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Reynolds County Ambulance District Operational Guidelines Adopted January 1st, 2017 ADOPTED BY THE BOARD OF DIRECTORS MARCH 6th, 2014 REVISED BY THE BOARD OF DIRECTORS NOVEMBER 6th, 2014 PAGES 5 (Section I for A19 form), 46, (Section I and II), 55 (Section V), 69 (Firearms policy), A19 (addition) REVISED BY THE BOARD OF DIRECTORS JANUARY 7TH, 2016 PAGE 51 (Full time/Part time mandatory meeting and training. Section II added word Mandatory to beginning of the section) REVISED BY THE BOARD OF DIRECTORS DECEMBER 6TH, 2016 ADOPTED NEW PROTOCOLS AND POLICIES JANUARY 1 ST, 2017 1 CLINICAL PRACTICE GUIDELINES INTRODUCTORY STATEMENT These pages represent the hard work and dedication to quality patient care, of all clinicians at Reynolds County Ambulance District. This document will be maintained by the Operations Manager with the Administrator, approved by the Medical Director, at Reynolds County Ambulance District. This document is living and breathing. It will be edited and updated frequently to stay on the cutting edge of pre-hospital medicine. These changes will be driven by our robust Continuous Quality Improvement (CQI) program. These Clinical Practice Guidelines are just that, guidelines. We have moved away from traditional “protocols” in an effort to provide well-rounded patient care. We understand that most patients do not fit into an individual protocol. Therefore, it is our responsibility as professional clinicians, to understand physiology of the human body, understand physiology of disease processes, understand physiology of our treatment options, and then create a plan of care for each individual patient. It is highly likely and expected that most patients will require reference to multiple guidelines. It is because of these high standards that our education and training program has such strict standards. Each clinician should understand his or her licensure level and should use these guidelines only within his or her skill set and licensed scope of practice. If at any time there is a question regarding patient care, a medical control physician should be contacted immediately for consultation. 2 _________________________________ William Christmas Medical Director Reynolds County Ambulance District _________________________________ Shayne Keddy Assistant Medical Director Reynolds County Ambulance District ____________________________ ____________________________ JD Jagelovicz, NRP Administrator Reynolds County Ambulance District Aaron Parker, NRP Operations Manager Reynolds County Ambulance District 3 CLINICAL PRACTICE GUIDELINES PHYSICIAN AUTHORIZATION STATEMENT These operational policies, clinical guidelines, authorized skills and drug formulary have been created by the Clinical Practice Department at Reynolds County Ambulance District, with the authorization of the medical director, as allowed by the State of Missouri. These operational policies, clinical guidelines, authorized skills and drug formulary will be continuously reviewed and revised based on the Continuous Quality Improvement Process at Reynolds County Ambulance District. All treatments, transportation decisions, procedures and medication therapies are to be considered “STANDING ORDERS” unless specifically noted otherwise. Based on significant recommended changes in drug therapies and / or procedures the medical director may authorize interim protocol changes as deemed appropriate at any time. All clinicians operating under these guidelines must adhere to education and training standards outlined in this document, in order to practice under the license of the medical director. This is a requirement and not an option. It should be noted that these Clinical Practice Guidelines (CPG’s) are to be utilized for both onscene response and inter-facility transports and that each provider should only use CPG’s to the skill level at which they are trained. I, William Christmas, DO authorize the use of these clinical practice guidelines, authorized skills and drug formulary within the statutes and laws of the State of Missouri and the scope of practice of each member for use by the Reynolds County Ambulance District. ____________________________ William Christmas Medical Director Reynolds County Ambulance District _________________________________ Shayne Keddy Assistant Medical Director Reynolds County Ambulance District ______________ Date _________________ Date 4 Clinical Practice Guideline Index SECTION ONE – OPERATIONAL POLICIES CPG NUMBER OPS1 OPS2 OPS3 OPS4 OPS5 OPS6 OPS7 OPS8 OPS9 OPS10 OPS11 OPS12 OPS13 OPS14 OPS15 OPS16 OPS17 OPS18 OPS19 OPS20 OPS21 OPS22 OPS23 CPG TITLE Destination Decision Medical Director Authority Education & Training Continuous Quality Improvement New Hire Orientation Process Controlled Substance Vaccine Administration Tuberculin Skin Testing Infection Control Triage Incident Rehab Air Ambulance Utilization Transfer of Care Refusal of Care Determination of Death Discontinuation of Resuscitation DNR Orders Incident Command System Inter-facility Transfers Specialty Care Transports Clinical Documentation RN Functioning as ALS Provider Emergency Medical Response Agencies PAGE NUMBER 10 13 14 16 19 20 22 24 26 28 29 30 31 32 34 35 36 37 38 39 41 43 44 5 Clinical Practice Guideline Index SECTION TWO – ADULT TREATMENT GUIDELINES CPG NUMBER ATG1 ATG2 ATG3 ATG4 ATG5 ATG6 ATG7 ATG8 ATG9 ATG10 ATG11 ATG12 ATG13 ATG14 ATG15 ATG16 ATG17 ATG18 ATG19 ATG20 ATG21 ATG22 ATG23 ATG24 ATG25 ATG26 ATG27 ATG28 ATG29 ATG30 ATG31 ATG32 ATG33 ATG34 ATG35 ATG36 ATG37 ATG38 CPG TITLE Routine Patient Care Airway Management Airway Obstruction Failed Airway Rapid Sequence Intubation Post Intubation Management Pulmonary Edema Bronchospasms Chest Pain STEMI Tachycardic Arrhythmias Bradycardic Arrhythmias Cardiac Arrest – BLS Cardiac Arrest – ACLS Post Resuscitative Care Shock (Non-Trauma) Overdose/Toxic Abnormalities General Pain Management Procedural Sedation Nausea & Vomiting Altered Mental Status Stroke Seizures Allergic Reaction/Anaphylaxis Abdominal Pain Behavioral Emergencies Hypertensive Emergencies Cold Related Emergencies Heat Related Emergencies Trauma Criteria General Trauma Care Traumatic Arrest Crush Injuries Amputations Burns Envenomation Child Birth Pregnancy Complications PAGE NUMBER 47 48 49 50 51 53 54 55 56 57 58 59 60 61 62 63 65 66 67 68 69 70 72 73 74 75 76 77 78 79 81 82 83 84 85 87 88 89 6 Clinical Practice Guideline Index SECTION THREE – PEDIATRIC TREATMENT GUIDELINES CPG NUMBER PED1 PED2 PED3 PED4 PED5 PED6 PED7 PED8 PED9 PED10 PED11 PED12 PED13 PED14 PED15 PED16 PED17 PED18 PED19 PED20 PED21 PED22 PED23 PED24 PED25 CPG TITLE Routine Patient Care Airway Management Airway Obstruction Failed Airway Rapid Sequence Intubation Post Intubation Management Bronchospasms Tachycardic Arrhythmias Bradycardic Arrhythmias Cardiac Arrest – BLS Cardiac Arrest – ACLS Shock (Non-Trauma) Overdose/Toxic Abnormalities General Pain Management Procedural Sedation Nausea & Vomiting Seizures Allergic Reaction/Anaphylaxis Fever Altered Mental Status Abdominal Pain Behavioral Emergencies Trauma Criteria General Trauma Care Burns PAGE NUMBER 91 92 93 94 95 97 98 99 100 101 102 103 105 106 107 108 109 110 111 112 113 114 115 116 117 7 Clinical Practice Guideline Index SECTION FOUR – MEDICATION FORMULARY CPG NUMBER MED1 MED2 MED3 MED4 MED5 MED6 MED7 MED8 MED9 MED10 MED11 MED12 MED13 MED14 MED15 MED16 MED17 MED18 MED19 MED20 MED21 MED22 MED23 MED24 MED25 MED26 MED27 MED28 MED29 MED30 MED31 MED32 MED33 MED34 MED35 MED36 MED37 MED38 MED39 MED40 MED41 MED42 MED43 MED44 MED45 MED46 MED47 CPG TITLE Adenosine Albuterol Amiodarone Aspirin Atropine Calcium Chloride Decadron Dextrose D5W Diazepam (Valium) Dilaudid Diltiazem (Cardizem) Diphenhydramine (Benadryl) Dopamine Duo-Neb Epinephrine Etomidate Fentanyl Furosemide (Lasix) Glucagon Glucose (Instant Oral) Haldol Ibuprofen Ketamine Lidocaine Lorazipam (Ativan) Magnesium Sulfate Methylprednisolone (Solu-Medrol) Metoprolol (Lopressor) Midazolam (Versed) Morphine Sulfate Naloxone (Narcan) Nitroglycerine (NTG) Norepinephrine (Levophed) Normal Saline Oxygen Oxytocin (Pitocin) Phenergan (Promethazine) Rocuronium Sodium Bicarbonate Sterile Water Succinylcholine (Anectine) Thiamine Tylenol Vecuronium (Norcuron) Xopenex Zofran PAGE NUMBER 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 8 Clinical Practice Guideline Index SECTION FIVE – SKILLS FORMULARY CPG NUMBER SKL1 SKL2 SKL3 SKL4 SKL5 SKL6 SKL7 SKL8 SKL9 SKL10 SKL11 SKL12 SKL13 SKL14 SKL15 SKL16 SKL17 SKL18 SKL19 SKL20 SKL21 SKL22 SKL23 SKL24 SKL25 SKL26 SKL27 SKL28 SKL29 SKL30 SKL31 SKL32 SKL33 SKL34 SKL35 SKL36 CPG TITLE Airway: Oxygen Administration Airway: Suction Airway: CPAP/BiPAP Airway: PEEP Valve Airway: Nasal Pharyngeal Airway Airway: Oral Pharyngeal Airway Airway: Nasal Tracheal Intubation Airway: Oral Tracheal Intubation Airway: Superglottic Airway Airway: Per-Trach Airway: Surgical Cricothyrotomy Airway: Gastric Tube Diagnostics: Vital Signs Diagnostics: Pulse Oximiter (SPO2) Diagnostics: Waveform ETCO2 Diagnostics: Multi-Lead EKG (12, 15, 18) Diagnostics: Blood Glucose Assessment Diagnostics: Doppler Procedure: Mechanical Ventilator Operations Procedure: Medication Infusion Pump Operations Procedure: IO Access Procedure: IV Access Procedure: Pre-Existing Catheter Access Procedure: Venous Blood Draw Procedure: Maintenance of Vascular Access Procedure: Cardioversion/Defibrillation Procedure: Transcutaneous Pacing Procedure: Medication Administration Procedure: Needle Thoracentesis Procedure: Restraints Trauma: Commercial Tourniquet Trauma: Spinal Immobilization Trauma: Spinal Clearance Trauma: Sager Traction Splint Trauma: General Splinting Trauma: Pelvic Binder PAGE NUMBER 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 185 186 187 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 9 SECTION ONE OPERATIONAL POLICIES 10 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS1 Date Created 1/1/2017 Date Revised 1/1/2017 Destination Decision Operational Policy Clinicians at Reynolds County Ambulance District should use the following guidelines when deciding on a destination for their patient(s). 1. Patients should be transported to the CLOSEST & MOST APPROPRIATE facility, if at all possible and practical. Serious considerations should be made for patients requiring a SPECIALTY RESOURCE CENTER (IE: trauma center, stroke center, STEMI center). It should be noted that the closest hospital MAY NOT be the most appropriate hospital for the patient. 2. Patients in extremis (in full arrest, impeding arrest, unmanageable airway) WILL BE TRANSPORTED to the closest Emergency Department. 3. Patients who are district residents MAY BE transported to the Emergency Department of their choice, within a 50 mile radius from the district boundary when possible and practical. The need for a SPECIALTY RESOURCE CENTER should be considered. 4. Patients who are non-district residents will be transported to the closest Emergency Department, unless a SPECIALTY RESOURCE CENTER is required. 5. An ABN should be obtained for any transport other than closest facility, unless a SPECIALTY RESOURCE CENTER is required. TRAUMA PATIENTS Trauma patients meeting level I or level II trauma criteria, should be transported to a level I or level II trauma center, when possible and practical. See Trauma Triage Guideline for further information. STROKE PATIENTS Patients meeting stroke criteria should be transported to a designated stroke center. Preference should be given to level I or II stroke centers when possible and practical. See Stroke Guideline for further information STEMI PATIENTS STEMI patients should be transported to a STEMI receiving center. Preference should be given to level I or II STEMI centers when possible and practical. See STEMI Guideline for further information. 11 Specialty Resource Centers for Reference Level One Trauma Centers – ADULT Mercy Hospital St. Louis St. Louis University Hospital Barnes-Jewish Hospital Level One Trauma Centers – PEDIATRIC St. Louis Children’s Hospital Cardinal Glennon Children’s Hospital Level TWO Trauma Centers – ADULT St. Anthony’s Medical Center DePaul Health Center Burn Center – ADULT Mercy Hospital St. Louis Burn Center – PEDIATRIC St. Louis Children’s Hospital 12 Specialty Resource Centers for Reference Continued Stroke Center Designations Mercy Hospital Jefferson – Level 3 St. Anthony’s Medical Center – Level 1 St. Claire Hospital – Level 2 Mercy Hospital St. Louis – Level 1 Barnes-Jewish Hospital – Level 1 SLUH – Level 1 STEMI Center Designations Mercy Hospital Jefferson – Level TBD St. Anthony’s Medical Center – Level TBD St. Claire Hospital – Level TBD Mercy Hospital St. Louis – Level TBD Barnes-Jewish Hospital – Level TBD SLUH – Level TBD Missouri Baptist – Level TBD 13 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS2 Date Created 1/1/2017 Date Revised 1/1/2017 Medical Director Authority Operational Policy The EMS Medical Director is designated as the final medical authority at Reynolds County Ambulance District. In the absence of the EMS Medical Director, the on-line Emergency Department Physician assumes this authority. Any orders provided from the on-line medical control Physician, must come DIRECTLY FROM THE PHYSICIAN. It is not acceptable for the Physician to relay orders through an RN. The lead Paramedic MUST consult directly with a Physician. Any issues should be IMMEDIATELY reported to Chief Medical Officer for corrective action. Physicians appearing at the scene of an emergency may, after appropriate identification and with the consent of Medical Direction via radio or telephone communication, assume full medical responsibility for patient care provided that this Physician will accompany the patient to the hospital with the transporting RCAD Ambulance. If the Physician at the scene will not assume full responsibility for patient care as defined above, Reynolds County Ambulance District clinicians will continue to function and provide care solely under the auspices of the EMS Medical Director or receiving Physician. EMS personnel should diplomatically decline Physician offers to provide services at the scene to avoid compromising patient care. 14 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS3 Date Created 1/1/2017 Date Revised 1/1/2017 Education & Training Operational Policy The Clinical Practice Department, led by the Chief Medical Officer at Reynolds County Ambulance District will maintain a training center in accordance to state regulatory standards. In addition to the state mandated requirements, the following are mandatory courses required to function as a clinician on independent status at Reynolds County Ambulance District. EMT-Basic: Basic Cardiac Life Support International Trauma Life Support OR Pre-Hospital Trauma Life Support NIMS 100, 200 & 700 HAZ-Mat at the Awareness Level (within first year of hire) Monthly In-House Education In-House Rapid Sequence Intubation Course Annual In-House Education & Training Symposium (Skills Fair) Paramedic: Basic Cardiac Life Support International Trauma Life Support OR Pre-Hospital Trauma Life Support NIMS 100, 200 & 700 HAZ-Mat at the Awareness Level (within first year of hire) Advanced Cardiac Life Support Pediatric Advanced Life Support Advanced Medical Life Support Monthly In-House Education In-House Rapid Sequence Intubation Course Annual In-House Education & Training Symposium (Skills Fair) 15 MONTHLY EDUCATION REQUIREMENTS The Clinical Practice Department at Reynolds County Ambulance District will provide monthly education to be announced annual in the form of an “education plan.” All education is considered mandatory. Failure to comply will result in loss of ability to function as a clinician on independent status until education has been satisfied. 16 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS4 Date Created 1/1/2017 Date Revised 1/1/2017 Continuous Quality Improvement Operational Policy The Clinical Practice Department, led by the Operations Manager and/or Administrator at Reynolds County Ambulance District will maintain a comprehensive Continuous Quality Improvement (CQI) program to ensure quality care is provided to every patient we encounter and to promote change in an effort to stay on the cutting edge of pre-hospital medicine. Goals To provide a consistent, program wide approach to clinical quality management that focuses on process improvement To establish a framework designed to systematically measure and assess the performance of clinicians providing direct patient care. To evaluate outcomes of the service we provide and identify opportunities for improvement. To promote collaborative and cross-functional team activities to improve services and patient care. To establish the plan and processes for communicating the results of performance measurement and improvement activities to all personnel. Our Approach Find a process to improve Organize to improve the process Clarify current knowledge of the process Understand the sources of process variation Select the process changes to test Plan the experiment and the data collection Do the experiment and the data collection Check the results of the experiment Act to hold the gain and continue to improve the process Repeat the cycle 17 Aspects for Review The Clinical Practice Department at Reynolds County Ambulance District will identify clinical aspects for review considered most important to the health and safety of patients we transport. We will focus our chart review on high acuity/low frequency patients as well as review of new processes and or procedures. CQI activities include monitoring and evaluating the following: Assessment of patients Care of patients Invasive and non-invasive procedures Processes related to medication use Appropriate receiving facility Diversion by facilities Response times, scene times, transport times and reason for delays Clinical outcomes Education & Training Safety Chart Review Process The Clinical Practice Department at Reynolds County Ambulance District will provide 100% chart review and provide documentation for the following multi-level processes: LEVEL ONE CHART REVIEW This level of review will be completed by the on-duty Paramedic with the following goals: Will verify all charts being 100% complete. Will verify all signatures are present. Will verify all forms are present and complete; making the case ready for billing. Will notify the on shift supervisor, Operations Manager, or Administrator immediately of any potential clinical issues. LEVEL TWO CHART REVIEW This level of review will be completed by the on-duty Paramedic with the Supervisor, Operations Manager, or Administrator: Will determine status (DOA, Life Threat). Will flag the chart with appropriate comments based on clinical practice guidelines. 18 Will follow up with primary clinician on all normal transport or PRC charts via email or in person to provide feedback on an AS NEEDED basis. Will follow up with both clinicians on all DOA’s or Life Threat charts either in-person or via phone as appropriate to provide feedback. LEVEL THREE CHART REVIEW All Life Threat charts will be forwarded to the Medical Director for this level of review. Will request further information regarding follow up with clinicians as needed. Will require in-person meetings with clinicians on an as needed basis. Will require education, training and/or remediation on an as needed basis. Will follow up with both clinicians on all DOA or Life Threat charts either in-person or via phone as appropriate to provide feedback. The Clinical Practice Department at Reynolds County Ambulance District will use the following guidelines to appropriately “code” charts: Life Threat o All specialty care transport patients o All intubated patients; or where intubation was attempted o All RSI patients o All full arrest patients o All STEMI Alert patients o All Stroke Alert patients o All Trauma Alert patients o All patients being flown from the scene o Any patients in which an advanced procedure is performed 1. I.O. access 2. Chest decompression Transports or PRC’s o Any chart that needs corrective action as determined by the Operations Manager o All patient refusals o Any patients requiring restraints (physical or chemical) o Any inter-facility transfer patient (hospital to hospital) All other charts not identified above. The Clinical Practice Department at Reynolds County Ambulance District will use the CQI process to improve clinical care as a whole as outlined below: Establish opportunities for district wide education & training Establish opportunities for process improvement Establish individual remediation type training as needed 19 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS5 Date Created 1/1/2017 Date Revised 1/1/2017 New Hire Orientation Process Operational Policy The Clinical Practice Department, led by the Operations Manager and Administrator at Reynolds County Ambulance District will maintain a robust new hire orientation process to ensure that new clinicians are able to provide quality patient care when released to function independently. A clinicians’ final release to function independently will only be approved by the Operations Manager and/or Administrator. Orientation Step Day 1: Review Major Objectives Step 2: Drivers Training Day 2: Field Training Step 4 : Final Testing Duration Advancement Requirement Review of Policies/Guidelines with an FTO. Prove initial competency regarding equipment, CPG’s, policies & procedures 12 hour shift Competency Assessment: Policies/Procedures RCAD Guidelines Report Writing Complete CEVO II course Demonstrate ability to safely operate emergency vehicle Major Hwy Review Continued Competency Assessment: Driving Ambulance Location recognition Map comprehension ER locations from Scene Function as 3rd person on ambulance with a FTO Complete all objectives as outlined in the orientation manual 12 hour shift Competency Assessment: Equipment Clinical Guidelines Policies/Procedures Prove competency to function as primary clinician, independently by working a shift with the Operations Manager Provide complete and accurate records of checkoff forms, Narc forms, and reporting. 24 hour shift Competency Assessment: Equipment checkoff Clinical Guidelines Policies/Procedures Narc Sheet Report/Billing Completion 20 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS6 Date Created 1/1/2017 Date Revised 1/1/2017 Controlled Substances Operational Policy Employees will follow the policy set forth in the Reynolds County Ambulance District Policy and Procedure Manual, regarding controlled substances. The following outlines the storage and use of narcotics, from a clinical practice stand-point. Power of Attorney for Controlled Substances The authority to purchase and store controlled substances lies with the Administrator The Administrator may provide his power of attorney for the purchasing and storage of controlled substances to the Operations Manager Documentation of such is to be housed with the controlled substances in stock Storage of Controlled Substances All controlled substances shall remain double locked at all times, unless in use This is applicable for on trucks and storage of stock medicines Chain of Custody Chain of custody must be documented for all controlled substances Chain of custody will be signed to/from crews at the time of shift change Counts must remain accurate at all times including receiving and transferring medicines to/from stock and expired stock Lost/Broken/Stolen/Damaged Controlled Substances In the event that a controlled substance is damaged or the containers seal is damaged, the on-duty Paramedic and Administrator and/or Operations Manager shall be notified immediately o A controlled substance incident report shall be completed immediately o Copies of controlled substance sheets and broken seals shall be attached to the controlled substance incident report with the vial of wasted medicine (when applicable) In the event that a controlled substance is lost or stolen, the unit will be taken out of service, the on-duty Paramedic, Administrator and/or Operations Manager shall be notified immediately o The on-duty Paramedic shall notify the proper authorities if a controlled substance is reported as lost or stolen 21 o A controlled substance incident report shall be completed immediately o Copies of controlled substance sheets and broken seals shall be attached to the controlled substance incident report with the vial of wasted medicine (when applicable) Field Use of Controlled Substances – Documentation The use of controlled substances must be clearly documented in the patient care report The use of controlled substances must be clearly documented on the controlled substances log The waste of unused controlled substances must be witnessed and signed for on the controlled substances log These all must correlate 100% The on-duty Paramedic is responsible for ensuring accuracy and quality with the use and documentation of controlled substances Any errors will be reported to the Operations Manager and/or Administrator and documented in the employees personnel file Documentation of Stock Controlled Substances Controlled substances in stock will remain accounted for at all times under double lock unless in use (re-stocking, discarding expired, etc.) Controlled substances will be logged on individual forms for each medicine and their status o Non-Expired (useable) o Expired Re-stocking of trucks controlled substances will take place with the Operations Manager and/or Administrator and a witness (Paramedic) if needed to confirm accuracy Controlled substances purchased from supplier will be added directly to stock medications by the Operations Manager and/or Administration EMS with a witness (Paramedic) to confirm accuracy Removal of medicines from stock (expired going to reverse distributor) will take place with the Operations Manager and Administrator to confirm accuracy 22 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS7 Date Created 1/1/2017 Date Revised 1/1/2017 Vaccine Administration Operational Policy This operational policy will address the administration of Influenza Vaccine to children and adults at least 5 years of age. Reynolds County Ambulance District Paramedics in partnership with the Reynolds County Health Department can provide flu vaccine to area residents and employees. About 2 weeks after the vaccination, antibodies that provide protection against influenza virus infection develop in the body. October and November are usually the best time to get vaccinated, but vaccination can still be given in December or later. Recommendation from the CDC (Centers for Disease Control) and Jefferson county Health Department should be followed each season. People who should not be vaccinated without first consulting a physician include: 1. People who have severe allergy to chicken eggs. 2. People who have had a severe reaction to an influenza vaccination in the past. 3. People who developed Guillain-Barre syndrome (GBS) within 6 weeks of getting the vaccine (1-2 cases per million people vaccinated) 4. Influenza vaccine is not approved for children less than 6 months of age. 5. Children who are under 5 or have never had the vaccine. 6. Pregnant women should be referred to their OB> Different side effects can be associated with the flu shot. Minor side effects that occur are: 1. Soreness, redness, or swelling to the injection site 2. Low grade fever 3. Aches If these problems occur, they begin soon after the shot and usually last 1-2 days. Ice or Tylenol may be used to control the soreness. Almost all people who receive influenza vaccine have no serious problems from it. 23 INFLUENZA VACCINE ADMINISTRATION Procedure: 1. 2. 3. 4. Obtain influenza Vaccine Consent as provided by Reynolds County Health Department. Advice regarding possible side effects. Assure that no contraindication exist before proceeding. Using standard precautions obtain a disposable syringe and needle; draw up 0.5ml of Influenza Vaccine. (22-25g, 5/8 to 1” needles should be used if possible to assure that the injection in intramuscular). 5. Prepare the site for injection in either the right or left deltoid muscle by preparing with alcohol. Identify the acromial process and the point on the arm in line with the axilla. Place the needle 2.5 cm below the acromial process at 90 degrees. Asking patients to put their hand on their hip relaxes the muscle and makes it easier to access. Bunching up the muscle in older patients with reduced muscle mass also makes the injection easier. 6. Discard disposable needles and syringes in an appropriate sharps container. 7. Provide Reynolds County Health Department with vaccination report. 24 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS8 Date Created 1/1/2017 Date Revised 1/1/2017 Tuberculin Skin Testing Operational Policy Not Yet Accepted Or Approved This operational policy will address the administration and reading of Terbuclin Skin Testing for employees and students of the Reynolds County Ambulance District. Reynolds County Ambulance District Paramedics are NOT authorized to administer the Tuberculin Skin Test as well as read for a “positive” or “negative” result. EXCLUSION CRITERIA Persons who have had a previously “positive” Tuberculin Skin Test and/or are confirmed as allergic to tuberculin should not receive the skin test. These persons should receive a chest x-ray as per district policy. SUPPLIES A vial of tuberculin, a single-dose disposable tuberculin syringe, a ruler with millimeter (mm) measurements, 2x2 gauze pads or cotton balls, alcohol swabs, a puncture resistant sharps disposal container, record-keeping forms for the patient and provider, and a pen. ADMINISTRATION Choose a site free of lesions, excess hair, and veins. The usual site for injection is the anterior aspect of the forearm. Clean injection site with an alcohol swab. Allow area to air dry completely before the injection. Intradermally inject all of the tuberculin using a ¼ to ½ inch 27-gauge needle with a short bevel. This will produce a 6-10 mm wheal. If a wheal of 6-10 mm is not produced, another test should be done immediately at a site at least 2 inches from the original site. Use a cotton ball to dab the area lightly and to wipe off any drops of blood. Do not apply pressure or use a bandage on the test site. Instruct patient to avoid scratching the test site. DOCUMENTATION OF ADMINISTRTAION Use the Reynolds County Ambulance District Tuberculin Skin Test Form Name and signature of person administering test Date and time test administered Location of test (e.g., right forearm, left forearm) Tuberculin manufacturer, lot number and expiration date 25 READING Confirm that TST was applied within 48 to 72 hours prior to reading. If < 48 hours, patient must return after 48 hours and before 72 hours. Use a millimeter ruler to measure the diameter of induration perpendicular to the long axis of the arm. A reading of LESS THAN 5mm across is considered negative DOCUMENTATION OF READING Use the Reynolds County Ambulance District Tuberculin Skin Test Form Name and signature of person reading test Date and time test read Interpretation of reading (i.e., positive or negative, based on individual's risk factors) 26 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS9 Date Created 1/1/2017 Date Revised 1/1/2017 Infection Control Operational Policy This operational policy was designed to prevent the occupational exposure to communicable diseases. All personnel will follow Reynolds County Ambulance District’s Infection Control plan. General Guidelines A. Gloves are to be worn with all patients contact. B. Protection of the eyes and mouth can be accomplished with face shield or masks and protective eyewear in those circumstances that may find you exposed to blood or body fluids being sprayed, e.g. vomit or blood. C. Your uniform in most instances will afford you adequate protection. After suspected or confirmed exposure, changing your uniform is suggested. Washing and drying you uniforms in the usual manner is adequate. D. Administration of the Hepatitis Vaccine is required by OSHA, for all personnel involved in pre hospital care. Each individual has the right to refuse said vaccine, signing a form he/she refused. E. Wash your hands after each patient contact. 1. Hospital anti-germicidal and water 2. Waterless hand cleaner is carried on ambulances Discarding of Sharps and Containment Items A. A sharps container is provided in the ambulance and in the drug bag. Anytime an I.V. catheter is used, it should not be recapped, but placed in one of the sharps containers B. The sharps container shall be replaced anytime the needles or catheters will not fall into the container. Do not force any sharps into the container; this may result in a needle stick. C. Full sharps containers shall have the lid locked into place and the container deposited in the ED soiled room for proper disposal 27 D. Contaminated dressings, bandages, and paper towels used to wipe up contaminates shall be placed in a red contaminated bag for disposal. This shall be left be left in the E.D. soiled room for proper disposal. Disinfecting of Ambulance After each call the ambulance interior shall be wiped down and disinfected. 1. Gloves shall be worn during this process 2. All blood, vomit, urine and feces shall be wiped up with paper towel. This should then be discarded in a red contaminated bag. 3. A 10% bleach solution should be used to wipe down all surface areas and left to air dry. Disinfecting of Equipment After each call equipment shall be cleaned and disinfectant 1. Gloves shall be worn during this process 2. Intermediate level: may be accomplished by use of a 10% bleach solution after wiping any surface dirt off with light soap and water a. Blood pressure cuff b. Stethoscope c. Monitor cables d. Splints that came into contact with intact skin Needle Sticks Should you receive a needle stick, follow the protocol listed in the Policy Manual 1. Cleansing of the wound shall be immediately accomplished with an antibacterial solution All communicable Disease Exposures should be reported by receiving medical facilities to Emergency Responder Personnel under state regulations. Personal Protective Equipment The appropriate PPE should be worn as required for the nature of the call 28 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS10 Date Created 1/1/2017 Date Revised 1/1/2017 SMART Triage Operational Policy Clinicians at Reynolds County Ambulance District will follow the SMART Triage guidelines for multi-patient incidents. 29 Reynolds County Ambulance District Incident Rehab Clinical Practice Guidelines CPG Number OPS11 Date Created 1/1/2017 Date Revised 1/1/2017 Operational Policy This operational policy will apply to all responders on the scene of an emergency or training event with prolonged exposure to the elements, exertion and/or scene hazards. If a responder has a medical emergency, refer to the appropriate guideline. This guideline is for the purpose of evaluation and clearing a responder to return to duty. If treatment is rendered, a treat and release form DOES NOT need to be completed however a refusal form needs to be completed as well as a Report. Disposition of the responder will be communicated with the incident commander. The incident commander on the scene has the final authority with allowing a responder to return to duty. For this evaluation, we will encourage the responder to remove all PPE to include bunker pants being pushed down on top of his or her boots. We will encourage rest, passive cooling and oral rehydration prior to the evaluation as outlined below. Heart Rate >140? OR Blood Pressure SBP >200 Or DBP >110? OR Respirations <8 per min Or >30 per min? OR Temperature >101 Tympanic/oral? OR Pulse Oximetery <90%? NO Return to Full Duty Perform orthostatic vitals YES Does pulse increase >20 or Systolic drop <20? NO YES Mandatory rest, rehydration and re-evaluate in 10 min. IV rehydration up to 2 liters until pulse is less than 100 and systolic is <100. If pulse remains elevated or BP low, transport to ED. If pulse/BP is WNL, do not return to scene activities. Transport to ED if no improvement 30 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS12 Date Created 1/1/2017 Date Revised 1/1/2017 Air Ambulance Utilization Operational Policy Clinicians at Reynolds County Ambulance District should utilize the following guidelines when utilizing an air ambulance for rapid transport to a specialty resource center, for service not available in the local area. 1. A standby (air or ground) should be requested when en route to a scene when a helicopter is potentially needed. An ETA should be given at that time. 2. Once on scene communication regarding GO or NO GO of the helicopter should be relayed through command. 3. The closest appropriate helicopter and LZ should be chosen. No preference should be given as to what service is used. 4. Helicopter times should be included in you report including: Dispatch time, on scene time, departure time, and ETA that was originally given. Please attempt to obtain crew names and unit I.E. (Flight Medic John Doe Air Evac 24). 5. A helicopter should be considered when one or more of the following criteria exist: A significant reduction in transport time exists compared to ground transport for seriously ill or injured patient requiring a SPECIALTY RESOURCE CENTER. Severely injured or acutely ill patients are located in remote or off road areas not readily accessible to ground ambulance. Ground resources exhausted (i.e. disaster). Prolonged vehicle extrication time is anticipated over 20 minutes. Special environmental conditions (i.e. extreme cold) are present which affect potential patient outcome Delayed ground access to hospital (i.e. road, bridge damage, flood, traffic conditions). 31 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS13 Date Created 1/1/2017 Date Revised 1/1/2017 Transfer of Care Operational Policy The intent of this operational policy is to insure continuity of patient care through communication and transmission of patient care information to subsequent providers. 1. Upon transfer of patient care to the Emergency Department RN or Physician, air ambulance RN or Paramedic, nursing home staff, or to another ambulance crew; the receiving individual shall be advised of the patient’s condition, treatment provided, patient history, medications, allergies, and any applicable further care instructions. 2. After patient transfer, the crew shall have the receiving person sign to accept the responsibility of patient treatment, including use of air ambulance. The report shall be completed, including all times and a copy left with the receiving facility or individual, excluding air ambulance and residential transfers. If it is not feasible to leave a report at that time, one may be faxed to a secure fax line. 3. The report shall include the time care was transferred and the condition of the patient at the time of transfer and names and title of individual patient care was left in. 32 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS14 Date Created 1/1/2017 Date Revised 1/1/2017 Refusal of Care Operational Policy This operation policy refers to those situations in which a patient refuses evaluation, treatment, and/or transportation by clinicians at Reynolds County Ambulance District. The patient or guardian must understand the risks and consequences associated with their decision, up to and including death or serious disability. The patient or guardian must verbally refuse and agree to the risks and consequences outlined to them. The patient or guardian must sign refusal and it must be witnessed. Only Persons presumed competent to make decisions affecting their medical care shall be allowed to make such decisions. Evaluating Competency A patient may not be considered competent to refuse medical care and/or transportation if the severity of their medical condition prevents them from making rational decisions regarding their medical care. A patient MAY NOT refuse medical care and/or transport if any of the following criteria are met: 1. Alter level of consciousness, including those with a head injury or under the influence of drugs and/or alcohol. 2. Attempted suicide or verbalized suicidal intent. 3. Are mentally retarded or have a mental deficiency. 4. Are clearly not acting as a reasonably person would, given the same circumstances. 5. Medical Control may be contacted if there is any question about the patient’s ability to refuse evaluation, treatment, and/or transport. 6. Are under eighteen (18) years of age and do not qualify as an adult. Under 18 Exceptions: 1. An emancipated minor 2. A minor who is married 3. A minor who is in the military A parent, guardian, or immediate family member over 18 may refuse medical care for the patient. A signature or verbal confirmation via phone is needed. If unavailable the patient must be transported. 33 DOCUMENTATION OF REFUSAL The following items should be included in your patient refusal documentation: A clear description of the patient’s mental status. All pertinent negatives regarding the patient’s chief complaint. A statement that you advised the patient of the risk and consequences of refusing treatment and/or transport, up to and including death or serious disability. The reason the patient is refusing. The patient’s person plan of care and/or follow-up regarding the event. If Medical Control contacted, document who you talked to and their recommendation. Name of parent, legal guardian, or immediate family member refusing for a minor. If a Treat and Release is obtained, an improvement of symptoms must be documented. A full set of appropriate vital signs given the patients complaint. TREAT AND RELEASE SITUATION A Treat and Release may be obtained with a refusal of transport. A patient may have a transient condition that is quickly remedied at the scene and has the right to refuse transport. The patient should be made aware of the charges of a Treat and Release prior to receiving a medication, if a refusal is suspected. The following drugs may be given, following the appropriate protocol: 1. IV Fluids 2. Oxygen 3. Zofran 4. Dextrose 50% 5. Epinepherine 1:1,000 6. Benadryl 7. Duoneb 8. Albuterol 9. Solu-Medrol 10. Oral Glucose 11. Aspirin 12. Nitroglycerin PO 13. Narcan If patient symptoms are alleviated and transport is no longer needed or wanted, follow the Refusal Protocol and also have patient sign the Treat and Release form. The form shall be completed with prices totaled prior to the patient signing. 34 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS15 Date Created 1/1/2017 Date Revised 1/1/2017 Determination of Death Operational Policy The following operational policy will provide guidance when the resuscitation of a patient should not be attempted. If, upon examination, it is evident that resuscitation is impossible or the patient has been dead for an extended period of time, the Paramedic may determine that death has occurred and not begin resuscitation measures. The Paramedic must use clinical judgment and discretion. Some findings consistent with determination of death: 1. 2. 3. 4. 5. Extended down time >20 minutes Rigor mortis (i.e. stiff, cold) Venous pooling/lividity Body in state of decomposition Major traumatic injury (i.e. severe chest trauma, brain injury, etc. that is incompatible with life) 6. Pupils fixed and dilated 7. Absence of carotid pulse 8. Absence of respirations 9. Absence of heart tones 10. Asystole per EKG monitor, verified in 3 leads If the Paramedic determines death has occurred, Law Enforcement must be contacted. The scene must be turned over to Law Enforcement prior to returning to service. In the event of a crime scene death in which a Paramedic has determined death has occurred, the clinician must make every attempt to preserve evidence by not moving the body or manipulating the scene. Thorough documentation including physical signs of death, mechanism, and historical factors must be completed. An EKG strip is required even if death is obvious and easily documented. 35 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS16 Date Created 1/1/2017 Date Revised 1/1/2017 Discontinuation of Resuscitation Operational Policy The following operational policy will provide guidance when the resuscitation of a patient has proven futile and should be discontinued in the field. The following items must be completed prior to a patient being pronounced dead in the field: 1. Airway secured (ET tube, Rescue Airway or Surgical Cricothyrotomy) and confirmed patent with waveform ETCO2. 2. Vascular access obtained and patent. 3. Continuous quality CPR has been performed. 4. At least 2 rounds of ACLS medications have been administered. 5. A minimum of 20 minutes of ACLS resuscitation has been attempted. 6. Noted Asystole or PEA with a rate less than 60 documented in 3 or more leads. If all of the above criteria have been met, the lead Paramedic WILL MAKE ON-LINE CONTACT WITH A MEDICAL CONTROL PHYSICIAN. It will be the responsibility of the on-line medical control physician to make the final decision if the patient is to be pronounced dead in the field or not. Should on-line medical control authorize the patient being pronounced dead in the field, the scene will be turned over to Law Enforcement. It is the responsibility of the lead Paramedic to discuss the situation with family members on scene. If at any time there are questions regarding the appropriate disposition of the patient, transport should be initiated. 36 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS17 Date Created 1/1/2017 Date Revised 1/1/2017 DNR Orders Operational Policy The following operational policy will provide guidance when clinicians at Reynolds County Ambulance District encounter a patient with a valid Do Not Resuscitate order. It is the responsibility of the lead Paramedic to confirm that the DNR order is in fact, valid. If the DNR order is not valid, there is questions regarding its validity, the patient verbally requests treatment and/or the family on scene requests treatment; treatment will be initiated as if the DNR order did not exist. When in doubt, resuscitate! The lead Paramedic on scene should thoroughly read the DNR order to confirm exactly what or what not the patient would like done as far as treatment aggressiveness. Please remember, a DNR order IS NOT a Do Not TREAT order. Patient should be treated aggressively up until the point resuscitation efforts are necessary. CONTACT WITH ON-LINE MEDICAL CONTROL PHYSICIAN SHOULD BE MADE IF THERE ARE ANY QUESTIONS AND/OR FOR CONSULTATION PURPOSES. 37 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS18 Date Created 1/1/2017 Date Revised 1/1/2017 Incident Command System Operational Policy It is the purpose of this operational policy to establish responsibilities and determine actions required to manage and coordinate our agency response to incidents of any size within the Reynolds County Ambulance District. DEFINITION OF THE INCIDENT COMMAND SYSTEM ICS is a combination of equipment, personnel, and procedures for communications operating within a common organizational structure with responsibilities for the management of assigned resources to effectively accomplish objectives pertaining to an emergency incident. ICS is a sub-system of the National Inter-Agency Incident Management System (NIIMS). OUR POLICY All incidents in which the Reynolds County Ambulance District responds to will employ some type of incident command. The size and requirements of the incident command system will expand and contract along with the size and complexity of the incident. All Reynolds County Ambulance District personnel will utilize the NIMS type command system and will make every effort to ensure that a unified command is utilized on each and every incident. Reynolds County Ambulance District employees will make sure that patient care is priority, but in all situations the employee must function at some level in the ICS. Reynolds County Ambulance clinicians will function as the EMS BRANCH or DIVISION of the ICS. The first arriving unit on any scene should give a brief “size up” of the incident if one is warranted and if no other unit has given one and then move onto the following: Conduct a scene safety assessment. Perform an initial size up of the incident to determine the number of patients and the level of resources needed. Call for or cancel additional resources if needed though the ICS. All requests for information or additional equipment should go through the FIRE DEPARTMENT’S ICS unless this is not feasible, practical, or the fire department does not have an ICS in place. Provide appropriate patient care. After the incident has been mediated and all patient care is finished the remaining EMS personnel at the scene should disband through the ICS also. 38 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS19 Date Created 1/18/2017 Date Revised 1/1/2017 Inter-Facility Transfers Operational Policy The purpose of this operational policy is to outline the procedure for conducting emergency, infer-facility transfers. DEFINITION: The definition of an inter-facility transfer is the moving of a patient from one hospital to another, for the purpose of a higher level of care or services not available at the sending facility. POLICY: All inter-facility transfers must be handled on a case-by-case basis. The on-duty Paramedic will make the decision if an inter-facility transfer request is to be accepted. If there is any question, the Operations Manager and/or Administrator will be contacted for guidance. The closest, readily available resource will be dispatched to the inter-facility transfer, unless specialty crew assignments are deemed necessary by the sending facility and Reynolds County Ambulance District leadership team member approving the transfer. The assigned crew will follow Reynolds County Ambulance District CPG’s with regards to patient care. Should a required treatment or medication therapy be required for the transfer, a Specialty Care Transport should be initiated. At any time, the transferring lead paramedic may contact the sending physician or any member of the Reynolds County Ambulance District leadership team for guidance. 39 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS20 Date Created 1/1/2017 Date Revised 1/1/2017 Specialty Care Transport Operational Policy CCP staff is minimal The purpose of this operational policy is to outline the procedure for conducting emergency, Specialty Care Transports with the use of Critical Care Paramedics (CCP’s). DEFINITION: The definition of a Specialty Care Transport (SCT) is the moving of a CRITICALLY ILL patient from one hospital to another, for the purpose of a higher level of care or services not available at the sending facility that requires treatment by a clinician with training beyond that of a Paramedic. POLICY: All SCT requests must be handled on a case-by-case basis. The on-duty Paramedic will make the decision if an SCT request is to be accepted. If there is any question, Operations Manager and/or Administrator or Medical Director will be contacted for guidance, as needed. The SCT will be handled by an approved CCP and that CCP will follow Reynolds County Ambulance District CPG’s with regards to patient care. The CCP may utilize the Critical Care Paramedic Clinical Practice Guidelines, in addition to these standard CPG’s. All intubated patients should have two providers in the patient compartment. For all other types of SCT transfers, a second attendant is highly encouraged. Ultimately the addition of a second paramedic is up to the discretion of the attending CCP. At any time, the attending CCP may contact the sending physician, receiving physician, medical director or any member of the Reynolds County Ambulance District leadership team for guidance. 40 CRITICAL CARE PARAMEDIC (CCP) PROVIDER QUALIFICATIONS: To be qualified as a Critical Care Paramedic (CCP) at Reynolds County Ambulance District, the clinician must have completed the in-house “Fundamentals of Critical Care Transport” course or hold CURRENT certification or licensure as a critical care transport provider. Below are examples of acceptable licenses or certifications: CCEMT-P CCP-C FP-C RN with CEN RN with CCRN RN with CFRN RN with CTRN EXAMPLES OF SCT RUNS: SCT runs must originate at a sending facility, usually a hospital ER and must end at a receiving facility with services necessary to treat the critically ill patient. Below are examples of SCT runs: Any patient requiring advanced airway management or the potential for advanced airway management Ventilator dependant patients Patients requiring vaso-active medications Patients receiving blood or blood product transfusions Patients receiving thrombolytic therapy Patients with potential for circulatory collapse Patients requiring invasive hemodynamic monitoring Please Note: Any therapy that does not fall into Reynolds County Ambulance District CPG’s requires a written physician order that is accepted by the transferring SCT provider. LIMITATIONS: Reynolds County Ambulance does not have the capabilities to transport patients requiring the following therapies: Ventilator dependant patients less than 25kg Neonatal patients of any kind 41 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS21 Date Created 1/1/2017 Date Revised 1/1/2017 Clinical Documentation Operational Policy The purpose of this operational policy is to outline documentation expectations for every patient encounter. All members of the clinical team who render care during patient contact are responsible for completing and ensuring that all aspects of the patient care record generated are accurate and complete. A. Dispatch Information a. Incident number as provided by Reynolds County 911 b. Referring type i.e. 911 call, walk in, etc. c. Category: classification of patient d. Outcome i.e. treated and transported, transport refused, call cancelled, etc. e. Signatures of all crew members involved in the patient care required f. The chart must identify the crew members and credentials who completed the patient care record g. Referring Location h. Receiving Location; with justification i. Times as provided by Reynolds County 911 j. Loaded miles B. Patient Information a. Patient’s full name b. Home address c. Date of birth d. Age, if unknown due to injuries- approximate age e. Social security number (if available) f. Sex g. Weight in kilograms h. Barriers to care i. Race j. Current PMHX k. Current medications l. Current allergies C. Billing information a. Patient signature obtained b. Receiving facilities signatures obtained 42 c. All available insurance information should be obtained; copies of cards appreciated D. Chief complaint or history of present Illness a. Patient presentation, how the patient was found b. Primary and secondary impressions c. Chief complaint and duration d. History of Present Illness e. Scene description/vehicle description if applicable f. Factors affecting care g. Additional injury details, Cardiac arrest, Drugs/Alcohol options when applicable E. Primary and secondary assessment information a. Airway Status b. Breathing Status c. Circulation status d. Neurological assessment e. GCS (Glasgow coma scale) f. Secondary systems and findings as appropriate g. Extremities: presence of pulses, sensation, motor function h. Appearance of skin i. Pain level F. General documentation guidelines a. All “procedures” must be documented in the flow chart and filled out completely b. Vital signs shall be assessed every 5 minutes on “unstable” patients or when titration of vasoactive medications is taking place. c. Vital signs shall be assessed every 15 minutes on “stable” patients d. EKG strips will be attached to the record when EKG monitoring has been documented e. 12 lead EKG’s will be attached to the record when 12 lead monitoring has been documented f. ETCO2 strips will be attached to the record on any intubated patient g. For intubated patients document a general statement that airway placement was reassessed with each patient move and at the receiving facility h. For intubated patients document the physician that confirmed airway placement and have them sign for such i. For trauma patients immobilized on a long spine board, document movement of all extremities before and after each patient move j. There should be detailed documentation as to how the patient was moved to the stretcher and secured 43 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS22 Date Created 1/1/2017 Date Revised 1/1/2017 RN Functioning as ALS Provider Operational Policy The purpose of this operational policy is to outline the necessary training for a Registered Nurse to function as an Advanced Life Support provider at Reynolds County Ambulance District. Allowing a RN to function as an ALS provider will be on a case-by-case basis, as approved by the medical director. Items Required Current and valid license as a Registered Nurse in the state of Missouri Current certifications required for Paramedics Documented airway management experience, specifically endotracheal intubations o Operating room clinical time highly encouraged Current licensure as an EMT is needed Should the RN be approved by the medical director and meets the above criteria, he/she may replace a paramedic at Reynolds County Ambulance District. The RN will be held to the same education and training standards as any paramedic would be. 44 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number OPS23 Date Created 1/1/2017 Date Revised 1/1/2017 Emergency Medical Response Agencies Operational Policy The purpose of this operational policy is to outline the relationship between Reynolds County Ambulance District and the emergency medical response agencies that follow our clinical practice guidelines. Authorization Clinicians at each department or district functioning under the Reynolds County Ambulance District Clinical Practice Guidelines are authorized to practice at the EMT-B level as long as they are licensed as such. EMRA clinicians are NOT authorized to complete patient refusals. EMRA clinicians are authorized to perform any “skill” that is noted to be “BLS” in nature as per these guidelines. Should a Reynolds County Ambulance District paramedic be on-duty with the EMRA and are requested to perform ALS procedures by the on-scene ambulance, that paramedic will immediately be “on-duty” with Reynolds County Ambulance District and will then be authorized to function in an ALS capacity. They will be required to log the time they are functioning as an ALS provider on their time card at Reynolds County Ambulance District. This situation is addressed in the Reynolds County Ambulance District policy manual which has the final authority on the situation. Licensure & Certification The Operations Manager and Administrator is responsible for ensuring licensure and certification of their clinicians meet accreditation standards as outlined. Records will be verified and maintained by Reynolds County Ambulance District Education department. Education & Training The Operations Manager and Administrator are responsible for complying with Reynolds County Ambulance District education plan that ensures clinicians meet state of Missouri BEMS requirements. Records will be verified and maintained by Reynolds County Ambulance District Education department. Continuous Quality Improvement The Paramedic, Operations Manager and Administrator will be responsible for submitting required charts for review as per the CQI policy. Charts meeting Life Threat criteria as well as 10% of other charts by random draw will be submitted to the Operations Manager and/or 45 Administrator on a quarterly basis for review. The medical director will review the cases and provided feedback on an as needed basis. Accreditation Standards: EMT-B In order to obtain accreditation as an EMT-B under the Valle Ambulance District clinical practice department, the following items must be obtained and maintained in a current state. State of Missouri licensure as an EMT-B or higher Healthcare Provider BLS CPR with AED certification An EVOC course completion with ambulance drive time (to be qualified to drive a RCAD Ambulance) 48 hours of ride time (initial) with 12 hours on an annual basis Completion of required education Annual skills competency verification *If EMT-B course is completed at Reynolds County Ambulance District, all requirements for accreditation will have been met upon verification of state licensure. Accreditation Standards: Medical First Responder (EMR) In order to obtain accreditation as a Medical First Responder (EMR) under the Reynolds County Ambulance District clinical practice department, the following items must be obtained and maintained in a current state. Completion of a State of Missouri approved Medical First Responder course National Registry Medical First Responder/EMR (optional, may substitute the above) Healthcare Provider BLS CPR with AED An EVOC course completion with ambulance drive time (to be qualified to drive a RCAD Ambulance) 24 hours of ride time (initial) with 12 hours on an annual basis Completion of required education Annual skills competency verification *If Medical First Responder (EMR) course is completed at Reynolds County Ambulance District, all requirements for accreditation will have been met upon successful course completion. Accreditation Standards: Firefighter – CPR & First Aid In order to obtain accreditation a Firefighter – CPR & First Aid under the Reynolds County Ambulance District clinical practice department, the following items must be obtained and maintained in a current state. Completion of a Reynolds County Ambulance approved CPR, AED & First Aid Course An EVOC course completion with ambulance drive time (to be qualified to drive a RCAD Ambulance) Completion of required education Annual skills competency verification 46 Please Note: Any Reynolds County Ambulance District employee who is on active status with the district, meet all requirements for accreditation while on-duty with an EMRA. SECTION TWO ADULT TREATMENT GUIDELINES FOR THE PURPOSE OF THESE GUIDELINES, AN ADULT PATIENT WILL BE CONSIDERED ANY HUMAN AT OR ABOVE THE AGE OF 18 YEARS OLD. 47 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG1 Date Created 1/1/2017 Date Revised 1/1/2017 Routine Care Adult Treatment Guidelines It is the policy of Reynolds County Ambulance District to provide quality clinical care in the safest manner possible. Through that vision, we have developed the following routine care procedures that shall be used on every adult patient encounter. Ensure scene safety Bring all necessary equipment to the patient’s side Demonstrate professionalism and courtesy Don personal protective equipment Airborne or droplet precautions if indicated Assess CABs, and intervene if indicated Control any major bleeding Provide oxygen and assist ventilations if indicated Spinal immobilization if indicated Obtain chief complaint, associated signs/symptoms Obtain complete set of vital signs Obtain past medical history and SAMPLE-type history Where appropriate, provide routine ALS care: Establish vascular access, draw blood Monitor cardiac rhythm Perform multi-lead EKG as appropriate Measure and monitor waveform ETCO2 Measure and monitor SPO2 Measure blood glucose CONTACT MEDICAL CONTROL PHYSICIAN AT ANY TIME DURING PATIENT ENCOUNTER WHEN GUIDANCE IS NEEDED TRANSPORT PATIENTS ACCORDING TO DESTINATION DECISION OPERATIONAL POLICY 48 Reynolds County Ambulance District General Airway Management Clinical Practice Guidelines CPG Number ATG2 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines Assess ABC’s Assess Respiratory Rate, Rhythm Quality Assess Airway Patency ADEQUATE Provide Appropriate Monitoring INADEQUATE Consider monitoring ETCO2 Provide BLS Airway Management Position/Adjunct/Suction Ventilatory Support w/ O2 Provide Basic Treatment Provide Oxygen as appropriate Transport in position of comfort mO Consider monitoring SPO2 IF AIRWAY OBSTRUCTION ENCOUNTERED AT ANY TIME: GO DIRECTLY TO: AIRWAY OBSTRUCTION GUIDELINE Provide Appropriate Monitoring SPO2 & ETCO2 EKG & NIBP Provide ALS Airway Management BiPAP/CPAP as needed/toelrated Intubation (Oral/Nasal) RSI as needed Package & Transport Follow Post Intubation Management Guideline as appropriate IF UNABLE TO MAINTAIN AIRWAY, UNABLE TO VENTILATE, AND/OR UNABLE TO OXYGENATE AT ANY TIME: GO DIRECTLY TO: FAILED AIRWAY GUIDELINE 49 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG3 Date Created 1/1/2017 Date Revised 1/1/2017 Airway Obstruction Adult Treatment Guidelines CONFIRM AIRWAY OBSTRUCTION IS PRESENT Assess Mental Status CONSCIOUS PATIENT Perform Heimlich maneuver until: A. Obstruction is removed or B. Patient becomes unconscious UNCONSCIOUS PATIENT Check for foreign body visible in mouth; remove if found Begin CPR with compressions first IF ABOVE IS UNSUCCESSFUL: INITIATE ALS PROCEDURES Perform direct laryngoscopy and attempt to remove obstruction o Suction o Forceps If able to remove obstruction, go to Airway Management Guideline If unable to remove obstruction, go to Failed Airway Guideline IF SUCCESSFUL: GO TO AIRWAY MANAGEMENT GUIDELINE IF UNSUCCESSFUL: GO TO FAILED AIRWAY GUIDELINE 50 Reynolds County Ambulance District Failed Airway Clinical Practice Guidelines CPG Number ATG4 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines The encountered failed airway is something that each clinician at Reynolds County Ambulance District must be prepared for. Proper reaction to the failed airway is paramount in the survivability of the critically ill patient. Should a failed airway be encountered, use the following algorithm. FALL BACK TO BASICS – BLS AIRWAY MANAGEMENT Good positioning of patient BLS airway adjuncts Good suction 2 person BVM technique CONSIDER RESCUE AIWAY (if unable to ventilate/oxygenate with BVM) Superglottic Airway EMERGENCY CRICOTHYROTOMY (if unable to ventilate/oxygenate with BVM and unable to place rescue airway) Per-Trach Needle Cricothyrotomy Surgical Cricothyrotomy GO TO POST INTUBATION MANAGEMENT GUIDELINE AS APPROPRIATE 51 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG5 Date Created 1/1/2017 Date Revised 1/1/2017 Rapid Sequence Intubation Adult Treatment Guidelines CONFIRM RSI IS INDICATED (one of the items below) Inadequate ventilation and/or oxygenation is present Patient is unable to maintain airway Predicted clinical course indicates need for airway management PREPERATION Gather and assemble all tools, 2 IV’s in place Ready all medications (RSI and post intubation) PREOXYGENATION Provide 100% FiO2 by LEAST INVASIVE means possible (NPPV Preferred) Avoid BVM if at all possible PREMEDICATION Consider Fentanyl for pain: 0.5-2.0mcg/kg SIVP Fluid bolus if patient is hypotensive or borderline hypotensive PARALYSIS WITH INDUCTION SEDATION (pick one) o o Etomidate: 0.3mg/kg IV or IO ***Head Injuries / Hypertensive*** Ketamine: 1-2mg/kg IV or IO ***General / Hypotensive / Septic / Respiratory*** If using Ketamine, give Ativan: 0.1mg/kg (max 4mg) IVP x 1 PARALYTIC (pick one) o o Succinylcholine: 1-2mg/kg IV or IO (max single dose 200mg) Rocuronium: 1mg/kg IV or IO (max single dose 100mg) o PLACEMENT WITH PROOF Oral Intubation, use bougie Confirm placement, use ETCO2 IF SUCCESSFUL GO TO POST INTUBATION MANAGEMENT GUIDELINE IF UNSUCCESSFUL: GO TO FAILED AIRWAY GUIDELINE 52 INFORMATION ON RAPID SEQUENCE INTUBATION The process of Rapid Sequence Intubation is designed to take an airway from a patient that has one of the following at the time of exam: A. Inadequate ventilation and/or oxygenation present and not responding to conventional treatments (Oxygen by mask, NPPV, other treatments, etc.). B. Inability to maintain airway (altered mental status, unconsciousness, etc.). C. Predicted clinical course that indicates a need for airway management (severe combative nature, obvious head injury, major trauma, etc.). Rapid Sequence Intubation should not be taken lightly. This is a skill that by definition, is taking away something the patient has. The clinician performing the RSI should be completely confident in his or her ability to manage the patient’s airway. Prior to performing the RSI, the clinician should perform a thorough risk vs. benefit analysis on the patient to confirm that RSI is in fact the indicated and appropriate treatment. The clinician should perform a complete assessment of the airway and predict any difficulties that may arise. The clinician should go into the RSI situation with the “worst case scenario” in mind, and be prepared to manage that scenario. Please Note: After any attempt at RSI, the Shift Supervisor, Operations Manager, and/or Administrator will be contacted by the on-duty crew immediately after transferring care to discuss the case. 53 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG6 Date Created 1/1/2017 Date Revised 1/1/2017 Post Intubation Management Adult Treatment Guidelines The post intubation management guideline was developed for the treatment of any patient who has an artificial airway in place (ET tube, rescue airway, emergency cricothyrotomy). CONFIRM AIRWAY IS PATENT AND SECURED Lung sounds remain present, epigastric sounds remain absent Continuous monitoring of waveform ETCO2 is REQUIRED (ideal range is 35-45) Secure the airway with a commercial device, when available CONSIDER PLACEMENT A GASTRIC TUBE Oral route is preferred; with 18f. Ensure via mechanical ventilator Start with 100% FIO2, unless otherwise indicated and titrate to desired effect Ensure adequate tidal volume (6-8cc/kg) ; monitor airway pressures Ensure adequate respiratory rate (usually 8-12/min) Consider adding mechanical PEEP, unless contraindicated (usually 5-10cm/H2O) See mechanical ventilation procedure for further information on ventilator use ENSURE ADEQUATE VENTILATION & OXYGENATION CONSIDER SEDATION & ANALGESIA Hypertensive o Versed: 2.5-5.0mg IV or IO, every 10-20 minutes o Fentanyl: 0.5-2mcg/kg IV or IO, every 10-20 minutes Normotensive/Hypotensive o Ketamine: 1-2mg/kg, every 10-20 minutes CONSIDER CONTINED PARALYSIS ONLY IF ABSOLUETELY NECESSARY Rocuronium: 1mg/kg IV or IO (will last 30 minutes) PROVIDE CONTINUOUS REASSESSMENT Maintain constant ETCO2 monitoring Vital signs every 5 minutes Assume intubated patients are under sedated and in pain; treat accordingly Any sign of or potential for seizure: give Ativan bolus 54 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG7 Date Created 1/1/2017 Date Revised 1/1/2017 Pulmonary Edema Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood ASSESS FOR RESPIRATORY FAILURE Consider early NPPV therapy; titrate I-Pressure and E-Pressure to desired effect Consider RSI at any time in this guideline Consider NTG: 400mcg SL, repeat PRN (5 minute intervals between doses) Consider NTG Infusion: 5-100mcg/min IVPB, titrate to effect (hypertension, obvious pulmonary edema) Consider Lasix: 40mg IVP or double patients current dose (obvious pulmonary edema) Have high suspicion for Acute MI with obvious pulmonary edema; EKG is imperative. Primary treatment should focus on NPPV and Nitrates (aggressive) NTG contraindicated with hypotension or use of E.D. medications. Remember, patients must be able to maintain airway and be alert to use NPPV. Consider RSI if patient does not improve with treatments provided and/or unable to tolerate NPPV. 55 Reynolds County Ambulance District Bronchospasm Clinical Practice Guidelines CPG Number ATG8 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood ASSESS FOR RESPIRATORY FAILURE Consider early NPPV therapy Consider RSI at any time in this guideline Consider Duo-Neb: x 1 (Albuterol 2.5mg and Atrovent 0.5mg) via UDN (respiratory distress – wheezing and/or rhonchi) Consider Xopenex: 1.25mg via UDN, repeat x 2 PRN (if patient is tachycardic) Consider Solu-Medrol: 125mg IVP, IM or UDN (presumed lung injury) Consider Continuous Albuterol: 5.0mg via UDN, repeat PRN (severe distress) Consider Magnesium Sulfate: Infusion 2gm in 100cc IVPB over 10 minutes (severe distress) Have high suspicion for Acute MI caused by hypoxia; EKG is imperative. Remember, patients must be able to maintain airway and be alert to use NPPV. Consider RSI if patient does not improve with treatments provided and/or unable to tolerate NPPV. ETCO2 with “shark fin” waveform indicative of bronchospasm. 56 Reynolds County Ambulance District Chest Pain Clinical Practice Guidelines CPG Number ATG9 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood ASA 324 mg PO (Baby ASA 81 mg x4) Consider NTG: 400mcg SL, repeat PRN (5 minute intervals between doses) Consider Morphine: 2-10mg IVP OR Fentanyl 0.5-2mcg/kg IVP (continued pain) Consider Lopressor: 5mg SIVP, repeat x 2 (15mg total) (hypertension and tachycardia) Consider NTG Infusion: 5-50mcg/min IVPB, titrate to effect (hypertension, presumed true cardiac event, continued pain and/or relief with NTG SL) Use caution (if at all) with NTG and inferior wall STEMI. . NTG contraindicated with hypotension or use of E.D. medications. Lopressor should be used only in presence of suspected cardiac event, with hypertension and tachycardia both present. Obtain EKG (multi-lead) prior to any treatment, if at all possible. This guideline may be used for atypical presentation of MI when appropriate. 57 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG10 Date Created 1/1/2017 Date Revised 1/1/2017 Suspected STEMI Adult Treatment Guidelines STEMI IS SUSPECTED Continue to follow appropriate individual guidelines PROVIDE NOTIFICATION TO RECEIVING FACILITY AS QUICKLY AS PRACTICLE AND POSSIBLE! Transmit EKG if possible and practical Follow STEMI/AMI Checklist for receiving facility Establish a second IV, ensure blood has been drawn Ensure pacer-pads are on patient as a precaution STEMI CRITERIA ST elevation of 2mm or more in 2 or more contiguous leads Reciprocal changes are present New or presumed new LEFT bundle branch block ST elevation in any right sided leads (V3R, V4R or V5R) with good clinical presentation ST elevation in any posterior leads (V7, V8 or V9) with good clinical presentation STEMI PEARLS RAPID transport to PCI capable facility is key Early and good communication with PCI capable facility will speed up the process; be confident in your findings STEMI recognized to PCI goal is 90 minutes or less Be prepared for arrhythmias 58 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG11 Date Created 1/1/2017 Date Revised 1/1/2017 Tachycardia Adult Treatment Guidelines For Atrial Fibrillation consider Cardizem 5-10mg SIVP, second bolus of 10-20mg SIVP for the purpose of rate control For Atrial Fibrillation, or other narrow complex Tacycardia, consider Lopressor 5mg, SIVP, repeat x 2, for the purpose of rate control For pulsing V-Tach consider Lidocaine bolus: 1.0-1.5mg/kg, followed by infusion if conversion is successful 59 Consider underlying cause of the tachycardia; treat appropriately Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG12 Date Created 1/1/2017 Date Revised 1/1/2017 Bradycardia Adult Treatment Guidelines 60 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG13 Date Created 1/1/2017 Date Revised 1/1/2017 Cardiac Arrest BLS Resuscitation Adult Treatment Guidelines 61 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG14 Date Created 1/1/2017 Date Revised 1/1/2017 Cardiac Arrest ACLS Resuscitation Adult Treatment Guidelines For VF/VT, consider Lidocaine bolus: 1.0-1.5mg/kg IVP, followed by infusion if conversion successful – IN PLACE OF AMIODARONE. 62 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG15 Date Created 1/1/2017 Date Revised 1/1/2017 Post Resuscitative Care Adult Treatment Guidelines GO TO SHOCK (NON-TRAUMA) GUIDELINE FOR SPECIFIC PRESSOR GUIDELINES 63 Reynolds County Ambulance District Shock (Non-Trauma) Clinical Practice Guidelines CPG Number ATG16 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood IS PATIENT SYMPTOMATIC? NO OVSERVE AND TRANSPORT MAINTAIN SUPPORTIVE CARE YES CONSIDER UNDERLYING CAUSES PRIMARILLY CARDIAC CONCERNS USE APROPRIATE GUIDLINE PRN CONSIDER FLUID BOLUS: 20CC/KG CONSIDER LUNG SOUNDS CONSIDER ADDITIONAL FLUIDS PRN USE CAUTION WITH VASOPRESSORS MAINTAIN INFUSION ON MEDICATION PUMP IF AVAILABLE CONSIDER DOPAMINE INFUSION Indicated for HR and BP control Dose is 5-20mcg/kg/min IVPB TAKE SERIOUS CONSIDERATION OF UNDERLYING CAUSE INTO ACCOUNT CONSIDER EPINEPHERINE INFUSION Indicated for HR and BP control Dose is 2-20mcg/min IVPB ENSURE PROPER PRE-LOAD IS PRESENT (FLUID STATUS) PRIOR TO STARTING VASOPRESSORS CONSIDER NOREPINEPHERINE INFUSION Indicated for BP control Dose is 2-20mcg/min IVPB 64 INFORMATION ON VASOPRESSORS DOPAMINE Dopamine is an inotrope, alpha drug and beta drug. Dopamine infusions will provide the following effects based on dose: o 5mcg/kg/min: primarily isotropic and beta effects Increase contractility (squeeze on heart) Increase heart rate o 10-15mcg/kg/min: alpha and beta effects Increase contractility (squeeze on heart) Increase heart rate Increase systemic vascular resistance (squeeze the pipes) o 20mcg/kg/min: primarily alpha effects Increase systemic vascular resistance (squeeze the pipes) Dopamine is primarily used for true cardiogenic shock patients (IE: post arrest or impending arrest), at the 10-15mcg/kg/min range. EPINEPHERINE Epinephrine is a naturally occurring hormone in the body. Epinephrine has both alpha and beta effects on the body. Epinephrine is to be used primarily for “COLD SHOCK” type states. o Bradycardic patients that are also hypotensive Epinephrine is to be used as the primary vasopressor for severe anaphylaxis. NOREPINEPHERINE Norepinephrine (Levophed) is primarily an alpha medicine. Norepinephrine will increase systemic vascular resistance (squeeze the pipes) but will not affect the patient’s heart rate. Norepinephrine is the drug of choice in severe sepsis. Use caution and ensure the patient has appropriate pre-load (fluid status) prior to use. FOR FURTHER DETAILED INFORMATION, PLEASE SEE EACH INDIVIDUAL DRUG PROFILE IN THE APPROVED MEDICATION FORMULARY AT THE END OF THIS DOCUMENT. 65 Reynolds County Ambulance District Overdose/Toxic Abnormalities Clinical Practice Guidelines CPG Number ATG17 Date Created 1/1/2017 Date Revised 1/1/2017 Abnormality Adult Treatment Guidelines History / Symptoms Treatment Opiate Overdose Pain Medicines Heroine - Unconsciousness Inadequate breathing Narcan: 2mg IN, IM, IV Titrate to effect and repeat as needed Calcium Channel Blocker Overdose IE: Cardizem - Bradycardia Present Hypotension Present Calcium Chloride: 1gm IVP Beta-Blocker Overdose IE: Metoprolol - Bradycardia Present Hypotension Present Glucagon: 2-5mg IVP Tricyclic Overdose IE: Amitriptyline - Wide QRS Noted V-Tach Noted Sodium Bicarbonate: 1mEQ/kg IVP Organo-Phosphate Poisoning Most pesticides - SLUDGE Noted Atropine: 1-5mg IVP Titrate to effect Stimulant Ingestion Cocaine Meth Bath Salts - Tachycardia Present Hypertension Present Combative Hallucinating Ativan: 1-4mg IV or IM Valium: 5-15mg IV Versed: 5-10mg IV or IM Hyperkalemia History of Renal Failure or insufficiency - Bradycardia Present Hypotension Present Peaked “T Waves” Wide QRS Noted Sodium Bicarbonate: 1mEQ/kg IVP and Calcium Chloride: 1gm IVP GO TO SHOCK (NON-TRAUMA) GUIDELINE AS APPROPRIATE 66 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG18 Date Created 1/1/2017 Date Revised 1/1/2017 General Pain Management Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood ASSESS PAIN LEVEL Pain is considered a vital sign; should be documented as such. Pain should be interpreted as mild, moderate or severe MINOR PAIN TREATMENT OPTIONS Position of Comfort Verbal distractions Morphine: 2-5mg, repeat PRN Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN Toradol: Morphine: 2-5mg, repeat PRN Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN Ketamine: 1mg/kg IVP or IM, repeat PRN (Sedation & Analgesia) o If using Ketamine, give Ativan: 1-2mg IVP or IM x 1 only Confirm all contraindications of medicines prior to use. Confirm medication allergies prior to use of pain medicines. Full patient monitoring must be used when narcotics are administered. MODERATE PAIN TREATMENT OPTIONS SEVERE PAIN TREATMENT OPTIONS 67 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG19 Date Created 1/1/2017 Date Revised 1/1/2017 Procedural Sedation Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONFIRM THE NEED FOR SEDATION IS PRESENT (pacing, cardioversion, etc.) ENSURE HEMODYNAMIC STABILITY CONSIDER SEDATION Ativan: 1-2mg IM or IVP, repeat PRN Versed: 2-5mg IM or IVP, repeat PRN Valium: 5-10mg IVP, repeat PRN Ketamine: 1mg IVP or IM, repeat PRN (Sedation & Analgesia) o If using Ketamine, give Ativan: 1-2mg IVP or IM x 1 only The use of procedural sedation is intended for patients requiring invasive procedures not able to be tolerated in an awake and alert state. Most of these procedures are painful; be sure to treat for pain as well as providing sedation. 68 Reynolds County Ambulance District Nausea & Vomiting Clinical Practice Guidelines CPG Number ATG20 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood PROVIDE GENERAL COMFORT MEASURES Position of comfort Consider: Fluid Bolus of 500cc TREATMENT OPTIONS Zofran: 4mg IVP, may repeat x 2 (12mg total) Phenergan (Promethazine): 12.5mg diluted in 10cc of NS IVP, may repeat x 1 (25mg total) Benadryl (Diphenhydramine): 25mg IVP, may repeat x 1 (50mg total) Be sure to consider underlying causes of nausea and vomiting. Be mindful of potential for Acute MI with unexplained nausea and/or vomiting. Be mindful of the potential for dehydration with nausea and vomiting patients. Consider potential electrolyte imbalances with nausea and vomiting, especially for prolonged durations and in the elderly. 69 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG21 Date Created 1/1/2017 Date Revised 1/1/2017 Altered Mental Status Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE Overdose (intentional or unintentional) Possible Stroke Sepsis Hyperglycemia or Hypoglycemia FOR SUSPECTED OVERDOSE: GO TO OVERDOSE/TOXIC ABNORMALITIES GUIDELINE FOR SUSPECTED STROKE: GO TO STROKE GUIDELINE HYPOGLYCEMIC EMERGENCY IDENTIFIED FINGER STICK BLOOD GLUCOSE: LESS THAN 70 MG/DL Consider oral glucose or carbohydrate rich meal Consider D50: 25gm IVP, repeat PRN Consider Glucagon: 1mg IM, repeat PRN (if unable to obtain IV access) HYPERGLYCEMIC EMERGENCY IDENTIFIED FINGER STICK BLOOD GLUCOSE: GREATER THAN 200 MG/DL Provide supportive care as needed Consider Fluid Bolus: 20cc/kg, repeat PRN when appropriate 70 Reynolds County Ambulance District Stroke Clinical Practice Guidelines CPG Number ATG22 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood PERFORM CINCINATI STROKE SCALE ANY ABNORMALITIES TO ABOVE = STROKE ALERT ESTABLISHE LAST SEEN NORMAL TIME Transport a witness to the event with the patient if at all possible and practical FOR ENCOUNTERED HYPOGLYCEMIA: GO TO ALTERED MENTAL STATUS GUIDELINE PROVIDE NOTIFICATION TO RECEIVING FACILITY AS QUICKLY AS PRACTICAL AND POSSIBLE! Establish a second IV enroute, ensure blood has been drawn 71 STROKE DESTINATION DECISION GUIDELINE Evidence of Severe Stroke? Severe stroke defined as: Complete neurological deficits, unable to speak, evidence of hemorrhagic stroke, etc. If “SEVERE STROKE” – transport to Level I stroke center (SAMC) Non-Severe Stroke, onset of symptoms: less than 4 hours Transport to closest Level I II or III stroke center If patient is unstable, transport to closest facility Non-Severe Stroke, onset of symptoms: 4-12 hours Transport to closest Level I stroke center (SAMC) If extended transport time to Level I stroke center, consider air transport to Level I stroke center, or consider transport to level II or III stroke center If patient is unstable, transport to closest facility Non-Severe Stroke, onset of symptoms: Greater than 12 hours Transport to closest Level I, II, III, or IV stroke center If patient is unstable, transport to closest facility WHEN IN DOUBT, UP-TRIAGE TO LEVEL 1 STROKE CENTER! Please Note: This guideline was created in accordance to MO BEMS TCD regulations and East Central Regional EMS Triage and Transport Protocol. 72 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG23 Date Created 1/1/2017 Date Revised 1/1/2017 Seizures Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE Overdose (intentional or unintentional) Possible Stroke Traumatic Event Hyperglycemia or Hypoglycemia REFER TO SPECIFIC UNDERLYING CAUSE GUIDELINE AS APPROPRIATE AND PRACTICAL IF PATIENT ACTIVELY SEIZING Consider Ativan: 1-2mg IVP, IM or IN; repeat PRN Consider Versed: 2-5mg IVP, IM or IN; repeat PRN Consider Valium: 5-10mg IVP, IM, IN or Rectal; repeat PRN Special consideration should be paid to underlying cause. Status Epilepticus as a primary cause is a true emergency and aggressive attempts to “break” the seizure should take place. Pay close attention to airway patency with the seizing patient. In female patients who appear to be pregnant, be sure to rule out eclampsia as the cause for the seizure. If that is the case, Magnesium will be required to control the seizure activity. 73 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG24 Date Created 1/1/2017 Date Revised 1/1/2017 Allergic Reaction/Anaphylaxis Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood MILD REACTION (hives present, no respiratory distress noted) Position of comfort Consider: Fluid Bolus of 500cc Consider: Benadryl 25-50mg IV or IM Consider: Solu-Medrol 125mg IV, IM or UDN MODERATE REACTION (hives present, WITH wheezing noted) Position of comfort Consider: Fluid Bolus of 500cc Consider: Benadryl 25-50mg IV or IM Consider: Solu-Medrol 125mg IV, IM or UDN Consider: Albuterol 2.5mg via UDN, may repeat PRN SEVERE REACTION (respiratory failure present, severe distress, impending arrest/shock) Consider: Fluid Bolus of 500cc Consider: Epi 1:1,000 0.3-0.5mg SQ or IM Consider: Epi 1:10,000 0.3-0.5mg IVP if no improvement with SQ or IM, or severe cases Consider: Benadryl 25-50mg IV or IM Consider: Solu-Medrol 125mg IV, IM or UDN Consider: Albuterol 2.5mg via UDN, may repeat PRN 74 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG25 Date Created 1/1/2017 Date Revised 1/1/2017 Abdominal Pain Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE Cardiac Event Abdominal Aortic Anurysm Pregnancy Complications Infection REFER TO SPECIFIC UNDERLYING CAUSE GUIDELINE AS APPROPRIATE AND PRACTICAL PATIENT TO REMAIN NPO CONSIDER ORTHOSTATIC VITAL SIGN ASSESSMENT CONSIDER FLUID BOLUS: 20CC/KG, repeat PRN 75 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG26 Date Created 1/1/2017 Date Revised 1/1/2017 Behavioral Emergencies Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE Overdose (intentional or unintentional) Trauma Sepsis Hyperglycemia or Hypoglycemia ATTEMPT VERBAL DEESCELATION CONSIDER SEDATION/CHEMICAL RESTRAINTS Ativan: 1-2mg IM or IVP, repeat PRN Versed: 2-5mg IM or IVP, repeat PRN Valium: 5-10mg IVP, repeat PRN Haldol: 5mg IM or IVP, repeat PRN Ketamine: 1-2mg/kg IVP or IM, repeat PRN (Sedation & Analgesia) o If using Ketamine, give Ativan: 1-2mg IM or IVP CONSIDER PHYSICAL RESTRAINTS Employ restraints only if necessary 4-point technique should be used Evaluate pulse, motor and sensation post restraint applications The use of sedation/chemical restraints should be considered early The use of physical restrains should only be used if necessary Any patient being sedated or restrained deserves a full ALS work up and monitoring Haldol 5mg and Ativan 2mg IM work very well as a combination Any patient with witnessed Suicidal or Homicidal Ideations MUST be transported for evaluation 76 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG27 Date Created 1/1/2017 Date Revised 1/1/2017 Hypertensive Emergencies Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONFIRM TRUE HYPERTENIVE EMERGENCY WITH SYMPTOMS CONSIDER UNDERLYING CAUSE IF APPLICABLE, GO TO DIFFERENT GUIDLINE (IE: CP, Pulmonary Edema, Pregnancy Complications, etc.) CHECK BP IN BOTH ARMS AND CONFIRM HYPERTENSION WITH MANUAL CUFF CONSIDER NTG: 400MCG SL, repeat PRN CONSIDER NTG INFUSION: 5-50mcg/min IVPB, titrate to effect Consider Lopressor: 5mg SIVP, repeat x 2 (15mg total) (hypertension and tachycardia) Pay very close attention to probable underlying cause of hypertension Hypertension is often times a compensatory mechanism Hypertension is very rarely treated as a primary complaint 77 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG28 Date Created 1/1/2017 Date Revised 1/1/2017 Cold Related Emergencies Adult Treatment Guidelines REMOVE PATIENT FROM THE EVNIRONMENT PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood HYPOTHERMIA Initiate infusion of warm IV fluids Provide heat packs to axillary areas and groin Cover with warm blankets HYPOTHERMIC CARDIAC ARREST CONSIDERATIONS Obtain core temperature Core temperature greater than 86 F = normal arrest Core temperature less than 86 F o Limit defibrillation to 1 total until re-warmed o CPR only; no drug therapy o Warm IV fluids only 78 Reynolds County Ambulance District Heat Related Emergencies Clinical Practice Guidelines CPG Number ATG29 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines REMOVE PATIENT FROM THE EVNIRONMENT PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood HEAT EXAUSTION (core temp less than 105) Passive cooling only o Cool PO fluids are acceptable HEAT STROKE (core temp greater than 105; with symptoms present) Active cooling techniques o Ice packs to axillary and groin areas o Cool fluids IV only 79 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG30 Date Created 1/1/2017 Date Revised 1/1/2017 Trauma Criteria Adult Treatment Guidelines TRIAGE PATIENT AND PROVIDED A TRAUMA LEVELING USE THE FOLLOWING CRITERIA & GUIDELINES FOR TRANSPORT DECISIONS TRUMA LEVEL ONE CRITERIA Physiologic Criteria Glasgow Coma Scale < 14 Systolic Blood Pressure: <90 at any time and/or clinical signs of shock Respiratory rate: < 10 or > 29 Heart Rate: >120 Anatomic criteria All penetrating injuries to head, neck, torso, and extremities (boxer short and T-shirt areas) proximal to elbow and knee Flail chest, airway compromise or obstruction, hemo- or pneumothorax, or Any intubated trauma patient Two or more proximal long-bone fractures Extremity trauma with loss of distal pulse Amputation proximal to wrist and ankle Pelvic fractures Open or depressed skull fractures Paralysis or signs of spinal cord or cranial nerve injury Active or uncontrolled hemorrhage Burns greater than 20% BSA LEVEL ONE TRAUMA PATIENTS SHOULD BE TRANSPORTED TO A LEVEL I OR II TRAUMA CENTER GOAL = PATIENT TO TRAUMA CENTER WITHIN 60 MINUTES FROM TIME OF INJURY CONTINUED ON NEXT PAGE 80 TRUMA LEVEL TWO CRITERIA Falls > or = 20 feet (one story = 10 ft.) High-risk auto crash: o Any auto crash > 40 mph or highway speeds o Passenger Space Intrusion > 12 inches o Ejection (partial or complete) from automobile o Rollover o Death in same passenger compartment High-risk Pedestrian, Cycle, ATV Crash Auto v. Pedestrian/bicyclist thrown, run over, or with significant (> or = 20 mph) impact Motorcycle or ATV crash > or = 20 mph with separation of rider or with rollover Crush, degloved, or mangled extremity All open fractures Femur fracture Trauma with prolonged Loss of Consciousness Pregnancy with acute abdominal pain and traumatic event Penetrating injuries distal to T-shirt and boxer area to wrist and to ankle LEVEL TWO TRAUMA PATIENTS SHOULD BE TRANSPORTED TO A LEVEL I OR II TRAUMA CENTER GOAL = PATIENT TO TRAUMA CENTER WITHIN 90 MINUTES FROM TIME OF INJURY TRUMA LEVEL THREE CRITERIA Age: > age 55 Falls: 5-20 Feet Burns less than 20% BSA Lower-risk Crash: o MVC < 40 MPH or UNK speed, o Auto v. Pedestrian/bicyclist with <20 mph impact o Motorcycle or ATV crash < 20 mph with separation of rider or rollover Anticoagulation and bleeding disorder End-stage renal disease requiring dialysis All pregnant patients involved in traumatic event Near drowning/ Near hanging LEVEL THREE TRAUMA PATIENTS MAY BE TRANSPORTED TO A LEVEL III TRAUMA CENTER GOAL = PATIENT TO TRAUMA CENTER WITHIN 120 MINUTES FROM TIME OF INJURY 81 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG31 Date Created 1/1/2017 Date Revised 1/1/2017 General Trauma Care Adult Treatment Guidelines PERFORM ROUTINE CARE (on scene or enroute to hospital as deemed appropriate) Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood PERFORM TRAUMA TRIAGE If Level I or II trauma criteria met, transport to Level I or II trauma center UNLESS IN EXTREMIS REFER TO DESTINATION DECISION GUIDELINE CONSIDER AIR TRANSPORT IF APPROPRIATE - REFER TO AIR AMBULANCE UTILIZATION GUIDLINE RECOMMENDED ON SCENE TRAUMA CARE Expose patient for appropriate assessment Identify and address obvious life threats Consider spinal immobilization RECOMMENDED ENROUTE TO HOSPITAL TRAUMA CARE Provide constant re-assessment Ensure 2 points of large bore vascular access are achieved, ensure blood is drawn Consider Fluid Bolus: 20cc/kg, titrate to SBP of 90mm/hg. Consider splinting any fractures Ensure patient is warm Trauma care should focus on rapid assessment, appropriate trauma triage and rapid transport to the APPROPRIATE facility. Most, if not all treatments can and should be done while enroute to the hospital. A major trauma victim (level I or II) should ONLY be transported to a level III or lower center if the patient is in extremis (see destination decision guideline). When in doubt, up-triage the trauma patient and transport to a level I or II trauma center. 82 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG32 Date Created 1/1/2017 Date Revised 1/1/2017 Traumatic Arrest Adult Treatment Guidelines CONFIRM PATIENT IN FULL ARREST FROM APPARENT TRAUMATIC EVENT CONSIDER UNDERLYING MEDICAL CAUSE FOR ARREST CONSIDER NOT RESUSITATING THE PATIENT – GO TO DEATH GUIDLINE AS APPROPRIATE YES: RESUSCITATION IS INDICATED Rapid transport to closest facility; all interventions to be done enroute INITIATE BLS CPR BLS Airway if adequate and appropriate Compressions at 100/min ADVANCED AIRWAY MANAGEMENT BILATERAL NEEDLE THORACENTESIS OBATAIN LARGE BORE VASCULAR ACCESS X 2 RAPID FLUID ADMINISTRATION ALL ACCESS POINTS TO NS AT W/O RATE CONSIDER BINDING PELVIS IS APPROPRIATE AND PRACTICAL CONSIDER SPLINTING LONG BONE FRACTURES IF APPROPRIATE AND PRACTICAL CONSIDER SODIUM BICARBONATE: 1MEQ/KG IVP CONSIDER EPI 1:10,000: 1MG IVP, repeat every 3-5 minutes RETURN OF SPONTANEUS CIRCULATION ACHIEVED? YES: CONSIDER TRANSPORT TO LEVEL I OR II TRAUMA CENTER SEE DESTINATION DECISION GUIDELINE AS APPROPRIATE 83 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG33 Date Created 1/1/2017 Date Revised 1/1/2017 Crush Injuries Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood FLUID BOLUS: 2L OF NORMAL SALINE CONSIDER SODIUM BICARBONATE: 1MEQ/KG IN 1L OF NS, WIDE OPEN REFER TO GENERAL TRAUMA GUIDELINE AS APPROPRIATE AND PRACTICAL REFER TO OVERDOSE/TOXIC AMBNORMALITIES GUIDELINE IF S/S OF HYPERAKELMIA Crush injuries should be suspected with entrapment/compression of greater than one hour, especially when a large muscle mass/group is involved Treatment of the patient at risk for Crush Syndrome should begin before the patient is removed when practical 84 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG34 Date Created 1/1/2017 Date Revised 1/1/2017 Amputations Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CARE OF THE AMPUTATED PART Rinse off contaminates with sterile water or saline Wrap amputated part with sterile dressing moistened with saline and place in sealed bag Place sealed bag in into ice REFER TO GENERAL TRAUMA GUIDELINE AS APPROPRIATE AND PRACTICAL 85 Reynolds County Ambulance District Burns Clinical Practice Guidelines CPG Number ATG35 Date Created 1/1/2017 Date Revised 1/1/2017 Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood THE FOLLOWING SHOULD TRIAGE A PATIENT TO A BURN CENTER (Mercy Hospital St. Louis) Partial thickness burns greater than 10% total body surface area (TBSA) Any burn that involve the face, hands, feet, genitalia, perineum, or major joints Any full thickness (3rd degree) burns Any electrical burns, including lightning injury Any chemical burns Any inhalation injury STOP THE BURNING PROCESS COVER THE BURN AREA WITH DRY STERILE DRESSINGS FLUID RESUSCITATE USING THE PARKLAND FORMULA Use the rule of 9’s for calculation Consider RSI early, if any signs of airway burn / inhalation injury Burns are very painful, treat pain very aggressively Be cautious to over fluid resuscitate 86 RULE OF 9’S CRITERIA FOR ADULT PATIENTS PARKLAND FORMULA 2CC X %BSA X WEIGHT (KG) THIS AMOUNT TO BE ADMINISTERED OVER THE FIRST 8 HOURS REMEMBER: FLUID RESCUSITATION AS NEEDED FOR HEMODYNAMIC STATUS OVER-RULES PARKLAND FORMULA 87 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG36 Date Created 1/1/2017 Date Revised 1/1/2017 Envenomation Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood PROVIDE SUPPORTIVE CARE CONSIDER TRANSPORT TO BARNES-JEWISH HOSPITAL FOR TOXICOLOGY SPECIALTY SERVICES FOR SEVERE CASES OF ENVENOMATION SEE DESTINATION DECISION GUIDELINE AS APPROPRIATE 88 Reynolds County Ambulance District Child Birth Clinical Practice Guidelines CPG Number ATG37 Date Created 1/1/2010 Date Revised 2/25/2014 Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood NORMAL PRESENTATION Assist with delivery Create an airway for the infant with a gloved hand Rapid transport LIMB PRESENTATION BREECH PRESENTATION Allow buttocks and limbs to deliver If head does not deliver; create an airway for the infant with a gloved hand Rapid transport Lift the infants head off of the wall of the vaginal wall Attempt to slip the umbilical cord off from around the infants neck Rapid transport Basic care for the new-born as needed; keep warm Clamp and cut umbilical cord; 10 inches from the infants body Prepare for delivery of the placenta For post-partum hemorrhage: Pitocin 10mg/1000cc NS @ w/o rate PROLAPSED CORD PRESENTATION POST DELIVERY CARE 89 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number ATG38 Date Created 1/1/2017 Date Revised 1/1/2017 Pregnancy Complications Adult Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood GENERAL OB COMPLAINTS Transport in the left-lateral recumbent position Provide routine care as appropriate PRE-ECLAMPSIA Defined as 3 trimester hypertension with noted edema; no seizure activity Consider: Magnesium Sulfate 4gm/100cc D5W, IVPB over 20 minutes Transport in the left-lateral recumbent position Defined as 3rd trimester hypertension, noted edema and with seizure activity Consider: Magnesium Sulfate 4gm/100cc D5W, IVPB over 20 minutes Transport in the left-lateral recumbent position rd ECLAMPSIA 90 SECTION THREE PEDIATRIC TREATMENT GUIDELINES FOR THE PURPOSE OF THESE GUIDELINES, A PEDIATRIC PATIENT WILL BE CONSIDERED ANY HUMAN UNDER THE AGE OF 18 YEARS OLD. CLINICIANS WILL HAVE TO USE THEIR BEST JUDGEMENT FOR MEDICATION DOSEAGES WITH REGARDS TO THEIR PATIENTS SIZE. AS A GENERAL RULE, IF THE PATIENT IS TOO TALL TO USE THE LENGTH BASED RESUSITATION TAPE AS A GUIDE; USE ADULT MEDICATION DOSEAGES. 91 Reynolds County Ambulance District Routine Care Clinical Practice Guidelines CPG Number PED1 Date Created 1/1/2017 Date Revised 1/1/2017 Pediatric Treatment Guidelines It is the policy of Reynolds County Ambulance District to provide quality clinical care in the safest manner possible. Through that vision, we have developed the following routine care procedures that shall be used on every pediatric patient encounter. Ensure scene safety Bring all necessary equipment to the patient’s side Demonstrate professionalism and courtesy Don personal protective equipment Airborne or droplet precautions if indicated Assess CABs, and intervene if indicated Control any major bleeding Provide oxygen and assist ventilations if indicated Spinal immobilization if indicated Obtain chief complaint, associated signs/symptoms Obtain complete set of vital signs Obtain past medical history and SAMPLE-type history Where appropriate, provide routine ALS care: Establish vascular access, draw blood Monitor cardiac rhythm Perform multi-lead EKG as appropriate Measure and monitor waveform ETCO2 Measure and monitor SPO2 Measure blood glucose REFER TO LENGTH BASED RESUSCITATION TAPE FOR ALL MEDICIATION DOSEAGES EQUIPMENTGUIDELINES CONTACT MEDICAL CONTROL PHYSICIAN AT ANY TIME DURING PATIENT ENCOUNTER WHEN GUIDANCE IS NEEDED TRANSPORT PATIENTS ACCORDING TO DESTINATION DECISION OPERATIONAL POLICY 92 Reynolds County Ambulance District General Airway Management Clinical Practice Guidelines CPG Number PED2 Date Created 1/1/2017 Date Revised 1/1/2017 Pediatric Treatment Guidelines Assess ABC’s Assess Respiratory Rate, Rhythm Quality Assess Airway Patency ADEQUATE Provide Appropriate Monitoring mO Consider monitoring SPO2 Consider monitoring ETCO2 Provide Basic Treatment Provide Oxygen as appropriate Transport in position of comfort INADEQUATE Provide BLS Airway Management Position/Adjunct/Suction Ventilatory Support w/ O2 Provide Appropriate Monitoring SPO2 & ETCO2 EKG & NIBP Provide ALS Airway Management Intubation (Oral/Nasal) RSI as needed IF AIRWAY OBSTRUCTION ENCOUNTERED AT ANY TIME: GO DIRECTLY TO: AIRWAY OBSTRUCTION GUIDELINE Package & Transport Follow Post Intubation Management Guideline as appropriate IF UNABLE TO MAINTAIN AIRWAY, UNABLE TO VENTILATE, AND/OR UNABLE TO OXYGENATE AT ANY TIME: GO DIRECTLY TO: FAILED AIRWAY GUIDELINE 93 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED3 Date Created 1/1/2017 Date Revised 1/1/2017 Airway Obstruction Pediatric Treatment Guidelines CONFIRM AIRWAY OBSTRUCTION IS PRESENT Assess Mental Status CONSCIOUS PATIENT Perform Heimlich maneuver or back blows/chest thrusts until: C. Obstruction is removed or D. Patient becomes unconscious UNCONSCIOUS PATIENT Check for foreign body visible in mouth; remove if found Begin CPR with compressions first IF ABOVE IS UNSUCCESSFUL: INITIATE ALS PROCEDURES Perform direct laryngoscopy and attempt to remove obstruction o Suction o Forceps If able to remove obstruction, go to Airway Management Guideline If unable to remove obstruction, go to Failed Airway Guideline IF SUCCESSFUL: GO TO AIRWAY MANAGEMENT GUIDELINE IF UNSUCCESSFUL: GO TO FAILED AIRWAY GUIDELINE 94 Reynolds County Ambulance District Failed Airway Clinical Practice Guidelines CPG Number PED4 Date Created 1/1/2017 Date Revised 1/1/2017 Pediatric Treatment Guidelines The encountered failed airway is something that each clinician at Reynolds County Ambulance District must be prepared for. Proper reaction to the failed pediatric airway is paramount in the survivability of the critically ill patient. Should a failed airway be encountered, use the following algorithm. FALL BACK TO BASICS – BLS AIRWAY MANAGEMENT Good positioning of patient BLS airway adjuncts Good suction 2 person BVM technique CONSIDER RESCUE AIWAY (if unable to ventilate/oxygenate with BVM) Superglottic Airway EMERGENCY CRICOTHYROTOMY (if unable to ventilate/oxygenate with BVM and unable to place rescue airway) Needle Cricothyrotomy (under 8 years old) Quick-Trach (over 8 years old) Surgical Cricothyrotomy (over 8 years old) GO TO POST INTUBATION MANAGEMENT GUIDELINE AS APPROPRIATE 95 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED5 Date Created 1/1/2017 Date Revised 1/1/2017 Rapid Sequence Intubation Pediatric Treatment Guidelines CONFIRM RSI IS INDICATED (one of the items below) Inadequate ventilation and/or oxygenation is present Patient is unable to maintain airway Predicted clinical course indicates need for airway management PREPERATION Gather and assemble all tools, 2 IV’s in place Ready all medications (RSI and post intubation) PREOXYGENATION Provide 100% FiO2 by LEAST INVASIVE means possible (NPPV Preferred) Avoid BVM if at all possible PREMEDICATION Consider Fentanyl for pain: 0.5-2.0mcg/kg IV or IO Consider Atropine: .02mg/kg (max 0.5mg) IV or IO Fluid bolus if patient is hypotensive or borderline hypotensive PARALYSIS WITH INDUCTION SEDATION (pick one) o Etomidate: 0.3mg/kg IV or IO ***Head Injuries/Hypertensive*** o Ketamine: 1-2mg/kg IV or IO ***Hypotensive / Septic / Respiratory*** If using Ketamine, give Ativan: 0.1mg/kg (max 4mg) IVP x 1 PARALYTIC (pick one) o Succinylcholine: 1-2mg/kg IV or IO (max single dose 200mg) o Rocuronium: 1.0mg/kg IV or IO (max single dose 100mg) PLACEMENT WITH PROOF Oral Intubation, use bougie IF SUCCESSFUL GO TO POST INTUBATION MANAGEMENT GUIDELINE IF UNSUCCESSFUL: GO TO FAILED AIRWAY GUIDELINE 96 INFORMATION ON RAPID SEQUENCE INTUBATION The process of Rapid Sequence Intubation is designed to take an airway from a patient that has one of the following at the time of exam: A. Inadequate ventilation and/or oxygenation present and not responding to conventional treatments (Oxygen by mask, NPPV, other treatments, etc.). B. Inability to maintain airway (altered mental status, unconsciousness, etc.). C. Predicted clinical course that indicates a need for airway management (severe combative nature, obvious head injury, major trauma, etc.). Rapid Sequence Intubation should not be taken lightly. This is a skill that by definition, is taking away something the patient has. The clinician performing the RSI should be completely confident in his or her ability to manage the patient’s airway. Prior to performing the RSI, the clinician should perform a thorough risk vs. benefit analysis on the patient to confirm that RSI is in fact the indicated and appropriate treatment. The clinician should perform a complete assessment of the airway and predict any difficulties that may arise. The clinician should go into the RSI situation with the “worst case scenario” in mind, and be prepared to manage that scenario. Use a length based resuscitation tape to guide your medication doses. Please Note: After any attempt at RSI, the Supervisor, Operations Manager and/or Administrator will be contacted by the on-duty crew immediately after transferring care to discuss the case. 97 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED6 Date Created 1/1/2017 Date Revised 1/1/2017 Post Intubation Management Pediatric Treatment Guidelines The post intubation management guideline was developed for the treatment of any patient who has an artificial airway in place (ET tube, rescue airway, emergency cricothyrotomy). CONFIRM AIRWAY IS PATENT AND SECURED Lung sounds remain present, epigastric sounds remain absent Continuous monitoring of waveform ETCO2 is REQUIRED (ideal range is 35-45) Secure the airway with a commercial device, when available CONSIDER PLACEMENT A GASTRIC TUBE Oral route is preferred; see length based resuscitation tape for sizing. ENSURE ADEQUATE VENTILATION & OXYGENATION Provide 100% FIO2, unless otherwise indicated Either with bag valve device or mechanical ventilator Ensure adequate tidal volume (6-8cc/kg) Ensure adequate respiratory rate (usually 8-12/min) – normal ETCO2 35-45 Consider adding mechanical PEEP, unless contraindicated (usually 5-10cm/H2O) See mechanical ventilation procedure for further information on ventilator use CONSIDER SEDATION & ANALGESIA Hypertensive o Versed: 0.1mg/kg (max 5mg single dose) IV or IO, every 10-20 minutes o Fentanyl: 0.5-2mcg/kg IV or IO, every 10-20 minutes Normotensive / Hypotensive o Ketamine: 1-2mg/kg, every 10-20 minutes CONSIDER CONTINED PARALYSIS ONLY IF ABSOLUETELY NECESSARY Rocuronium: 1mg/kg IV or IO (will last 30 minutes) PROVIDE CONTINUOUS REASSESSMENT Maintain constant ETCO2 monitoring Vital signs every 5 minutes Assume intubated patients are under sedated and in pain; treat accordingly Patient with or likelihood for seizure: give Ativan bolus 98 Reynolds County Ambulance District Bronchospasm Clinical Practice Guidelines CPG Number PED7 Date Created 1/1/2017 Date Revised 1/1/2017 Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood ASSESS FOR RESPIRATORY FAILURE Consider assisting ventilations as needed Consider RSI at any time in this guideline Consider Albuterol: 2.5mg via UDN, repeat PRN (respiratory distress – wheezing and/or rhonchi) Consider Xopenex: .63mg via UDN, repeat x 2 PRN (if patient is tachycardic for age) Consider Nebulized Epinephrine: .25mg 1:1,000 in 3cc of NS via UDN, 1 time only (for suspected croup only) Consider Decadron: 0.6mg/kg, max 16mg, IVP or IM (presumed lung injury – patient under the age of 6 years) Consider Solu-Medrol: 125mg IVP, IM or UDN (presumed lung injury – patient over the age of 6 years) Consider Magnesium Sulfate: Infusion 40mg/kg (max 2gm) in 100cc IVPB over 10 minutes (severe distress) 99 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED8 Date Created 1/1/2017 Date Revised 1/1/2017 Tachycardia Pediatric Treatment Guidelines For pulsing V-Tach consider Lidocaine bolus: 1.0-1.5mg/kg, followed by infusion if conversion is successful Consider sedation and pain management for the purpose of cardioversion, when possible and practical 100 Consider underlying cause of the tachycardia; treat appropriately Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED9 Date Created 1/1/2017 Date Revised 1/1/2017 Bradycardia Pediatric Treatment Guidelines Consider underlying cause of the bradycardia; treat appropriately The presence of bradycardia in pediatric patients is hypoxia until proven otherwise 101 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED10 Date Created 1/1/2017 Date Revised 1/1/2017 Cardiac Arrest BLS Resuscitation Pediatric Treatment Guidelines 102 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED11 Date Created 1/1/2017 Date Revised 1/1/2017 Cardiac Arrest PALS Resuscitation Pediatric Treatment Guidelines 103 Reynolds County Ambulance District Shock (Non-Trauma) Clinical Practice Guidelines CPG Number PED12 Date Created 1/1/2017 Date Revised 1/1/2017 Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood IS PATIENT SYMPTOMATIC? NO OVSERVE AND TRANSPORT MAINTAIN SUPPORTIVE CARE YES CONSIDER UNDERLYING CAUSES PRIMARILLY CARDIAC CONCERNS USE APROPRIATE GUIDLINE PRN CONSIDER FLUID BOLUS: 20CC/KG CONSIDER LUNG SOUNDS CONSIDER ADDITIONAL FLUIDS PRN USE CAUTION WITH VASOPRESSORS MAINTAIN INFUSION ON MEDICATION PUMP IF AVAILABLE CONSIDER DOPAMINE INFUSION Indicated for HR and BP control Dose is 5-20mcg/kg/min IVPB TAKE SERIOUS CONSIDERATION OF UNDERLYING CAUSE INTO ACCOUNT CONSIDER EPINEPHERINE INFUSION Indicated for HR and BP control Dose is 0.1-1.0mcg/kg/min IVPB ENSURE PROPER PRE-LOAD IS PRESENT (FLUID STATUS) PRIOR TO STARTING VASOPRESSORS CONSIDER NOREPINEPHERINE INFUSION Indicated for BP control Dose is 0.1-1.0mcg/kg/min IVPB 104 INFORMATION ON VASOPRESSORS DOPAMINE Dopamine is an inotrope, alpha drug and beta drug. Dopamine infusions will provide the following effects based on dose: o 5mcg/kg/min: primarily isotropic and beta effects Increase contractility (squeeze on heart) Increase heart rate o 10-15mcg/kg/min: alpha and beta effects Increase contractility (squeeze on heart) Increase heart rate Increase systemic vascular resistance (squeeze the pipes) o 20mcg/kg/min: primarily alpha effects Increase systemic vascular resistance (squeeze the pipes) Dopamine is primarily used for true cardiogenic shock patients (IE: post arrest or impending arrest), at the 10-15mcg/kg/min range. EPINEPHERINE Epinephrine is a naturally occurring hormone in the body. Epinephrine has both alpha and beta effects on the body. Epinephrine is to be used primarily for “COLD SHOCK” type states. o Bradycardic patients that are also hypotensive Epinephrine is to be used as the primary vasopressor for severe anaphylaxis. NOREPINEPHERINE Norepinephrine (Levophed) is primarily an alpha medicine. Norepinephrine will increase systemic vascular resistance (squeeze the pipes) but will not affect the patient’s heart rate. Norepinephrine is the drug of choice in severe sepsis. Use caution and ensure the patient has appropriate pre-load (fluid status) prior to use. FOR FURTHER DETAILED INFORMATION, PLEASE SEE EACH INDIVIDUAL DRUG PROFILE IN THE APPROVED MEDICATION FORMULARY AT THE END OF THIS DOCUMENT. 105 Reynolds County Ambulance District Overdose/Toxic Abnormalities Clinical Practice Guidelines CPG Number PED13 Date Created 1/1/2017 Date Revised 1/1/2017 Abnormality Pediatric Treatment Guidelines History / Symptoms Treatment Opiate Overdose Pain Medicines Heroine Calcium Channel Blocker Overdose IE: Cardizem - Unconsciousness Inadequate breathing Narcan: 0.1mg/kg IN, IM, IV Titrate to effect; repeat PRN - Bradycardia Present Hypotension Present Calcium Chloride: 20mg/kg IVP Beta-Blocker Overdose IE: Metoprolol - Bradycardia Present Hypotension Present Glucagon: 0.5-5mg IVP Tricyclic Overdose IE: Amitriptyline - Wide QRS Noted V-Tach Noted Sodium Bicarbonate: 1mEQ/kg IVP Organo-Phosphate Poisoning Most pesticides - SLUDGE Noted Atropine: 0.02mg/kg IVP Titrate to effect; repeat PRN Stimulant Ingestion Cocaine Meth Bath Salts - Tachycardia Present Hypertension Present Combative Hallucinating Ativan: 0.5-4mg IV or IM Valium: 1-15mg IV Versed: 1-10mg IV or IM Hyperkalemia History of Renal Failure or insufficiency - Bradycardia Present Hypotension Present Peaked “T Waves” Wide QRS Noted Sodium Bicarbonate: 1mEQ/kg IVP and Calcium Chloride: 20mg/kg IVP GO TO SHOCK (NON-TRAUMA) GUIDELINE AS APPROPRIATE 106 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED14 Date Created 1/1/2017 Date Revised 1/1/2017 General Pain Management Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood ASSESS PAIN LEVEL Pain is considered a vital sign; should be documented as such. Pain should be interpreted as mild, moderate or severe MINOR PAIN TREATMENT OPTIONS Position of comfort Verbal distractions Ice or heat pack for comfort MODERATE PAIN TREATMENT OPTIONS Morphine: 0.01mg/kg IVP or IM, max single dose 5mg, repeat PRN Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN Toradol: Morphine: 0.01mg/kg IVP or IM, max single dose 5mg, repeat PRN Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN Toradol: Ketamine: 1mg/kg IVP or IM, repeat PRN (sedation and analgesia) o If using Ketamine, give Ativan: 0.1mg/kg (max 4mg) IVP x 1 Confirm all contraindications of medicines prior to use. Confirm medication allergies prior to use of pain medicines. Full patient monitoring must be used when narcotics are administered. SEVERE PAIN TREATMENT OPTIONS 107 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED15 Date Created 1/1/2017 Date Revised 1/1/2017 Procedural Sedation Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONFIRM THE NEED FOR SEDATION IS PRESENT (pacing, cardioversion, etc.) ENSURE HEMODYNAMIC STABILITY CONSIDER SEDATION Ativan: 0.1mg/kg, max 2mg IVP or IM, repeat PRN Versed: 0.1mg/kg, max 5mg IVP or IM, repeat PRN Valium: 1-5mg IVP, repeat PRN Ketamine: 1mg/kg IVP or IM, repeat PRN (sedation and analgesia) o If using Ketamine, give Ativan: 0.1mg/kg (max 4mg) IVP x 1 The use of procedural sedation is intended for patients requiring invasive procedures not able to be tolerated in an awake and alert state. Most of these procedures are painful; be sure to treat for pain as well as providing sedation. The need for procedural sedation in the pediatric patient in the field should be very rare. 108 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED16 Date Created 1/1/2017 Date Revised 1/1/2017 Nausea & Vomiting Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood PROVIDE GENERAL COMFORT MEASURES Position of comfort Consider: Fluid Bolus of 20cc/kg, repeat PRN TREATMENT OPTION Zofran: 0.15mg/kg, max 4mg IVP or IM, may repeat x 2 Be mindful of the potential for dehydration with nausea and vomiting patients. Consider potential electrolyte imbalances with nausea and vomiting, especially for prolonged durations. 109 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED17 Date Created 1/1/2017 Date Revised 1/1/2017 Seizures Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE Overdose (intentional or unintentional) Possible Stroke Traumatic Event Hyperglycemia or Hypoglycemia REFER TO SPECIFIC UNDERLYING CAUSE GUIDELINE AS APPROPRIATE AND PRACTICAL IF PATIENT ACTIVELY SEIZING Consider Ativan: 0.1mg/kg, max 2mg IVP, IM or IN; repeat PRN Consider Versed: 0.2mg/kg, max 5mg IVP, IM or IN; repeat PRN Consider Valium: 1-5mg IVP, IM, IN or Rectal; repeat PRN Special consideration should be paid to underlying cause. Status Epilepticus as a primary cause is a true emergency and aggressive attempts to “break” the seizure should take place. Pay close attention to airway patency with the seizing patient. In pediatric patients, fever is a very common cause of seizures. 110 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED18 Date Created 1/1/2017 Date Revised 1/1/2017 Allergic Reaction/Anaphylaxis Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood MILD REACTION (hives present, no respiratory distress noted) Position of comfort Consider: Fluid Bolus of 20cc/kg Consider: Benadryl Consider: Benadryl: 1-2mg/kg, max 50mg IVP Consider: Solu-Medrol: 1-2mg/kg, max of 125mg IVP, IM or UDN MODERATE REACTION (hives present, WITH wheezing noted) Position of comfort Consider: Fluid Bolus of 20cc/kg Consider: Benadryl: 1-2mg/kg, max 50mg IVP Consider: Solu-Medrol: 1-2mg/kg, max of 125mg IVP, IM or UDN Consider: Albuterol: 2.5mg via UDN, repeat PRN SEVERE REACTION (respiratory failure present, severe distress, impending arrest/shock) Consider: Fluid Bolus of 20cc/kg Consider: Epi 1:1,000: 0.01mg/kg, max of 0.3mg IM Consider: Epi 1:10,000: 0.01mg/kg, max of 0.1mg IVP Consider: Benadryl: 1-2mg/kg, max 50mg IVP Consider: Solu-Medrol: 1-2mg/kg, max of 125mg IVP, IM or UDN Consider: Albuterol: 2.5mg via UDN, repeat PRN 111 Reynolds County Ambulance District Fever Clinical Practice Guidelines CPG Number PED19 Date Created 1/1/2017 Date Revised 1/1/2017 Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE PROVIDE GENERAL COMFORT MEASURES Position of comfort Consider: Fluid Bolus of 20cc/kg, repeat PRN Consider Tylenol: 10mg/kg PO Consider Ibuprofen: 10mg/kg PO (patient must be older than 6 months) 112 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED20 Date Created 1/1/2017 Date Revised 1/1/2017 Altered Mental Status Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE Overdose (intentional or unintentional) Possible Stroke Sepsis Hyperglycemia or Hypoglycemia FOR SUSPECTED OVERDOSE: GO TO OVERDOSE/TOXIC ABNORMALITIES GUIDELINE HYPOGLYCEMIC EMERGENCY IDENTIFIED FINGER STICK BLOOD GLUCOSE: LESS THAN 70 MG/DL Consider oral glucose or carbohydrate rich meal Consider D25 (1 y/o to 6 y/o): 1gm/kg IVP, repeat PRN Consider D10 (less than 1 y/o): 1gm/kg IVP, repeat PRN HYPERGLYCEMIC EMERGENCY IDENTIFIED FINGER STICK BLOOD GLUCOSE: GREATER THAN 200 MG/DL Provide supportive care as needed Consider Fluid Bolus: 20cc/kg, repeat PRN when appropriate 113 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED21 Date Created 1/1/2017 Date Revised 1/1/2017 Abdominal Pain Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE REFER TO SPECIFIC UNDERLYING CAUSE GUIDELINE AS APPROPRIATE AND PRACTICAL PATIENT TO REMAIN NPO CONSIDER ORTHOSTATIC VITAL SIGN ASSESSMENT CONSIDER FLUID BOLUS: 20CC/KG, repeat PRN 114 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED22 Date Created 1/1/2017 Date Revised 1/1/2017 Behavioral Emergencies Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood CONSIDER UNDERLYING CAUSE Overdose (intentional or unintentional) Trauma Sepsis Hyperglycemia or Hypoglycemia ATTEMPT VERBAL DEESCELATION CONSIDER SEDATION/CHEMICAL RESTRAINTS Ativan: 0.1mg/kg, max 2mg IVP or IM, repeat PRN Versed: 0.1mg/kg, max 5mg IVP or IM, repeat PRN Valium: 1-5mg IVP, repeat PRN Ketamine: 1-2mg/kg IVP or IM, repeat PRN (sedation and analgesia) o If using Ketamine, give Ativan: 0.1mg/kg (max 4mg) IVP x 1 CONSIDER PHYSICAL RESTRAINTS Employ restraints only if necessary 4-point technique should be used Evaluate pulse, motor and sensation post restraint applications The use of sedation/chemical restraints should be considered early The use of physical restrains should only be used if necessary Any patient being sedated or restrained deserves a full ALS work up and monitoring Any patient with witnessed Suicidal or Homicidal Ideations MUST be transported for evaluation 115 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED23 Date Created 1/1/2017 Date Revised 1/1/2017 Trauma Criteria Pediatric Treatment Guidelines TRIAGE PATIENT AND ESTABLISH IF CRITERIA IS MET USE THE FOLLOWING CRITERIA & GUIDELINES FOR TRANSPORT DECISIONS PEDIATRIC TRUMA CRITERIA Physiologic Criteria Glascow Coma Scale < 14 Respiratory distress or failure Any intubated trauma patient Shock of any type, compensated or uncompensated Anatomic Criteria Fractures and penetrating injuries to an extremity which may be complicated by neurovascular and/or compartment injury Fracture of two or more long bones Suspected Injury to the axial skeleton or spinal cord Traumatic amputation and crush injuries Significant head injury Penetrating wounds to the head, neck, thorax, abdomen, pelvis or proximal extremity Pelvic fracture Blunt injury to the chest or abdomen Ocular injuries Burns greater than 10% or any 3rd degree burns PEDIATRIC TRAUMA PATIENTS SHOULD BE TRANSPORTED TO A PEDIATRIC LEVEL I TRAUMA CENTER (ST. LOUIS CHILDRENS HOSPITAL OR CARDINAL GLENNON). GOAL = PATIENT TO TRAUMA CENTER WITHIN 60 MINUTES FROM TIME OF INJURY 116 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number PED24 Date Created 1/1/2017 Date Revised 1/1/2017 General Trauma Care Pediatric Treatment Guidelines PERFORM ROUTINE CARE (on scene or enroute to hospital as deemed appropriate) Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Establish vascular access, draw blood PERFORM TRAUMA TRIAGE If trauma criteria met, transport to PEDIATRIC Level I trauma center UNLESS IN EXTREMIS REFER TO DESTINATION DECISION GUIDELINE CONSIDER AIR TRANSPORT IF APPROPRIATE - REFER TO AIR AMBULANCE UTILIZATION GUIDELINE RECOMMENDED ON SCENE TRAUMA CARE Expose patient for appropriate assessment Identify and address obvious life threats Consider spinal immobilization RECOMMENDED ENROUTE TO HOSPITAL TRAUMA CARE Provide constant re-assessment Ensure 2 points of access are achieved, ensure blood is drawn Consider Fluid Bolus: 20cc/kg, titrate to low end of normal BP for patient’s age. Consider splinting any fractures Ensure patient is warm Trauma care should focus on rapid assessment, appropriate trauma triage and rapid transport to the APPROPRIATE facility. Most, if not all treatments can and should be done while enroute to the hospital. A major trauma victim (meeting trauma criteria) should ONLY be transported to a level III or lower center if the patient is in extremis (see destination decision guideline). When in doubt, up-triage the trauma patient and transport to a PEDIATRIC level I trauma center.117 Reynolds County Ambulance District Burns Clinical Practice Guidelines CPG Number PED25 Date Created 1/1/2017 Date Revised 1/1/2017 Pediatric Treatment Guidelines PERFORM ROUTINE CARE Assess and monitor vital signs and EKG Assess and support ABC’s as needed Provide Oxygen, as appropriate, titrate SPO2 >94% Provide routine monitoring: EKG, NIBP & SPO2, as appropriate Perform multi-lead EKG as appropriate Establish vascular access, draw blood THE FOLLOWING SHOULD TRIAGE A PATIENT TO A BURN CENTER (St. Louis Children’s Hospital) Partial thickness burns greater than 10% total body surface area (TBSA) Any burn that involve the face, hands, feet, genitalia, perineum, or major joints Any full thickness (3rd degree) burns Any electrical burns, including lightning injury Any chemical burns Any inhalation injury STOP THE BURNING PROCESS COVER THE BURN AREA WITH DRY STERILE DRESSINGS FLUID RESUSCITATE USING THE PARKLAND FORMULA Use the modified rule of 9’s for calculation Consider RSI early, if any signs of airway burn / inhalation injury Burns are very painful, treat pain very aggressively Be cautious to over fluid resuscitate 118 RULE OF 9’S CRITERIA FOR PEDIATRIC PATIENTS PARKLAND FORMULA 2CC X %BSA X WEIGHT (KG) THIS AMOUNT TO BE ADMINISTERED OVER THE FIRST 8 HOURS REMEMBER: FLUID RESCUSITATION AS NEEDED FOR HEMODYNAMIC STATUS OVER-RULES PARKLAND FORMULA 119 SECTION FOUR MEDICATION FORMULARY 120 Reynolds County Ambulance District Adenosine Clinical Practice Guidelines CPG Number MED1 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Antiarrhythmic ACTION: Slows AV conduction INDICATIONS: SVT CONTRAINDICATIONS: Second or third degree heart block Sick-sinus syndrome Known hypersensitivity to the drug SIDE EFFECTS: Facial flushing, headache, shortness of breath, dizziness, and nausea ADULT DOSE: 1ST: 6mg rapid IVP 2ND: 12MG rapid IVP PEDIATRIC DOSE: 1st: 0.1mg/kg rapid IVP 2nd: 0.2mg/kg rapid IVP ROUTE: Rapid IV push Should be given via IV in AC or EJ if at all possible IO route is acceptable Be cautious to consider underlying cause of tachycardia 121 Reynolds County Ambulance District Albuterol Clinical Practice Guidelines CPG Number MED2 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Beta-adrenergic; sympathomemetic bronchodilator ACTION: Relaxes bronchial smooth muscles INDICATIONS: Respiratory distress with evidence of bronchospasms CAUTIONS: Patients with tachycardia SIDE EFFECTS: Palpatations, tachycardia, nervousness, GI upset ADULT DOSE: 2.5mg in 3cc, repeat as needed PEDIATRIC DOSE: 0.05mg/kg, max single dose of 2.5mg, repeat as needed ROUTE: Up-draft nebulizer 122 Reynolds County Ambulance District Amiodarone Clinical Practice Guidelines CPG Number MED3 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Class III Antiarrhythmic ACTIONS: Sodium, Calcium, Potassium channel blocker Prolongs intranodal conduction Prolongs refractory period of AV node INDICATIONS: Any ventricular arrhythmia, any malignant tachycardia CONTRAINDICATIONS: Second and third degree heart blocks, bradycardia SIDE EFFECTS: Hypotension, bradycardia ADULT DOSE: Full Arrest: 300mg IVP, then 150mg IVP Pulse Present or Post Conversion: 150mg/100cc D5W IVPB over 10min Maintenance Infusion: 900mg/500cc D5W, 1mg/min or 33.3cc/hr PEDIATRIC DOSE: 5mg/kg, max single dose 300mg, all situations ROUTE: IVP, IVPB, IO 123 Reynolds County Ambulance District Aspirin Clinical Practice Guidelines CPG Number MED4 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Platelet inhibitor ACTIONS: Blocks platelet aggregation INDICATIONS: Chest pain of suspected cardiac origin CONTRAINDICATIONS: Hypersensitivity ADULT DOSE: 324mg PEDIATRIC DOSE: NOT INDICATED ROUTE: PO 124 Reynolds County Ambulance District Atropine Clinical Practice Guidelines CPG Number MED5 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Anticholinergic ACTIONS: Blocks acetylcholine receptors Increases heart rate Decreases gastrointestinal secretions INDICATIONS: Symptomatic Bradycardia Organophosphate Poisoning CONTRAINDICATIONS: None when used in emergency situations ADULT DOSE: Bradycardia: 0.5mg every 5 minutes (max 3mg) Organophosphate Poisoning: 2-5mg PEDIATRIC DOSE: Bradycardia: 0.02mg/kg (min. dose 0.1mg) Organophosphate Poisoning: 0.05mg/kg (max 3mg) ROUTE: IVP or IO 125 Reynolds County Ambulance District Calcium Chloride Clinical Practice Guidelines CPG Number MED6 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Electrolyte ACTIONS: Increases cardiac contractility INDICATIONS: Hyperkalemia Calcium Channel Blocker overdose Antidote for Magnesium Sulfate CONTRAINDICATIONS: None when used in emergency situations ADULT DOSE: 1-4g, repeat PRN PEDIATRIC DOSE: 2-4mg//kg, max single dose 4g, repeat PRN ROUTE: IVP or IO 126 Reynolds County Ambulance District Decadron Clinical Practice Guidelines CPG Number MED7 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Corticosteroid ACTIONS: Anti-inflammatory INDICATIONS: Pediatric respiratory distress with presumed lung injury CONTRAINDICATIONS: None when used in emergency situations ADULT DOSE: Not recommended PEDIATRIC DOSE: 0.6mg/kg x 1 only; max single dose = 16mg ROUTE: IM, IVP or IO 127 Reynolds County Ambulance District Dextrose Clinical Practice Guidelines CPG Number MED8 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Carbohydrate ACTIONS: Elevates blood glucose level rapidly INDICATIONS: Hypoglycemia CONTRAINDICATIONS: None when used in emergency situations ADULT DOSE: D50%: 25g IVP, repeat PRN PEDIATRIC DOSE: D25% (1yr-6yr): 1g/kg, repeat PRN D10% (less than 1 year): 1g/kg, repeat PRN ROUTE: IVP or IO 128 Reynolds County Ambulance District D5W Clinical Practice Guidelines CPG Number MED9 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Water soluble carbohydrate source ACTIONS: Provides calories for some metabolic needs The fluid is isotonic when in the container. After administration, the dextrose is quickly metabolized in the body, leaving only water which is a hypotonic fluid. INDICATIONS: Vehicle for mixing medications for IV delivery for all age groups CONTRAINDICATIONS: None when used in emergency situations ADULT DOSE: Dependant on specific medication mixed with solution PEDIATRIC DOSE: Dependant on specific medication mixed with solution ROUTE: IVP or IO 129 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number MED10 Date Created 1/1/2017 Date Revised 1/1/2017 Diazepam (Valium) Medication Formulary CLASS: Benzodiazepine, sedative-hypnotic, anticonvulsant ACTIONS: Acts on the CNS to potentiate the effects of inhibitory neurotransmitters INDICATIONS: Status epilepticus Chemical restraint Acute alcohol withdraws Muscle relaxant Procedural sedation CONTRAINDICATIONS: Sever hypotension ADULT DOSE: 1-10mg, repeat PRN PEDIATRIC DOSE: 1-5mg, max single dose 10mg, repeat PRN ROUTE: IN, IM, IVP, IO, Rectal 130 Reynolds County Ambulance District Dilaudid Clinical Practice Guidelines CPG Number MED11 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary Not Approved or Accepted CLASS: Narcotic, opiate ACTIONS: Central nervous system depressant Causes peripheral vasodilatation Decreases sensitivity to pain INDICATIONS: Severe pain CONTRAINDICATIONS: Profound hypotension ADULT DOSE: 1-2mg, repeat PRN PEDIATRIC DOSE: 0.02mg/kg, max single dose 2mg, repeat PRN ROUTE: IM, IVP or IO 131 Reynolds County Ambulance District Diltiazem (Cardizem) Clinical Practice Guidelines CPG Number MED12 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Calcium Chanel Blocker ACTIONS: Slows conduction through the AV node INDICATIONS: Atrial Fibrillation Atrial Flutter SVT CONTRAINDICATIONS: Bradycardia WPW ADULT DOSE: 5-10mg, SIVP, repeat at 10-20 mg x 1 only Use Caution with Hypotensive patients Use Caution with the elderly, consider lower dose range PEDIATRIC DOSE: Not recommended ROUTE: IVP or IO 132 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number MED13 Date Created 1/1/2017 Date Revised 1/1/2017 Diphenhydramine (Benadryl) Medication Formulary CLASS: Antihistamine ACTIONS: Blocks histamine receptors INDICATIONS: Anaphylaxis Allergic reactions Dystonic reactions CONTRAINDICATIONS: None when used in emergency situations ADULT DOSE: 25-50mg PEDIATRIC DOSE: 1-2mg/kg, max single dose 50mg ROUTE: IM, IVP or IO 133 Reynolds County Ambulance District Dopamine Clinical Practice Guidelines CPG Number MED14 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Sympathomimetic ACTIONS: Increased cardiac contractility Increased heart rate Increased systemic vascular resistance INDICATIONS: Cardiogenic shock CONTRAINDICATIONS: Tacycardia ADULT DOSE: 5-20mcg/kg/min, titrate to effect PEDIATRIC DOSE: 5-20mcg/kg/min, titrate to effect ROUTE: IVP or IO via infusion 134 Reynolds County Ambulance District Duo-Neb Clinical Practice Guidelines CPG Number MED15 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Beta 2 agonist & Anticholinergic ACTIONS: Relaxes bronchial smooth muscle Dries out secretions INDICATIONS: Bronchospasms with suspected secretions CONTRAINDICATIONS: Profound tachycardia ADULT DOSE: 3ml single dose vial PEDIATRIC DOSE: Not recommended ROUTE: UDN 135 Reynolds County Ambulance District Epinephrine Clinical Practice Guidelines CPG Number MED16 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Sympathomimetic ACTIONS: Increases heart rate Increases cardiac contractility Increases systemic vascular resistance Causes Bronchodilation INDICATIONS: Cardiac arrest Anaphylaxis Severe bronchospasms Suspected croup CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: Cardiac Arrest: 1:10,000 – 1mg IVP, repeat every 3-5min Anaphylaxis: 1:1,000 – 0.3mg IM; 1:10,000 – 0.1mg IVP Severe bronchospasms: 1:1,000 – 0.3mg IM Infusion: 2-20mcg/min, titrate to effect (1mg in 100cc D5W) PEDIATRIC DOSE: Cardiac Arrest: 1:10,000 – 0.01mg/kg IVP (max 1mg single dose) repeat every 3-5min Anaphylaxis: 1:1,000 – 0.01mg/kg IM (max 0.3mg single dose); 1:10,000 – 0.01mg/kg IVP (max 0.1mg single dose) Severe bronchospasms: 1:1,000 – 0.01mg/kg IM (max 0.3mg single dose) Infusion: 0.1-1mcg/kg/min, titrate to effect (1mg in 100cc D5W) Suspected croup: 1:1,000 – 0.25mg in 3cc of NS via UDN ROUTE: IM, IVP, IVPB, UDN 136 Reynolds County Ambulance District Etomidate Clinical Practice Guidelines CPG Number MED17 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Hypnotic sedative ACTIONS: General sedation INDICATIONS: Sedation prior to RSI CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 0.3mg/kg, repeat x 1 PEDIATRIC DOSE: 0.3mg/kg, repeat x 1 ROUTE: IVP or IO 137 Reynolds County Ambulance District Fentanyl Clinical Practice Guidelines CPG Number MED18 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Narcotic analgesic ACTIONS: Analgesia with sedation CNS depressant INDICATIONS: Pain of any kind CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 0.5-2mcg/kg, repeat PRN PEDIATRIC DOSE: 0.5-2mcg/kg, repeat PRN ROUTE: IM, IVP, IO, IN 138 Reynolds County Ambulance District Furosemide (Lasix) Clinical Practice Guidelines CPG Number MED19 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Loop diuretic ACTIONS: Decreases sodium and chloride release INDICATIONS: Pulmonary Edema CONTRAINDICATIONS: Hypotension Renal failure ADULT DOSE: 40mg or double the patient’s daily dose PEDIATRIC DOSE: Not recommended ROUTE: SLOW IVP 139 Reynolds County Ambulance District Glucagon Clinical Practice Guidelines CPG Number MED20 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Non-Classified Metabolic Medicine ACTIONS: Converts hepatic Glycogen to Glucose INDICATIONS: Hypoglycemia when unable to establish vascular access Beta Blocker overdose CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: Hypoglycemia: 1mg IM Beta Blocker overdose: 2-5mg IVP/IO PEDIATRIC DOSE: Hypoglycemia: 0.1mg/kg (max single dose 1mg) IM Beta Blocker overdose: 0.5mg-5mg IVP/IO ROUTE: IM, IVP, IO 140 Reynolds County Ambulance District Glucose (oral) Clinical Practice Guidelines CPG Number MED21 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Simple Carbohydrate ACTIONS: Elevates blood glucose levels INDICATIONS: Hypoglycemia with good mental status CONTRAINDICATIONS: Altered mental status ADULT DOSE: One tube (25g) PEDIATRIC DOSE: One tube (25g) ROUTE: PO 141 Reynolds County Ambulance District Haldol Clinical Practice Guidelines CPG Number MED22 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Antipsychotic ACTIONS: Competitive Dopamine receptor blocker INDICATIONS: Need for chemical restraint CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 5mg x 1 only PEDIATRIC DOSE: Not recommended ROUTE: IM, IVP or IO 142 Reynolds County Ambulance District Ibuprofen Clinical Practice Guidelines CPG Number MED23 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: NSAID ACTIONS: Analgesic and Antipyretic INDICATIONS: Fever CONTRAINDICATIONS: Altered mental status ADULT DOSE: Not recommended in the emergency setting PEDIATRIC DOSE: 10mg/kg (patient must be 6months old) ROUTE: PO 143 Reynolds County Ambulance District Ketamine Clinical Practice Guidelines CPG Number MED24 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: General anesthetic, NMDA receptor antagonist ACTIONS: Analgesic and Sedative Dissociative agent INDICATIONS: Chemical Restraint Pain Management Procedural Sedation Rapid Sequence Induction Post intubation sedation/analgesia CONTRAINDICATIONS: Hypertension Head Injuries ADULT DOSE: RSI: 1-2mg/kg IV or IO Post Intubation: 1-2mg/kg IV or IO q 10-20min, repeat PRN Chemical Restraint: 1-2mg/kg IV or IM, repeat PRN Procedural Sedation: 1mg/kg IV or IM, repeat PRN Pain Management: 1mg/kg IV or IM, repeat PRN PEDIATRIC DOSE: RSI: 1-2mg/kg IV or IO Post Intubation: 1-2mg/kg IV or IO q 10-20min, repeat PRN Chemical Restraint: 1-2mg/kg IV or IM, repeat PRN Procedural Sedation: 1mg/kg IV or IM, repeat PRN Pain Management: 1mg/kg IV or IM, repeat PRN ROUTE: IV (push), IO, IM – depending on indication NOTE: Patient should also receive Ativan bolus with initial Ketamine bolus, any indication 144 Reynolds County Ambulance District Lidocaine Clinical Practice Guidelines CPG Number MED25 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Antiarrhythmic and local anesthetic ACTIONS: Suppresses ventricular ectopic activity Increases ventricular fibrillation threshold Reduces velocity of electrical impulse through conductive system Alleviates pain, locally INDICATIONS: Ventricular Arrhythmia Pain management with IO placement CONTRAINDICATIONS: High degree heart blocks Known bifasicular block ADULT DOSE: Cardiac Arrest: 1-1.5mg/kg, repeat every 3-5min, max 3mg/kg Infusion: 1-4mg/min (2g in 500ml D5W) Pain with IO: 0.5mg/kg, max 50mg x 1 only PEDIATRIC DOSE: Cardiac Arrest: 1-1.5mg/kg, repeat every 3-5min, max 3mg/kg Pain with IO: 0.5mg/kg, max 50mg x 1 only ROUTE: IV or IO 145 Reynolds County Ambulance District Lorazapam (Ativan) Clinical Practice Guidelines CPG Number MED26 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Benzodiazepine, sedative-hypnotic, anticonvulsant ACTIONS: Anticonvulsant Skeletal muscle relaxant Sedative INDICATIONS: Status epilepticus Chemical restraint Acute alcohol withdraws Muscle relaxant Procedural sedation Sedation after intubation CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 1-2mg (consider double dose for intubated patients), repeat PRN PEDIATRIC DOSE: 0.1mg/kg (max single dose 2mg), repeat PRN ROUTE: IM, IN, IVP or IO 146 Reynolds County Ambulance District Magnesium Sulfate Clinical Practice Guidelines CPG Number MED27 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Electrolyte ACTIONS: CNS Depressant Smooth muscle relaxer General electrolyte replacement INDICATIONS: Eclampsia Pre-Eclampsia Torsades de Pointes Severe bronchospasms CONTRAINDICATIONS: None in the emergency situation ADULT DOSE: Eclampsia: 4g in 100cc D5W over 20min Pre-Eclampsia: 4g in 100cc D5W over 20min Torsades de Pointes: 2g IVP Severe bronchospasms: 2g in 100cc D5W over 10min PEDIATRIC DOSE: Severe bronchospasms: 40mg/kg (max 2g) in 100cc D5W over 10min x 1 only ROUTE: IVP, IVPB or IO 147 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number MED28 Date Created 1/1/2017 Date Revised 1/1/2017 Methelprednisone (Solu-Medrol) Medication Formulary CLASS: Steriod ACTIONS: Anti-inflammatory INDICATIONS: Respiratory distress with presumed lung injury Allergic reaction CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 125mg x 1 only PEDIATRIC DOSE: 1-2mg/kg (max single dose 125mg) x 1 only ROUTE: IVP, IM or UDN 148 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number MED29 Date Created 1/1/2017 Date Revised 1/1/2017 Metoprolol (Lopressor) Medication Formulary CLASS: Beta-Blocker ACTIONS: Reduces heart rate Reduces blood pressure INDICATIONS: Acute STEMI with tachycardia Tachy-disrythmias Hypertensive emergencies CONTRAINDICATIONS: Bradycardia Hypotension ADULT DOSE: 5mg, repeat x 2 ever 5min (15mg max) PEDIATRIC DOSE: Not recommended ROUTE: SLOW IVP 149 Reynolds County Ambulance District Midazolam (Versed) Clinical Practice Guidelines CPG Number MED30 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Benzodiazepine, sedative-hypnotic, anticonvulsant ACTIONS: Anticonvulsant Skeletal muscle relaxant Sedative INDICATIONS: Status epilepticus Chemical restraint Acute alcohol withdraws Muscle relaxant Procedural sedation Sedation after intubation CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: Sedation for RSI: 0.1mg/kg x 1 only All other indications: 2.5-5mg, repeat PRN PEDIATRIC DOSE: Sedation for RSI: 0.1mg/kg x 1 only All other indications: 0.1mg/kg (max single dose 5mg), repeat PRN ROUTE: IV, IM, IO or IN 150 Reynolds County Ambulance District Morphine Sulfate Clinical Practice Guidelines CPG Number MED31 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Narcotic analgesic ACTIONS: Analgesia with sedation CNS depressant INDICATIONS: Pain of any kind CONTRAINDICATIONS: Hypotension ADULT DOSE: 2-5mg, repeat PRN PEDIATRIC DOSE: 0.1mg/kg (max single dose 5mg), repeat PRN ROUTE: IV, IM or IO 151 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number MED32 Date Created 1/1/2017 Date Revised 1/1/2017 Naloxone (Narcan) Medication Formulary CLASS: Narcotic antagonist ACTIONS: Blocks the effects of opiates INDICATIONS: Unresponsiveness and hypoventilation with a patient suspected of ingesting narcotics (opiates) CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 2mg, repeat PRN PEDIATRIC DOSE: 0.1mg/kg (max single dose 2mg), repeat PRN ROUTE: IV, IM, IO or IN 152 Reynolds County Ambulance District Nitroglycerine Clinical Practice Guidelines CPG Number MED33 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Vasodilator ACTIONS: Decreases SVR Decreases pre-load INDICATIONS: Chest pain with suspected cardiac origin Hypertensive emergency Pulmonary edema CONTRAINDICATIONS: Hypotension Use of ED medicines (Viagra, Cialas, etc.) ADULT DOSE: Via SL: 400mcg SL, repeat x 2 every 5 min Infusion for Cardiac: 5-50mcg/min, titrate to effect Infusion for CHF: 5-100mcg/min, titrate to effect PEDIATRIC DOSE: Not recommended ROUTE: IVPB or SL 153 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number MED34 Date Created 1/1/2017 Date Revised 1/1/2017 Norepinepherine (Levophed) Medication Formulary CLASS: Vasopresser ACTIONS: Alpha antagonist INDICATIONS: Hypotension S/P volume replacement, non-bradycardic CONTRAINDICATIONS: Hypotension in trauma ADULT DOSE: 2-20mcg/min, titrate to effect PEDIATRIC DOSE: 0.1-1mcg/kg/min, titrate to effect ROUTE: IVPB only TO PREPARE: MIX 4MG/250CC OF D5W 154 Reynolds County Ambulance District Normal Saline Clinical Practice Guidelines CPG Number MED35 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Isotonic Solution ACTIONS: Volume replacement solution Remains in the vasculature INDICATIONS: Fluid replacement To keep vein open To saline lock vascular access Vehicle for medication delivery / flush CONTRAINDICATIONS: Pulmonary edema ADULT DOSE: Fluid replacement: 20cc/kg, repeat PRN PEDIATRIC DOSE: Fluid replacement: 20cc/kg, repeat PRN ROUTE: IV or IO 155 Reynolds County Ambulance District Oxygen Clinical Practice Guidelines CPG Number MED36 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Gas ACTIONS: Maintenance of homeostasis INDICATIONS: Hypoxia CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 2-15lpm, titrate to effect PEDIATRIC DOSE: 2-15lpm, titrate to effect ROUTE: Inhaled via: NC, NRBM, CPAP, BiPAP, BVM or Ventilator 156 Reynolds County Ambulance District Oxytocin (Pitocin) Clinical Practice Guidelines CPG Number MED37 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Pituitary hormone ACTIONS: Increases uterine tone Promotes contractions (dose dependant) INDICATIONS: Post partum hemorrhage CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 10mg in 1000cc of NS at w/o rate, x 1 only PEDIATRIC DOSE: Not recommended ROUTE: IV or IO 157 Reynolds County Ambulance District Phenergan Clinical Practice Guidelines CPG Number MED38 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Antiemetic ACTIONS: H1 antagonist INDICATIONS: Nausea / Vomiting CONTRAINDICATIONS: Altered mental status ADULT DOSE: 12.5mg in 10cc of NS, repeat x1 PEDIATRIC DOSE: Not recommended ROUTE: IV 158 Reynolds County Ambulance District Rocuronium Clinical Practice Guidelines CPG Number MED39 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Paralytic ACTIONS: Non-depolarizing neuromuscular blocker INDICATIONS: Paralysis for RSI when Succinylcholine is contraindicated CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 1mg/kg PEDIATRIC DOSE: 1mg/kg ROUTE: IV or IO 159 Reynolds County Ambulance District Sodium Bicarbonate Clinical Practice Guidelines CPG Number MED40 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Buffer Agent ACTIONS: Increases PH Provides rapid influx of Sodium ions INDICATIONS: Suspected severe acidosis TCA overdoses Crush syndrome Hyperkalemia CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 1 mEq/kg, repeat PRN PEDIATRIC DOSE: 1 mEq/kg, repeat PRN ROUTE: IV or IO 160 Reynolds County Ambulance District Sterile Water Clinical Practice Guidelines CPG Number MED41 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Water ACTIONS: None INDICATIONS: Cleansing wounds Reconstitution on medications CONTRAINDICATIONS: None ADULT DOSE: As needed PEDIATRIC DOSE: As needed ROUTE: Topical, IV or IO 161 Reynolds County Ambulance District Succinylcholine Clinical Practice Guidelines CPG Number MED42 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Paralytic ACTIONS: Rapidly depolarizing neuromuscular blocker INDICATIONS: Paralysis for RSI CONTRAINDICATIONS: Hyperkalemia or potential for History of malignant hyperthermia ADULT DOSE: 1-2mg/kg (max single dose 200mg), repeat x 1 PEDIATRIC DOSE: 1-2mg/kg (max single dose 200mg), repeat x 1 ROUTE: IV or IO 162 Reynolds County Ambulance District Thiamine Clinical Practice Guidelines CPG Number MED43 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Vitamin ACTIONS: Allows for normal breakdown of glucose INDICATIONS: Alcoholism Malnutrition CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 100mg in 1000cc of NS at w/o rate PEDIATRIC DOSE: Not recommended ROUTE: IV 163 Reynolds County Ambulance District Tylenol Clinical Practice Guidelines CPG Number MED44 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Acetaminophen ACTIONS: Analgesic Antipyretic INDICATIONS: Fever CONTRAINDICATIONS: Altered mental status ADULT DOSE: Not recommended PEDIATRIC DOSE: 10mg/kg x 1 only ROUTE: PO 164 Reynolds County Ambulance District Vecuronium Clinical Practice Guidelines CPG Number MED45 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Paralytic ACTIONS: Non-depolarizing neuromuscular blocker INDICATIONS: Maintenance of paralysis after intubation CONTRAINDICATIONS: Lack of sedation & pain management after intubation ADULT DOSE: 0.1mg/kg (dose normally lasts 60 minutes) PEDIATRIC DOSE: 0.1mg/kg (dose normally lasts 60 minutes) ROUTE: IV or IO 165 Reynolds County Ambulance District Xopenex Clinical Practice Guidelines CPG Number MED46 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Beta2 Agonist ACTIONS: Relaxes bronchial smooth muscles INDICATIONS: Bronchospasms Usually used in place of Albuterol with tachycardic patients CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 1.25mg, repeat x 2 PRN PEDIATRIC DOSE: 0.63mg, repeat x 2 PRN ROUTE: UDN 166 Reynolds County Ambulance District Zofran Clinical Practice Guidelines CPG Number MED47 Date Created 1/1/2017 Date Revised 1/1/2017 Medication Formulary CLASS: Antiemetic ACTIONS: Selective 5-HT receptor antagonist INDICATIONS: Nausea / Vomiting CONTRAINDICATIONS: None in the emergency setting ADULT DOSE: 4mg, repeat x 2 PRN PEDIATRIC DOSE: 0.15mg/kg (max single dose 4mg), repeat x 2 PRN ROUTE: IV, IM, IO or IN 167 SECTION FIVE SKILLS FORMULARY 168 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL1 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Oxygen Administration Skills Formulary BLS INDICATIONS Any patient suffering from hypoxia Any patient deemed to benefit or potentially benefit from supplemental Oxygen CONTRAINDICATIONS No absolute contraindications Use caution with COPD patients PROCEDURE Monitor SPO2 and ETCO2 as appropriate Nasal Cannula: 2-6lpm Up-Draft Nebulizer: 6-8lpm Non-Rebreather Mask: 10-15lpm Bag-Valve Mask: 10-15lpm 169 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL2 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Suction Skills Formulary BLS INDICATIONS Needed removal of substances from the airway CONTRAINDICATIONS None in the emergency setting PROCEDURE (BASIC) Manually open the airway Insert suction catheter (soft or rigid) into the mouth or nare Suction on the way out, in a circular motion; no longer than 15 seconds PROCEDURE (ADVANCED) Select the largest size suction catheter for the ET tube in place Measure the catheter against an equally sized ET tube not being used Insert the suction catheter into the ET tube to that pre-measured length Suction on the way out; no longer than 15 seconds 170 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL3 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: CPAP/BiPAP Skills Formulary ALS INDICATIONS Respiratory distress not improving or severe Hypoxia Hypercapnia Pulmonary edema CONTRAINDICATIONS Altered mental status Inability to maintain airway Prepare the equipment Turn on the oxygen; start at 5cm/H2O Hold the mask firmly against the patient After the patient has tolerated the mask the straps may be attached Titrate up to 10cm/H2O if severe hypoxia does not improve PROCEDURE – CPAP – O2 RESQ PROCEDURE – NPPV – REVEL VENTILATOR Monitor theequipment patient for signs of clinical changes, comfort, anxiety, and nausea Prepare the Select appropriately sized mask Rate Consideration for NPPV Turn ReVel Ventilator on Patient completely alert? Rate: 0 Select “new patient” Select “adult” Altered/Sedated? Rate: 12 Select “not intubated” Initial settings are generic Pre Ox/Vent for DSI? Rate: 12 o IPAP = 16cm/H2O o EPAP = 6 cm/H2O Titrate IPAP and EPAP to patients tolerance and over-all status o IPAP (PC) up 2cm/H2O (ventilation problem) or EPAP (PEEP) up 1cm/H2O (oxygenation problem) Titrate FiO2 up/down as needed (pre-set to 21%) to maintain SPO2 of 94% 171 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL4 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: PEEP Valve Skills Formulary ALS INDICATIONS Any patient being ventilated via a confirmed ET tube placed in the trachea Cardiac arrest Hypotension PROCEDURE Place the PEEP valve on the end of the BVM Start at 5cm/H2O Titrate up to 10cm/H2O if severe hypoxia does not improve CONTRAINDICATIONS 172 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL5 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Nasal Pharyngeal Airway Skills Formulary BLS INDICATIONS Unconscious or semi-conscious patients that are unable to maintain their airway None in the emergency setting CONTRAINDICATIONS PROCEDURE Pre-oxygenate the patient Measure the tube from the tip of the patient’s nose to the tip of the earlobe Lubricate the airway with water soluble jelly Insert the airway with the bevel of the tube towards the septum, angling towards the base floor of the nasopharynx Reassess the airway 173 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL6 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Oral Pharyngeal Airway Skills Formulary BLS INDICATIONS Unconscious patients that are unable to maintain their airway None in the emergency setting CONTRAINDICATIONS PROCEDURE Pre-oxygenate patient if possible Measure from the corner of the mouth to the earlobe Insert the airway inverted and rotate 1800 into place Reassess the airway 174 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL7 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Nasal Tracheal Intubation Skills Formulary ALS INDICATIONS Need for airway management that oral tracheal intubation is contraindicated Predicted difficult airway that RSI would be contraindicated CONTRAINDICATIONS Head injuries (relative) PROCEDURE Lubricate both nasal passages by placing large NPA’s Remove NPA’s and insert #7.0 ETT with bevel towards the septum Advance tube aiming the tip down along the nasal floor Gently advance the tube along the airway while rotating it medially slightly until the best airflow is heard through the tube Gently and swiftly advance the tube during inspiration Inflate the cuff with 5-10 cc of air Confirm patency and secure Reassess airway 175 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL8 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Oral Tracheal Intubation Skills Formulary ALS INDICATIONS Patients requiring definitive airway management Failed airway CONTRAINDICATIONS PROCEDURE – DIRECT LARYNGOSCOPY Insert Laryngoscope Sweep tongue to the left, place blade in proper position Lift the laryngoscope forward to displace the jaw Visualize the vocal cords Advance the tube past the vocal cords If using a bougie, first pass bougie through vocal cords, then pass tube over the bougie Inflate cuff with 5-10 cc air Confirm patency and secure Reassess airway PROCEDURE – KING VISION Insert King Vision Sweep tongue to the left, place blade in proper position Lift the King Vision forward as needed to displace the jaw Visualize the vocal cords Advance the tube past the vocal cords If using a bougie, first pass bougie through vocal cords, then pass tube over the bougie Inflate cuff with 5-10 cc air Confirm patency and secure Reassess airway 176 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL9 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Superglottic Skills Formulary BLS INDICATIONS Patients requiring definitive airway management when intubation is not possible Failed airway CONTRAINDICATIONS Intact gag reflex Airway swelling PROCEDURE – KING TUBE Select appropriate size per manufacturer guidelines Place head in sniffing position Maintain c-spine stabilization on trauma patients Hyperextend the neck slightly (non-trauma patients) Grab hold of the patients bottom jaw and insert the King airway until resistance is felt Inflate the cuff with the appropriate amount of air noted on the airway tube Confirm patency and secure Reassess airway PROCEDURE – iGEL O2 Based on patient weight, select the appropriate size iGEL O2 o Size 3 for patient 30-60kg o Size 4 for patient 60-90kg o Size 5 for patient 90+kg. Properly lubricate the back, sides, and front of gel cuff with a thin layer of lubricant Pull mandible down to open the mouth Insert iGel O2into oral cavity with the gel cuff facing away from the hard palate Advance the iGel O2 downwards and backwards into until definitive resistance is felt At this point the tip of the airway should be should be located in the upper esophageal opening and the cuff should be located against the laryngeal framework. The incisors should be resting on the integral bite-block Confirm patency and secure the iGel with provided strap Reassess airway 177 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL10 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Per-Trach Skills Formulary ALS INDICATIONS Failed airway Inability to identify landmarks CONTRAINDICATIONS PROCEDURE Remove dilator from the package and protective sheath; advance it into the tracheotomy tube. Locate the landmarks to identify the cricothyroid membrane Insert the splitting needle through the skin directly over cricothyroid membrane While advancing the splitting needle perpendicular to the skin, lightly pull back on the plunger of syringe. When air bubbles occur or you feel a break in resistance, stop advancing the splitting needle Incline needle more than 45o towards the carina and complete the insertion Always maintain the tip of the needle midline of the airway Remove syringe Insert tip of the dilator into the hub of the splitting needle Squeeze the wings of the needle together, then open them out completely split the needle Remove the needle, continue pulling it apart in opposite directions, while leaving the dilator in the trachea Place thumb on dilator knob while first and second fingers are curved under flange of trachea tube By exerting pressure, advance dilator and tracheotomy tube into position until the flange is against the skin Remove the dilator Inflate the cuff until you have control of the airway Confirm patency and secure Reassess airway 178 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL11 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Surgical Cricothyrotomy Skills Formulary ALS INDICATIONS Failed airway Inability to identify landmarks PROCEDURE Stabilize the larynx with the thumb and index finger of non-dominant hand Identify the landmarks for the cricothyroid membrane Make 2-6cm vertical incision at the cricothyroid membrane Visualize the cricothyroid membrane Make an horizontal “puncture” into the trachea Place a bougie into the trachea Enlarge the incision site as needed to be able to pass ETT Place an endotracheal tube into the incision Inflate cuff with 5-10 cc air Confirm patency and secure Reassess airway CONTRAINDICATIONS 179 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL12 Date Created 1/1/2017 Date Revised 1/1/2017 Airway: Gastric Tube Skills Formulary ALS INDICATIONS Any patients with an ET tube in place Esophageal avarices CONTRAINDICATIONS PROCEDURE Select appropriate size o 18f is preferred in adult patients Measure the distal end of the tube from the xiphoid process, up the center of the chest, around the ear and to the corner of the mouth Insert the lubricated tube in the mouth (or nose) and advance until resistance is felt Insert 60cc of air while listening over the abdomen Gurgling noises should be heard from the abdomen After confirming patency, secure and attach to low suction 180 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL13 Date Created 1/1/2017 Date Revised 1/1/2017 Diagnostics: Vital Signs Skills Formulary BLS INDICATIONS Any patient contact None in the emergency setting CONTRAINDICATIONS PROCEDURE Obtain appropriate readings per specific guideline as appropriate for the patient o Heart rate o Blood pressure o Respiratory rate o Skin signs o Lung sounds o SPO2 o ETCO2 o Blood glucose o Glascow coma scale o Pain level Record findings 181 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL14 Date Created 1/1/2017 Date Revised 1/1/2017 Diagnostics: Pulse Oximitery Skills Formulary BLS INDICATIONS Any patient contact None in the emergency setting CONTRAINDICATIONS PROCEDURE Place SPO2 probe at a suitable location o Finger tip o Ear lobe Record findings 182 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL15 Date Created 1/1/2017 Date Revised 1/1/2017 Diagnostics: ETCO2 Skills Formulary BLS INDICATIONS Any patients with an artificial airway in place Altered mental status Respiratory distress None in the emergency setting PROCEDURE – ARTIFICAL AIRWAY SAMPLING Plug the selected testing device into the module in the right zipper pocket Allow the device to warm up before trying to get reading Zero the device per manufacturer recommendations Place the sensor in-line between the airway and the ventilation device Record findings PROCEDURE – NASAL CANNULA SAMPLING Plug the selected testing device into the module in the right zipper pocket Allow the device to warm up before trying to get reading Zero the device per manufacturer recommendations Place the sensor on the patient like a nasal cannula Record findings CONTRAINDICATIONS 183 Reynolds County Ambulance District Diagnostics: Multi-Lead EKG Clinical Practice Guidelines CPG Number SKL16 Date Created 1/1/2017 Date Revised 1/1/2017 Skills Formulary ALS INDICATIONS Chest pain, pressure or discomfort Shortness of breath General weakness Syncope Any diabetic patient Abdominal pain or discomfort Dizziness Nausea CONTRAINDICATIONS None in the emergency setting PROCEDURE 12 Lead EKG o See lead placement reference on next page 15 Lead EKG (right sided) o V3R, V4R, V5R o See lead placement reference on next page 18 Lead EKG (right sided, plus posterior) o V7, V8, V9 o See lead placement reference on next page 184 Please note, 18 lead is called such because it’s assumed you would complete a right sided EKG (15 lead) before doing a posterior EKG, adding 3 more views, making it 18 total. 185 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL17 Date Created 1/1/2017 Date Revised 1/1/2017 Diagnostics: Blood Glucose Analysis Skills Formulary BLS INDICATIONS Altered mental status Known diabetic CONTRAINDICATIONS None PROCEDURE Obtain blood specimen o Finger stick o IV catheter Place drop of blood at the end of check strip that is inserted in the glucometer Record the reading 186 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL18 Date Created 1/1/2017 Date Revised 1/1/2017 Diagnostics: Doppler Skills Formulary BLS INDICATIONS To verify pulses that cannot be felt or heart To assess fetal heart tones CONTRAINDICATIONS None in the emergency setting PROCEDURE Connect the probe to the unit with the arrow on the probe pointing up. Place the ultrasonic gel on the probe tip or on the patients skin Press the probe button to turn the unit on, make sure the power indicator is lit Turn the volume control to MAXIMUM Place the probe on the skin at a 45 degree angle and move slowly to locate the point where the Doppler sounds are maximum When using the probe to assess for fetal heart tones, the probe should be at a 90 degree angle to the skin 187 Reynolds County Ambulance District Procedure: Mechanical Ventilator Clinical Practice Guidelines CPG Number SKL19 Date Created 1/1/2017 Date Revised 1/1/2017 Skills Formulary ALS INDICATIONS Any patient with an artificial airway in place None in the emergency setting Prepare the equipment Turn ReVel Ventilator on Select “new patient” CONTRAINDICATIONS PROCEDURE ADULT CHILD INFANT 1. Select “adult” 2. Select “intubated – YES” You will now have basic settings programmed – Assist Control Mode 3. Adjust FiO2 (Pre-set to 21%) 4. Adjust Rate (Pre-set to 12) 5. Adjust Volume (Pre-set to 500) 6. Consider adjusting “I” time (.7-2 sec, usually 1 sec) 7. Consider titrating PEEP (5-10, usually 6) 8. Adjust / Set Alarms 9. Move from A/C to SIMV with PS of 10cm/H2O 10. Consider PC ventilation if patient requires; titrate as needed 1. Select “child” 2. Select “intubated – YES” You will now have basic settings programmed – Pressure Control Mode 3. Adjust FiO2 (Pre-set to 21%) 4. Adjust Rate (Pre-set to 15) 5. Adjust “I” pressure (pre-set to 15) 6. Consider adjusting “I” time (.7-2 sec, usually .7 sec) 7. Consider titrating PEEP (5-10, usually 6) 8. Adjust / Set Alarms 9. Move from A/C to SIMV with PS of 10cm/H2O 1. Select “infant” 2. Select “intubated – YES” You will now have basic settings programmed – Pressure Control Mode 3. Adjust FiO2 (Pre-set to 21%) 4. Adjust Rate (Pre-set to 20) 5. Adjust “I” pressure (pre-set to 15) 6. Consider adjusting “I” time (.3-2 sec, usually .3 sec) 7. Consider titrating PEEP (5-10, usually 5) 8. Adjust / Set Alarms 9. Move from A/C to SIMV with PS of 10cm/H2O *Monitor exhaled tidal volumes created with pressure settings and titrate PRN *Monitor exhaled tidal volumes created with pressure settings and titrate PRN 188 VENTILATOR SETTINGS – CLINICAL CONSIDERATIONS Mode Choose a ventilatory mode appropriate for patient condition Synchronized Intermittent Mandatory Ventilation (SIMV) o Synchronized Intermittent Mandatory Ventilation (SIMV) mode should typically be utilized. SIMV interferes with normal cardiovascular function less than AssistControl (AC) mode o Always utilize SIMV in conjunction with 10cm/H20 of Pressure Support (PS) to offset the resistance created by the endotracheal tube and ventilator circuit. Assist Control (AC) Mode o AC mode advantages include decreased work of breathing when compared with spontaneous breathing, but disadvantages include adverse hemodynamic effects, risk of inappropriate hyperventilation, and potentially for increased work of breathing if vT and flow are not adequate for the patient’s needs Note: SIMV w/PS of 10 is our general standard of care; either in pressure control or volume control modes of ventilation. FiO2 Initial FiO2 should be 21% The FiO2 can thereafter be titrated upward to maintain SpO2 of 94%. Lower FiO2 may be acceptable in certain disease states. If initial evidence of Hypoxia, start FiO2 at 50% and titrate up/down PRN TIDAL VOLUME (VT) When volume ventilating, select an initial VT of 6-8 cc/kg of ideal body weight. Adjust as needed to produce visible chest wall expansion and achieve PIP 20-30 cm H20 and Plateau Pressure (Pplat) < 30 cm H20. To calculate ideal body body weight (IBW) o Males = 50 + 2.3 [height (inches) - 60] o Females = 45.5 + 2.3 [height (inches) -60] PRESSURE CONTROL When pressure control ventilating, use the lowest pressure control setting that produces visible chest wall expansion and fine tune to a pressure control level that delivers Vt of 58 ml/kg. Default to pressure control in pediatric patients. May pressure control ventilate other patients if in PCV prior to arrival or if clinically indicated. If PC >30 cm H20 is required to ventilate the lungs, consider expert consultation RATE Select a respiratory rate appropriate for patient age and clinical presentation. Remember that respiratory rate should target pH first then CO2 . INSPIRATORY TIME (Ti) Set inspiratory time (Ti) appropriate for patient age and disease process. When setting the Ti, consider the inspiratory to expiratory (I:E) ratio. In general, I time should be 1 second (adult patients). POSITIVE END EXPIRATORY Apply PEEP to achieve and maintain optimal alveolar recruitment o Initially set to 6cm/H20, titrate per below in 2-3 cm H20 increments. o PEEP >10cm/H2O = contact medical control. 189 o PRESSURE (PEEP) o o o PRESSURE SUPPORT SENSITIVITY Beware of hypotension as a consequence of decreased venous return when using higher levels of PEEP. In at-risk patients, volume expansion and inotropic/vasopressor support may be required to maintain adequate cardiac output while achieving a strategy that produces acceptable oxygenation. The lone absolute contraindication of PEEP is pulseless arrest. Traumatic Brain Injury and ventilation during acute resuscitation of other patients with traumatic injury are not contraindications to PEEP. Consider increasing PEEP when FiO2 requirements >70%. Provide pressure support to all patients ventilated in SIMV mode to offset the resistance of the artificial airway and ventilator circuit. 10cm/H20 is a reasonable pressure support level. Set the sensitivity so as to require minimal patient effort to initiate inspiration, but beware of autocycling if trigger sensitivity is too low. o Initial Sensitivity Profile: 3 (Adults and Children), 2 (Infants) ALARMS Low Exhaled Minute Volume Adjust to about 25% under actual VE. o This alarm is extremely critical in patients undergoing pressure control ventilation. o Example: Infant with vTe of 50 ml times rate of 20, VE=1L. 25% of 1L is 250 ml, so the LMV alarm should be set to 750 ml, or 0.75L Low Pressure ~ 10 cm H20 below actual PIP High Pressure May set at 50 cm H20 then adjust to ~ 10 cm H2O above actual PIP 190 MONITORING AIRWAY PRESSURES When volume ventilating, closely monitor airway pressures. When pressure control ventilating, closely monitor exhaled volumes. PEAK INSPIRATORY PRESSURE (PIP OR PPEAK) PLATEAU PRESSURE (PPLAT) INTRINSIC PEEP (AutoPEEP) Peak Inspiratory Pressure (PIP) is the pressure at end-inspiration and is a function of the inflation volume, flow resistance in the airways, and elastic recoil force of the lungs and chest wall. PIP is the sum of both airway resistance and lung compliance. PIP should generally be between 20-40cm/H20. PIP is determined during volume ventilation by the tidal volume delivered, the airway resistance, and the lung compliance. PIP greater than 40cm/H2O = investigate cause and correct. Plateau pressure is measured at the end of inspiration when an inflation volume is held in the lungs (inspiratory hold), so no airflow is present, thus eliminating the resistance (RAW) component of the pPEAK equation. pPLAT is a reflection of lung compliance. Measure and document PPLAT in every patient who is volume ventilated when commencing ventilation. Re-check PPLAT after every change in Vt, PEEP, or as clinically indicated. Pplat Goal < 30 cm/H20. Pplat greater than 30cm/H2O = investigate cause and correct. Checking for Auto PEEP - If air trapping is a concern, the presence and level of intrinsic PEEP (AutoPEEP) can be identified in either PC or VC, however, accurate measurement requires the patient to not be breathing spontaneously. Auto-peep causes a reduction in returned volumes and increased difficulty triggering the ventilator in the setting of pressure control ventilation. To reduce intrinsic PEEP: o Ensure the patient is adequately sedated. o Extend expiratory time (indirectly by shortening the Ti) and/or reduce respiratory rate (see Asthma/COPD Exacerbation). o Consider reduction of set PEEP unless the patient needs it. o Consider matching intrinsic PEEP with extrinsic PEEP in consultation with medical control. 191 TROUBLESHOOTING AND PEARLS Troubleshooting HIGH airway pressures o Airway patent? Rule out right main stem intubation o Patient sedated? Sedation / Analgesia / Paralytic PRN o Auto PEEP present? Correct underlying cause o Pneumothorax / Hemothorax? Chest decompression o Pulmonary edema? Nitro and Lasix o Bronchospasms? B2 agonist, Magnesium, Steroid o Abdominal distension? OG Tube o ETT obstruction? Suction Troubleshooting LOW airway pressures o Airway patent? Rule out extubation or ETT cuff failure o Circuit intact? Confirm patent and attached properly o Adequate Vt? Titrate up PRN To improve Oxygenation, if patient is hypoxic o Unless FiO2 already > 0.75, increase the FiO2 o Confirm adequate Vt and RR; monitor airway pressures o Titrate PEEP up 1-2cm/H2O at a time; max 10cm/H2O To improve Ventilation, if patient is hypercarbic or hypocarbic o To increase CO2, decrease minute ventilation Decrease Vt or RR Use caution; consider underlying cause o To decrease CO2, increase minute ventilation Ensure adequate Vt; monitor airway pressures Increase RR; titrate slowly Pearls: Ventilator Adjustments o In general, wide swings in minute ventilation in response to ETCO2 may be more harmful than beneficial – avoid major changes just to make the numbers look good o Make gentle progress o Only change 1 paramater at a time o No more than 1 change per 5 minutes o Keep underlying physiology in mind Pearls: Oxygenation and Ventilation adjustments in Pressure Control o Increasing the PIP will increase Vt, which should decrease CO2 o Increasing the PEEP without increasing PIP will decrease Vt o Remember if you extend the Ti but do not change rate, the expiratory time will decrease o If CO2 is high and the patient is hypoxic, increase pressure controls (both Ti & PEEP) 192 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL20 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Medication Pump Skills Formulary ALS INDICATIONS Any vasoactive medication infusion Fluid administration to pediatric patients CONTRAINDICATIONS None in the emergency setting PROCEDURE Attach pump tubing to desired infusion Use medication library o Enter medication o Enter concentration o Enter desired dose Verify accurate drip rate If infusing fluids only, simply set desired drip rate Reassess patient 193 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL21 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: IO Access Skills Formulary ALS INDICATIONS Any patient requiring vascular access where an IV is unable to be obtained Critical patient where IV access success may be questionable CONTRAINDICATIONS Fracture above where the IO will be placed Obvious infection at the site PROCEDURE Identify IO Site: o Proximal Tibia o Humeral Head Cleanse the puncture site Stabilize the leg and skin over the site Position the driver at the insertion site perpendicular (90o) to the bone surface. Insert the needle set through the skin until resistance is met Ensure one black line (minimum) is visible above the skin Penetrate the bone by powering the drill while applying firm pressure Release the trigger when the flange is against the skin or when a sudden give is felt Flush or bolus with NS; consider Lidocaine for pain PRN Confirm placement, and check for infiltration Connect tubing and pressure bag to infuse if needed Secure with dressing 194 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL22 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: IV Access Skills Formulary ALS INDICATIONS Any patient requiring vascular access None PROCEDURE Inform the patient about the procedure Choose appropriate site and catheter size for patient condition Clean site with approved antiseptic Stabilize the vein with distal traction to the vein and skin Pass the needle into the vein, bevel up until you get blood return in catheter hub Advance the needle 2mm more into the vein Slide the catheter off of the needle into the vein Remove the needle and dispose of properly Attach tubing and infuse about 10-20 cc to assure patency, watch for signs of infiltration. Secure the IV and tubing CONTRAINDICATIONS 195 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL23 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Pre-Existing Catheter Access Skills Formulary ALS INDICATIONS Any patient requiring vascular access with a pre-existing catheter in place o Power Port o PICC Line CONTRAINDICATIONS None in the emergency setting PROCEDURE – PORT ACCESS Palpate port site, identify landmarks Cleanse site with betadine and alcohol Insert the Huber needle at a 90 degree angle until access to the port is felt Attached extension tubing, aspirate for blood return Flush with NS to confirm patency Attached fluids Secure with dressing PROCEDURE – PICC ACCESS Identify PICC line (NOT DIALYSIS CATHEDER) Unclamp the extension tubing Flush and aspirate to confirm patency Attach fluids Secure with dressing 196 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL24 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Venous Blood Draw Skills Formulary ALS INDICATIONS Any patient which may benefit from laboratory studies from the hospital None PROCEDURE After establishing vascular access, attach vacutainer Place tube in vacutainer, allow to fill with blood Full all tubes available with blood, note time of draw Flush line after draw is complete CONTRAINDICATIONS 197 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL25 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Maintenance of Vascular Access Skills Formulary ALS INDICATIONS For use with any form of vascular access o Peripheral I.V. o I.O. o Porta-Catheter o P.I.C.C. Line CONTRAINDICATIONS Patients requiring active fluid resuscitation Patients requiring infusions of medications PROCEDURE Choose one of the following: o Maintain at Keep Open (TKO) or Keep Vein Open (KVO) rate o Maintain with a saline lock, flush with NS as needed to verify line patency or flush medicines 198 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL26 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Cardioversion/Defibrillation Skills Formulary ALS INDICATIONS Tachycardic dysrhythmias requiring electrical conversion per guidelines None in the emergency setting PROCEDURE – DEFIBRILATION Ensure appropriate pad placement per manufacturer guidelines Charge to desired energy level Clear the patient Press the shock button PROCEDURE – CARDIOVERSION Ensure appropriate pad placement per manufacturer guidelines Place into synchronized mode Charge to desired energy level Clear the patient Press and hold the shock button until energy delivered CONTRAINDICATIONS 199 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL27 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Transcutaneous Pacing Skills Formulary ALS INDICATIONS Bradycardic dysrythmias requiring external pacing per guidelines None in the emergency setting PROCEDURE Ensure appropriate pad placement per manufacturer guidelines Ensure 4-lead EKG is on patient and placed appropriately Set rate on monitor to 70 BPM Increase MA until electrical capture is achieved Verify mechanical capture is achieved Increase by 10 MA after capture (electrical and mechanical) verified Ensure constant re-assessment; often MA will need to be increased to maintain both electrical and mechanical capture CONTRAINDICATIONS 200 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL28 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Medication Administration Skills Formulary ALS INDICATIONS Any patient requiring medication administration per guidelines CONTRAINDICATIONS See specific drug reference for contraindications PROCEDURE Administer medicines as per specific guidelines and drug reference information The following routes are approved: o IVP (IV Push) o SIVP (Slow IV Push) o IVPB (IV Piggy Back) o IM (Intramuscular) o SQ (Subcutaneous) o IN (Intranasal) o PO (Oral) o PR (Rectal) o UDN (Up-Draft Nebulizer) 201 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL29 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Needle Thoracentesis Skills Formulary ALS INDICATIONS Presumed Tension Pneumothorax Presumed Tension Hemothorax Presumed Pneumo/Hemothorax requiring positive pressure ventilation Traumatic cardiac arrest CONTRAINDICATIONS None in the emergency setting PROCEDURE Identify landmarks (affected side) o 2nd or 3rd intercostal space, mid-clavicular line o 4th or 5th intercostal space, mid-axillary line Cleanse the site with antiseptic Insert large bore needle with catheter over the top of the posterior rib at 90 degree angle Remove needle leaving catheter in place Attach one-way valve if available Secure with dressing Re-assess constantly; repeat PRN 202 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL30 Date Created 1/1/2017 Date Revised 1/1/2017 Procedure: Restraints Skills Formulary BLS INDICATIONS Combative patients posing a risk to self and/or others None in the emergency setting PROCEDURE Assess for and correct underlying medical causes as appropriate Consider chemical restraints Employ 4-point restraint technique (wrists and ankles); secure to stretcher Assess CSM every 15 minutes CONTRAINDICATIONS 203 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL31 Date Created 1/1/2010 Date Revised 2/25/2014 Trauma: Commercial Tourniquet Skills Formulary Also known as C.A.T. BLS INDICATIONS Extremity bleeding that cannot be controlled with direct pressure None in the emergency setting PROCEDURE Route the band around the limb and pass the red tip through the inside slit of the buckle Pull the band tight Pass the red tip through the outside of the buckle The friction buckle will lock the band in place Pull the band VERY TIGHT and securely fasten the band back on itself Twist the rod until the bleeding has stopped and the distal pulse is eliminated Place the rod inside the clip locking it in place Secure the rod inside the clip with the strap Record the time the tourniquet was applied CONTRAINDICATIONS 204 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL32 Date Created 1/1/2017 Date Revised 1/1/2017 Trauma: Spinal Immobilization Skills Formulary BLS INDICATIONS Patient with potential spinal injury Inability to clear the spine per guideline The backboard was designed as an extrication tool and full body splint; use it as such o If a patient is self-extricated and ambulatory but has cervical neck tenderness; place patient on cot in position of comfort with c-collar in place o If a patient requires c-collar placement but not a backboard, consider scoop stretcher or soft stretcher with c-collar in place o Patients that are multi-system trauma victims or require extrication (non-mobile) meet criteria for full spinal immobilization CONTRAINDICATIONS None in the emergency setting PROCEDURE – CERVICAL COLLAR ONLY Appropriately size the c-collar per manufacturer recommendations Place c-collar on patient Assess CSM status PROCEDURE – FULL SPINAL IMMOBILIZATION Appropriately size the c-collar per manufacturer recommendations Place patient on long spine board via means that produce the least manipulation Secure the patient with all available straps Place head blocks and secure with all available straps Assess CSM status 205 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL33 Date Created 1/1/2017 Date Revised 1/1/2017 Trauma: Spinal Clearance Skills Formulary ALS INDICATIONS Patient awake, alert an oriented x 4 Patient with GCS of 15 Patient without drugs or alcohol ingestion (suspected or actual) Patient without distracting injury Patient without C-Spine tenderness in the presence of trauma Patient without neurological deficits in the presence of trauma CONTRAINDICATIONS Altered mental status Inability to answer questions Obvious impairment PROCEDURE Clear the spine, no spinal immobilization is necessary Clearly document the spinal immobilization clearance 206 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL34 Date Created 1/1/2017 Date Revised 1/1/2017 Trauma: Sager Traction Splint Skills Formulary BLS INDICATIONS Mid-shaft femur fracture CONTRAINDICATIONS Multiple fractures or injuries to the extremity Suspected pelvic fracture PROCEDURE Position the sager splint between the patient’s legs, resting the cushion saddle against the ischial tuberosity with the shortest end of the cushion saddle toward the ground. Apply the thigh strap around the upper thigh of the fractured limb. Push the ischial cushion gently down while at the same time pulling the thigh strap laterally under the thigh Tighten the thigh strap snugly Lift the spring clip to extend the inner shaft of the splint Extend the inner shaft until the cross bar is even with the patients heel Using the attached hook and loop straps wrap the ankle harness around the ankle Pull the control tabs to secure the ankle harness tightly against the crossbar Grasp the padded shaft with 1 hand and the traction handle with the other hand and gently extend the inner shaft until the desired amount of traction is gained At the knees wrap the large elastic strap and apply thee other straps to help stabilize the limb Apply the strap around the feet to stop rotation Reassess CSM 207 Reynolds County Ambulance District Trauma: General Splinting Clinical Practice Guidelines CPG Number SKL35 Date Created 1/1/2017 Date Revised 1/1/2017 Skills Formulary BLS INDICATIONS Presumed fracture or dislocation Major trauma victim CONTRAINDICATIONS PROCEDURE Select the appropriate tool to stabilize the fracture o SAM splint o Rigid splint o Pillow Immobilize the injury; include the joint above and joint below the injury Secure with tape Place and secure in position of comfort Reassess CSM 208 Reynolds County Ambulance District Clinical Practice Guidelines CPG Number SKL36 Date Created 1/1/2017 Date Revised 1/1/2017 Trauma: Pelvic Binder Skills Formulary BLS INDICATIONS Suspected pelvic fracture CONTRAINDICATIONS None in the emergency setting PROCEDURE Slide the pelvis wrap under the patients buttocks and situate around pelvic girdle Remove excess wrap, leaving approximately 6” of opening on the front of the patient Place securing device on the front of the pelvis wrap Tighten the securing device until pelvis becomes stable Secure in place Document time pelvic binder was placed 209
