systolic BP > 100 mmHg. OR Nitroglycerin Paste 1 inch (if systolic BP is > 100 mmHg) Consider CPAP if: o Patient is and remains alert; No active vomiting o Is able to follow commands o No history of pneumothorax ADVANCED EMT STOP CRITICAL CARE Consider Acute Respiratory Distress - Asthma or COPD Protocol Obtain 12 Lead ECG if appropriate CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician and Paramedic: Furosemide 40 – 80 mg IV or IM Key Points/Considerations Nitroglycerin, in any form, is not to be administered to patients that have taken erectile dysfunction medications within the last 72 hours Remove Nitro Paste if systolic BP falls below 100 mmHg Revised 2014 28 RAPID SEQUENCE INTUBATION (RSI) PARAMEDIC Prepare Equipment: o o o o o o o o Suction and BVM with reservoir connected to 100% oxygen Endotracheal Tube with Stylet and Commercial tube holder device Laryngoscope with blade and functioning light Venous Access and Required medications prepared Cardiac monitor with continuous waveform capnography & SPO2 Secondary confirmation device Secondary advanced airway Surgical airway kit Routine Medical Care and Preoxygenate patient Presedate: o Lidocaine 100mg IV and o For Suspected Head Injury or Stroke: Vecuronium 1 mg IV OR Lidocaine 1.0 – 1.5mg/kg IV o For Bradycardia: Atropine 0.5 mg IV Sedate: o Etomidate 0.2 – 0.4 mg/kg IV (20-40mg IV) Paralysis: o Succinylcholine 1- 2 mg/kg IV (100 – 200 mg IV) OR o For severe burns, major crush injury or pre-existing spinal cord injury Rocuronium 0.6 mg/kg IV (up to 60 mg IV) o Intubation: 3 attempts with GumBougie o Confirm tube placement using primary & secondary methods Successful Intubation: o Monitor heart rate, continuous waveform capnography & SPO2 o Midazolam 2 - 4 mg IV every 5 minutes as needed o Vecuronium 0.1 mg/kg IV (up to 10 mg) Unsuccessful Intubation: o Utilize secondary advanced airway OR o BLS airway & ventilations OR Surgical cricothyroidotomy PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations This procedure requires two paramedics to be present. For ground, both paramedics must be credentialed for this procedure by the REMAC & Regional Medical Director. Patient requires sedation and/or paralysis to secure airway. Includes combative patient that threatens airway, spinal cord stability or safety of crew and/or patient. Contraindications: Patients unable to be effectively ventilated using BVM should not receive paralytics prior to establishment of a definitive airway. 29 SEIZURES INTERMEDIATE Routine Medical Care Protect patient from harm Assess Blood Glucose INTERMEDIATE STOP ADVANCED EMT If Blood Glucose < 60 mg/dL: o Dextrose 50% 50 ml IV o If unable to start IV: Glucagon 1mg IM ADVANCED EMT STOP CRITICAL CARE If continued seizure activity, administer: o Midazolam 5 mg IV or IM or IN (Active Seizures Only) After seizures are controlled, consider 12 Lead ECG CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER May repeat Midazolam 5 mg IV or IM or IN, if seizures continue Key Points/Considerations Consider other etiologies: o Hypoglycemia o Cardiac o Overdose o Obstetric Complications Midazolam: Maximum volume 1 ml per nostril Revised 2014 30 STROKE INTERMEDIATE Routine Medical Care Time of onset - last seen “normal” Obtain Blood Glucose NYS DOH BLS Protocol Stroke Assessment o Cincinnati Prehospital Stroke Scale INTERMEDIATE STOP CRITICAL CARE CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Contact Medical Control (REQUIRED) Transport the patient to the closest NYS DOH Designated Stroke Center if the total prehospital time (time from when the patient’s symptoms and/or began to when the patient is expected to arrive at the Stroke Center) is less than two (2) hours. 31 SYMPTOMATIC BRADYCARDIA INTERMEDIATE Routine Medical Care INTERMEDIATE STOP CRITICAL CARE Atropine 0.5 mg IV; May repeat every 3-5 min. up to 3 mg Transcutaneous Pacing (TCP) o Consider Sedation: Etomidate 10 mg IV or IO; May repeat x 1 as needed Obtain 12 Lead ECG Consider Fluid Challenge CRITICAL CARE STOP PARAMEDIC Dopamine Drip 5 -10 mcg/kg/min; Titrate to BP > 100 mmHg systolic PARAMEDIC STOP MEDICAL CONTROL ORDER Consider Sedation for Transcutaneous Pacing (TCP): o Midazolam Consider Pain Management for Transcutaneous Pacing (TCP) Key Points/Considerations Symptomatic Bradycardia is defined by a pulse rate < 50 bpm with a systolic BP < 90 mmHg AND one or more of the following: o Chest Pain o Dyspnea o Altered Mental Status o Pulmonary Edema o Other Signs of Hypoperfusion 32 TACHYCARDIA - STABLE INTERMEDIATE Routine Medical Care INTERMEDIATE STOP CRITICAL CARE If Stable and Narrow: o Vagal Maneuvers OR o Adenosine 6 mg IV rapid push. Adenosine 12 mg IV rapid push. May repeat once in 1-2 min. OR o Cardizem 0.25 mg/kg slow IV push over 10 min. Maximum single dose 25 mg If Stable and Wide: o Amiodarone 150 mg in 50 ml NS over 10 min. Obtain 12 Lead ECG CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Lopressor 5 mg in 50 ml NS over 5–10 min. Key Points/Considerations HR > 150 bpm Stable Tachycardia is defined as tachycardia with a pulse and adequate perfusion. 33 TACHYCARDIA - UNSTABLE INTERMEDIATE Routine Medical Care INTERMEDIATE STOP CRITICAL CARE If Unstable and Wide: o Consider Sedation: Etomidate 10 mg IV o Cardiovert : 100 joules, 200 joules, 300 joules, 360 joules If Unstable and Narrow: o Consider Sedation: Etomidate 10 mg IV o Cardiovert: 50 joules, 100 joules, 200 joules, 300 joules, 360 joules o Consider Adenosine: Adenosine 6 mg IV rapid push. Adenosine 12 mg IV rapid push. May repeat once in 1-2 min. CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician and Paramedic: Consider Sedation for Cardioversion: o Midazolam 5 mg IV Key Points/Considerations HR > 150 bpm Unstable Tachycardia is defined as tachycardia with a pulse and inadequate perfusion. 34 TENSION PNEUMOTHORAX CRITICAL CARE Routine Medical or Trauma Care Confirm indications for emergency Needle Chest Decompression If patient is in cardiac arrest, proceed with Needle Chest Decompression Needle Chest Decompression - Use second intercostal space, midclavicular line for landmark. Once catheter is in place, it should be left open. CRITICAL CARE STOP PARAMEDIC For any patient in need of proceed with Needle Chest Decompression PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician: If patient is not in cardiac arrest, contact Medical Control for consideration of Needle Chest Decompression Key Points/Considerations Signs of tension pneumothorax include: o severe respiratory distress o absent lung sounds on the affected side o diminished lung sounds on the opposite side o hypotension o tachycardia o distended neck veins o tracheal deviation away from the affected side 35 V-FIB / PULSELESS V-TACH INTERMEDIATE CPR Defibrillation – AED Resume CPR immediately for 2 minutes Routine Medical Care and Consider Advanced Airway INTERMEDIATE STOP ADVANCED EMT Epinephrine 1:10,000 (1 mg IV or IO). Repeat every 3-5 min. during arrest. ADVANCED EMT STOP CRITICAL CARE Defibrillation – deliver 1 shock o Manual biphasic – device specific (typically 120 to 200 joules) OR o Monophasic – 360 joules o Repeat 1 shock every 2 minutes Shocks are not stacked; Second and subsequent doses should be equivalent, and higher doses may be considered. Resume CPR immediately for 2 minutes Epinephrine 1:10,000 (1 mg IV or IO or 2 mg ET). Repeat every 3-5 min. during arrest. OR Vasopressin 40 units IV or IO (as replacement for first or second dose of Epinephrine) Amiodarone 300 mg IV or IO; Repeat 150 mg in 5 minutes OR Lidocaine 1-1.5 mg/kg IV or IO or ET. Repeat 0.5 – 0.75 mg/kg IV or IO or ET every 5 minutes up to total of 3 mg/kg In Torsades de Pointes, administer Magnesium Sulfate 1- 2 grams in 50 ml NS over 5 minutes as the first line antiarrhythmic drug CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Sodium Bicarbonate 1 mEq/kg IV or IO Key Points/Considerations CPR for 2 minutes prior to defibrillation; If witnessed arrest, defibrillate immediately. Use same antiarrhythmic drug for duration of protocol. Consider ET medication administration. Revised 2014 36 ROUTINE MEDICAL CARE - Pediatric INTERMEDIATE The following procedures will be performed on medical emergencies requiring Advanced Life Support: Assure scene safety Patients 16 years and older Bring ALS equipment to the patient and utilize as indicated: o AED, Pulse oximetry, Suction, Oxygen o Glucometer (Agencies with Regional approval) o Capability for field to hospital communications Initial patient assessment and vital signs; blood pressure, pulse, and respirations every 5- 15 minutes and after every treatment (first BP manually) Reassurance and proper positioning Medical Control notification as soon as reasonable INTERMEDIATE STOP CRITICAL CARE o Bring ALS equipment to the patient and utilize as indicated: o Advanced airway equipment (refer to Airway Management Pediatric Protocol), Continuous waveform capnography o IV access: Patients 6 years and older : IV or IO access Patients < 6 years in cardiac arrest: IV or IO access o Monitor/defibrillator; Obtain 12 Lead ECG if appropriate o Medications CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Multiple Patient Procedures: If a potential MCI exists, contact 911 center and medical control ASAP. The medical control physician may authorize standing orders during the MCI. Document incident commander’s name and affiliated agency. Pediatric protocols apply to patients from birth to onset of puberty. Onset of puberty is usually 12 -14 years of age with the development of axillary hair on males and breast buds on females. 37 ROUTINE TRAUMA CARE – Pediatric INTERMEDIATE Intercept with ALS Patients 16 years and older INTERMEDIATE STOP CRITICAL CARE Advanced airway equipment (refer to Airway Management Pediatric Protocol) Establish large bore Normal Saline IV or IO (refer to IV or IO Pediatric Protocol) Apply & Monitor ECG If indicated consider Fluid Challenge CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Patients meeting Trauma Triage Criteria will be transported to a designated Trauma Center, unless one of the following conditions exists transport to nearest hospital: o Patient in Cardiac Arrest o Unmanageable Airway o Directed by Medical Control Pediatric protocols apply to patients from birth to onset of puberty. Onset of puberty is usually 12 -14 years of age with the development of axillary hair on males and breast buds on females. 38 ACUTE RESPIRATORY DISTRESS - Pediatric INTERMEDIATE INTERMEDIATE STOP CRITICAL CARE Routine Medical Care Wheezing or History of Asthma/ Bronchiolitis: o Albuterol Sulfate (2.5 mg in 3 ml NS) and Ipratropium Bromide (0.5 mg in 2.5 ml NS) via nebulizer o Repeat Albuterol Sulfate (2.5 mg in 3 ml NS) via nebulizer o Epinephrine 1:1000 (0.01 mg/kg IM) (Maximum single dose 0.3 mg); May repeat in 20 min. Stridor or Drooling: o Administer 100% oxygen o Allow position of comfort, do not agitate patient o Transport without delay CRITICAL CARE STOP PARAMEDIC Wheezing or History of Asthma/ Bronchiolitis: o Epinephrine 1:1000 (0.01 mg/kg IM) (Maximum single dose 0.3 mg); May repeat in 20 min. OR o Epinephrine 1:1000 (5 mg combined with 3 ml NS via nebulizer) Stridor or Drooling: o Epinephrine 1:1000 (5 mg combined with 3 ml NS via nebulizer) PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician and Paramedic: o Methylprednisolone 2mg/kg slow IV push (Maximum dose single 125 mg) Key Points/Considerations You may begin nebulizer therapy prior to establishing IV access. Consider respiratory protection for all non-patients in the immediate area of patient receiving a nebulized epinephrine treatment. 39 AIRWAY MANAGEMENT – Pediatric INTERMEDIATE Patients 16 years and older Manually open the airway Suction as needed Insert oropharyngeal or nasopharyngeal airway Ventilate patient with Bag-Valve Mask and 100% oxygen May place appropriate alternative rescue airway device for patients in respiratory or cardiac arrest. INTERMEDIATE STOP ADVANCED EMT ADVANCED EMT STOP CRITICAL CARE May perform endotracheal intubation up to a total of 3 attempts on patients in respiratory or cardiac arrest. Consider using GumBougie. (If unsuccessful place appropriate alternative rescue airway device) May attempt endotracheal intubation if patient has an altered mental status, respiratory rate < 10, and tolerates an oropharyngeal airway. CRITICAL CARE STOP PARAMEDIC May attempt endotracheal intubation on patients requiring definitive airway management. If direct laryngoscopy is impossible, digital intubation may be attempted. If abdominal distention occurs, pass an Orogastric Tube. PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations In trauma, manual stabilization is required. Confirm and monitor airway device with continuous End-Tidal CO2 waveform capnography. If capnography unsuccessful, confirm position with EDD or End-Tidal CO2 Detector. Revised 2014 40 AIRWAY OBSTRUCTION - Pediatric INTERMEDIATE Follow NYS BLS Protocols Routine Medical Care or Trauma Care INTERMEDIATE STOP CRITICAL CARE If BLS maneuvers are unsuccessful: Use direct laryngoscopy and Magill forceps If unsuccessful, insert an ET tube and attempt to push through the obstruction or push it into the lower airway If unsuccessful, continue BLS efforts and transport CRITICAL CARE STOP PARAMEDIC If unable to adequately ventilate with BLS/ALS techniques, perform Needle Cricothyroidotomy. Refer to Percutaneous Airway Protocol. PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations 41 ALLERGIC REACTION / ANAPHYLAXIS - Pediatric INTERMEDIATE Routine Medical Care Assess BP and respiratory status If hemodynamically unstable, consider Epinephrine Autoinjector INTERMEDIATE STOP CRITICAL CARE Adequate Perfusion with hives and no respiratory distress: o Diphenhydramine – PO: 2 - 6 years old: 6.25 mg 7 - 12 years old: 12.5 mg >12 years old: 25 mg OR o Diphenhydramine 1mg/kg up to 50 mg slow IV or IM Inadequate Perfusion with respiratory distress, stridor, wheezing, hypotension, altered mental status, throat tightness, or shock: o Epinephrine 1:1000 (0.01 mg/kg IM up to dose 0.3 mg) o Diphenhydramine 1mg/kg up to 50 mg slow IV or IM o Albuterol (2.5 mg in 3 ml NS) and Ipratropium Bromide o (0.5 mg in 2.5 ml NS) via nebulizer o Fluid Challenge CRITICAL CARE STOP PARAMEDIC Repeat Epinephrine 1:1000 (0.01 mg/kg IM up to 0.3 mg) PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician: o Repeat Epinephrine 1:1000 (0.01 mg/kg IM up to 0.3 mg) Critical Care Technician and Paramedic: o Methylprednisolone 2mg/kg slow IV or IM up to 125 mg Paramedic: o Dopamine Drip 5-10 mcg/kg/min; Titrate to BP > 100mmHg systolic Key Points/Considerations Consider immediate drug therapy prior to IV access in critical patients. 42 ALTERED MENTAL STATUS - Pediatric INTERMEDIATE Routine Medical Care Assess Blood Glucose for patients 16 years and old INTERMEDIATE STOP CRITICAL CARE Assess Blood Glucose: o Hypoglycemia: If Blood Glucose < 60 mg/dL: Dextrose 25% 2ml/kg IV (Maximum single dose 100 ml) If unable to start IV, Glucagon 0.1 mg/kg IM (Maximum single dose 1 mg) If no response, consider Naloxone 0.1 mg/kg IV or IM or IN (Maximum single dose 2 mg) o If Blood Glucose > 60 mg/dL: Consider Naloxone 0.1 mg/kg IV or IM or IN (Maximum single dose 2 mg) CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Suspected Sympathomimetic OD - (Cocaine or Amphetamines) o Benzodiazepines Suspected Tricyclic OD o Sodium Bicarbonate Suspected Beta Blocker OD o Glucagon **Doses to be determined by Medical Control** Key Points/Considerations To make D25: Add 50 ml D50 into 50 ml NS 43 ASYSTOLE and PULSELESS ELECTRICAL ACTIVITY (PEA) – Pediatric INTERMEDIATE Rendezvous with ALS Intercept or transport to hospital, whichever is closer CPR AED INTERMEDIATE STOP CRITICAL CARE Routine Medical Care Confirm Asystole in 2 leads Epinephrine 1:10,000 (0.01 mg/kg IV or IO repeat every 3-5 min.) Consider Advanced Airway CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Consider Epinephrine 1:1,000 (0.1 mg/kg ET if no IV or IO every 3-5 min.) Key Points/Considerations Use adult paddles/electrodes for children weighing > 10 kg Consider Underlying Causes: o Hypovolemia o Hypoxia o Hydrogen Ion (acidosis) o Hypo / Hyperkalemia o Hypothermia o Toxins o Tamponade, cardiac o Tension Pneumothorax o Thrombosis o Trauma 44 FACILITATED INTUBATION -Pediatric PARAMEDIC Spray hypopharynx with topical anesthetic spray (optional) >10 years: Etomidate 0.3 mg/kg IV over 30 to 60 seconds ; (Maximum single dose 20 mg) After successful intubation, consider medical control option for continued sedation PARAMEDIC STOP MEDICAL CONTROL ORDER For intubation in place of Etomidate: o Midazolam > 6 months 0.025 – 0.05 mg/kg IV (Maximum single dose 5mg) If Intubation unsuccessful: o May repeat Midazolam 0.025 – 0.05 mg/kg IV (Maximum single dose 5mg) Continued Sedation: o Midazolam 0.025 – 0.05 mg/kg IV (Maximum single dose 5mg) Key Points/Considerations SPO2 monitoring is required during intubation attempts. Continuous End-Tidal CO2 waveform capnography is required. Confirm and document proper ETT placement. Confirm and monitor airway device with continuous End-Tidal CO2 waveform capnography. If capnography unsuccessful, confirm position with EDD or End-Tidal CO2 Detector. Consult Pediatric Measuring Device for adjunct sizes and drug dosages; contact Medical Control for any discrepancies. 45 FLUID CHALLENGE - Pediatric INTERMEDIATE INTERMEDIATE STOP ADVANCED EMT Routine Medical Care/Trauma Care Confirm indications for fluid challenge Administer 20 ml/kg NS IV or IO bolus Repeat bolus of 20 ml/kg if indicated x 2 unless contraindicated. If potential cardiogenic shock or other significant cardiac disease, limit fluid administration to 5-10 ml/kg IV or IO unless directed otherwise by medical control. ADVANCED EMT STOP CRITICAL CARE CRITICAL CARE STOP PARAMEDIC Patients in cardiac arrest or profound hypovolemia with alteration in mental status: IO access any age PARAMEDIC STOP MEDICAL CONTROL ORDER Advanced EMT and Critical Care Technician: o Patients under 6 years: IV or IO access Key Points/Considerations Use large syringe to administer NS bolus. Revised 2014 46 IV / IO THERAPY - Pediatric INTERMEDIATE Patients 16 years and older: May establish Normal Saline IV or IO INTERMEDIATE STOP ADVANCED EMT Patients 6 years and older : IV or IO access Patients < 6 years in cardiac arrest: IV or IO access ADVANCED EMT STOP CRITICAL CARE CRITICAL CARE STOP PARAMEDIC Patients any age: IV access Patients in cardiac arrest or profound hypovolemia with alteration in mental status: IV or IO access any age Critical patients 6 years and older when no other access is available: External Jugular access PARAMEDIC STOP MEDICAL CONTROL ORDER Advanced EMT and Critical Care Technician: Patients < 6 years: IV or IO access Key Points/Considerations Do not delay transport for IV or IO access Revised 2014 47 NEONATAL RESUSCITATION - Pediatric INTERMEDIATE Perform an initial assessment of the infant. Quickly assess the infant’s respiratory status, pulse and general condition. o If the infant is breathing spontaneously and crying vigorously and has a pulse greater than 100/min: Ongoing assessment. Obtain and record vital signs, as often as the situation indicates. If the infant is not breathing spontaneously and crying vigorously: o If the infant’s respirations are absent or depressed (less than 30/minute in a newborn): Gently stimulate o If the respirations remain absent or become depressed (less than 30/minute in a newborn) despite stimulation, or if cyanosis is present: Clear the infant’s airway by suctioning the mouth and nose gently with a bulb syringe. Monitor the infant’s pulse rate continuously. o If the pulse rate drops below 100 beats per minute at any time, assist ventilations at a rate of 40 – 60/minute with supplemental oxygen. o If the pulse rate drops below 60 beats per minute at any time, or does not increase above 60 beats per minute after 30 seconds of assisted ventilations, add chest compressions to assisted ventilations following AHA/ARC/NSC guidelines. o If respirations remain absent or depressed (less than 30/minute in a newborn) despite stimulation and oxygen: Insert the proper size oral airway gently. Ventilate the infant without supplemental oxygen at a rate of 40 – 60 /minute with an appropriately sized pocket mask or bag-valve-mask as soon as possible. Each ventilation given over one second assuring that the chest rises with each ventilation. If patient does not respond within 30 seconds add supplemental oxygen. INTERMEDIATE STOP continued on next page…… 48 NEONATAL RESUSCITATION - Pediatric continued…… CRITICAL CARE CRITICAL CARE STOP PARAMEDIC Establish ET and IV or IO access Assess blood glucose. If less than 40 mg/dL, treat with Dextrose 10% 2-4 ml/kg Treat dysrhythmias; If heart rate less than 60 bpm after adequate ventilation; o Epinephrine 1:10,000 (0.01 mg/kg IV or IO) Repeat every 3-5 min. Fluid Challenge @ 10 ml/kg Consider Naloxone 0.1 mg/kg IV or IO; Maximum single dose is 2mg PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations To Make Dextrose 10%: Add 12 ml D50 into 50 ml NS bag Naloxone can be administered in the case of respiratory depression and history of narcotic administered to mother within 4 hours before delivery, unless mother has a history of narcotic addiction (may precipitate withdrawal in infant with severe seizures). 49 PAIN MANAGEMENT - Pediatric INTERMEDIATE Routine Medical Care or Trauma Care INTERMEDIATE STOP CRITICAL CARE CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician and Paramedic: Morphine Sulfate 0.1 mg/kg IV; Maximum single dose 5mg o May repeat every 5 minutes Fentanyl 1 mcg/kg IV Key Points/Considerations Indicated for patients experiencing pain due to musculoskeletal injuries, burns (without airway involvement) abdominal pain (without suspected obstruction) and cancer pain 50 PERCUTANEOUS AIRWAY - Pediatric PARAMEDIC Routine Trauma Care Confirm indications for percutaneous airway Percutaneous airway device or equivalent PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Situations in which standard endotracheal intubations cannot be performed. This procedure is to be used as a last resort and may not provide adequate oxygenation for long periods of time. Rapid transport to the closet hospital is required for definitive airway management. Use slow ventilations with extended exhalation periods. Medical control must be notified following performance of the procedure. For patients 3 years and younger utilize needle cricothyrotomy. 51 POISONING / OVERDOSE - Pediatric INTERMEDIATE Routine Medical Care INTERMEDIATE STOP CRITICAL CARE Evaluate potential substance involved and utilize specific treatments as listed below. CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Tricyclic Antidepressants: o Sodium Bicarbonate 1 mEq/kg IV Beta Blockers: o Glucagon 0.1 mg/kg IV or IM, up to 2 mg maximum Organophosphate insecticides/cholinesterase inhibitors (ingested, absorbed, or inhaled): o Atropine 0.02 – 0.05 mg/kg IV or IN Key Points/Considerations Give nothing by mouth unless directed by medical control Initiate transport with attention to protection of airway Determine substance, quantity and route of exposure Transport substance container to hospital 52 SEIZURES - Pediatric INTERMEDIATE Routine Medical Care Protect patient from harm Assess Blood Glucose for patients 16 years and older INTERMEDIATE STOP CRITICAL CARE If Blood Glucose < 60 mg/dL: o Administer Dextrose according to following dosing schedule: < 6 years old: Administer Dextrose 25% 2 ml/kg IV (Maximum single dose 100 ml) > 6 years old: Administer Dextrose 50% 2 ml/kg IV (Maximum single dose 50 ml) o If unable to start IV: Glucagon 0.1 mg/kg IM (Maximum single dose is 1 mg) o If continued seizure activity, administer: Midazolam 0.1 mg/kg IV or IM or IN (Maximum single dose is 2 mg) Dextrose or Glucagon may be repeated in 10 minutes if repeat Blood Glucose is < 60mg/dL CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER May order additional doses of Midazolam Key Points/Considerations If status epilepticus, begin rapid transport Treat Underlying Causes To make D25: Add 50 ml D50 into 50 ml NS 53 SYMPTOMATIC BRADYCARDIA - Pediatric INTERMEDIATE Rendezvous with ALS unit or transport to hospital, whichever is closer INTERMEDIATE STOP CRITICAL CARE Routine Medical Care CPR if heart rate < 60 bpm with poor perfusion Epinephrine 1:10,000 (0.01 mg/kg IV or IO every 3-5 min.) Atropine 0.02 mg/kg IV or IO; May repeat once o (Minimum single dose 0.1 mg) o (Maximum single dose 0.5 mg) o (Maximum total dose 1 mg) Obtain 12-Lead ECG CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Consider Epinephrine 1:1,000 (0.1 mg/kg ET if no IV or IO every 3-5 min.) Consider Atropine 0.04 mg/kg ET if no IV or IO; May repeat once o (Minimum single dose 0.1 mg) o (Maximum single dose 1 mg) Consider Transcutaneous Pacing Key Points/Considerations Treat Underlying Causes 54 TACHYCARDIA – STABLE - Pediatric INTERMEDIATE Rendezvous with ALS Intercept or transport to hospital, whichever is closer INTERMEDIATE STOP CRITICAL CARE Routine Medical Care Obtain 12 Lead ECG Treat Underlying Causes CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations HR > 150 bpm Stable Tachycardia is defined as tachycardia with a pulse and adequate perfusion. 55 TACHYCARDIA – UNSTABLE - Pediatric INTERMEDIATE Rendezvous with ALS Intercept or transport to hospital, whichever is closer INTERMEDIATE STOP CRITICAL CARE Routine Medical Care Obtain 12 Lead ECG Treat Underlying Causes Consider Paramedic Intercept or transport to hospital, whichever is closer CRITICAL CARE STOP PARAMEDIC EVALUATE QRS: QRS Normal <0.09 (SVT) QRS Wide >0.09 (VT) Vagal Maneuver *Synchronized Cardioversion 0.5 – 1 joules/kg May repeat at 2 joules/kg Adenosine 0.1 mg/kg rapid IV Amiodarone 5mg/kg in 50 ml NS (Maximum single dose 6mg) over 20-60 min. (Maximum single dose 300 mg) *Consider sedation prior to cardioversion PARAMEDIC STOP MEDICAL CONTROL ORDER Paramedic: Consider Midazolam 0.1 mg/kg IV for sedation Key Points/Considerations HR > 150 bpm Unstable Tachycardia is defined as tachycardia with a pulse and inadequate perfusion. 56 TENSION PNEUMOTHORAX – Pediatric PARAMEDIC Routine Medical or Trauma Care Confirm indications for emergency needle chest decompression Needle Decompression - Use second intercostal space, midclavicular line for landmark. Once catheter is secured in place secure to the chest wall. PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Signs of tension pneumothorax include: o severe respiratory distress o absent lung sounds on the affected side o diminished lung sounds on the unaffected side o hypotension o tachycardia o distended neck veins o tracheal deviation away from the affected side 57 V-FIB / PULSELESS V-TACH - Pediatric INTERMEDIATE Rendezvous with ALS Intercept or transport to hospital, whichever is closer CPR Defibrillation – AED o Resume CPR immediately for 2 minutes INTERMEDIATE STOP CRITICAL CARE CPR for 2 minutes prior to defibrillation; If witnessed arrest, defibrillate immediately. Defibrillate at 2 joules/kg – deliver 1 shock Resume CPR immediately for 2 minutes Routine Medical Care Consider Advanced Airway Defibrillate at 4 joules/kg – deliver 1 shock Epinephrine 1:10,000 (0.01 mg/kg IV or IO every 3-5 min.) Resume CPR immediately for 2 minutes Defibrillate at 4 joules/kg – deliver 1 shock Amiodarone 5mg/kg IV or IO (Maximum single dose 300 mg) o Repeat once in 3-5 min. (Maximum single dose 150 mg) Resume CPR immediately for 2 minutes CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Consider Epinephrine 1:1,000 (0.1 mg/kg ET if no IV or IO every 3-5 min.) Key Points/Considerations Use adult paddles/electrodes for children weighing > 10 kg 58 AIR MEDICAL SPECIAL PROTOCOL Air Medical transport should be considered for the following: Anytime a patient outcome could be improved by shortened transport time such as: o Ground transport greater than 30 minutes o Prolonged extrication o A remote or wilderness area, difficult terrain, or any other time when ground ambulance access is prevented or delayed. o Multiple critical / unstable patients / multiple casualty incident o To bring special medical personnel and equipment to the scene, such as a physician or surgeon, o Paramedic level care is otherwise unavailable Request for Air Medical Service should be made immediately when one of the above criteria is met. Patient transport should not be delayed awaiting a helicopter. Begin transport to the hospital and rendezvous with the helicopter, if possible and at a predetermined safe landing site, enroute to the hospital. Requests from the scene should be made by the highest trained EMS provider (through the incident commander, as appropriate) to the County Dispatch (Fire control or 911 centers). Requests will be made through the Central NY Air Medical Clearing House. The pilot will determine if the mission will be flown. Once at the scene the flight medical crew may elect to fly the patient, accompany the patient by ground, or have the patient transported by ground with the on-scene crew. 59 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) SPECIAL PROTOCOL CRITICAL CARE Routine Medical Care Confirm indications for CPAP Assemble equipment per manufacturer’s directions Explain procedure to the patient Start CPAP at 5 cm H2O pressure Evaluate respiratory status in 3 - 5 minutes If patient does not improvement, then increase CPAP to 10 cm CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Critical Care Technician and Paramedic: o Consider Midazolam 2.5 mg IV for sedation Key Points/Considerations Contraindications: Respiratory arrest (or obvious need for intubation) Systolic BP < 90 mmHg Pneumothorax Decreased level of consciousness (must be coachable) Severe facial injuries / deformity Active vomiting Warning: If patient fails to improve with treatment, begin positive ventilation with BVM or intubation. 60 DO NOT RESUSCITATE / MOLST SPECIAL PROTOCOL If a valid DNR/MOLST exists, and a patient becomes pulseless and or apneic DO NOT ATTEMPT RESUSCITATION: DNR/MOLST forms should be honored: Transferring a patient from a health care facility with a valid DNR/MOLST order, or an order signed by a physician to accompany the patient in the ambulance. When the patient has a valid DNR/MOLST form. DNR/MOLST should be disregarded: The provider in good faith believes the order has been revoked. A physical confrontation with a family member, who disagrees with the order, appears likely. Living Will and Health Care Proxies: Living Wills have no validity in the pre-hospital setting and should be disregarded if necessary contact Medical Control for assistance. When a health care proxy is present (both the document and the designated individual) and there is a disagreement as to the validity, and whether resuscitation attempts should be initiated/continued, contact Medical Control. In the event a patient expires during transport between medical facilities that patient should be returned to the sending facility. Contact Medical Control for additional assistance. 61 INTERFACILITY TRANSFERS SPECIAL PROTOCOL Field providers may transport patients with the following IV equipment and IV drips without facility staff: EMT EMT-I Saline lock Stable patient with no anticipation of further interventions enroute Peripheral IV lines with no additives Stable, non-intubated patients with no further interventions needed enroute EMT-CC Peripheral IV lines Cardiac monitor/defibrillator Intubated patients > 5 years old Antibiotic (may not be 1st dose ) drip Amiodarone drip [1, 2] Chest Tubes [1, 2] Diltiazem drip [1, 2] Glycoprotein (GPIIb/IIIa) Inhibitor drip [1, 2] Insulin drip [1, 2] Lidocaine drip Bretylium drip [1, 2] Heparin drip [1, 2] Methylprednisolone drip [1, 2] IV drips: All electrolyte and lipid solutions Dobutamine Procainamide Aminophylline EMT-CC protocol drugs EMT-CC protocol drugs (MS, NTG. Etc.) EMT-P In addition to above: Benzodiazepine drip or bolus [1, 2] Levophed drip [1, 2] Propofol drip [1, 2] Intubated patients any age Central venous lines/PICC Lines [3] Hickman catheters [3] Subclavian IV [3] Internal jugular IV [3] Port-a-Cath [3] Arterial lines-May not be used for IV access or any medications Paramedic protocol drugs Key Points/Considerations 1. The transferring facility must supply the IV pump and training for the above drips. Unless the agency has their own equipment. 2. Contingent on approval of the Agency Medical Director. In addition, a provider must have received chest tube training as prescribed by the Agency Medical Director. 3. Not to be accessed by EMT-P during transport. If the line is to be used for medication infusion, facility personnel must access it prior to leaving the hospital. 62 LEFT VENTRICULAR ASSIST DEVICE (LVAD) SPECIAL PROTOCOL INTERMEDIATE Criteria: Any request for service that requires evaluation and transport of a patient with a Left Ventricular Assist Device (LVAD). Assess airway and breathing. Treat airway obstruction or respiratory distress per protocol. Treat medical or traumatic condition per protocol. Assess pump function and circulation: o Listen to motor of pump over heart and observe green light on system control device. Assess perfusion based on mental status, capillary refill, and skin color. The absence of a palpable pulse is normal for patients with a functioning LVAD. They may not have a blood pressure. o DO NOT PERFORM CPR. Perform secondary assessment, treat per protocol. Notify Heart Failure Coordinator ASAP, regardless of the patient's complaint. Patient will have contact numbers. Contact Medical Control. Bring patient's power unit and batteries to the Emergency Department. Trained support member must remain with patient. Do not delay transport to hospital. INTERMEDIATE STOP CRITICAL CARE If hypotensive (defined as poor perfusion based on mental status, capillary refill, or skin color): o Establish IV or IO access and administer 500 ml NS bolus. o Reassess and repeat up to 1000 ml total. Contact Medical Control for additional fluid boluses. If patient does not have evidence of adequate perfusion and oxygenation with treatment, despite the device being on, treat with standard ACLS measures. CRITICAL CARE STOP continued on next page…… 63 LEFT VENTRICULAR ASSIST DEVICE (LVAD) continued…… PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations Community patients are entirely mobile and independent. Keep device and components dry. Batteries and the emergency power pack can provide 24-36 hours of power. Trained support members include family and caregivers who have extensive knowledge of the device. Its function, and its battery units and are a resource to the EMS provider when caring for a LVAD patient. Patients are frequently on three different anticoagulants and are prone to bleeding complications. Patient may have VF/VT and be asymptomatic. Contact Medical Control for treatment instructions. 64 PHYSICIAN ON SCENE SPECIAL PROTOCOL A patient's personal physician may assume medical control responsibility for his/her patient if he/she desires. In such circumstances, do the following: o Give the physician the card describing the function of the Regional Medical Control System. o If the physician still desires that the patient be transported without ALS, he should order "NO ALS, TRANSPORT ONLY" on the Patient Care Report and sign this order. o Notify the destination hospital of the case after you are enroute o If the patient's condition deteriorates enroute, contact the Emergency Department physician who will decide if ALS protocols should be started. o If the patient's physician accompanied the patient in the ambulance, he/she will be responsible for this decision. o Bystander physicians may not circumvent standard operating procedures or assume Medical Control without approval from the Resource Hospital physician. Key Points/Considerations Physicians Only: Physician Assistants, Nurse Practitioners, etc. are excluded. 65 PHYSICIAN ON SCENE CARD SPECIAL PROTOCOL CENTRAL NEW YORK EMS, MIDSTATE EMS and NORTH COUNTRY EMS PROGRAM AGENCIES Thank you for your offer of assistance. Please be advised that we are working under Medical Control from physicians at a hospital. We are not permitted to relinquish Medical Control to a physician on the scene without approval from the physician at the Resource Hospital. Should you wish to assume Medical Control, you may request to speak with the Resource Hospital Physician. If you are authorized to provide Medical Control, you must sign the patient's Prehospital Care Report and accompany the patient to the hospital. If you have any questions regarding this Physician-On-Scene Policy, please contact the Central New York Emergency Medical Services Program Agency at: (315) 701-5707 or Midstate EMS Program Agency at: (315) 738-8351 or North Country EMS Program Agency at: (315) 379-3977. Daniel J. Olsson, DO Regional Medical Director, Central New York EMS Program Agency John J. DeTraglia, MD Regional Medical Director, Midstate EMS Program Agency Sarah Delaney-Rowland, MD Regional Medical Director, North Country EMS Program Agency 66 RADIO FAILURE SPECIAL PROTOCOL In the event that direct communications with any hospital cannot be established because the crew is not in UHF/VHF radio range due to either distance from the radio tower, or radio dead spots, or the UHF/VHF radio is malfunctioning, making voice communications impossible, and no telephones are available at the scene, and no other means of direct communications are available, the following policy will be in effect: Given the above circumstances, to allow for the immediate treatment of any emergency deemed appropriate in the judgment of the EMT-CC or EMT-P in charge, all treatments in the Regional ALS Protocol Handbook, except for controlled substances (excluding seizures), which would ordinarily require a physician's order may be carried out by any individual appropriately certified to use the protocols within the Region. All time sequences, as specified in the protocols will be followed. All indications for the treatment, the time treatments were performed, and patient responses to the treatment MUST be thoroughly documented on the PCR or other appropriate run record. Key Points/Considerations Use of this protocol assumes that attempts have been made via all available means to make contact with Medical Control. Thorough documentation is MANDATORY with regard to description of the communications problems encountered including location, number of attempts at communications which were made, and the description of the patient's condition which warranted immediate treatment. In addition, attempts to contact Medical Control will be repeated at 5-minute intervals. All documentation regarding each case utilizing the Radio Failure protocol will be submitted to the Program Agency within one week from the date of occurrence for review by the Executive CQI Committee. YOU MAY NOT USE THE RADIO FAILURE PROTOCOL TO TERMINATE RESUSCITATION EFFORTS IN THE FIELD 67 PATIENT REFUSALS AGAINST MEDICAL ADVICE SPECIAL PROTOCOL Talk with patient, family and friends and attempt to convince of the need for treatment/transport. Offer to call Medical Control and have patient speak with a physician.ie still refuses treatment/transport and If patient still refuses treatment/transport and > 18 years old Assess Level of Consciousness: Alert and oriented x 3 / GCS x 15 Altered Mental Status Assess for the following: Attempted/threatened suicide, minor (<18) refusing care, parent refusing and the potential for a serious illness/child abuse exists Criteria Absent: Criteria Present: Patient cannot refuse. Contact Medical Control. Elicit assistance from law enforcement Patient can Patient cannot refuse. refuse. Educate patient Contact Medical and family. Control. Patient signs Elicit assistance from AMA on law enforcement. Regional Refusal Form. Key Points/Considerations Contact On-Line Medical Control for ALS Refusals. Under no circumstances should field personnel allow themselves to be placed in danger. If this potential exists, go to a safe area and call for assistance. 68 TERMINATION OF RESUSCITATION SPECIAL PROTOCOL CRITICAL CARE Document Asystole in 2 leads Contact Medical Control for order to discontinue Contact local law enforcement and medical examiner/coroner Leave invasive therapies in place Provide support to family members Bring or fax Prehospital Care Report to hospital for signature immediately upon completion of call CRITICAL CARE STOP PARAMEDIC PARAMEDIC STOP MEDICAL CONTROL ORDER Key Points/Considerations THIS PROTOCOL CANNOT BE USED DURING RADIO FAILURE Once begun, you may terminate resuscitation efforts if a DNR or MOLST form with a valid DNR order is found to exist or if you have completed the Adult Asystole Protocol with no success. Do not delay transport in traumatic cardiac arrest. 69 TRANSFER OF CARE SPECIAL PROTOCOL ALS assessment complete Mechanism of injury, chief compliant or assessment warrants ALS intervention and/or ALS transport o ALS shall care for and transport patient OR Mechanism of injury, chief compliant or assessment does not warrant ALS intervention and/or ALS transport o ALS provider may transfer care or contact Medical Control to affirm decision to transfer patient to EMT-Basic or EMT-I. Document decision on Patient Care Report.e Key Points/Considerations ALS providers are authorized to transfer care of a patient to an EMT Basic or EMT–I after patient assessment indicates no need or anticipated need for ALS. EMT-P providers are authorized to transfer ALS care to EMT-CC providers if no Paramedic interventions have been initiated or are anticipated or after contacting Medical Control to affirm decision to transfer patient care. Document this decision on the PCR. Transfer of care may not be made by any level to a CFR. 70 TRAUMA TRIAGE CRITERIA SPECIAL PROTOCOL Adult and Pediatric: Major trauma is present if the patient’s physical findings or the mechanism of injury meets any one of the following criteria: Glasgow Coma Scale < 13 or deterioration of Glasgow Coma Scale – trauma related Trauma with hypotension (systolic BP 90 mmHg or less), tachycardia (pulse 120 or greater) Multiple system trauma Penetrating head, neck, chest or abdominal injuries Major chest wall injury/flail chest Two or more proximal long bone fractures Patients requiring assisted ventilation – trauma related Head injury with changing neurological status Suspected spinal cord injury or limb paralysis Comatose, trauma related Crushed chest or pelvis/major amputations Falls 20 feet or greater in an adult / 10 feet or greater in a child Patient ejected from closed vehicle Burns > 20% of body surface area or 20% with airway or facial burns Severe facial, airway, or neck injuries Pediatric trauma that meets any of above criteria All near-drowning victims with hypothermia or respiratory distress Hanging victims with respiratory distress Trauma transfer patients from other hospitals receiving blood to maintain vital signs Emergency physician discretion Source: 2012 American College of Surgeons Standards 71 ADULT - PROTOCOL DRUG CHART DRUG DOSE INDICATIONS Adenosine (Adenocard) 6 mg IV, 12 mg IV Anti-Arrhythmic Albuterol Sulfate 2.5 mg in 3 ml NS via Nebulizer Amiodarone 300 mg IV/IO 150 mg IV/IO 150 mg in 50 ml NS over 10 min 1 spray Respiratory Distress Allergic Reaction V. Fibrillation/Pulseless V. Tach V. Fibrillation/Pulseless V. Tach Tachycardia-Stable Facilitated Intubation Anesthetic Spray (Cetacaine) Aspirin Acute Coronary Syndrome Cardizem 325 mg PO 324 mg PO (Baby Aspirin) 0.5 mg IV 0.02-0.05 mg/kg IV/IN 0.5 mg IV 0.25 mg/kg IV over 10 min 50% Dextrose 50 ml IV Diphenhydramine (Benadryl) 50 mg IV/IM 50 mg IV/IM 5-10 mcg/kg/min drip Hypoglycemia Seizures Allergic Reaction/Anaphylaxis Sedation Allergic Reaction/Anaphylaxis Hypoperfusion Symptomatic Bradycardia Cardiac Arrest Anaphylaxis Allergic Reaction/Anaphylaxis Respiratory Distress Facilitated Intubation Sedation Rapid Sequence Intubation Pain Management Acute Coronary Syndrome Pulmonary Edema Atropine Dopamine Epinephrine 1:10,000 Epinephrine 1:1,000 Etomidate 1 mg IV/IO, 2 mg ET 0.5 IV 0.3 mg IM Fentanyl 20mg IV 10 mg IV/IO 0.2-0.4 mg/kg IV 50 mcg IV/IM Furosemide (Lasix) 40 – 80 mg IV/IM Glucagon 1 mg IM 0.1mg/kg IV/IM Haloperidol (Haldol) 5 mg IV/IM Ipratropium Bromide (Atrovent) 0.5 mg in 2.5 ml NS via Nebulizer 30 mg IV or 60 mg IM 66 years and older 15 mg IV or 30 mg IM Ketorolac (Toradol) Symptomatic Bradycardia Poisoning / Overdose Rapid Sequence Intubation Anti-Arrhythmic Hypoglycemia without IV Poisoning/Overdose Allergic Reaction/Anaphylaxis Alerted Mental Status, Seizures Sedation Bronchospasm, Respiratory distress Pain Management 72 ADULT- PROTOCOL DRUG CHART DRUG Lidocaine Magnesium Sulfate Methylprednisolone (Solu-Medrol) Metoprolol (Lopressor) Midazolam (Versed) Morphine Sulfate continued…… DOSE 1 – 1.5 mg/kg IV/IO/ET 0.5 – 0.75 mg/kg IV/IO/ET 100 mg IV 1-2 GM in 50 ml NS over 5 min 4 GM in 50 ml NS over 15 min 2 grams IM 125 mg IV/IM 5 mg IV 5 mg in 50 ml NS over 5-10 min 5 mg IV/IM/IN 2 -4 mg IV INDICATIONS V. Fibrillation/Pulseless V. Tach V. Fibrillation/Pulseless V. Tach Rapid Sequence Intubation V. Fibrillation/Pulseless V. Tach Pre-Eclampsia/Eclampsia Pre-Eclampsia/Eclampsia Respiratory Distress Allergic Reaction/Anaphylaxis Acute Coronary Syndrome Tachycardia-Stable Sedation, Seizures Rapid Sequence Intubation Naloxone (Narcan) 4-5mg IV 4 mg IV 2 mg IV/IM/IN Nitroglycerin Nitroglycerin Paste Nitrous Oxide 0.4 mg SL or 1 spray 1 inch Pt. demand, inhaled gas Pain Management Acute Coronary Syndrome Poisoning Overdose Altered Mental Status ACS, Pulmonary Edema ACS, Pulmonary Edema Pain Management Ondansetron (Zofran) 4mg IV/IM/PO/ODT Antiemesis Rocuronium 0.6mg/kg IV Rapid Sequence Intubation Sodium Bicarbonate 1 mEq/kg IV/IO Succinylcholine 1-2 mg/kg IV Asystole, V. Fibrillation/Pulseless V. Tach Poisoning Overdose, Altered Mental Status Rapid Sequence Intubation Terbutaline 0.25mg IM Respiratory Distress Vasopressin 40 units IV/IO Cardiac Arrest Vecuronium 1mg IV 0.1mg/kg IV Rapid Sequence Intubation 1 mEq/kg IV 73 DRUG ADULT - IV DRIP CHART CONCENTRATION DRIP RATE (MICRODRIP) Dopamine 5-10 mcg/kg/min 200 mg in 250 ml NS 400 mg in 500 ml NS (800 mcg/ml) Magnesium Sulfate (PreEclampsia/Eclampsia) 4 grams in 50 ml NS over 15 min 200 mcg/min. 15 drops/min. 400 mcg/min. 30 drops/min. 600 mcg/min. 45 drops/min. 800 mcg/min. 60 drops/min. 4 grams in 50 ml NS (run wide open) PEDIATRIC - PROTOCOL DRUG CHART DRUG DOSE INDICATIONS Adenosine Albuterol Sulfate 0.1 mg/kg 2.5 mg in 3 ml NS via Nebulizer Atropine 0.02 mg/kg IV/IO; 0.04 mg/kg ET 0.02-0.05 mg/kg IV/IN 5 mg/kg in 50ml NS over 20-60 min 5mg/kg (max. dose 300 mg); 5mg/kg (max. dose150 mg) 1 spray Amiodarone Anesthetic Spray 50% Dextrose 25% Dextrose 10% Dextrose Diphenhydramine Tachycardia-Unstable Respiratory Distress Allergic Reaction/Anaphylaxis Symptomatic Bradycardia Poisoning/Overdose Tachycardia-Unstable V. Fib./Pulseless V. Tach Facilitated Intubation Seizures Hypoglycemia; Seizures Hypoglycemia (Neonate) Allergic Reaction/Anaphylaxis Dopamine 2 ml/kg IV > 6 yrs old (max. 50ml) 2 ml/kg IV < 6 yrs old (max. 100 ml) 2-4 ml/kg 1 mg/kg IV/IM (max. dose 50 mg) PO / Elixir: 2-6 yrs. 6.25 mg; 7-12 yrs. 12.5 mg; >12 yrs. 25 mg 5-10 mcg/kg/min drip Epinephrine 1:10,000 0.01mg/kg/IV/IO Epinephrine 1:1,000 Epinephrine 1:1,000 Epinephrine 1:1,000 Etomidate Fentanyl Ipratropium Bromide Glucagon Methylprednisolone Midazolam Morphine Sulfate Naloxone 0.1 mg/kg ET 5 mg in 3 ml NS via Nebulizer 0.01 mg/kg IM (max. dose 0.3 mg) 0.3 mg/kg IV (max. dose 20 mg) 1mcg/kg IV 0.5 mg in 2.5 ml via Nebulizer 0.1mg/kg IM (max dose 1mg) 2 mg/kg IV (max. dose 125 mg) >6 mos. 0.025 – 0.05 mg/kg IV (max. 5 mg) 0.1 mg/kg IV/IM/IN 0.1 mg/kg IV 0.1 mg/kg IV (max. 5 mg) 0.1 mg IV/IM/IN (max. 2 mg) Cardiac Arrest Symptomatic Bradycardia Cardiac Arrest, Bradycardia Croup, Epiglottitis Anaphylaxis, Resp. Distress Facilitated Intubation > 10 yrs Pain Management Anaphylaxis, Resp. Distress Hypoglycemia, AMS,Overdose Anaphylaxis, Resp. Distress Facilitated Intubation Sodium Bicarbonate 1 mEq/kg IV Midazolam Allergic Reaction/Anaphylaxis Seizures Sedation Pain Management Alerted Mental Status, Neonatal Resuscitation Poisoning/Overdose 74 APGAR CHART SIGN 0 1 2 Heart Rate Absent Below 100 Over 100 Respiration Absent Slow and irregular Normal crying Limp Some flexion- Active; good motion in extremities (effort) Muscle Tone extremities Irritability No Response Crying; some motion Crying; vigorous Skin Color Bluish or paleness Pink or typical newborn color; hands and feet are blue Pink or typical newborn color; entire body ABNORMAL PEDIATRIC VITAL SIGNS CHART AGE RR PULSE (YEARS) B/P (SYSTOLIC) < 1 month <40 or > 60 <80 or > 160 < 60 1 month - 1 year <15 or > 30 <80 or > 140 < 70 1 year - 10 years <12 or > 25 <60 or > 120 <(70 + 2 x age) > 10 years <10 or > 20 <50 or > 110 < 90 75 GLASGOW COMA SCALE Physical Signs Infants Children Adult Points Eye Opening Spontaneous To Voice To Pain None Coos and Babbles Irritable Cry Cries to Pain Moans to Pain None Spontaneous Withdraws to Touch Withdraws to Pain Flexion Extension None Spontaneous To Voice To Pain None Smiles Cries Consolable Inconsolable None Spontaneous Localizes Pain Withdraws to Pain Flexion Extension None Spontaneous To Voice To Pain None Oriented Confused Inappropriate Words Incomprehensible Sounds None Obeys Commands Localizes Pain Withdraw (pain) Flexion (pain) Extension (pain) None 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 Verbal Response Motor Response CINCINNATI PREHOSPITAL STROKE SCALE FACIAL DROOP: Have the patient show their teeth or smile Normal – Both sides of face move equally well Abnormal – One side of face does not move as well as the other side ARM DRIFT : Have the patient close their eyes and hold both arms out Normal – Both arms move the same or both arms do not move at all (other findings, such as pronator grip, may be helpful) Abnormal – One arm does not move or one arm drifts down compared with the other SPEECH : Have the patient say, “you can’t teach an old dog new tricks” Normal – Patient uses correct words with no slurring Abnormal – Patient slurs words, uses inappropriate words, or is unable to speak 76 ONE-MINUTE CRANIAL NERVE EXAM CHART Cranial Nerve I II, III III, IV & VI V VII IX, X XII VIII XI The Test Normally not done in the field Direct response to light “H” test for extraocular movement Clench teeth, test sensory Show teeth Say “ahh”, test gag reflex Stick tongue out and move around Test balance and hearing Shrug shoulders, turn head against resistance VISUAL ANALOG PAIN SCALE If you are having pain, Point to the number that describes your pain. Sin Dolor Duele un Poquito Duele un Duele todavia Poquito mas mas Duele mucho El peor dolor Infant Pain Scale 0 1-2 3-4 5-6 7-8 9-10 Restful Sleep Quiet, awake, calm face Restless, occasional grimace or whimper Irritable with intermittent crying and occasional grimace (easily consolable) Frequent crying, constant grimace, tense muscles (difficult to console) Constant high-pitched cry, thrashing of limbs, constant grimace (unable to console) 77 RULE OF NINES CHART 78 CODE HOSPITAL EMERGENCY DEPT. 053 053 446 446 221 221 541 541 441 441 442 442 331 331 261 261 114 114 332 332 448 448 241 241 212 212 445 445 n/a n/a n/a 262 262 372 372 Auburn Community Hospital Auburn Community Hospital Canton-Potsdam Hospital Canton-Potsdam Hospital Carthage Area Hospital Carthage Area Hospital Cayuga Medical Center Cayuga Medical Center Claxton-Hepburn Medical Center Claxton-Hepburn Medical Center Clifton-Fine Hospital Clifton-Fine Hospital Upstate University Hospital at Community Upstate University Hospital at Community Community Memorial Hospital - Hamilton Community Memorial Hospital - Hamilton Cortland Regional Medical Center Cortland Regional Medical Center Crouse Hospital Crouse Hospital E. J. Noble Hospital E. J. Noble Hospital Lewis County General Hospital Lewis County General Hospital Little Falls Hospital Little Falls Hospital Massena Memorial Hospital Massena Memorial Hospital Midstate Resource Midstate Resource Midstate Resource Oneida Healthcare Oneida Healthcare Oswego Hospital Oswego Hospital continued on next page …. TELEPHONE # 315-253-1700 315-255-7189 (fax) 315-265-3300 ext. 1000 315-261-6410 (fax) 315-493-1000 ext. 2499 315-493-6360 607-274-4514 607-274-4132 (fax) 315-393-3600 315-393-8995 (fax) 315-848-3351 ext. 262 315-848-3692 315-492-5684 315-492-5222 (fax) 315-824-6094 315-824-1956 (fax) 607-756-3740 607-756-3515 (fax) 315-470-7411 315-470-2682 (fax) 315-287-1000 315-535-9226 (fax) 315-376-5071 315-376-6775 (fax) 315-823-3189 315-823-5335 (fax) 315-769-4263 315-769-4278 (fax) 315-724-4979 (line #1) 315-724-0704 (line #2) 315-624-6623 (fax) 315-361-2327 315-361-2305 (fax) 315-349-5522 315-349-5714 (fax) 79 CODE HOSPITAL EMERGENCY DEPT. TELEPHONE # 227 227 324 324 223 223 326 326 334 334 327 327 336 336 336 336 n/a 338 338 River Hospital River Hospital Rome Memorial Hospital Rome Memorial Hospital Samaritan Medical Center Samaritan Medical Center St. Elizabeth Hospital St. Elizabeth Hospital St. Joseph's Hospital St. Joseph's Hospital St. Luke’s Hospital St. Luke’s Hospital Upstate University Hospital - Adult ED Upstate University Hospital - Adult ED Upstate University Hospital - Peds ED Upstate University Hospital - Peds ED Upstate New York Poison Center VA Medical Center VA Medical Center 315-482-1212 315-482-7153 (fax) 315-338-7230 315-338-7293 (fax) 315-785-4504 315-779-5227 (fax) 315-798-8174 315-734-3158 (fax) 315-448-5101 315-448-5732 (fax) 315-624-6068 315-624-6308 (fax) 315-464-5612 315-464-6520 (fax) 315-464-5613 315-464-6521 (fax) 800-222-1222 315-425-4400 ext. 54100 315-425-4623 (fax) NOTES ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ 80 NOTES ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ 81