Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Aurora Fire Rescue / Falck Rocky Mountain Authorized Version of Denver Metropolitan Prehospital Protocols Approved January 23, 2017 Version 1.6 Approved January 23, 2017 1 Table of Contents 1 Introduction Confidentiality Consent Decision Making Capacity Physician at the Scene / Medical Direction Physician at the Scene / Medical Direction Algorithm Adult Pulseless Arrest - General Termination of Resuscitation Advanced Medical Directives Patient Determination: Patient or No Patient Algorithm Patient Non-Transport or Refusal Algorithm Emergency Department Divert and Advisory Emergency Department Capabilities Chart Emergent vs. Non-Emergent Patient Transport Prehospital Trauma Triage Guideline for patients 15 years and older Prehospital Trauma Triage Guideline for patients less than 15 years old Multiple Patient Incident Criteria Free-Standing ED as EMS Destination START Triage JumpSTART Pediatric MCI Triage Multiple Patient Incident-Distribution Worksheet Procedures: 10 Orotracheal Intubation 15 Nasotracheal Intubation 20 Percutaneous Cricothyrotomy 25 i-gel Airway 30 Continuous Positive Airway Pressure Algorithm 35 Capnography 40 Synchronized Cardioversion Algorithm 45 Transcutaneous Cardiac Pacing 55 Restraint 60 Tourniquet 65 Needle Thoracostomy for Tension Pneumothorax 70 Intraosseous Catheter 75 Vascular Access Devices Approved January 23, 2017 Index 2 Table of Contents 2 Protocols: Respiratory 100 Adult Epistaxis Management Algorithm 105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations 110 Adult Obstructed Airway Algorithm: Conscious Patient 110 Adult Obstructed Airway Algorithm: Unconscious Patient 115 Adult Respiratory Distress Algorithm 120 Adult Asthma 121 Adult COPD 125 Adult CHF / Pulmonary Edema Algorithm 130 Adult Allergy and Anaphylaxis Algorithm Cardiac 2000 Adult Cardiac Arrest-ACLS 2001 Adult Cardiac Arrest Algorithm-ACLS 2010 Adult Pulseless Arrest – BLS Algorithm-AED 2020 Adult Pulseless Arrest – VF / VT 2021 Adult Pulseless Arrest – Asystole / PEA 2025 Adult Return of Spontaneous Circulation (ROSC) 2030 Adult Tachyarrhythmia Algorithm-ACLS 2040 Adult Bradycardia Algorithm-ACLS 2050 Adult Chest Pain 2051 Adult Cardiac Alert 2100 Adult Hypertension Neuro 3000 Adult Syncope 3010 Adult Stroke Algorithm 3011 Adult Mobile Stroke Treatment Unit 3020 Adult Altered Mental Status Algorithm 3030 Adult Seizure Algorithm Medical 4010 Adult Abdominal Pain / Vomiting Algorithm 4020 Adult Overdose and Acute Poisoning Algorithm 4025 Adult Hypoglycemia Algorithm 4030 Adult Medical Hypotension / Shock Algorithm 4031 Adult Adrenal Insufficiency 4040 Adult Drowning Algorithm 4050 Adult Hypothermia Algorithm 4060 Adult Hyperthermia Algorithm 4070 Adult Insect / Arachnid Bite and Stings Algorithm 4080 Adult Snake Bite Algorithm Behavioral 5000 Adult Psychiatric / Behavioral Emergency 5010 Adult Combative Patient Algorithm 5020 Adult Transport of the Handcuffed Patient 5030 Adult Tasered Patients 5040 Adult Drug / Alcohol Intoxication Algorithm Approved January 23, 2017 Index 3 Table of Contents 3 Obstetrics 6000 Pre-Eclampsia / Eclampsia Algorithm 6010 Emergency Childbirth Algorithm 6020 Abnormal Delivery Algorithm 6030 Postpartum Hemorrhage Algorithm Trauma 7000 Adult General Trauma Care Algorithm 7005 Adult Special Trauma Scenarios Algorithm 7010 Adult Trauma in Pregnancy Algorithm 7015 Adult Traumatic Pulseless Arrest Algorithm 7020 Adult Traumatic Shock Algorithm 7025 Adult Amputations Algorithm 7026 Adult Extremity Injuries 7029 Adult Head Trauma 7030 Adult Face and Neck Trauma Algorithm 7035 Adult Spinal Trauma Algorithm 7040 Adult Selective Spinal Stabilization Algorithm 7045 Adult Chest Trauma Algorithm 7050 Adult Abdominal Trauma Algorithm 7055 Adult Burns Algorithm Pediatrics 001p General Guidelines for Pediatric Patients 002p Pediatric Assessment Algorithm 003p Pediatric Shock 004p Transport of the Pediatric Patient Pediatric Respiratory 100p Pediatric Epistaxis Management 105p Pediatric Respiratory Failure / Arrest Algorithm 110p Pediatric Obstructed Airway Algorithm: Conscious Patient 110p Pediatric Obstructed Airway Algorithm: Unconscious Patient 115p Pediatric Respiratory Distress 120p Pediatric Asthma 125p Pediatric Croup 126p Pediatric Bronchiolitis 130p Pediatric Allergy and Anaphylaxis Pediatric Cardiac 2000p Pediatric Cardiac Arrest General Principles 2010p Pediatric Pulseless Arrest BLS / AED Algorithm 2020p Pediatric Pulseless Arrest - VF / VT 2021p Pediatric Pulseless Arrest – Asystole / PEA 2025p Pediatric Return of Spontaneous Circulation (ROSC) 2030p Pediatric Tachycardia 2040p Pediatric Bradycardia 2200p Newborn Resuscitation Algorithm Approved January 23, 2017 4 Index Table of Contents 4 Pediatric Neuro 3000p Pediatric Syncope 3010p Pediatric Stroke Algorithm 3020p Pediatric Altered Mental Status 3030p Pediatric Seizure Algorithm Pediatric Medical 4010p Pediatric Abdominal Pain / Vomiting 4020p Pediatric Overdose and Acute Poisoning Algorithm 4025p Pediatric Hypoglycemia 4031p Pediatric Adrenal Insufficiency 4040p Pediatric Drowning 4050p Pediatric Hypothermia 4060p Pediatric Hyperthermia 4070p Pediatric Insect/Arachnid Bite and Sting 4080p Pediatric Snake Bite 4090p Pediatric Apparent Life Threatening Event (ALTE) Algorithm 4095p Care of the Child with Special Needs Pediatric Behavioral 5000p Pediatric Psychiatric / Behavioral Emergencies 5040p Pediatric Alcohol Intoxication Pediatric Trauma 7000p Pediatric General Trauma Care 7010p Pediatric Special Trauma Scenarios 7015p Pediatric Traumatic Pulseless Arrest 7020p Pediatric Traumatic Shock 7025p Pediatric Amputations 7029p Pediatric Head Trauma 7030p Pediatric Face and Neck Trauma 7035p Pediatric Spinal Trauma 7040p Pediatric Spinal Immobilization Considerations 7045p Pediatric Chest Trauma 7050p Pediatric Abdominal Trauma 7055p Pediatric Burns Approved January 23, 2017 5 Index Table of Contents 5 Medications: Albuterol Sulfate (Proventil,Ventolin) Adenosine (Adenocard) Amiodarone (Cordarone) Aspirin (ASA) Atropine Sulfate Calcium Gluconate Calcium Chloride Dextrose 50% Diphenhydramine (Benadryl) Dopamine (Intropin) Epinephrine (Adrenalin) Fentanyl (Sublimaze) Glucagon Ipratropium Bromide (Atrovent) Magnesium Sulfate Methylprednisolone (Solu-Medrol) Midazolam (Versed) Naloxone (Narcan) Nerve Agent Kit (DuoDote) Nitrogylcerine (NitroStat) Odansetron (Zofran) Oral Glucose (Glutose, Insta-Glucose) Oxygen Phenylephrine (Intranasal) Racemic Epinephrine (Vaponephrine) Sodium Bicarbonate Topical Ophthalmic Anesthetics Core Competencies: Adult Medical Arrest – Compressor Adult Medical Arrest – Ventilator Adult Medical Arrest – Lead Paramedic Adult Traumatic Arrest – Compressor Adult Traumatic Arrest – Ventilator Adult Traumatic Arrest – Lead Paramedic Pediatric Medical Arrest – Compressor Pediatric Medical Arrest – Ventilator Pediatric Medical Arrest – Lead Paramedic Pediatric Traumatic Arrest – Compressor Pediatric Traumatic Arrest – Ventilator Pediatric Traumatic Arrest – Lead Paramedic Index Approved January 23, 2017 6 General Guidelines: Introduction INTRODUCTION The following protocols have been developed and approved by the Aurora Fire Rescue Medical Directors and is based on the consensus document produced by the Denver Metropolitan EMS Medical Directors (DMEMSMD) group. These protocols define the standard of care for EMS providers in the City of Aurora, and delineate the expected practice, actions, and procedures to be followed. No protocol can account for every clinical scenario encountered, and the Medical Directors recognize that in rare circumstances deviation from these protocols may be necessary and in a patientʼs best interest. Variance from protocol should always be done with the patientʼs best interest in mind and backed by documented clinical reasoning and judgment. Whenever possible, prior approval by direct verbal order from base station physician is preferred. Additionally, all variance from protocol should be documented and submitted for review in a timely fashion. The protocols have a new look and are presented in an algorithm format. An algorithm is intended to reflect real-life decision points visually. An algorithm has certain limitations, and not every clinical scenario can be represented. Although the algorithm implies a specific sequence of actions, it may often be necessary to provide care out of sequence from that described in the algorithm if dictated by clinical needs. An algorithm provides decision-making support, but is no substitute for sound clinical judgment. In order to keep protocols as uncluttered as possible, and to limit inconsistencies, individual drug dosing has not been included in the algorithms. It is expected the EMTs will be familiar with standard drug doses. Drug dosages are included with the medications section of the protocols as a reference. If viewing protocol in an electronic version, it will be possible to link directly to a referenced protocol by clicking on the hyperlink, which is underlined. PROTOCOL KEY Boxes without any color fill describe actions applicable to all levels of EMT. Splint with bulky dressing Boxes with blue fill are for EMT-paramedic level. 12 lead ECG to identify STEMI if present When applicable, actions requiring base contact are identified in the protocol: CONTACT BASE for consideration of field pronouncement Teaching points deemed sufficiently important to be included in the protocol are on the second page of the applicable protocol. PEDIATRIC PROTOCOLS For the purposes of these clinical care protocols, pediatric patients are those < 12 years of age, except where identified in a specific protocol. Index Approved January 23, 2017 7 General Guidelines: Confidentiality A. The patient-physician relationship, the patient-registered nurse relationship, and the patient-EMT relationship are recognized as privileged. This means that the physician, nurse, or EMT may not testify as to confidential communications unless: 1. The patient consents 2. The disclosure is allowable by law (such as Medical Board or Nursing Board proceedings, or criminal or civil litigation in which the patient's medical condition is in issue) B. The prehospital provider must keep the patient's medical information confidential. The patient likely has an expectation of privacy, and trusts that personal, medical information will not be disclosed by medical personnel to any person not directly involved in the patient's medical treatment. 1. Exceptions i. The patient is not entitled to confidentiality of information that does not pertain to the medical treatment, medical condition, or is unnecessary for diagnosis or treatment. ii. The patient is not entitled to confidentiality for disclosures made publicly. iii. The patient is not entitled to confidentiality with regard to evidence of a crime. C. Additional Considerations: 1. Any disclosure of medical information should not be made unless necessary for the treatment, evaluation or diagnosis of the patient. 2. Any disclosures made by any person, medical personnel, the patient, or law enforcement should be treated as limited disclosures and not authorizing further disclosures to any other person. 3. Any discussions of prehospital care by and between the receiving hospital, the crewmembers in attendance, or at in-services or audits are done strictly for educational or performance improvement purposes. Further disclosures are not authorized. 4. Radio communications should not include disclosure of patient names. 5. This procedure does not preclude or supersede the Aurora Fire Department’s HIPAA policy and procedures. Approved January 23, 2017 Index 8 General Guidelines: Consent General Principles A. Consent is a legal concept. Decision Making Capacity (DMC) is a medical concept. B. A person is deemed to have decision-making capacity if he/she: (Must meet all criteria) 1. Is not clinically intoxicated with alcohol or drugs 2. Understands nature of illness or injury 3. Understands consequences of refusal of care 4. Given the risks and options, voluntarily refuses treatment or transport 5. Criteria that does NOT meet a Mental Health Hold: a. Not homicidal or suicidal b. Not gravely disabled or psychotic c. Not a danger to self or others General Principles: Adult A. An adult in the State of Colorado is 18 years of age or older. B. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient. C. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient with DMC may refuse medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, and treat to the extent possible. D. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment. E. Implied Consent: An unconscious adult is presumed to consent to treatment for lifethreatening injuries/illnesses. F. Involuntary Consent: a person other than the patient in rare circumstances may authorize Consent. This may include a court order (guardianship), authorization by a law enforcement officer for prisoners in custody or detention, or for persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled. G. Consent may be inferred by the patient's actions or by express statements. If you are not sure that you have consent, clarify with the patient or CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock). This may include consent for treatment decisions or transport/destination decisions. H. If the patient lacks decision-making capacity and the patient's life or health is in danger, and there is no reasonable ability to obtain the patient's consent, proceed with transport and treatment of life-threatening injuries/illnesses. If you are not sure how to proceed, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock). I. For patients who refuse medical treatment, if you are unsure whether or not a situation of involuntary consent applies, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock). Approved January 23, 2017 Index 9 General Guidelines: Consent General Principles: Minors A. A parent, including a parent who is a minor, may consent to, or refuse medical or emergency treatment of his/her child. There are exceptions: 1. Neither the child nor the parent may refuse medical treatment on religious grounds if the child is in imminent danger as a result of not receiving medical treatment, or when the child is in a life-threatening situation, or when the condition will result in serious handicap or disability. 2. If a minor has an injury or illness, but not a life-threatening medical emergency, you should attempt to contact the parent(s) or legal guardian. If this cannot be done promptly, transport. 3. If the minor has a life-threatening injury or illness, transport and treat per protocols. If the parent objects to treatment, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) immediately and treat to the extent allowable, and notify police to respond and assist. 4. The consent of a parent is not necessary to authorize hospital or emergency health care when an EMT in good faith relies on a minor's consent, if the minor is at least 15 years of age and emancipated or married. 5. Minors may seek treatment for abortion, drug addiction, and venereal disease without consent of parents. Minors > 15 years may seek treatment for mental health. 6. BASE CONTACT (AIP, Children’s TMCA, CMP, SaddleRock) is required any time a minor patient is left on scene. B. When in doubt, your actions should be guided by what is in the minor's best interests and base contact. 10 Approved January 23, 2017 Index General Guidelines: Physician at the scene / Medical Direction Purpose A. To provide guidelines for prehospital personnel who encounter a physician at the scene of an emergency General Principles A. The prehospital provider has a duty to respond to an emergency, initiate treatment, and conduct an assessment of the patient to the extent possible. B. A physician who voluntarily offers or renders medical assistance at an emergency scene is generally considered a "Good Samaritan." However, once a physician initiates treatment, he/she may feel a physician-patient relationship has been established. C. Good patient care should be the focus of any interaction between prehospital care providers and the physician. Procedure A. See algorithm below and sample note to physician at the scene Special notes A. Every situation may be different, based on the physician, the scene, and the condition of the patient. B. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) when any question(s) arise. Approved January 23, 2017 Index 11 General Guidelines: Physician at the scene/Medical Direction NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMS PROVIDERS THANK YOU FOR OFFERING YOUR ASSISTANCE. The prehospital personnel at the scene of this emergency operate under standard policies, procedures, and protocols developed by their Medical Director. The drugs carried and procedures allowed are restricted by law and written protocols. After identifying yourself by name as a physician licensed in the State of Colorado and providing identification, you may be asked to assist in one of the following ways: 1. 2. Offer your assistance or suggestions, but the prehospital care providers will remain under the medical control of their base physician, or With the assistance of the prehospital care providers, talk directly to the base physician and offer to direct patient care and accompany the patient to the receiving hospital. Prehospital care providers are required to obtain an order directly from the base physician for this to occur. THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY. _____________________________ Medical Director Approved January 23, 2017 ___________________________________ Agency Index 12 General Guidelines: Physician at the scene/Medical Direction EMS arrives on scene EMT attempts patient care Physician reports on patient and relinquishes patient care Physician wants to help or is involved in or will not relinquish patient care Prehospital provider identifies self and level of training Provide care per protocol Physician willing to just help out Provide general instructions and utilize physician assistance Physician does not relinquish patient care and continues with care inconsistent with protocols CONTACT BASE for Medical Consult Approved January 23, 2017 Index Physician requests or performs care inappropriate or inconsistent with protocols Shares Physician At The Scene/Medical Direction Note with physician and advise physician of your responsibility to the patient Physician complies Provide care per protocol 13 Adult Pulseless Arrest - General Dependent lividity Or Rigor mortis Or Decomposition Yes No Place patient on cardiac monitor Not Asystole Asystole * Advanced Directives indicating DNR Yes CONTACT BASE for consideration of field pronouncement No Ref. Asystole / PEA or VF / VT if medical cause OR Ref. Adult Traumatic Pulseless Arrest if traumatic cause Cardiac arrest from the following causes should approached as a medical cardiac arrest: Overdose Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage * Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. Include the AFR incident number on the strip. Approved January 23, 2017 14 Index Termination of Resuscitation Purpose A. To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the prehospital setting General Principles A. Attempt resuscitation for all patients found pulseless and apneic, unless any of the following are present: 1. Physician orders as specified on the Colorado Medical Orders for Scope of Treatment (MOST) form: “No CPR. Do Not Resuscitate/DNR/Allow Natural Death”, present with the patient 2. A valid CPR directive present with the patient 3. Dependent lividity with Asystole: OR 4. Rigor Mortis with Asystole: OR 5. Decomposition with Asystole Medical Pulseless Arrest: A. Continue Resuscitation until: 1. ROSC 2. Continuous asystole for at least 15 minutes after ALS care a. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for consideration of TOR at any point if continuous asystole for at least 15 minutes after ALS care. b. Regardless of cardiac rhythm, the following patients should be aggressively resuscitated and transported as soon as possible: i. Hypothermia ii. Drowning with hypothermia and submersion < 60 minutes iii. Pregnant patient with estimated gestational age ≥ 20 weeks c. After pronouncement, do not alter condition in any way or remove equipment (lines, tubes, etc.), as the patient is now a potential coroner’s case. Traumatic Pulseless Arrest: A. Follow guidelines per 7015 Adult Traumatic Pulseless Arrest Index Approved January 23, 2017 15 General Guidelines: Advanced Medical Directives A. These guidelines apply to both adult and pediatric patients. B. There are several types of advance medical directives (documents in which a patient identifies the treatment to be withheld in the event the patient is unable to communicate or participate in medical treatment decisions). C. Some patients may have specific physician orders on a Colorado Medical Orders for Scope of Treatment (MOST) form. A MOST form order to withhold CPR or resuscitation should be honored by EMS. D. Resuscitation may be withheld from, or terminated for, a patient who has a valid CPR Directive, Do Not Resuscitate Order (DNR), or other advance medical directive when: 1. It is clear to the prehospital provider from the document that resuscitation is refused by the patient or by the patient's attending physician who has signed the document; and 2. Base physician (AIP, Children’s, TMCA, CMP, SaddleRock) has approved withholding of or ceasing resuscitation. E. Suspected suicide does not necessarily negate an otherwise valid CPR Directive, DNR order or other advanced medical directive. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) F. The Colorado CPR Directive directs EMS providers to withhold CPR in the event of cardiac or respiratory arrest or malfunction. 1. “Cardiopulmonary Resuscitation” (CPR) means measures to restore cardiac function or to support breathing in the event of cardiac or respiratory arrest or malfunction. “CPR” includes, but is not limited to, artificial ventilation, chest compression, delivering electric shock, placing tubes in the airway to assist breathing or other basic and advanced resuscitative therapies. 2. CPR Directive bracelet or necklace may be used by an individual and shall be complied with in the same manner as a written CPR Directive. 3. A signed CPR directive form that has been photocopied, scanned, faxed is valid. G. A Living Will ("Declaration as to Medical or Surgical Treatment") requires a patient to have a terminal condition, as certified in the patient's hospital chart by two physicians. H. Other types of advance directives may be a "Durable Medical Power of Attorney," or "Health Care Proxy". Each of these documents can be very complex and require careful review and verification of validity and application to the patient's existing circumstances. Therefore, the consensus is that resuscitation should be initiated until a physician can review the document or field personnel can discuss the patient’s situation with the base physician. If there is disagreement at the scene about what should be done, CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for guidance. I. Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family or an attending physician directs resuscitation be ceased, the prehospital provider should immediately CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock). The prehospital provider should accept verbal orders to cease resuscitation only from the Base physician. J. There may be times in which the prehospital provider feels compelled to perform or continue resuscitation, such as a hostile scene environment, family members adamant that "everything be done," or other highly emotional or volatile situations. In such circumstances, the prehospital provider should attempt to confer with the BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for direction and if this is not possible, the prehospital provider must use his or her best judgment in deciding what is reasonable and appropriate, including transport, based on the clinical and environmental conditions, and establish base contact as soon as possible. Approved January 23, 2017 16 Index General Guidelines: Advanced Medical Directives Additional Considerations: A. Patients with valid DNR orders or advanced medical directives should receive supportive or comfort care, e.g. medication by any route, positioning and other measures to relieve pain and suffering. Also the use of oxygen, suction and manual treatment of an airway obstruction as needed for comfort. B. Mass casualty incidents are not covered in detail by these guidelines. C. If the situation appears to be a potential crime scene, EMS providers should disturb the scene as little as possible and communicate with law enforcement regarding any items that are moved or removed from the scene. D. In all cases of unattended deaths occurring outside of a medical facility, the Aurora Police Department should be contacted immediately. 17 Approved January 23, 2017 Index General Guidelines: Patient Determination: “Patient or No Patient” Acute illness or injury possible based on history or appearance or mechanism. No Is the person a minor (< 18)? Yes No Airbag Deployment? Yes No MVC Rollover? Yes Individual meets definition of a Patient (PCR Required) No Involved person’s vehicle has broken glass? Yes No Yes Person lacks decision-making capacity ref. Consent No Person has an acute medical complaint resulting in a call for help Yes No 3rd party* indicates individual is ill, injured or gravely disabled Yes No Person does not meet definition of a patient, and does not require PCR or refusal of care *Cell phone call by concerned citizen driving by a perceived emergency excluded. 18 Approved January 23, 2017 Index General Guidelines: Patient Non-Transport or Refusal Dispatch Arrived on scene Cancelled PTA Not a patient ref. Patient Determination Patient Pt refusing transport Pt requesting transport Standing Order Refusal Base Contact Refusal No Base Contact required if ALL criteria met: All calls not meeting criteria for Standing Order Refusal “CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) for documentation of refusal and / or consult” Adult patient (≥18) Decision-making capacity* Minor isolated soft tissue injury to an extremity Documentation Requirements for Refusal Clarify calling to document vs authorization *A person who has decision-making capacity may refuse examination, treatment and transport Ref: GENERAL GUIDELINES: CONSENT for Decision-Making Capacity guidelines Approved January 23, 2017 Index Confirm decision-making capacity EMS assistance offered and declined Risks of refusal explained to patient Patient understands risks of refusal Name of Base Station physician authorizing refusal of care unless standing order refusal Signed refusal of care and against medical advice document, if applicable. 19 General Guidelines: Emergency Department Divert and Advisory Purpose A. To provide a standard approach to ambulance diversion that is practical for field use B. To facilitate unobstructed access to hospital emergency departments for ambulance patients C. To allow for optimal destination policies in keeping with general EMS principles and Colorado State Trauma System Rules and Regulations General Principles A. EMSystem, an internet-based tracking system, is used to manage diversion in the Denver Metro area B. The only time an ambulance can be diverted from a hospital is when that hospital is posted on EMSystem as being on official divert (RED) status. C. Overriding factors: the following are appropriate reasons for a paramedic to override ED Divert and, therefore, deliver a patient to an emergency department that is on ED divert: 1. Cardiopulmonary arrest 2. Imminent cardiopulmonary arrest 3. Unmanageable airway emergencies 4. Unstable trauma and burn patients transported to Level I and Level II Trauma Centers 5. Patients meeting “Cardiac Alert“ criteria (participating hospitals) 6. Patients meeting “Stroke Alert“ criteria (participating hospitals) 7. Imminent delivery D. Prehospital personnel should honor advisory categories, when possible, considering patient’s condition, travel time, and weather. Patients with specific problems that fall under an advisory category should be transported to a hospital not on that specific advisory when feasible. E. There are several categories that are considered advisory (yellow) alert categories. These categories are informational only and should alert field personnel that a hospital listed as being on an advisory alert may not be able to optimally care for a patient that falls under that advisory category. F. The following are advisory (yellow) categories recognized by the State. Individual facilities may not utilize these categories often, or ever: 1. ICU (Intensive Care Unit) 2. Psych (Psychiatric) G. Zone saturation exists when all hospitals within that zone are on ED Divert. H. A Zone Master is the designated hospital within a Zone responsible for determining and tracking hospital assignments when the zone is saturated. I. When an ambulance is transporting a patient that the paramedic feels cannot go outside the zone due to patient acuity or other concerns, the paramedic should contact the Zone Master and request a destination assignment. J. In general, patients contacted within a zone should be transported to an appropriate facility within the zone. Patients may be transported out of the primary zone at the paramedic’s discretion, if it is in the patient’s best interest or if the transport to an appropriate facility is shorter. K. The zones, hospitals in each zone, Zone Masters, and the Zone Master contact phone numbers are listed on EMSystem. Approved January 23, 2017 20 Index General Guidelines: Emergency Department Divert and Advisory Purpose A. To provide a set of guidelines to help ensure proper disposition of the various patients encountered in the field. Philosophy A. Critical patients with a special medical need should be taken to the nearest facility that can best provide for that need. B. Critical patients without a special need (i.e., cardiopulmonary arrest) should be taken to the closest emergency department. C. All other patients should have their request accommodated, consistent with the ability of the system to meet that request. D. Aurora Fire Rescue Paramedics are required to accompany any patient(s) that require or may require advanced life support care who are being transported by ambulance to any hospital emergency department. Special Needs A. Burns 1. Patients older than 12 years of age, with second degree or third degree burns greater than 20% body surface area, should be transported directly to the AIP emergency department. Patients 12 years of age and younger, with second degree or third degree burns greater than 20% body surface area, should be transported directly to The Children's Hospital emergency department. 2. Special Considerations. Complications of airway compromise or cardiovascular instability, require transport to the nearest appropriate emergency department. Burns associated with multi-system trauma should be transported to the closest appropriate Trauma Center. B. Trauma 1. Trauma patients should be transported to the closest appropriate Trauma Center. C. Psychiatric patients 1. Patients placed on a MHH shall be taken to the closest appropriate facility. 2. Patients with psychiatric problems not on an MHH shall be taken to the closest appropriate facility. 3. Patients with psychiatric problems who have an acute medical or traumatic concern shall be treated according to the appropriate medical or trauma protocol. 4. MHH may be placed by a state-certified EMT-P under the auspices of the receiving physician. D. Obstetric/Gynecologic 1. For patients in uncomplicated labor: a. Delivery not imminent: i. If the patient has a private obstetrician or gynecologist, then follow the patient's request for destination, when possible. b. If the patient has no private physician, then follow the patient's request for destination (if expressed), or transport to the closest hospital. 2. Imminent delivery a. If the patient has a private obstetrician/care giver, then follow the patient's request for destination, when appropriate. If the requested facility does not meet these time constraints and the patient still requests the facility, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) physician. b. If the patient has no private physician, then transport to the closest appropriate hospital. 21 Approved January 23, 2017 Index General Guidelines: Emergency Department Capabilities Hospital AIP Children's (< 21 yrs) Littleton DHMC Parker Adventist Porter Denver PSL Rose Saint Joseph's Swedish TMCA Sky Ridge Centennial Southlands Saddlerock Cardiac Alert Stroke Alert Trauma Level Pediatrics OB/GYN YES II Ped – I > 40kg YES NO YES NO YES YES (<12yo) YES NO II I YES YES YES NO YES YES YES YES II YES YES YES YES YES YES YES NO NO IV NO NO YES YES NO YES YES YES YES YES YES NO NO NO NO YES YES YES NO NO NO NO I II II NO NO NO NO YES YES YES YES YES YES YES YES YES YES NO NO NO Special Considerations > 20% burns over 12 yrs > 20% burns up to 12 yrs 22 Approved January 23, 2017 Index General Guidelines: Emergent vs. Non-Emergent Patient Transport Background: 1. Emergent (“lights and sirens”) transport of patients has not been demonstrated to improve patient outcomes. 2. Emergent patient transports place EMS providers and the public at risk. Emergent patient transports should be reserved for situations that meet the following two criteria. 1. Patient has injury or illness that requires emergent hospital intervention not immediately available to the EMS providers. AND 2. Benefit to the patient of emergent transport outweighs risks to the patient, EMS providers, and the public that are created by emergency transport. Criteria 1 Patient is has injury or illness that may require emergent hospital intervention. Examples: 1. Airway a. Inability to establish or maintain a patent airway b. Upper airway stridor 2. Breathing a. Severe respiratory distress 3. Circulation a. Cardiac Arrest b. Hemodynamic instability c. Severe, uncontrolled hemorrhage 4. Neurologic a. GCS <8 b. Seizure activity unresponsive to treatment 5. Obstetric a. Complicated Delivery 6. Trauma a. Penetrating/blunt trauma to head, neck, or torso b. Two or more suspected proximal long bone fractures with symptoms of shock or absence of distal pulses after manipulation Criteria 2 Benefit to the patient of emergent transport outweighs risks to the patient, EMS providers, and the public that are created by emergency transport. Notes: In most situations time saved by emergent transport will not outweigh risks when transport time is short (< 10 minutes) Emergent transport should never be used solely to “get the attention” of the receiving facility. The decision to transport emergent should be made jointly by the primary treating EMS provider (who must consider patient condition and availability of treatments enroute) and the Emergency vehicle operator (who must consider time of day, anticipated transport time, and road/traffic conditions at time of call). 23 Approved January 23, 2017 Index Patients 15 years old and over Transport to a Level I or II Trauma Center Transport to a Level I or II Trauma Center 24 Approved January 23, 2017 Index Patients less than 15 years old Transport to a designated pediatric Level I or II Trauma Center. Transport to a designated pediatric Level I or II Trauma Center. Transport to a designated pediatric Level I or II Trauma Center. Transport to a designated pediatric Level I or II Trauma Center. 25 Approved January 23, 2017 Index Multiple Patient Incident – Patient Criteria The Multiple Patient Incident Criteria should be used on all incidents involving more than one patient. If the total number of patients in any one category exceeds the maximum number indicated, the event should be considered a Mass Casualty Incident (MCI). If START Triage criteria have been utilized to initially triage patients, the Multiple Patient Criteria should be used as a secondary triage method and the Multiple Patient Incident Distribution Worksheet should be utilized. Category: Injury Types: Maximum Number: Category: Injury Types: Maximum Number: Category: Injury Types: Maximum Number: Approved January 23, 2017 CRITICAL GCS Motor < 5 (Pt. can’t localize pain) Assisted Ventilations Respiratory rate <10 or >29 Uncontrolled, severe bleeding Traumatic Shock / Absent radial pulse Penetrating injury to neck / torso 12 (2 per Trauma Center) SERIOUS Altered Mental Status Suspected femur fracture Open long bone fracture Motor or sensory deficits No critical criteria (see above) 24 (4 per Trauma Center) MODERATE Closed, single extremity fracture Isolated soft tissue injury No critical criteria (see above) No serious criteria (see above) 56 (8 per Emergency Dept.) 26 Index Free-Standing Emergency Departments as EMS Destination The term “free-standing emergency department” (FSED) may refer to both licensed emergency departments that accept EMS traffic as an extension of an affiliated hospital, as well as independent emergency departments unaffiliated with a hospital. The following recommendations apply to those FSEDs that accept EMS traffic as an extension of its affiliated hospital: Patients may be considered for transport to a hospital-affiliated FSED with the following exceptions: 1. No OB patients > 20 weeks estimated gestational age 2. No trauma patients meeting RETAC trauma center destination guidelines. 3. No Alerts (e.g. STEMI, Stroke). 4. No cardiac arrest or post-cardiac arrest patients unless unable to oxygenate or ventilate Hospital-affiliated free-standing emergency departments accepting EMS traffic include: Centennial Medical Plaza (The Medical Center of Aurora) Saddle Rock ER (The Medical Center of Aurora) Southlands ER (Parker Adventist) Approved January 23, 2017 Index 27 START Triage Approved January 23, 2017 Index 28 29 Approved January 23, 2017 Index Multiple Patient Incident – Destination Distribution Worksheet Approved January 23, 2017 30 Index 10 Procedure Protocol: Orotracheal Intubation Indications: In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible. Inability to oxygenate / ventilate via BVM using two person technique with OPA / NPA AND Inability to oxygenate / ventilate via i-gel O2. Contraindications: Endotracheal intubation is contraindicated in pediatric patients (< 12 years) Endotracheal intubation is contraindicated prior to attempting i-gel O2 Airway. Endotracheal intubation is contraindicated prior to reattempting via BVM and OPA/NPA with corrective actions after i-gel Endotracheal intubation is contraindicated in the absence of measurable end tidal CO2 by continuous wave form capnography/capnometry o Measurable end tidal CO2 is not required when using ETT to push foreign body into mainstem bronchus. o An atypical report is required and to be submitted to the Medical Branch at the conclusion of the incident if Intubation is performed without measureable CO2 General: Orotracheal intubation is associated with worse outcomes among pediatric patients and head injured patients when compared to BLS airway maneuvers. Intubation is associated with interruptions in chest compressions during CPR, which is associated with worse patient outcomes. Additionally, intubation itself has not been shown to improve outcomes in cardiac arrest Technique: 1. 2. 3. 4. 5. 6. 7. 8. Continue BLS airway sequence Suction airway and pre-oxygenate with BVM ventilations using two person technique and capnography Check equipment and position patient: a. If trauma: have assistant hold in-line spinal immobilization in neutral position b. If no trauma, sniffing position or slight cervical hyperextension is preferred Perform laryngoscopy a. To improve laryngeal view, use right hand to manipulate larynx, or have assistant apply backwards, upwards, rightward pressure (BURP) Place ETT. Confirm tracheal location and appropriate depth and secure tube a. Correct tube depth may be estimated as 3 times the internal diameter of tube at teeth or gums (e.g: 7.0 ETT is positioned at 21 cm at teeth) Confirm and document tracheal location by: a. ETCO2 b. Presence and symmetry of breath sounds c. Rising SpO2 d. Other means as needed Ventilate with Ambu Bag. Assess adequacy of ventilations During transport, continually reassess ventilation, oxygenation and tube position with continuous ETCO2 and SpO2 31 Approved January 23, 2017 Index 10 Procedure Protocol: Orotracheal Intubation Precautions: Ventilate at age-appropriate rates. Do not hyperventilate If the intubated patient deteriorates, think “DOPE” o Dislodgement o Obstruction o Pneumothorax o Equipment failure (no oxygen) Reconfirm and document correct tube position before and after moving patient 32 Approved January 23, 2017 Index 15 Procedure Protocol: Nasotracheal Intubation Indications: In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible Age ≥ 12 years spontaneously breathing patient with indication for intubation who cannot tolerate either supine position or laryngoscopy Nasotracheal Intubation may be considered for failure to oxygenate and ventilate in the presence of: a. Respiratory failure b. Absence of protective airway reflexes c. Present or impending complete airway obstruction Contraindications: Age < 12 years Absence of measurable end tidal CO2 by continuous wave form capnography/capnometry Apnea Severe mid-face trauma Technique: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Initiate BLS airway sequence Suction airway and pre-oxygenate with BVM ventilations and capnography Check equipment, choose correct ETT size (usually 7.0 in adult, limit is size of naris) Position patient with head in midline, neutral position If trauma: cervical collar may be in place, or assistant may hold in-line stabilization in neutral position If no trauma, patient may be sitting upright Administer phenylephrine nasal drops in each nostril Lubricate ETT with Lidocaine jelly or other water-soluble lubricant With gentle steady pressure, advance the tube through the nose to the posterior pharynx. Use the largest nostril. Abandon procedure if significant resistance is felt Keeping the curve of the tube exactly in midline, continue advancing slowly There will be slight resistance just before entering trachea. Wait for an inspiratory effort before final passage through cords. Listen for loss of breath sounds Continue advancing tube until air is definitely exchanging through tube, then advance 2 cm more and inflate cuff Note tube depth and tape securely Confirm and document endotracheal location by: a. ETCO2 b. Presence and symmetry of breath sounds c. Rising SpO2 d. Other means as needed Ventilate with Ambu Bag. Assess adequacy of ventilations During transport, continually reassess ventilation, oxygenation and tube position with continuous ETCO2 and SpO2 33 Approved January 23, 2017 Index 15 Procedure Protocol: Nasotracheal Intubation Precautions: Before performing BNTI, consider if patient can be safely ventilated with non-invasive means such as CPAP or BVM Ventilate at age-appropriate rates. Do not hyperventilate If the intubated patient deteriorates, think “DOPE” o Dislodgement o Obstruction o Pneumothorax o Equipment failure (no oxygen) Reconfirm and document correct tube position after moving patient and before disconnecting from monitor in ED Blind nasotracheal intubation is a very gentle technique. The secret to success is perfect positioning and patience. Approved January 23, 2017 34 Index 20 Procedure Protocol: Percutaneous Cricothyrotomy Introduction: Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be used only in extraordinary circumstances as defined below. An atypical with the reason for performing this procedure must be documented and submitted for review to the Medical Branch at conclusion of the incident. Indications: A life-threatening condition exists AND advanced airway management is indicated, AND adequate oxygenation and ventilation cannot be accomplished by other less invasive means. Contraindications: Age < 12 is a contraindication Technique: Perform cricothyrotomy according to manufacturer’s instructions for Rusch Quick Trach (Rusch Quick Trach Training Video Link 1. Place the patient in a supine position. Assure stable positioning of the neck and hyperextend the neck (unless cervical spine injury suspected) 2. Secure the larynx laterally between the thumb and forefinger. Find the cricothyroid membrane (in the midline between the thyroid cartilage and the cricoid cartilage). This is puncture site. 3. Prep the site by vigorously scrubbing with alcohol or iodine preps. 4. Using the scalpel make a 3mm vertical incision into the skin 5. Firmly hold device and puncture cricothyroid membrane at a 90-degree angle. a. After puncturing the cricothyroid membrane, check the entry of the needle into the trachea by aspirating air through the syringe. b. If air is present, needle is within trachea, change the angle of insertion to 60 degrees (from the head) and advance the device forward into the trachea to the level of the stopper. The stopper reduces the risk of inserting the needle too deeply and causing damage to the rear wall of the trachea. c. Should no aspiration of air be possible because of an extremely thick neck, it is possible to remove the stopper and carefully insert the needle further until entrance into the trachea is made. 6. Remove the stopper. After the stopper is removed, be careful not to advance the device further with the needle still attached. 7. Hold the needle and syringe firmly and slide only the plastic cannula along the needle into the trachea until the flange rests on the neck. Carefully remove the needle and syringe. 8. Secure the cannula with the neck strap 9. Apply the connecting tube to the 15 mm connection and connect the other end to the bagvalvemask with supplemental oxygen. 10. Continue ventilation with 100 percent oxygen and periodically assess the airway Complications: 1. Respiratory arrest and patient demise due to: a. Severity of patient's airway injury. b. Lack of attention to other potential airway maneuvers. c. Subcutaneous air due to improper tube or catheter positioning, along with positive ventilation. d. Bleeding from superficial neck vessels is very common. Use direct pressure after QuickTrach is in place. e. Perforations of the back wall of the trachea and the esophagus from excessively deep penetration by the QuickTrach. With stopper in place, this should be an extremely rare complication. Approved January 23, 2017 Index 35 Precautions: Success of procedure is dependent on correct identification of cricothyroid membrane Bleeding will occur, even with correct technique. Straying from the midline is dangerous and likely to cause hemorrhage Approved January 23, 2017 36 Index 25 Procedure Protocol: i-gel Airway Indications: In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible. Cardiac arrest: o The i-gel O2 Airway is the primary advanced airway for adult and pediatric cardiac arrest patients Respiratory Failure/Arrest requiring assisted ventilations o Primary advanced airway if less invasive ventilation measures are ineffective Contraindications: Intact gag reflex Caustic ingestion Suspected esophageal disease Technique: 1. Initiate BLS airway sequence 2. For adult patients select proper size i-gel O2 based on IDEAL patient body weight (not what the pt actually weighs) : a. # 3 Small adult 30-60kg (65-130 lbs) b. # 4 Medium adult 50-90kg (110-200 lbs) c. # 5 Large adult 90 + kg (200 + lbs) 3. For Pediatric patients refer to length based tape and AFR pediatric field guide a. #1 Neonate 2-5 kg b. #1.5 Infant 5-12 kg c. # 2 Small pediatric 10-25 kg d. # 2.5 Large pediatric 25-35 kg 4. Open packaging and remove inner tray, setting the support strap (adult) and packet of lubricant to one side within easy reach. Remove the i-gel O2. 5. Open the packet of lubricant and place a small bolus on the inner side of the main shell of the packaging. 6. Grasp the i-gel O2 along the integral bite block and lubricate the back, sides and front of the cuff with a thin layer of lubricant. (Ensuring any excess is removed prior to insertion.) 7. Grasp the lubricated i-gel O2 firmly along the bite block. The patient should be in the ‘sniffing the morning air’ position with head extended and neck flexed. * Unless suspected spinal trauma. 8. Position the device so that the i-gel O2 cuff outlet is facing towards the chin of the patient. Introduce the leading soft tip into the mouth of the patient towards the hard palate. 9. Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a definitive resistance is felt. 10. Once insertion has been completed, the tip of the airway should be located into the upper esophageal opening, with the cuff located against the laryngeal framework. The incisors should be resting on the bite block. 11. Secure the device underneath the patient’s neck with a head strap (or tape). Take care to ensure there is sufficient tension to hold the i-gel O2 securely in place, but not excessive tension that may cause trauma. Some adjustment of the strap may be needed to ensure optimal positioning. 12. For pediatric patients secure with tape 13. Place extension elbow and capnography sensor on the end of i-gel O2 14. Confirm tube placement by auscultation, chest movement and ETCO2 . 15. Lubricate and insert appropriate size suction catheater into gastric lumen. a. Size # 5 use 14F b. Size # 2 through # 4 use 12F c. Size # 1.5 use 10F d. Size # 1 not applicable 16. Once the i-gel O2 has been correctly prepared, inserted and secured, positive pressure ventilation can commence. Precautions: 1. Do not remove a properly functioning i-gel O2 Airway in order to attempt intubation. Approved January 23, 2017 Index 37 30 Procedure Protocol: Continuous Positive Airway Pressure (CPAP) Routine Medical Assessment Moderate to severe respiratory distress as evidenced by at least two (2) of the following: Rales (crackles) Dyspnea with hypoxia (SpO2 < 90% despite O2) Dyspnea with verbal impairment – i.e. cannot speak in full sentences Accessory muscle use Respiratory rate > 24/minute despite O2 Diminished tidal volume Talk pt through procedure Adjust oxygen flow to 15 Lpm initially. Monitor patient continuously, recording vital signs every 5 minutes Start with the lowest continuous pressure that appears to be effective. Adjust pressure following manufacturer instructions to achieve the most stable respiratory status Assess patient for improvement as evidenced by the following: Reduced dyspnea Reduced verbal impairment, respiratory rate and heart rate Increased SpO2 Stabilized blood pressure Increased tidal volume Observe for signs of deterioration or failure of response to CPAP: Decrease in level of consciousness Sustained or increased heart rate, respiratory rate or increased blood pressure Sustained low or decreasing SpO2 readings Diminished or no improvement in tidal volume Contraindications: Respiratory or cardiac arrest Systolic BP < 90mmHg Lack of airway protective reflexes Significant altered level of consciousness such that unable to follow verbal instructions or signal distress Vomiting or active upper GI bleed Suspected pneumothorax Trauma Patient size or anatomy prevents adequate mask seal Approved January 23, 2017 38 Index 30 Procedure Protocol: Continuous Positive Airway Pressure (CPAP) Indications: Symptomatic patients with moderate-to-severe respiratory distress as evidenced by at least two (2) of the following: o Rales (crackles) o Dyspnea with hypoxia (SpO2 < 90% despite O2) o Dyspnea with verbal impairment – i.e. cannot speak in full sentences o Accessory muscle use o Respiratory rate > 24/minute despite O2 o Diminished tidal volume Contraindications: Respiratory or cardiac arrest Systolic BP < 90mmHg Lack of airway protective reflexes Significant altered level of consciousness such that unable to follow verbal instructions or signal distress Vomiting or active upper GI bleed Suspected pneumothorax Trauma Patient size or anatomy prevents adequate mask seal Technique: 1. Place patient in a seated position and explain the procedure to him or her 2. Assess vital signs (BP, HR, RR, SpO2, and ETCO2) 3. Apply the CPAP mask and secure with provided straps, progressively tightening as tolerated to minimize air leak 4. Operate CPAP device according to manufacturer specifications 5. For oxygen flow driven devices: a. Adjust oxygen flow to 15 Lpm initially. Monitor patient continuously, recording vital signs every 5 minutes b. Start with the lowest continuous pressure that appears to be effective. Adjust pressure following manufacturer instructions to achieve the most stable respiratory status utilizing the signs described below as a guide 6. Assess patient for improvement as evidenced by the following: a. Reduced dyspnea b. Reduced verbal impairment, respiratory rate and heart rate c. Increased SpO2 d. Stabilized blood pressure e. Appropriate ETCO2 values and waveforms f. Increased tidal volume 7. Observe for signs of deterioration or failure of response to CPAP: a. Decrease in level of consciousness b. Sustained or increased heart rate, respiratory rate or increased blood pressure c. Sustained low or decreasing SpO2 readings d. Diminished or no improvement in tidal volume Precautions: Should patient deteriorate on CPAP: o Troubleshoot equipment o Consider other means of ensuring oxygenation and ventilation o Assess need for possible chest decompression due to pneumothorax o Assess for possibility of hypotension due to significantly reduced preload from positive pressure ventilation In-line nebulized medications may be given during CPAP as indicated and in accordance with manufacturer guidelines Approved January 23, 2017 Index 39 35 Procedure Protocol: Capnography Indications: MANDATORY to be used any time patient is being ventilated. Contraindications: None Technique: 1. Patients without ETT or advanced airway in place: place ETCO2 detector in-line between Ambu bag and face mask. 2. In patient with ETT or advanced airway: place ETCO2 detector in-line between airway adaptor and BVM after airway positioned and secured 3. Assess and document both capnography waveform and ETCO2 value Precautions: 1. To understand and interpret capnography, remember the 3 determinants of ETCO 2: a. Alveolar ventilation b. Pulmonary perfusion c. Metabolism 2. Sudden loss of ETCO2: a. Tube dislodged b. Circuit disconnected c. Cardiac arrest 3. Cardiac Arrest: a. In low-pulmonary blood flow states, such as cardiac arrest, the primary determinant of ETCO2 is blood flow, so ETCO2 is a good indicator of quality of CPR b. If ETCO2 is dropping, change out person doing chest compressions Approved January 23, 2017 Index 40 40 Procedure Protocol: Synchronized Cardioversion Tachyarrythmia with poor perfusion Check: O2 via NRBM IV Suction Airway equipment ready ref. Fentanyl for pain Perform synchronized cardioversion Adult: 100J Pediatric: 1-2J/Kg, or Pediatric Field Guide recommendation Reassess pt Reassess cardiac rhythm Tachyarrythmia with poor perfusion YES NO Repeat cardioversion x1 Contact Base Approved January 23, 2017 Reassess pt Transport 41 Index 40 Procedure Protocol: Synchronized Cardioversion This procedure protocol applies to conscious patients with signs of poor perfusion due to tachyarrhythmia in whom synchronized cardioversion is indicated according to Tachyarrhythmia with a Pulse protocol. If defibrillator does not discharge in “synch” mode, then deactivate “synch” and reattempt If sinus rhythm achieved, however briefly, then dysrhythmia resumes immediately, repeated attempts at cardioversion at higher energies are unlikely to be helpful. First correct hypoxia, hypovolemia, etc. prior to further attempts at cardioversion If pulseless, treat according to Asystole / PEA or VF / VT Algorithm Chronic atrial fibrillation is rarely a cause of hemodynamic instability, especially if rate is <150 bpm. First correct hypoxia, hypovolemia, before considering cardioversion of chronic atrial fibrillation, which may be difficult, or impossible and poses risk of stroke Sinus tachycardia rarely exceeds 150 bpm in adults or 220 bpm in children < 8 years and does not require or respond to cardioversion. Treat underlying causes. Transient dysrhythmias or ectopy are common immediately following cardioversion and rarely require specific treatment other than supportive care Approved January 23, 2017 42 Index 45 Procedure Protocol: Transcutaneous Cardiac Pacing Indications Symptomatic bradyarrhythmias not responsive to medical therapy Precautions Conscious patient will experience discomfort; ref. fentanyl if blood pressure allows. Technique 1. Apply limb leads, and pacing pads as per manufacturer specifications: (-) left anterior, (+) left posterior. 2. Turn pacer unit on. 3. Set initial current to 40 mAmps . 4. Select pacing rate at 80 beats per minute (BPM) 5. Select “Fixed” mode 6. Start pacing unit. 7. Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps (usually captures around 100 mAmps). 8. If there is electrical capture, check for femoral pulse. 9. If no capture occurs with maximum output, discontinue pacing and resume ACLS. Complications 1. Ventricular fibrillation and ventricular tachycardia are rare complications, follow appropriate protocols if either occur. 2. Pacing is rarely indicated in patients under the age of 12 years. 3. Muscle tremors may complicate evaluation of pulses, femoral pulse may be more accurate. 4. Pacing may cause diaphragmatic stimulation and apparent hiccups. Approved January 23, 2017 Index 43 55 Procedure Protocol: Restraint Protocol Indications: A. Physical restraint of patients is permissible and encouraged if the patient poses a danger to him/her self or to others. Only reasonable force is allowable, i.e., the minimum amount of force necessary to control the patient and prevent harm to the patient or others. Try alternative methods first (e.g., verbal de-escalation should be used first if the situation allows). B. Restraints may be indicated for patients who meet any of the following criteria: 1. A patient who is significantly impaired (e.g. intoxication, medical illness, injury, psychiatric condition, etc) and lacks decision-making capacity regarding his or her own care. 2. A patient who exhibits violent, combative or uncooperative behavior who does not respond to verbal de-escalation. 3. A patient who is suicidal and considered to be a risk for behavior dangerous to his/ herself or to healthcare providers. 4. A patient who is on a Mental Health Hold C. Paramedic: Consider pharmacological treatment (sedation) of agitation in patients that require transport and are behaving in a manner that poses a threat to him/her-self or others and in whom physical restraint is not possible or effective. 1. ref. Combative Patient Protocol: (The term “chemical restraint” is no longer preferred) Precautions: A. When appropriate, involve law enforcement B. Restraints shall be used only when necessary to prevent a patient from seriously injuring him/ herself or others (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be accomplished without restraints. They may not be used as punishment, or for the convenience of the crew. C. Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts to restrain a patient should only be done with adequate assistance present. D. Be sure to evaluate the patient adequately to determine his/ her medical condition, mental status and decision-making capacity. E. Do not use hobble restraints and do not restrain the patient in the prone position or any position that is impairing the airway or breathing. F. Search the patient for weapons. G. Handcuffs are not appropriate medical restraints and should only be placed by law enforcement personnel. ref. Handcuffed Pt Protocol. Technique: A. Treat the patient with respect. Attempts to verbally reassure or calm the patient should be done prior to the use of restraints. To the extent possible, explain what is being done and why. B. Have all equipment and personnel ready (restraints, suction, a means to promptly remove restraints). C. Use assistance such that, if possible, 1 rescuer handles each limb and 1 manages the head or supervises the application of restraints. D. Apply restraints to the extent necessary to allow treatment of, and prevent injury to, the patient. Inadequate-restraint may place patient and provider at greater risk. E. After application of restraints, check all limbs for circulation. During the time that a patient is in restraints, continuous attention to the patient’s airway, circulation and vital signs is mandatory. A restrained patient may never be left unattended. 44 Approved January 23, 2017 Index 55 Procedure Protocol: Restraint Protocol Documentation : Document the following in all cases of restraint: A. Description of the facts justifying restraint B. Efforts to de-escalate prior to restraint C. Type of restraints used D. Condition of the patient while restrained, including reevaluations during transport E. Condition of the patient at the time of transfer of care to emergency department staff F. Any injury to patient or to EMS personnel Complications: A. Aspiration: continually monitor patients airway B. Nerve injury: assess neurovascular status of patients limbs during transport C. Complications of medical conditions associated with need for restraint 1. Patients may have underlying trauma, hypoxia, hypoglycemia, hyperthermia, hypothermia, drug ingestion, intoxication or other medical conditions. D. Excited Delirium Syndrome. This is a life-threatening medical emergency. These patients are truly out of control. They will have some or all of the following symptoms: paranoia, disorientation, hyper-aggression, hallucination, tachycardia, increased strength, and hyperthermia. Approved January 23, 2017 45 Index 60 Procedure Protocol: Tourniquet Protocol Indications A. A tourniquet may be used to control potentially fatal hemorrhage only after other means of hemorrhage control have failed. Precautions A. A tourniquet applied incorrectly can increase blood loss. B. Applying a tourniquet can cause nerve and tissue damage whether applied correctly or not. Proper patient selection is of utmost importance. C. Injury due to tourniquet is unlikely if the tourniquet is removed within 1 hour. In cases of life threatening bleeding benefit outweighs theoretical risk. D. A commercially made tourniquet is the preferred tourniquet. If none is available, a blood pressure cuff inflated to a pressure sufficient to stop bleeding is an acceptable alternative. Other improvised tourniquets are not allowed. E. Do not place tourniquet to control bleeding from a Fistula or port. Control those bleeds with direct pressure or “pinching” the line directly. Technique A. First attempt to control hemorrhage by using direct pressure over bleeding area. B. If a discrete bleeding vessel can be identified, point pressure over bleeding vessel is more effective than a large bandage and diffuse pressure. C. If unable to control hemorrhage using direct pressure, apply tourniquet according to manufacturer specifications and using the steps below: 1. Cut away any clothing so that the tourniquet will be clearly visible. NEVER obscure a tourniquet with clothing or bandages. 2. Apply tourniquet proximal 2-4” above the wound and not across any joints. 3. Tighten tourniquet until bleeding stops. Applying tourniquet too loosely will only increase blood loss by inhibiting venous return. 4. Mark the time and date of application on the patient’s skin next to the tourniquet. 5. Keep tourniquet on throughout hospital transport – a correctly applied tourniquet should only be removed by the receiving hospital. 46 Approved January 23, 2017 Index 65 Procedure Protocol: Needle Thoracostomy for Tension Pneumothorax Decompression Indication: A. Needle decompression of tension pneumothorax is a standing order for Paramedics. B. All of the following clinical indicators must be present: 1. Severe respiratory distress / Hypotension / Unilateral, absent, or decreased breath sounds OR 2. Traumatic Pulseless arrest with trauma to trunk (perform bilateral needle thoracostomy) Technique: A. Expose entire chest B. Clean skin overlying site with available skin prep C. > 12 year old: Insert Air Release System (ARS) catheter at 2nd intercostal space at midclavicular line. D. < 12 year old use 18g 1 ½ “ angiocath at 2nd intercostal space at midclavicular line. E. Notify receiving hospital of needle decompression attempt Precautions: A. A simple pneumothorax is NOT an indication for needle decompression Approved January 23, 2017 Index 47 70 Procedure Protocol: Intraosseous Catheter Protocol Indications A. Primary vascular access device in a patient with critical illness defined as: 1. Cardiopulmonary arrest or impending arrest 2. Profound shock (systolic BP < 80) with poor perfusion (Adult patient) 3. Decompensated shock (adult patient) 4. Decompensated shock based on hypotension for age. (pediatric patient) B. Utilization of IO access for all other patients requires BASE CONTACT WITH (AIP, Chilren’s, TMCA, CMP, SaddleRock) E.g.: Hypoglycemia with severe symptoms (e.g. unresponsive) and no venous access Technique: A. Site: tibial plateau, 2 fingerbreadths below the tibial tuberosity on the anteromedial surface of tibia. B. Clean skin with povidone-iodine. C. Place intraosseous needle perpendicular to the bone. D. Follow manufacturer’s guidelines specific to the device being used for insertion. E. Entrance into the bone marrow is indicated by a sudden loss of resistance. F. Flush line with 10 cc saline. Do not attempt to aspirate marrow G. Secure line 1. Even if properly placed, the needle will not be secure. The needle must be secured and the IV tubing taped. The IO needle should be stabilized at all times. H. Observe for signs of limb swelling, decreased perfusion to distal extremity that would indicate a malpositioned IO catheter or other complication. If limb becomes tense or malperfused, disconnect IO tubing immediately and leave IO in place. I. A person should be assigned to monitor the IV at the scene and en route to the hospital. J. Do not make more than one IO placement attempt per bone. K. Do not remove IO needles in the field. L. Notify hospital staff of all insertion sites/attempts and apply patient wristband included with kit to identify IO patient. Complications: A. Fracture B. Compartment syndrome C. Infection Contraindications: A. DO NOT USE EZ IO Drill for patients less than 3kg (Shorter than grey color on Broselow) – Pink EZ IO needle should be placed by hand. B. DO NOT USE EZ IO Drill for newborns (pts less than 24 hours old) – Pink EZ IO needle should be placed by hand. C. Fracture of target bone D. Cellulitis (skin infection overlying insertion site) E. Osteogenesis imperfecta (rare condition predisposing to fractures with minimal trauma) F. Total knee replacement (hardware will prevent placement) Side Effects and Special Notes: A. Aspiration of marrow fluid or tissue to confirm needle location is not recommended for field procedures, as it increases the risk of plugging the needle. B. Expect flow rates to be slower than peripheral IVs. Pressure bags may be needed. Any drug or IV fluid may be infused. Approved January 23, 2017 Index 48 75 Vascular Access Devices Specific Information Needed: A. Obtain pertinent medical history if possible. B. Obtain any information possible regarding the type of Vascular Access Device (VAD), number of lumens, purpose of the VAD, etc. Indications A. To obtain rapid venous access for the critical patient when peripheral access cannot be obtained. Precautions A. Obtain information and assistance from family members or home health professionals who are familiar with the device. B. Discontinue any intermittent or continuous infusion pumps. C. Assure placement and patency of the VAD prior to infusing any fluids or medications. D. Flush the catheter completely with sterile normal saline. E. Use aseptic technique. Central Venous Catheters or PICC Lines A. Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of VAD. B. Identify the location and type of VAD (i.e. central venous catheter, peripheral inserted central catheter). C. Utilize knowledgeable family members, significant others or home visiting nurse if available. D. Discontinue and/or disconnect any pumps or medications. E. Clamp the VAD closed to prevent air embolus. F. If multiple lumen, identify the lumen to be used. G. Utilize aseptic technique. H. Briskly wipe the injection cap with an alcohol and/or povidone-iodine pad. I. Insert the needle (attached to syringe) into the cap. Aspirate slowly for a positive blood return. Obtain blood samples if necessary. Then flush the line with solution. J. Insert the needle (attached to a medication syringe or IV tubing) and infuse medications or fluids. K. Secure the IV tubing. L. Reassess the infusion site. M. Reassess patient condition. Implanted Ports A. Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of the VAD. B. Identify the location and type of VAD (e.g. implanted port). C. Utilize knowledgeable family members, significant others or home visiting nurse if available. D. Discontinue and/or disconnect any pumps or medications. E. Carefully palpate the location of the implanted port. F. If multiple ports, identify the port to be used. G. Using sterile technique, prep the site with alcohol and/or povidone-iodine pad. Wipe from the center outward three times in a circular motion. H. Using a sterile gloved hand, press the skin firmly around the edges of the port. I. Using a syringe filled with solution, insert the needle perpendicular to the skin. J. Aspirate slowly for blood return, then flush the port prior to infusion. When aspirating blood from a VAD, use a syringe that is 10cc or less to avoid complications. K. Secure the IV tubing. L. Reassess the infusion site. M. Reassess the patient. Approved January 23, 2017 49 Index 75 Vascular Access Devices Complications A. Patients with VADs are very susceptible to site infection or sepsis. Use sterile techniques at all times. B. Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is suspected, do not utilize the lumen. C. Rarely, a catheter will migrate. The symptoms may include the following: 1. burning with infusion 2. site bleeding 3. shortness of breath 4. chest pain 5. tachycardia 6. hypotension D. If a catheter migration is suspected, do not use the VAD and treat the patient according to symptoms. E. Catheters are durable but may leak or be torn. Extravasation of fluids or medications occurs and may cause burning and tissue damage. Clamp the catheter and do not use. F. Air embolism may occur if the VAD is not clamped in between infusions. Avoid this by properly clamping the catheter and preventing air from entering the system. Approved January 23, 2017 50 Index 100 Adult Epistaxis Management Active Nosebleed ABCs Compress nostrils with clamp or fingers, pinching over fleshy part of nose, not bony nasal bridge, for 10 minutes Transport in position of comfort, usually sitting upright Tilt Head Forward Have pt blow nose to expel clots Spray both nares with ref. Phenylephrine Reapply clamp or fingers pinching over fleshy part of not, not bony nasal bridge for 10 minutes. IV access and IV fluid bolus if signs of ref. hypoperfusion/shock. Approved January 23, 2017 51 Index 100 Adult Epistaxis Management General Guidelines: • Most nose bleeding is from an anterior source and may be easily controlled • Avoid phenylephrine in pts with known CAD • Anticoagulantion with aspirin, clopidogrel (Plavix), warfarin (Coumadin) will make epistaxis much harder to control. Note if your patient is taking these or other anticoagulant medications • Posterior epistaxis is a true emergency and may require advanced ED techniques such as balloon tamponade or interventional radiology. Do not delay transport. Be prepared for potential airway issues. • Patients using nasal cannula oxygen may have cannula placed in mouth while nares are clamped or compressed for nosebleed. Approved January 23, 2017 52 Index 105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible 2 Person BVM with OPA/NPA and capnography Effective oxygenation and ventilation? * No Yes Ref. i-gel O2 Airway Yes Effective oxygenation and ventilation? * No 2 Person BVM with OPA/NPA and capnography Effective oxygenation and ventilation? * Yes No Ref. Orotracheal Intubation, Nasotracheal Intubation Yes Effective oxygenation and ventilation? * No 2 Person BVM with OPA/NPA and capnography Effective oxygenation and ventilation? * Yes No Ref. Cricothyrotomy Continue Oxygenating and Ventilating patient Ref. i-gel O2 Airway in all cases of cardiac arrest Approved January 23, 2017 * Signs of adequate oxygenation / ventilation Examples include: a. Good CO2 Waveform b. Compliance with BVM c. Chest rise and fall d. Bilateral breath sounds e. Positive response to therapy 53 Index 105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations Indications A. Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory depression. B. To apply positive pressure ventilation in patients with pulmonary edema and severe fatigue. C. To ventilate patients in respiratory arrest. D. To ventilate patients in cardiac arrest. Precautions A. Two people are required to obtain an adequate mask fit and also ventilate. B. Assisted ventilation will not hurt a patient, and should be used whenever the breathing pattern seems shallow, slow, or otherwise abnormal. Do not be afraid to be aggressive about assisting ventilation, even in patients who do not require or will not tolerate advanced airways. Technique A. B. C. D. E. F. G. Open the airway. Check for ventilation. Administer ventilations. If unsuccessful, go to Airway Obstruction protocol. Check pulse. If absent, go to Cardiac Arrest protocol. Attach oxygen to BVM. Attach Capnography sensor to BVM. Measure and insert OPA / NPA as indicated / tolerated Position yourself above patient's head, continue to hold airway position, seat mask firmly on face, and begin assisted ventilation. H. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust mask fit as needed. I. If patient resumes spontaneous respirations, ref. oxygen. Intermittent assistance with ventilation may still be needed. J. Continuous monitoring of pulse oximetry is required. Complications A. B. C. D. E. Continued aspiration of blood, vomitus, and other upper airway debris Inadequate ventilations due to poor seal between patient's mouth and ventilatory device Gastric distention, possibly causing vomiting Trauma to the upper airway from forcible use of airways Pneumothorax Signs of Adequate oxygenation / ventilation A. B. C. D. E. Compliance with bag Chest rise and fall Bilateral breath sounds Good CO2 waveform Positive response to therapy Approved January 23, 2017 Index 54 110 Adult Obstructed Airway: Conscious Patient Attempt to determine cause of obstruction Does patient show signs of choking? Assess severity of obstruction Mild or Partial Obstruction (patient can speak) Severe or Complete Obstruction (mute, silent cough, severe stridor) Perform abdominal thrusts until obstruction relieved or patient loses consciousness For visibly pregnant or obese patients perform chest thrusts instead Consider chest thrusts in any patient if abdominal thrust ineffective If patient loses consciousness. Ref. Adult Obstructed Airway: Unconscious Do not interfere with a spontaneously breathing or coughing patient Position of comfort Give high flow oxygen Suction if needed Is obstruction cleared? Yes Transport POC O2 via NRB 15 Lpm Monitor ABCs, SpO2, vital signs Suction PRN and be prepared for vomiting, which commonly occurs after obstruction relieved No Supportive care and rapid transport If patient deteriorating or develops worsening distress proceed as for complete obstruction 55 Approved January 23, 2017 Index 111 Adult Obstructed Airway: Unconscious Patient If cause of airway obstruction is readily apparent, attempt removal Open airway with head tilt-chin lift Open airway with jaw thrust if craniofacial trauma present / suspected Ventilate pt with BVM / capnography using two person technique. Ability to ventilate? Yes No Perform laryngoscopy Use McGill forceps to remove object if possible Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation Ability to ventilate? Yes No Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation Perform 30 chest compressions Open pt mouth and remove obstruction if seen. Open airway and ventilate pt with BVM / capnography using two person technique. Ability to ventilate? Yes No Ref. oral intubation & attempt to push object into mainstem bronchus with ETT if suspected subglottic obstruction. Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation Ability to ventilate? Yes Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation No Ref. percutaneous cricothyrotomy if suspected supraglottic obstruction. Transport Notify medial branch of Cricothyrotomy attempt 56 Approved January 23, 2017 Index 115 Adult Respiratory Distress Respiratory Distress For all patients: While assessing ABCs: give supplemental O2, monitor vital signs, cardiac rhythm, and SpO2 Patent Airway? NO YES Are ventilations adequate for physiologic state? NO ref. Obstructed Airway Protocol: Conc. Obstructed Airway Protocol: Unconc. Ref. Adult Respiratory Failure / Arrest YES Is SpO2 > 90% with high flow O2 NO ref. CPAP YES Is anaphylaxis likely? YES ref. Allergy/Anaphylaxis NO Is Asthma likely? YES ref. Asthma NO Is COPD likely? YES ref. COPD NO Is CHF/Pulmonary edema likely? YES ref. CHF or Pulmonary edema NO Transport • Provide supportive care • Maximize oxygenation and ventilation • CONTACT BASE if needed for consult • 12 lead ECG q 5 min Approved January 23, 2017 57 Index 115 Adult Respiratory Distress Consider pulmonary and non-pulmonary causes of respiratory distress: • Pulmonary embolism • Pneumonia • Heart attack • Pneumothorax • Sepsis • Metabolic acidosis (e.g.: DKA) • Anxiety Mixed picture may exist: • Goal is maximization of oxygenation and ventilation in all cases • CPAP may be particularly useful in mixed picture with hypoxia and/or hypoventilation • Avoid albuterol in suspected pulmonary edema Don’t over-diagnose psychogenic causes of respiratory distress in the field. Your patient could have a pulmonary embolus or other serious problem; give him/her the benefit of the doubt. Treatment with oxygen will not harm the “hyperventilator”, and it will keep you from underestimating the problem. 58 Approved January 23, 2017 Index 120 Adult Asthma Routine Medical Assessment Respiratory Distress Protocol and prepare for transport Severe Attack Grossly abnormal respiratory rate, loud wheezes, or so tight no wheezes are heard, anxiety, gray or ashen skin color, diaphoresis Moderate Attack Marked increase in respiratory rate, wheezes easily heard and accessory muscle breathing. ref. Albuterol + ref. Ipratropium ref. Epinephrine IM ref. Albuterol + ref. Ipratropium Adequate response to treatment? Yes Monitor response to treatment Continue cardiac monitoring and SPO2 en route Be prepared to assist ventilations as needed Transport Mild Attack Slight increase in respiratory rate, mild wheezes, good skin color. Adequate response to treatment? Yes No ref. Epinephrine IM No Adequate response to treatment? Yes Monitor response to treatment Continue cardiac monitoring and SPO2 en route Be prepared to assist ventilations as needed Transport No Concern for impending respiratory failure? ref. CPAP ref. Adult Resp Failure/Arrest Adequate response to treatment? Therapeutic Goals: Maximize oxygenation / ventilation Decrease work of breathing Identify cardiac ischemia (Obtain 12 lead ECG q 5 min) Identify complications, e.g. pneumothorax Yes No ref. Magnesium IV ref. Methylprednisone IV 59 Approved January 23, 2017 Index 121 Adult COPD Routine Medical Assessment Respiratory Distress Protocol and prepare for transport Severe Attack Grossly abnormal respiratory rate, loud wheezes, or so tight no wheezes are heard, anxiety, gray or ashen skin color, diaphoresis ref. Albuterol + ref. Ipratropium ref. Albuterol + ref. Ipratropium Adequate response to treatment? Adequate response to treatment? Yes Monitor response to treatment Continue cardiac monitoring and SPO2 en route Be prepared to assist ventilations as needed Transport Mild Attack Slight increase in respiratory rate, mild wheezes, good skin color. Moderate Attack Marked increase in respiratory rate, wheezes easily heard and accessory muscle breathing. Yes No No Adequate response to treatment? Yes No Concern for impending respiratory failure? Monitor response to treatment Continue cardiac monitoring and SPO2 en route Be prepared to assist ventilations as needed Transport ref. CPAP ref. Adult Resp Failure/Arrest Adequate response to treatment? Yes No ref. Methylprednisone IV 60 Approved January 23, 2017 Index 121 Adult COPD Therapeutic Goals: Maximize oxygenation / ventilation Decrease work of breathing Identify cardiac ischemia (Obtain 12 lead ECG q 5 min) Identify complications, e.g. pneumothorax NOTES: • Correct hypoxia: do not withhold maximum oxygen for fear of CO2 retention • Consider pulmonary and non-pulmonary causes of respiratory distress: Examples: pulmonary embolism, pneumonia, pulmonary edema, anaphylaxis, heart attack, pneumothorax, sepsis, metabolic acidosis (e.g.: DKA), Anxiety • Patients with COPD are older and have comorbidities, including heart disease. • Wheezing may be a presentation of pulmonary edema, “cardiac asthma” • Common triggers for COPD exacerbations include: Infection, dysrhythmia (e.g.: atrial fibrillation), myocardial ischemia • CPAP may be very helpful in severe COPD exacerbation, however these patients are at increased risk of complications of CPAP Nosuch as hypotension and pneumothorax. Cardiopulmonary monitoring is mandatory. 61 Approved January 23, 2017 Index Index 125 Adult CHF / Pulmonary Edema Routine Medical Assessment Respiratory Distress Protocol and prepare for immediate transport ref. Nitroglycerine Yes Is oxygenation and ventilation adequate? No Yes ref. CPAP 12 lead ECG q 5 min: rule out unstable rhythm, ACS Is response to treatment adequate? No If failing above therapy: Remove CPAP and ventilate with BVM Assess for Pneumothorax Consider alternative causes/complications Monitor response to treatment Continue cardiac monitoring (12 lead ECG q 5 min), SPO2 en route Be prepared to assist ventilations as needed Therapeutic Goals: Maximize oxygenation Decrease work of breathing Identify cardiac ischemia (Obtain 12 lead ECG q 5 min) Approved January 23, 2017 Index 62 130 Adult Allergy and Anaphylaxis Allergic reaction, anaphylaxis or angioedema Assess ABCs, give oxygen If possible, determine likely trigger Determine PMH, medications, allergies Classify based on symptom severity and systems involved Other specific protocols may apply: e.g.: obstructed airway, bites & envenomations Localized Reaction Including isolated tongue, airway Generalized or Systemic Reaction Multisystem involvement: skin, lungs, airway, etc Does patient have any 2 of the following signs or symptoms of anaphylaxis? Hypotension Signs of poor perfusion Bronchospasm, stridor Altered mental status Urticaria No ref. diphenhydramine No Airway involvement? Tongue or uvula swelling, stridor Transport and reassess for signs of deterioration Yes Impending airway obstruction? Yes Yes No ref. epinephrine IM, then: Start IV and give IV fluid bolus 20cc/kg NS ref. diphenhydramine ref. methylprednisolone ref. albuterol if wheezing Immediately ref. epinephrine IM & manage airway and ref. Adult Resp Failure/Arrest Start IV ref. diphenhydramine ref. methylprednisolone Monitor ABCs, SpO2, cardiac rhythm Reassess for signs of deterioration If persistent signs of severe shock with hypotension not responsive to IM epinephrine and fluid bolus: Repeat IM ref. epinephrine Contact Base 63 Approved January 23, 2017 Index 130 Adult Allergy and Anaphylaxis Definitions: Anaphylaxis: severe allergic reaction that is rapid in onset and potentially life-threatening. Multisystem signs and symptoms are present including skin and mucus membranes o Mainstay of treatment is epinephrine Angioedema: deep mucosal edema causing swelling of mucus membranes of upper airway. May accompany hives Document: History of allergen exposure, prior allergic reaction and severity, medications or treatments administered prior to EMS assessment Specific symptoms and signs presented: itching, wheezing, respiratory distress, nausea, weakness, rash, anxiety, swelling of face, lips, tongue, throat, chest tightness, etc. EMT-B may use pt prescribed Epipen auto injector if available. 64 Approved January 23, 2017 Index 2000 Adult Cardiac Arrest General Principles - ACLS General Considerations • Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime before CPR and duration of CPR • Past History: medications, medical history, suspicion of ingestion, trauma, environmental factors (hypothermia, inhalation, asphyxiation) Penetrating and Blunt trauma arrest: Ref. Trauma Arrest Cardiac arrest from the following causes should approached as a medical cardiac arrest: overdose, respiratory arrest, airway obstruction, asphyxiation, hanging, drowning, electrocution, and lightning/high voltage Document Specific Objective Findings • Unconscious, unresponsive • Agonal, or absent respirations • Absent pulses • Any signs of trauma, blood loss • Skin temperature General Guidelines: Chest Compressions • Push hard and push fast (at least 100/minute) • Ensure full chest recoil • Rotate compressors every 2 minutes with rhythm checks • During CPR, any interruption in chest compressions deprives heart and brain of necessary blood flow and lessens chance of successful defibrillation o Continue CPR while defibrillator is charging, and resume CPR immediately after all shocks. Do not check pulses except at end of CPR cycle and if rhythm is organized at rhythm check General Guidelines: Defibrillation • In unwitnessed cardiac arrest, give first 2 minutes of CPR. If arrest is witnessed by EMS, immediate defibrillation is first priority • All shocks should be given as single maximum energy shocks o Manual biphasic: 150J (Phillips MRx) o AED: device specific General Guidelines: Ventilation during CPR • EMS personnel must use good judgment in assessing likely cause of pulseless arrest. In patients suspected of having a primary respiratory cause of cardiopulmonary arrest, (e.g.: COPD or status asthmaticus), adequate ventilation and oxygenation are a priority • In general, patients with cardiac arrest initially have adequately oxygenated blood, but are in circulatory arrest. Therefore, chest compressions are initially more important than ventilation to provide perfusion to coronary arteries • Do not interrupt chest compressions and do not hyperventilate. Hyperventilation decreases effectiveness of CPR and worsens outcome. •Compressions should be given continuously and breaths given asynchronously at 8-10 per minute • Always confirm ventilator effectiveness with ETCO2 (continuous waveform capnography) • i-gel O2 is preferred for adult patients in cardiac arrest and should be placed according to ref. Adult Cardiac Arrest Core Competencies Approved January 23, 2017 65 Index 2000 Adult Cardiac Arrest General Principles - ACLS General Guidelines: Pacing • Pacing is not indicated for asystole and PEA. Instead start chest compressions according to Ref. Asystole / PEA • Pacing should not be undertaken if it follows unsuccessful defibrillation of VT/VF as it will only interfere with CPR and is not effective General Guidelines: ICD/Pacemaker patients • If cardiac arrest patient has an implantable cardioverter defibrillator (ICD) or pacemaker: place pacer/defib pads at least 1 inch from device (anterior / posterior). 66 Approved January 23, 2017 Index 2001 Adult Cardiac Arrest General Principles – ACLS START CPR Give Oxygen Attach monitor/defibrillator CHECK RHYTHM IF VF/VT SHOCK Drug Therapy IV/IO Access Epi q 3-5 4 minutes Amiodarone for refractory VF/VF Oxygenate and Ventilate Quantitative waveform capnography Treat Reversible Causes Approved January 23, 2017 Index 67 2010 Adult Pulseless Arrest– BLS / AED No movement or response? Open airway and check breathing If not breathing give 2 breaths that cause chest to rise If still not responsive, check pulse. Is there a DEFINITE pulse? NO Yes Give 1 breath every 6 seconds. Recheck pulse every 2 minutes. Give 200 uninterrupted chest compressions (2 minutes) Continue compressions and ventilations until AED arrives, ALS assumes care, or patient starts to move. AED arrives Turn AED on, follow voice prompts. Approved January 23, 2017 68 2020 Adult Pulseless Arrest – VF / VT Start chest compressions Consider circumstances of arrest: Witnessed by EMS = immediate rhythm check Unwitnessed by EMS = 2 minutes CPR o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator Routine medical assessment VF / VT SHOCK 2 min CPR Ref. Adult Respiratory Failure/Arrest ROSC Rhythm Check ASYSTOLE/PEA VF / VT SHOCK 2 min CPR ref. IO / IV ROSC ASYSTOLE/PEA AA Rhythm Check VF / VT SHOCK 2 min CPR ref. Epinephrine q 4 min ROSC Rhythm Check ASYSTOLE/PEA VF / VT Ref. ROSC SHOCK Ref. Asystole / PEA 2 min CPR ref. Amiodarone Go To Box “A” Approved January 23, 2017 After 15 minutes of ALS Care: Continue resuscitation and Transport Index Index 69 2020 Adult Pulseless Arrest – ALS – ACLS Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history 1 g of Calcium gluconate /or 500mg of Calcium chloride and 2 amps Sodium bicarbonate. Flush IV line between meds Suspected Torsades de Pointe: Ref. Magnesium Suspected Hypothermia: Single dose of Epinephrine IV/ IO for Pulseless Arrests associated with Asystole, Vfib/ VT. For Vfib/ VT: single attempt defibrillation only Shock energy: All shocks at 150joules (Philips MRx) Reversible Causes: Hypovolemia Hypoxia H+ (Acidosis) Hypo/Hyperkalemia Hypothermia Tension Pneumothorax Approved January 23, 2017 Tamponade (cardiac) Toxins Thrombosis: PE, AMI 70 2021 Adult Pulseless Arrest Asystole / PEA Start chest compressions Consider circumstances of arrest: 2 minutes CPR o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator Routine medical assessment Treat reversible causes Asystole / PEA 2 min CPR Ref. Adult Respiratory Failure/Arrest ROSC Rhythm Check VF / VT Asystole / PEA 2 min CPR ref. IO / IV ROSC VF / VT A Rhythm Check Asystole / PEA Ref. ROSC 2 min CPR ref. Epinephrine q 4 min Ref. VF / VT Go To Box “A” After 15 minutes of ALS Care: Asystole = CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for consideration of TOR at any point if continuous asystole. Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. Include the AFR incident number on the strip. PEA = Continue resuscitation and Transport 71 Approved January 23, 2017 Index 2025 Adult Return of Spontaneous Circulation ROSC after Cardiac Arrest Reassess ABCs Obtain baseline vitals 12 lead EKG q 5 minutes Recurrent dysrhythmia? STEMI? YES Treat per protocol YES Initiate Cardiac Alert Place head of bed at 30degrees elevation Systolic BP <90 YES Assess for purposeful response Purposeful Response? Approved January 23, 2017 If NOT hypervolemic, administer 1000 ml Normal Saline bolus If persistent SBP < 90 after 1000ml saline bolus, ref. Dopamine YES Continue to monitor cardiac rhythm / pulse 72 Index 2030 Adult Tachyarrhythmia Assess appropriateness for clinical condition Heart rate typically > 150/min if tachyarrhythmia Routine Medical Assessment Identify and treat underlying cause YES NO Search for and treat underlying cause: e.g.: dehydration, fever, hypoxia, hypovolemia, pain Sinus Tachycardia? IS PATIENT UNSTABLE? A YES Unstable signs include any two of the following: Altered mental status Symptoms compatible with Acute Coronary Syndrome (ACS) (chest pain, diaphoresis, dyspnea, etc) Hypotension B UNSTABLE Ref. Synchronized Cardioversion NO STABLE 12 Lead EKG q 5 minutes Narrow QRS < 0.12sec REGULAR Valsalva maneuver ref. Adenosine if suspected AVNRT (formerly known as PSVT) Wide QRS > 0.12sec IRREGULAR A-Fib, A-Flutter or MAT Do NOT give Adenosine If pt. becomes unstable go to box B Monitor in transport Does rhythm convert? REGULAR V-Tach (>80%) or SVT with aberrancy Contact Base ref. Amiodarone IRREGULAR Contact Base for consult Do NOT give adenosine If pt becomes unstable go to box B If regular and polymorphic (Torsades de Pointes) Magnesium NO YES CONVERTS Monitor in Transport If recurrent dysrhythmia go to box A DOESN’T CONVERT Contact base for consult Monitor in transport If unstable, go to box B Approved January 23, 2017 73 Index Index 2040 Adult Bradycardia HR <50 and inadequate for clinical condition Routine Medical Assessment Identify and treat underlying cause IS PATIENT UNSTABLE? Unstable signs include any two of the following: Altered mental status Symptoms compatible with Acute Coronary Syndrome (ACS) (chest pain, diaphoresis, dyspnea, etc) Hypotension NO YES STABLE UNSTABLE Vascular Access? NO YES ref. Atropine If atropine ineffective begin pacing ref. Dopamine if pacing ineffective 12 lead EKG q 5 minutes Transport and Monitor for deterioration Prepare for immediate pacing If pacing ineffective ref. Atropine ref. Dopamine if atropine ineffective If the pt is not being paced perform 12 lead EKG q 5 minutes Transport and Monitor for deterioration Approved January 23, 2017 Index 74 2050 Adult Chest Pain Consider life threatening causes of chest pain* in all patients. While assessing ABCs ref. Oxygen, monitor vital signs, cardiac rhythm, start IV. 12 lead EKG q 5 min if possible acute coronary syndrome Ref. Aspirin if possible acute coronary syndrome STEMI? YES Initiate Cardiac Alert Ref. Nitroglycerine if suspected acute coronary syndrome. For hypotension following NTG administration give 250mL NS bolus. Reassess and repeat bolus as needed. Do not administer additional NTG. Ref. Fentanyl for persistent pain that is not relieved by 3 doses of SL Nitroglycerine in noninferior wall MIs and without prior Nitroglycerin in inferior wall MIs. *Life Threatening Causes of Chest Pain Acute coronary syndrome (ACS) Pulmonary embolism Thoracic aortic dissection Tension Pneumothorax Considerations: 20-30% of patients in the cath. lab, who have confirmed AMI’s, have reproducible chest pain upon palpation Only 30% of patients experiencing an Acute Myocardial Infarction will present with ST Segment Elevation. Approved January 23, 2017 75 Index Index 2050 Adult Chest Pain General: A. Consider life-threatening causes of chest pain first in all patients: 1. Acute coronary syndromes (ACS) 2. Pulmonary embolism (PE) 3. Thoracic aortic dissection (TAD) 4. Tension pneumothorax (PTX) B. Do not delay obtaining 12 lead ECG, if available, and notify receiving facility immediately if Cardiac Alert criteria met. Document specific findings: A. Complete set of vital signs B. General appearance: skin color, diaphoresis C. Cardiovascular exam: presence of irregular heart sounds, JVD, murmur, pulse asymmetry, dependent edema D. Pulmonary exam: crackles/râles and/or wheezes/rhonchi E. Chest wall and abdominal tenderness Treatment: A. ABCs B. Reassure patient and place in position of comfort C. Place patient on cardiac monitor D. Ref. oxygen E. Start IV F. Paramedics: 1. Obtain 12-lead ECG. a. If patient has at least 1 mm ST segment elevation in at least 2 anatomically contiguous leads (STEMI), notify receiving hospital and request CARDIAC ALERT (ref. Cardiac Alert Protocol). 2. If history and physical exam suggest possible ACS: a. ref. aspirin b. ref. nitroglycerine c. ref. fentanyl for persistent pain that is not relieved by 3 doses SL nitroglycerine 3. Consider CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for additional medication orders if pain persists. G. EMTs: 1. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for verbal order for patient-assisted and supplied nitroglycerine if applicable Contraindications: A. If hypotension develops following nitroglycerine administration in any patient, treat with 250cc NS boluses. B. Nitroglycerine is contraindicated in patients taking medication for erectile dysfunction (phosphodiesterase inhibitors, e.g.: Viagra, Cialis, Revatio). C. Nitroglycerine is contraindicated in patients with pulmonary hypertension who are taking Revatio. D. Nitroglycerine is contraindicated in patients with Inferior STEMI pattern (Lead II, III, aVF) Approved January 23, 2017 76 2051 Adult Cardiac Alert Goal: A. To identify patients with ST-segment elevation myocardial infarction (STEMI) in the prehospital setting and provide advanced receiving hospital notification in order to minimize door-to-balloon times for percutaneous coronary intervention (PCI) Inclusion Criteria: (MUST MEET ALL 3 CRITERIA) A. Chest discomfort consistent with Acute Coronary Syndrome (ACS) or post ROSC (and) B. 12-lead ECG showing ST-segment elevation (STEMI) at least 2 mm in two or more anatomically contiguous leads (and) C. Age 35-85 years old *If STEMI patient outside inclusion criteria, advise receiving hospital of assessment/ findings* Exclusion Criteria: A. Paced rhythm, Left Bundle Branch Block B. If unsure if patient is appropriate for Cardiac Alert, discuss with receiving hospital MD Actions: A. ref. chest pain protocol en route B. Notify receiving hospital ASAP with ETA and request CARDIAC ALERT. Do not delay hospital notification. If possible, notify ED before leaving scene C. Start 2 large bore peripheral IVs D. Transport E. Acute coronary syndrome may present without chest discomfort and include symptoms such as upper abdominal pain, back/ shoulder/ arm pain, nausea/ vomiting, or shortness of breath. One should have a low threshold to obtain EKG in patients with such symptoms are reflective of ACS. CONTACT APPROPRIATE RECEIVING HOSPITAL PHYSICIAN for consultation and possible initiation of Cardiac Alert. Additional Documentation Requirements: A. Time of first patient contact B. Time of first ECG Approved January 23, 2017 77 Index 2100 Adult Hypertension Intent: A. Even with extremes of blood pressure, treat the medical emergency associated with hypertension (“treat the patient, not the number”) 1. Treat chest pain, pulmonary edema, or stroke according to standard protocols (pain control will usually improve BP significantly) B. Do not use medication to treat hypertension Approved January 23, 2017 78 Index 3000 Adult Syncope Specific Information Needed A. History of the event: onset, duration, seizure activity, precipitating factors. Was the patient sitting, standing, or lying? Pregnant? B. Past history: medications, diseases, prior syncope C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache, palpitations Specific Objective Findings A. B. C. D. Vital signs Neurological status: level of consciousness, residual neurological deficit Signs of trauma to the head or mouth or incontinence Neck stiffness Treatment A. Place patient in position of comfort: do not sit patient up prematurely; supine or lateral positioning if not completely alert B. Monitor vital signs and level of consciousness closely for changes or recurrence. C. Establish venous access and administer Normal Saline if indicated. D. Consider hypoglycemia. If signs of hypoglycemia are present ref. Hypoglycemia E. If vital signs unstable or age > 40 years: 1. Ref. Oxygen 2. Keep patient supine. 3. Establish venous access. 4. Monitor cardiac rhythm (12-lead EKG) Specific Precautions A. Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the patient is still unconscious, treat as coma. If the patient is confused, treat according to Altered Mental Status protocol. B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes. Recumbent position should be sufficient to restore vital signs and level of consciousness to normal. C. Syncope that occurs without warning or while in a recumbent position is potentially serious and often caused by an arrhythmia. D. Patients with syncope, even though apparently normal, should be transported. In middleaged or elderly patients, syncope can be due to a number of potentially serious problems. The most important of these to monitor and recognize are arrhythmias, occult GI bleeding, seizure, or ruptured abdominal aortic aneurysm. E. Any elderly patient with syncope and back pain should be considered to have a ruptured abdominal aortic aneurysm until proven otherwise. Approved January 23, 2017 Index 79 3010 Adult Stroke POSSIBLE STROKE (Acute onset neurological deficit not likely due to trauma) Assess and stabilize ABCs, ref.O2 Assess Cincinnati Prehospital Stroke Scale (Presence of single sign sufficient) Rule out or treat ref. hypoglycemia Determine when last KNOWN to be normal and document specific time “At 2:15 PM”, not “1 hour ago” Obtain medical history Document medications Identify family or friend who may assist with history and decision-making, get contact info and strongly encourage to come to ED as they may be needed for consent for treatments Start IV and draw blood Document cardiac rhythm Ensure full monitoring in place: cardiac, SpO2 Fully monitor patient and continually reassess: Improvement or worsening of deficit Adequacy of ventilation and oxygenation Cardiovascular stability Transport to CHC for pts < 12 years old. Notify receiving hospital of Stroke Alert Approved January 23, 2017 80 Index 3010 Adult Stroke Cincinnati Prehospital Stroke Scale Think “FAST” (face, arm, speech, time) Assess Facial Droop Say: “Smile for me”, or “Show me your teeth” Assess Arm Pronator Drift Demonstrate, and say: “Put your arms up for me like this and hold them while I count to 10” Assess Speech Say: “Repeat after me: you can’t teach on old dog new tricks”, or “No ifs, ands, or buts” The Cincinnati Prehospital Stroke Scale (CPSS) is designed to be very reproducible and identify those strokes most likely to benefit from reperfusion therapy, but does not identify all strokes. The CPSS is highly specific for stroke, but is not extremely sensitive, meaning if you have a positive CPSS, you are almost certainly having a stroke, but if you do not have a positive CPSS, you still may be having a stroke Stroke signs may be very subtle, therefore it is important to know other signs of stroke, which include: o Impaired balance or coordination o Vision loss o Headache o Confusion or altered mental status o Seizure Stroke Mimics Hypoglycemia Post-ictal paralysis Complex migraine Overdose Trauma Bell’s palsy 1. 2. 3. Stroke Alert Criteria Last known normal 8 hours or less BGL > 60 No seizure at onset or recent head trauma AND 1. 2. 3. Must have one or more new clinical signs New Speech impairment or aphasia Unequal smile or obvious facial asymmetry Arm weakness or drift 81 Approved January 23, 2017 Index 3011 Mobile Stroke Treatment Unit – Activation and Transfer of Care AFD Dispatched to Incident Review of CAD notes reveals possible Stroke patient AND Pt > 18 years old NO YES Do not request MSTU Response Request dispatch of MSTU via Aurora Comm. Center Treat and transport per protocol AFD arrival on scene Request 10 minute ticker Treat per protocol Does pt. meet Stroke Alert Criteria AND Pt > 18 years old YES NO Cancel MSTU response Treat per protocol Prepare pt for transport Treat and transport per protocol 10 minutes after AFD arrival MSTU NOT on scene Cancel MSTU Response Treat and transport per protocol MSTU Team DOES NOT accept transfer of care Treat and transport per protocol MSTU on scene Pt report made to MSTU team MSTU team ACCEPTS transfer of care Assist MSTU team loading pt into MSTU Pt care transferred to MSTU team 82 Approved January 23, 2017 Index 3020 Adult Altered Mental Status Altered Mental Status (AMS) Assess ABCs ref. Asystole / PEA or . VF / VT, respiratory distress or obstructed airway protocol as appropriate. Determine character of event Consider seizure, syncope and TIA Monitor and transport with supportive care No Persistent AMS? Yes Check BGL BGL < 60 mg/dL or clinical condition suggests hypoglycemia? Yes ref. Hypoglycemia protocol No Yes Seizure activity present? ref. Seizure protocol protocolprotocol No Perform rapid neurologic assessment including LOC and Cincinnati Prehospital Stroke Scale (CPSS) Focal neuro deficit or positive CPSS? Yes ref. Stroke protocol No Consider other causes of AMS: ref. overdose, Shock, heat emergency, cold emergency, EtOH Intoxication During transport: ref.O2, monitor vital signs, airway, breathing, and ECG. Give fluid bolus if volume depletion suspected Approved January 23, 2017 83 Index Index 3030 Adult Seizure Support ABCs: ref.O2 Seizure precautions Check BGL and ref. hypoglycemia Identify and treat reversible causes Actively Seizing? Check pulse and reassess ABC Give supplemental oxygen If seizure < 5 min medication not necessary If > 5 min or recurrent seizure then treat as follows: Transport and monitor ABCs, vital signs, and neurological condition Complete head to toe assessment ref. Midazolam via most readily available route Actively Seizing? No Common Causes of Seizures ref. Midazolam via most readily available route, IV preferred Actively Seizing? Epilepsy EtOH withdrawal or intoxication Hypoglycemia Stimulant use Trauma Intracranial hemorrhage Overdose (TCA) Eclampsia Infection: Meningitis, sepsis No Yes CONTACT BASE Approved January 23, 2017 84 Index 3030 Adult Seizure Seizure Precautions: Ensure airway patency, but do not force anything between teeth. NPA may be useful Give oxygen Suction as needed Protect patient from injury Check pulse immediately after seizure stops Keep patient on side Document: Document: Seizure history: onset, time interval, previous seizures, type of seizure Obtain medical history: head trauma, diabetes, substance abuse, medications, compliance with anticonvulsants, pregnancy Pregnancy and Seizure: If 3rd trimester pregnancy or post-partum: ref. pre eclampsia / eclampsia 85 Approved January 23, 2017 Index 4010 Adult Abdominal Pain / Vomiting Abdominal pain and/or vomiting Assess ABCs ref.O2 Complete set of Vital Signs Physical exam Ref. Hypotension / Shock as indicated Cardiac monitor and 12 lead ECG q 5 min if any one or more of the following: 1. Age > 50 2. Diabetic 3. Upper abdominal pain 4. Unstable vital signs ref.Ondansetron ref. Fentanyl Monitor and transport Frequent reassessment for deterioration and response to treatment 86 Approved January 23, 2017 Index 4010 Adult Abdominal Pain / Vomiting Abdominal exam: Gently palpate 4 quadrants, noting areas of tenderness, guarding, rigidity or distension Note any pulsatile mass Note surgical scars History: Onset, location, duration, radiation of pain Associated sx: vomiting, GU sx, hematemesis, coffee ground emesis, melena, rectal bleeding, vaginal bleeding, known or suspected pregnancy, recent trauma Elderly Patients: Much more likely to have life-threatening cause of symptoms Always consider vascular emergencies: AAA, MI Shock may be occult, with absent tachycardia in setting of severe hypovolemia 87 Approved January 23, 2017 Index 4020 Adult Overdose and Acute Poisoning PPE and decontaminate when appropriate ABCs IV, ref.O2, monitor Need for airway management? Yes ref. Naloxone Airway adjuncts and BVM ventilations as needed ref. resp.failure protocol No Hypotension? Yes IV fluid bolus ref. hypotension/shock protocol Yes Altered Mental Status Protocol ref. dopamine if no response to 20cc/kg NS bolus No Altered mental status? Consider specific ingestions No Known Specific ingestion? No Monitor Transport Yes Stimulant Tachycardia, HTN, agitation, sweating, psychosis ref.Combative Pt Tricyclic antidepressant Organophosphate or nerve agent Calcium Channel Blocker Wide complex tachycardia, seizure DUMBELS/SLUDGE syndrome Bradycardia, heart block, hypotension ref. Sodium bicarb for QRS > 120 msec ref.Atropine 20 cc/kg NS bolus Ref. Seizure ref.Nerve Agent Antidote Kit ref. Calcium and ref.dopamine ß-Blocker Bradycardia, heart block, hypotension 20 cc/kg NS bolus ref.Dopamine ref.Glucagon ref.Glucagon Approved January 23, 2017 Index 88 4020 Adult Overdose and Acute Poisoning Obtain specific information: Type of ingestion(s) What, when and how much ingested? Bring the poison, container, all medication and other questionable substances to the ED Note actions taken by bystanders or patient (e.g.: induced emesis, “antidotes”, etc) Supportive Care is key to overdose management 89 Approved January 23, 2017 Index 4025 Adult Hypoglycemia Check blood glucose level in ANY patient with signs or symptoms consistent with hypoglycemia. Use Capilarry blood for BGL sample Examples: Altered MS, agitation, focal neurologic deficit, seizure, weakness, diaphoresis, decreased motor tone, pallor If hypoglycemia still most likely despite normal reading on glucometer, administer sugar while considering other causes of ref. altered mental status No Is BGL < 60? Yes Can the patient safely tolerate oral glucose? intact gag reflex, follows verbal commands Yes ref. Oral Glucose Reassess patient No Yes ref. Glugacon IM No Still symptomatic? No Are you able to establish IV access? Yes ref. dextrose IV & reassess patient No Symptoms resolved? Recheck BGL and consider other causes of altered mental status Yes Monitor and transport or CONTACT BASE for refusal if indicated 90 Approved January 23, 2017 Index 4025 Adult Hypoglycemia Regarding refusals after a hypoglycemic episode: ref. Patient Non Transport protocol Transport is always indicated for the following patients: All pts with unexplained hypoglycemia Pts taking oral hypoglycemic meds Pts not taking PO Pts who do not have competent adult to monitor 91 Approved January 23, 2017 Index 4030 Adult Medical Hypotension / Shock Adult with SBP < 90 mmHg AND/OR signs of poor perfusion ABCs Complete set of vital signs Full monitoring O2 via NRB facemask @ 15L/min IV access Transport Signs of poor perfusion? Altered mental status Tachycardia Cool, clammy skin No Recheck and monitor If patient remains asymptomatic and clinically stable, further treatment may not be necessary Yes Life-threatening bradycardia or tachycardia? Yes Ref. bradycardia Ref. tachycardia No Consider etiology of shock state Give 20cc/kg NS bolus and reassess Repeat 20cc/kg boluses, reassessing for pulmonary edema, up to 2 liters total or until goal of SBP > 90 mmHg and signs adequate perfusion If patient is at risk for adrenal insufficiency, ref. Adrenal Insufficiency For ongoing hypotension, poor perfusion or pulmonary edema, CONTACT BASE ref.dopamine 92 Approved January 23, 2017 Index Index 4030 Adult Medical Hypotension Shock is a state of decreased tissue oxygenation. Significant vital organ hypoperfusion may be present without hypotension. Home medications and/or comorbidities may also limit development of tachycardia Goal is to maximize oxygen delivery with supplemental oxygen and assisted ventilations (if needed), and to maximize perfusion with IV fluids Consider the etiology of your patient’s shock state: Sepsis Hemorrhage Anaphylaxis Overdose Cyanide or Carbon Monoxide Poisoning Other: PE, MI, tension pneumothorax Approved January 23, 2017 93 4031 Adult Adrenal Insufficiency Patient at risk for adrenal insufficiency: Identified by family or medical alert bracelet Chronic steroid use Congenital Adrenal Hyperplasia Addison’s disease Assess for signs of acute adrenal crisis: Pallor, weakness, lethargy Vomiting, abdominal pain Hypotension, shock Congestive heart failure All symptomatic patients: Check blood glucose and treat hypoglycemia, if present Start IV and ref.O2 Give NS bolus IV 20 cc/kg up to 2 liters Does patient have hypotension and signs of poor perfusion? Altered mental status Tachycardia Cool, clammy skin Yes No Ref. Methylprednisolone 20 cc/kg NS bolus, as needed Continue to monitor for development of Hypoglycemia If otherwise considering administration of corticosteroid, CONTACT BASE for consult. Monitor 12 lead ECG q 5 min for signs of hyperkalemia Approved January 23, 2017 94 Index 4031 Adult Adrenal Insufficiency Notes: If the patient is confirmed to have a disease (such as congenital adrenal hyperplasia or chronic use of systemic steroids) that could lead to acute adrenal insufficiency or Addisonian crisis, then the administration of steroids may be life-saving and necessary for reversing shock or preventing cardiovascular collapse. Patients at risk for adrenal insufficiency may develop Addisonian crisis when under physiologic stress which would not lead to cardiovascular collapse in normal patients. Such triggers may include trauma, dehydration, infection, myocardial ischemia, etc. If no corticosteroid is available during transport, notify receiving hospital of need for immediate corticosteroid upon arrival. 95 Approved January 23, 2017 Index 4040 Adult Drowning ABCs Ref; Spinal Stabilization before moving patient if trauma suspected Assess mental status Awake and alert Awake but altered LOC Remove wet garments, dry and insulate patient Transport, even if initial assessment normal Monitor ABC, VS, mental status Remove wet garments, dry and insulate patient Suction as needed Start IV, check BGL, ref.O2 Transport Monitor ABC, VS, mental status Comatose or unresponsive Pulse Present? No Yes Monitor cardiac rhythm Start CPR, attach AED/monitor/defibrillator and treat Ref. Asystole / PEA or . VF / VT If suspected hypothermia ref. Hypothermia Remove wet garments, dry and insulate patient Heimlich maneuver NOT indicated Consider all causes of Altered Mental Status Suction as needed Start IV, obtain BGL and ref.O2 Monitor ABC, VS, mental status Monitor cardiac rhythm Approved January 23, 2017 Index 96 4040 Adult Drowning Specific Information Needed: Length of submersion Degree of contamination of water Water temperature Diving accident and/or suspected trauma Notes: Drowning/submersion commonly associated with hypothermia. Even profound bradycardias may be sufficient in setting of severe hypothermia and decreased O2 demand Good outcomes after even prolonged hypothermic arrest are possible Patients should not be pronounced dead until rewarmed in hospital BLS: pulse and respirations may be very slow and difficult to detect if patient is severely hypothermic. If no definite pulse, and no signs of life, begin CPR If not breathing, start rescue breathing ALS: Resuscitation medications are indicated 97 Approved January 23, 2017 Index 4050 Adult Hypothermia Hypothermia and Frostbite Localized cold injury Systemic hypothermia Presumed to be primary problem based on clinical scenario Frostbite, frostnip Remove wet garments, dry and insulate patient Transport, even if initial assessment normal Monitor ABC, VS, mental status Dress injured area lightly in clean cloth to protect from further injury Do not rub, do not break blisters Do not allow injured part to refreeze. Repeated thaw freeze cycles are especially harmful Monitor for signs of systemic hypothermia High flow O2 ABCs Awake but altered LOC Remove wet garments, dry and insulate patient Suction as needed Start IV, BGL, oxygen Transport Monitor ABC, VS, mental status Comatose or unresponsive Pulse Present? No Monitor cardiac rhythm Start CPR, attach AED/monitor/defibrillator and treat per Pulseless Arrest VF / VT or Pulseless Arrest Asystole / PEA with following changes: Yes Remove wet garments, dry and insulate patient ref. Altered Mental Status Suction as needed Start IV, check BGL and give oxygen Transport Monitor ABC, VS, mental status ref. Resp Failure PEA Handle very gently Start IV w. warm IVF Insulate patient Asystole or V-fib/VT Monitor cardiac rhythm Single dose ref. Epinephrine IV/IO For Vfib/VT: single attempt defibrillation only ref. Resp Failure Monitor cardiac rhythm Approved January 23, 2017 Index 98 4050 Adult Hypothermia Regardless of cardiac rhythm, the following patients should be aggressively resuscitated and transported as soon as possible: (per Termination of Resuscitation protocol) i. Hypothermia ii. Drowning with hypothermia and submersion < 60 minutes Even profound bradycardias may be sufficient in setting of severe hypothermia and decreased O 2 demand Good outcomes after even prolonged hypothermic arrest are possible Patients should not be pronounced dead until rewarmed in hospital BLS: pulse and respirations may be very slow and difficult to detect if patient is severely hypothermic. If no definite pulse, and no signs of life, begin CPR If not breathing, start rescue breathing One round of ALS resuscitation medications are indicated only on V-Fib/ VT or Asystole NOT used in PEA for hypothermia 99 Approved January 23, 2017 Index 4060 Adult Hyperthermia Hyperthermia Classify by clinical syndrome Consider non-environmental causes (see below) Heat Cramps Normal or slightly elevated body temperature Warm, moist skin Generalized weakness Diffuse muscle cramping Heat Stroke Heat Exhaustion Elevated body temperature Cool, diaphoretic skin Generalized weakness Anxiety Headache Tachypnea Possible syncope Very high core body temperature Hot, dry skin w. cessation of sweating Hypotension Altered mental status Seizure Coma Immediate Transport indicated 20cc/kg bolus NSL Monitor VS and transport Adequate airway and breathing? No Yes Ref. adult respiratory failure Start IV, ref.O2 20cc/kg bolus NSL unless signs of volume overload Remove excess clothing For heat stroke, consider external cooling measures if prolonged transport ref. seizures, cardiac arrhythmias per protocol Monitor and transport Approved January 23, 2017 Index 100 4060 Adult Hyperthermia Consider other causes of hyperthermia besides environment exposure, including: Neuroleptic malignant syndrome (NMS): patients taking antipsychotic medications Sympathomimetic overdose: cocaine, methamphetamine Anticholingergic toxidrome: overdose (“Mad as a hatter, hot as a hare, blind as a bat, red as a beet”) common w. ODs on psych meds, OTC cold medications, Benadryl, Jimson weed, etc. Infection: fever (sepsis) Thyrotoxicosis: goiter (enlarged thyroid) Excited Delirium 101 Approved January 23, 2017 Index 4070 Adult Insect/Arachnid Bite and Stings Protocol Initiate general care for bites and stings Assess for localized vs. systemic signs and symptoms and depending on animal involved Localized Symptoms: Systemic Symptoms: Pain, warmth and swelling Hives, generalized erythema, swelling, angioedema Hypotension Altered mental status Other signs of shock ref. fentanyl for black widow spider and /or ref. diphenhydramine if needed for itching ref.O2 Start IV ref.allergy & anaphylaxis protocol Approved January 23, 2017 Index 102 4070 Adult Insect/Arachnid Bite and Stings Protocol General Care For bees/wasps: Remove stinger mechanism by scraping with a straight edge. Do not squeeze venom sac For spiders: Bring in spider if captured or dead for identification Specific Information Needed: Timing of bite/sting Identification of spider, bee, wasp, other insect, if possible History of prior allergic reactions to similar exposures Treatment prior to EMS eval: e.g. Epipen, diphenhydramine, etc. Specific Precautions: For all types of bites and stings, the goal of prehospital care is to prevent further envenomation and to treat allergic reactions BLS personnel may assist patient with administering own Epipen and oral antihistamine Anaphylactoid reactions may occur upon first exposure to allergen, and do not require prior sensitization Anaphylactic reactions typically occur abruptly, and rarely > 60 minutes after exposure 103 Approved January 23, 2017 Index 4080 Adult Snake Bite Assess ABCs, mental status ref.O2 Start IV Monitor Vital signs Remove patient from proximity to snake Remove all constricting items from bitten limb (e.g.: rings, jewelry, watch, etc.) Immobilize bitten part Initiate prompt transport • Do NOT use ice, refrigerants, tourniquets, scalpels or suction devices • Mark margins of erythema and/or edema with pen or marker and include time measured. Transport Assess for localized vs. systemic signs and symptoms Systemic Symptoms: • Metallic or peculiar taste in mouth • Hypotension • Altered mental status • Widespread bleeding • Other signs of shock Localized Symptoms: • Pain and swelling • Numbness, tingling to bitten part • Bruising/ecchymosis Monitor pt and ref. Adult Respiratory Distress as indicated Immobilize bitten part ref. Fentanyl ref. Hypotension/Shock as indicated 104 Approved January 23, 2017 Index 4080 Adult Snake Bite Obtain specific information: • Appearance of snake (rattle, color, thermal pit, elliptical pupils) • Appearance of wound: location, # of fangs vs. entire jaw imprint • Timing of bite • Prior 1st aid • To help with identification of snake, photograph snake, if possible. Include image of head, tail, and any distinctive markings. • Do not bring snake to ED Specific Precautions: • The prairie rattlesnake is native to Denver Metro region and is most common venomous snake bite in the region • Exotic venomous snakes, such as pets or zoo animals, may have different signs and symptoms than those of pit vipers. In case of exotic snake bite, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) and consult zoo staff or poison center for direction. • Never pick up a presumed-to-be-dead snake by hand. Rather, use a shovel or stick. A dead snake may reflexively bite and envenomate. • > 25% of snake bites are “dry bites”, without envenomations. • Conversely, initial appearance of bite may be deceiving as to severity of envenomation. • Fang marks are characteristic of pit viper bites (e.g. rattlesnakes). • Jaw prints, without fang marks, are more characteristic of non-venomous species. Index Approved January 23, 2017 105 5000 Adult Psychiatric / Behavioral Emergency Scene Safety A. Scene safety and provider safety are a priority. Consider police contact if scene safety is a concern. B. Refer to restraint protocol as needed, especially as it relates to A. Specific Information Needed A. Obtain history of current event; inquire about recent crisis, toxic exposure, drugs, alcohol, emotional trauma, and suicidal or homicidal ideation. B. Obtain past history; inquire about previous psychiatric and medical problems, medications. Specific Objective Findings A. Evaluate general appearance 1. E.g.: Well groomed, disheveled, debilitated, bizarrely dressed B. Evaluate vital signs. 1. Is a particular toxidrome suggested, e.g.: symphathomimetic? C. Note medic alert tags, breath odors suggesting intoxication. D. Determine if patient has decision making capacity. E. Note behavior. Consider known predictors of violence: 1. Is the patient male, clinically intoxicated, paranoid or displaying aggressive or threatening behavior or language? Treatment A. If patient combative, see Combative Patient Protocol B. Attempt to establish rapport C. Assess ABCs D. Transport to closest Emergency Department E. Be alert for possible elopement F. Consider organic causes of abnormal behavior (trauma, overdose, intoxication, hypoglycemia) G. If patient restraint considered necessary for patient or EMS safety, refer to Restraint Protocol. H. Check blood sugar ref. Hypoglycemia I. If altered mental status or unstable vital signs: 1. Ref. Oxygen. 2. Establish venous access. 3. Refer to Altered Mental Status Protocol. 106 Approved January 23, 2017 Index 5000 Adult Psychiatric / Behavioral Emergency Mental Health Holds A. If a patient has an isolated mental health complaint (e.g. suicidality), and does not have a medical complaint or need specific medical intervention, then that patient may be appropriately transported by law enforcement according to their protocols. B. If a patient has a psychiatric complaint with associated illness or injury (e.g. overdose, altered mental status, chest pain, etc), then the patient should be transported by EMS C. If a patient with a psychiatric complaint is clinically intoxicated or otherwise lacks decision making capacity for any other reason, no Mental Health Hold is needed and such a patient should be brought to an emergency department for evaluation and stabilization with implied consent. D. If EMS is called to evaluate a patient with an isolated psychiatric complaint who is not clinically intoxicated, or otherwise lacking decision making capacity, and who refuses treatment or transport, and law enforcement are not willing to transport patient, then EMS should CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for medical consult with BASE PHYSICIAN. E. If there is a reasonable concern for suicidal or homicidal ideation, or grave disability from another mental health condition, then BASE PHYSICIAN may give a verbal order placing the patient on a Mental Health Hold and direct EMS personnel to transport the patient against his or her will in accordance with Colorado State statutes. The physician’s name, and time and date of the Mental Health Hold must be recorded on the PCR. Effort should be made to obtain consent for transport from the patient, and to preserve the patient’s dignity throughout the process. F. A patient being transported on a Mental Health Hold may be transported to any appropriate receiving emergency department, as it may not be operationally feasible to transport exclusively to the Base Station hospital, although this is preferred if time and conditions allow. G. It is expected that receiving facilities will receive such patients and perform an appropriate evaluation to determine if continuation of a Mental Health Hold is indicated at the time of their assessment. H. Although there is always a risk of accusations of kidnapping or assault in such cases, such accusations are extremely rare, and the Aurora Fire Department EMS Medical Directors feel strongly that the risk of abandonment of a potentially suicidal or otherwise gravely impaired patient far outweigh any theoretical risk of allegations of kidnapping when actions are taken in the interest of patient safety. Specific Precautions A. Psychiatric patients often have an organic basis for mental disturbances. Be suspicious of hypoglycemia, hypoxia, head injury, intoxication, or toxic ingestion. B. If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Try not to violate the patient's personal space. C. If the situation appears threatening, consider a show of force involving police before attempting to restrain. D. Beware of weapons. These patients can become very violent. E. An EMT or paramedic may initiate a Mental Health Hold only by direct verbal order from the BASE PHYSICIAN (AIP, Children’s, TMCA, CMP, SaddleRock). F. Document name of BASE PHYSICIAN. 107 Approved January 23, 2017 Index 5010 Adult Combative Patient Patient is combative and a danger to self or others Attempt to reasonably address patient concerns Assemble personnel Excited Delirium Syndrome Treat reversible causes Yes Does patient have signs of the Excited Delirium Syndrome? These patients are truly out of control and have a life-threatening medical emergency they will have some or all of the following sx: Paranoia, disorientation, hyper-aggression, hallucination, tachycardia, increased strength, hyperthermia No Patient does not respond to verbal de-escalation techniques ref. midazolam ref. Restraint Protocol Obtain IV access as soon as may be safely accomplished Still significantly combative? Reassess ABCs post sedation High flow O2 & prepare to assist Ventilations Start 2 large bore IVs as soon as may be safely accomplished Administer 2 liters NS bolus No Yes Sedate Consider cause of agitation ref.Midazolam Start external cooling measures Yes Still significantly combative? No Full cardiac and SpO2, monitoring and transport. Yes CONTACT BASE for re-sedation After re-sedation and if still significantly combative CONTACT BASE for further consultation Approved January 23, 2017 Monitor Patient Transport Index 108 5010 Adult Combative Patient General Guideline: Emphasis should be placed on scene safety, appropriate use of restraints and aggressive treatment of the patient’s agitation. Restraints: Do not transport in hobble or prone position. Do not inhibit patient breathing / ventilations 109 Approved January 23, 2017 Index 5020 Adult Transport of the Handcuffed Patient Purpose: 1. Guideline for transport of patients in handcuffs placed by law enforcement Guideline: 1. 2. 3. 4. 5. Handcuffs are only to be placed by law enforcement. EMS personnel are not permitted to use handcuffs. Request that law enforcement remain with the patient in the ambulance, if possible. If not possible, request that police ride behind ambulance so as to be readily available to remove handcuffs if needed in an emergency situation to facilitate medical care of the patient. EMS personnel are not responsible for the law enforcement hold on these patients. Handcuffed patients will not be placed in the prone position. Handcuffs may be used with spinal immobilization. Medical priorities should take priority in the positioning of the handcuffs. 110 Approved January 23, 2017 Index 5030 Adult Tasered Patients Indications: Patient with TASER probe(s) embedded in skin. Contraindications: 1. TASER probe embedded in the eye or genitals. In such cases, transport patient to an emergency department for removal. Precautions: The prehospital provider should consider the nature of the incident, potential mechanism(s) of injury, as well as patient complaints. The prehospital provider is responsible for a reasonable assessment of the patient to determine if there is an injury/illness or reason for transport or treatment. Use of the Taser device does not necessarily require the patient to be transported. Use of the Taser device does not relieve the prehospital provider of the responsibility to assess and treat the patient in a manner consistent with the body of the Aurora Authorized version of the Denver Metropolitan Emergency Medical Directors protocol. TASER Barb Removal Technique: 1. Confirm the TASER has been shut off and the barb cartridge has been disconnected. 2. Using a pair of shears cut the TASER wires at the base of the probe. 3. Place one hand on the patient in area where the probe is embedded and stabilize the skin surrounding the puncture site. Using the other hand (or use pliers/forceps) firmly grasp the probe. 4. In one uninterrupted motion, pull the probe out of the puncture site maintaining a 90° angle to the skin. Avoid twisting or bending the probe. 5. Repeat the process for any additional probes. 6. Once the probes are removed, inspect and assure they have been removed intact. In the event the probe is not removed intact or there is suspicion of a retained probe, the patient must be transported to the emergency department for evaluation. 7. Cleanse the probe site and surrounding skin with betadine and apply sterile dressing. (TASER barb removal demonstration) 8. Advise patient to watch for signs of infection including increased pain at the site, redness swelling or fever. 9. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Required for patient nontransport. 111 Approved January 23, 2017 Index 5040 Adult Drug / Alcohol Intoxication Clinically Intoxicated Patient: (Ataxia or Slurred Speech or Slow motor response) (Clinical impression of provider that patient is clinically intoxicated means patient does not have decision making capacity. EMS Provider must make medical decisions for pt.) No Refer to appropriate section of protocol Yes Incapacitated due to intoxication (Inability to stand from seated position and walk independently or unable to maintain airway) No Acute illness or injury suspected based on appearance, MOI, etc. or signs/symptoms/history of acute illness or injury? Yes No Yes Can patient be released to responsible person in a safe environment? Transport to ED Yes Document on PCR Base Contact not required No CONTACT BASE 112 Approved January 23, 2017 Index 5040 Adult Drugs / Alcohol Intoxication Introduction: When applying this protocol please remember: A. B. C. D. E. F. G. H. This protocol does not replace current protocols pertaining to Altered Mental Status, Overdose and Poisonings, Trauma etc. which supersede any and all applications of the alcohol protocol. A clear understanding that this protocol requires a thorough assessment of the situation to determine if there is any history, signs, or symptoms of an injury or illness. There remains a very low threshold for checking a blood sugar level as hypoglycemia may mimic and/or co-exist with intoxication. A clinically intoxicated person should never be left in an unsafe environment, and will not be left on scene in the absence of a responsible person who assures patient safety (e.g. law enforcement, family, friend) unless approved by BASE CONTACT (AIP, Children’s TMCA, CMP, SaddleRock) physician. This protocol is intended to aid with the disposition of acutely intoxicated patients. The criteria set forth are not all-inclusive, and do not take the place of a thorough patient assessment or sound clinical judgment. A thorough patient assessment is essential in every case as many medical and psychiatric conditions can mimic intoxication. In general, if a patient lacks decision-making capacity for reasons of clinical intoxication with alcohol and there is reasonable concern about the possibility of an acute illness or injury, then the patient should be transported to an emergency department for evaluation, including against the patient’s will if necessary. Clinical judgment about who does or does not have decision-making capacity may be difficult and consultation with On-line Medical Control is prudent if there is any question. Special Notes: A. Not every clinically intoxicated patient requires transport to an emergency department. Every effort should be made to determine the capacity of a patient to care for his or herself if transport is not immediately indicated. Definitions: Acute Illness or Injury Abnormal vital signs Physical complaints that might indicate an underlying medical emergency, e.g.: chest pain Seizure or hypoglycemia Signs of trauma or history of acute trauma Approved January 23, 2017 Index 113 6000 Pre-Eclampsia / Eclampsia Routine medical assessment IV BGL NO (Pre-Eclamptic) Patient Seizing? Position of Comfort (if supine elevate right side) Yes (Eclamptic) ref. Midazolam Give immediately via most readily available route ref. Resp Distress / ref. Resp Failure ref. Magnesium 114 Approved January 23, 2017 Index 6010 Emergency Childbirth Routine medical assessment Ominous signs? Yes ref. Abnormal Delivery NO Place mother supine and prepare delivery equipment Yes Imminent Delivery? Have mother “pant” during each contraction and relax between contractions. Spontaneous respirations and HR >100 within 30 seconds? As head emerges, check for cord around neck (If it can’t be slipped overhead, clamp x2 and cut immediately) Put newborn on mother’s abdomen and prevent heat loss. Record APGAR at 1 and 5 minutes. If signs of obstruction present immediately suction mouth then nose. Abnormally heavy bleeding? NO NO Transport Ref. Newborn Resuscitation NO Yes ref. Postpartum Hemorrhage Dry newborn and keep at level of mother’s vagina until cord stops pulsating and is double clamped. Transport Double clamp cord 6” from newborn’s abdomen and cut between clamps with sterile scalpel. 115 Approved January 23, 2017 Index 6010 Emergency Childbirth Overview: 1. 2. EMS providers called to a possible prehospital childbirth should determine if there is enough time to transport expectant mother to hospital or if delivery is imminent If imminent, stay on scene and immediately prepare to assist with the delivery Specific Information Needed: Obstetrical history: Number of pregnancies (gravida) Live births (PARA) Expected delivery date Length of previous labors Narcotic use in past 4 hours Emergency Childbirth Procedure 1. If there is a prolapsed umbilical cord or apparent breech presentation, go to abnormal delivery protocol and initiate immediate transport 2. For otherwise uncomplicated delivery: 1. Position mother supine on flat surface, if possible 2. Do not attempt to impair or delay delivery 3. Support and control delivery of head as it emerges 4. Protect perineum with gentle hand pressure 5. Check for cord around neck, gently remove from around neck, if present 6. If signs of obstruction present, suction mouth, then nose of infant 7. If delivery not progressing, baby is “stuck”, see obstetrical complications protocol and begin immediate transport 8. As shoulders emerge, gently guide head and neck downward to deliver anterior shoulder. Support and gently lift head and neck to deliver posterior shoulder. Rest of infant should deliver with passive participation – get a firm hold on baby 9. Keep newborn at level of motherʼs vagina until cord stops pulsating and is double clamped Critical Thinking: 1. 2. 3. 4. 5. 6. Normal pregnancy is accompanied by higher heart rates and lower blood pressures Shock will be manifested by signs of poor perfusion Labor can take 8-12 hours, but as little as 5 minutes if high PARA The higher the PARA, the shorter the labor is likely to be High risk factors include: no prenatal care, drug use, teenage pregnancy, DM, htn, cardiac disease, prior breech or C section, preeclampsia, twins Note color of amniotic fluid for meconium staining 116 Approved January 23, 2017 Index 6010 Emergency Childbirth For All Patients with obstetrical complications Do not delay: immediate rapid transport Give high-flow oxygen Start IV en route if time and conditions allow. Treat signs of shock w. IV fluid boluses per Medical Hypotension/Shock Protocol Possible actions for specific complications The actions listed may not be feasible in every case, nor may every obstetrical complication by anticipated or effectively managed in the field. These should be considered “best advice” for rare, difficult scenarios. In every case, initiate immediate transport to definite care at hospital Postpartum Care Infant Suction mouth and nose only if signs of obstruction by secretions Respirations should begin within 15 seconds after stimulating reflexes. If not, begin artificial ventilations at 30-40 breaths/min If apneic, cyanotic or HR < 100, ref. Newborn resuscitation Dry baby and wrap in warm blanket After umbilical cord stops pulsating, double clamp 6” from infant abdominal wall and cut between clamps with sterile scalpel. If no sterile cutting instrument available, lay infant on mother’s abdomen and do not cut clamped cord Document 1 and 5 minute APGAR scores Complications of Late Pregnancy 3rd Trimester Bleeding (6-8 months) High flow O2 via NRB, IV access Suspect placental abruption or placenta previa Initiate rapid transport Position patient on left side Note type and amount of bleeding IV NS bolus for significant bleeding or shock Pre Eclampsia/Eclampsia/Toxemia High flow O2 via NRB, IV access SBP > 140, DBP > 90, peripheral edema, headache, seizure Transport position of comfort Ref. Eclampsia Postpartum Care Mother Placenta should deliver in 20-30 minutes. If delivered, collect in plastic bag and bring to hospital. Do not pull cord to facilitate placenta delivery and do not delay transport awaiting placenta delivery If the perineum is torn and bleeding, apply direct pressure with sanitary pads Ref. Postpartum Hemorrhage Initiate transport once delivery of child is complete and mother can tolerate movement Approved January 23, 2017 117 6020 Abnormal Delivery Routine medical assessment Ominous signs? Transport Meconium Staining Prolapsed Cord Breech (Buttocks) Limb presentation Shoulder Dystocia Suction prior to stimulation and ventilation. Cover exposed cord with moistened towel. Deliver baby to waist then rotate to facedown position. Do not pull on presenting part. Do not pull on baby’s head. Quickly tie and cut 1st cord. ref. Newborn Resus Algo Put mother in Trendelenburg in knee-chest position Create breathing space around baby’s face with gloved hand. Cover exposed part with moistened towel. Support baby’s head Suction oral and nasal passages Proceed with subsequent deliveries. With gloved hand, push presenting part off of vaginal wall to decompress cord. Place mother left side down. Multiple Births Place mother with buttocks just off the end of bed. Flex mother’s thighs upward, apply gentle open hand pressure above the pubic bone Monitor Pts. 118 Approved January 23, 2017 Index Index 6030 Postpartum Hemorrhage Routine medical assessment ref. Resp Distress ref. Resp Failure as indicated Check BP ref. Hypotension Protocol IV NS (2 Lines if possible) Use vigorous external uterine massage to promote uterine tone. Transport Approved January 23, 2017 Index 119 7000 Adult General Trauma Care BSI Scene safety Consider mechanism Consider need for additional resources General impression ABCs and LOC Rapid Trauma Assessment Ref. Adult Traumatic Pulseless Arrest Prepare for immediate transport SAMPLE history Ref. Oxygen ref. Resp Distress as indicated ref. Resp Failure as indicated ref. Spinal Stabilization as indicated Control exsanguinating hemorrhage: Direct pressure ref. Tourniquet protocol if indicated Pelvic stabilization if indicated Assess disability and limitation: Brief neuro assessment Ref. Extremity splinting if indicated Transport to closest appropriate facility Large bore IV, 2nd if unstable Consider IV fluid bolus 20cc/kg if unstable or suspected significant injuries. ref. Traumatic Shock Protocol Monitor vital signs, ABCs, neuro status, GCS 120 Approved January 23, 2017 Index 7005 Adult Special Trauma Scenarios ref. General Trauma Care Sexual Assault Abuse / neglect Confine history to pertinent medical needs Observe pt’s behavior around caregivers Watch out for: Injury inconsistent with stated mechanism Delayed treatment Spreading blame Conflicting stories Prior/ healing injuries Respect patient’s emotional needs Don’t judge, accuse or confront victim Don’t judge, accuse or confront victim or suspected assailant Protect evidence: No washing or changing clothes Transport patient if suspected abuse or neglect, no matter how minor the injury may appear. Transport Notify Aurora Police Department of all suspected abuse / assault Request APD officer to respond to receiving facility if not on scene prior to patient transport. 121 Approved January 23, 2017 Index 7010 Adult Trauma in Pregnancy ref. General Trauma Care Protocol Pregnant Trauma (EGA > 20 weeks) Pregnant Trauma (EGA < 20 weeks) Priority is mother. Assure hospital is aware of pregnancy and EGA Priority is mother. Patients with any thoracic, abdominal, pelvic injury or complaint who are refusing transport require base contact for AMA refusal. Patients with any thoracic, abdominal, or pelvic complaint or injury may require prolonged fetal monitoring in hospital, even if asymptomatic at time of evaluation, and even for seemingly minor mechanism. Encourage transport of all patients. Avoid supine position: o Place in left lateral recumbent position if possible o If immobilized tilt backboard 15 to 30 degrees to the left side Interpret VS with caution. Pregnant patient has: Increased heart rate Decreased blood pressure Increased blood volume Approved January 23, 2017 122 Index Index 7010 Adult Trauma in Pregnancy Estimated Gestational Age (EGA) If EGA > 20 weeks, consider two patients: mother and fetus. Estimation of gestational age may be made based on fundal height by palpating for top of uterus: If uterus is at umbilicus then EGA > 20 weeks Estimation by Last Menstrual Period: Due Date = LMP + 9 months + 7 days EGA = due date – current date 123 Approved January 23, 2017 Index 7015 Adult Traumatic Pulseless Arrest CPR until cardiac monitor applied Place pt on Cardiac Monitor1 Asystole? * No Yes CONTACT BASE for consideration of Field Pronouncement Immediate transport to closest appropriate trauma center Control life threatening external bleeding Begin continuous compressions – change compressors q 2 min 1 breath every 6 seconds o OPA/NPA/Capnography/BVM 1Load and go is always a reasonable approach to penetrating trauma arrest. Ref. Adult Respiratory Failure/Arrest Ref. bilateral needle thoracostomy on all traumatic arrests with trauma to trunk Traumatic pulseless arrest is a unique situation. Do not apply “combo pads” Do not defibrillate Do not administer ACLS medications Do not treat as medical arrest IV. ref. IO access with NS bolus enroute Transport to closest Trauma Center Cardiac arrest from the following causes should approached as a medical cardiac arrest: Overdose Monitor cardiac rhythm Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage * Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. Include the AFR incident number on the strip. 124 Approved January 23, 2017 Index 7020 Adult Traumatic Shock Trauma w. suspected serious injury and/or signs of shock ref. General Trauma Care Pelvic sheet if indicated ref.O2 Large bore IV 2nd IV preferred Yes SBP < 90 and/or definite signs of shock? IV NS bolus 20 cc/kg Ref. Intraosseous Access x No Treat en route Keep patient warm Evaluate breath sounds, respiratory effort, and consider tension pneumothorax Repeat NS bolus 20 cc/kg as needed Reassess ref. needle thoracostomy if arrest or impending arrest Monitor: ABCs, VS, mental status Rapid transport to appropriate trauma center Monitor cardiac rhythm Approved January 23, 2017 Index 125 7020 Adult Traumatic Shock Shock is defined as impaired tissue perfusion and may be manifested by any of the following: Altered mental status Tachycardia Poor skin perfusion Low blood pressure Traditional signs of shock may be absent early in the process, therefore, maintain a high index of suspicion and be vigilant for subtle signs of poor perfusion Prehospital End-Points of Fluid Resuscitation: Over aggressive resuscitation with IV fluid before hemorrhage is controlled may worsen bleeding, hypothermia and coagulopathy. Do not withhold IV fluids in a critically injured patient, but give judiciously with goal to improve signs of perfusion and mental status rather than to achieve a “normal” blood pressure. Approved January 23, 2017 126 7025 Adult Amputations ref. General Trauma Care Bleeding Controlled Uncontrolled Bleeding Control with direct pressure to bleeding area or vessel Large bore IV If hypotensive, ref. Traumatic Shock Document neurovascular exam If bleeding not controlled with direct pressure, ref. Tourniquet Partial/Near-Amputation Complete Amputation Amputated part: Wrap in moist, sterile dressing Place in sealed plastic bag Place bag in ice water Do not freeze part Cover with moist sterile dressing Splint near-amputated part in anatomic position Stump: Cover with moist sterile dressing covered by dry dressing ref. fentanyl Monitor and transport to appropriate Trauma Center Treat other injuries per protocol Approved January 23, 2017 127 Index Index 7026 Adult Extremity Injuries Specific Information Needed A. Mechanism of injury: direction of forces, if known B. Areas of pain, swelling or limited movement C. Treatment prior to arrival: realignment of open or closed fracture, or dislocations, movement of patient D. Past medical history: medications, medical illnesses Specific Objective Findings A. Vital signs B. Observe: localized swelling, discoloration, angulation, lacerations, exposed bone fragments, loss of function, guarding C. Palpate: tenderness, crepitation, instability, quality of distal pulses, sensation D. Note estimated blood loss at scene. Treatment A. Treat airway, breathing, and circulation as first priorities. B. Immobilize cervical spine when appropriate. C. Examine for additional injuries to head, face, chest, and abdomen; treat those problems with higher priority first. D. If patient unstable, transport rapidly, treating life threatening problems en route. Splint patient to minimize fracture movement by securing to long board. E. If patient stable, or isolated extremity injury exists: 1. Check and record distal pulses and sensation prior to immobilization of injured extremity. 2. Apply sterile dressing to open fractures. Note carefully wounds that appear to communicate with bone. 3. Splint areas of tenderness or deformity: apply gentle traction throughout treatment and try to immobilize the joint above and below the injury in the splint. 4. Realign angulated fractures by applying gentle axial traction if necessary to restore circulation distally or to immobilize adequately, i.e., realign femur fracture. 5. Check and record distal pulses and sensation after reduction and splinting. 6. Elevate simple extremity injuries. Apply ice pack if time and extent of injuries allow. 7. Monitor circulation (pulse and skin temperature), sensation, and motor function distal to site of injury during transport. 8. Establish venous access. 9. ref. Fentanyl Special precautions A. Patients with multiple injuries have a limited capacity to recognize areas which have been injured. A patient with a femur fracture may be unable to recognize that he has other areas of pain. Be particularly aware of missing injuries proximal to the obvious ones (e.g., a hip dislocation with a femur fracture, or a humerus fracture with a forearm fracture). B. Do not use ice or cold packs directly on skin or under air splints. Pad with towels or leave cooling for hospital setting. C. Injuries around joints may become more painful and circulation may be lost with attempted realignment. If this occurs, stabilize the limb in the position of most comfort with the best distal circulation. Approved January 23, 2017 Index 128 7029 Head Trauma ref. General Trauma Care ref. Oxygen ref. Spinal Stabilization as indicated ref. Seizure as indicated ref. Combative patient as indicated Ref. Adult Respiratory Failure / Arrest Requiring Assisted Ventilations as indicated Systolic BP < 90 and/or definite signs of shock? Yes No Rapid Trauma Assessment Treat other injuries per protocol Watch for status changes Ref. Adult Traumatic Shock GCS < 8? Yes Head of bed should be elevated 300 unless BP < 90 IV Access No Monitor cardiac rhythm Transport to appropriate Trauma Center Continue to monitor for developing hypoxemia and shock Cushing’s Triad is a sign of increased intracranial pressure and consists of: Hypertension (often with a widening pulse pressure) Bradycardia Irregular respirations Approved January 23, 2017 Index 129 7030 Adult Face and Neck Trauma ref. General Trauma Care Clear airway Rapid trauma assessment ref. Spinal immobilization ref. Resp Distress as indicated ref. Resp Failure as indicated Laryngeal trauma* Yes Transport No Severe airway Bleeding? Direct pressure if appropriate Yes No Complete neuro exam Asses for subcutaneous air Cover/protect eyes as indicated Do not try to block drainage from ears, nose Save avulsed teeth in saline-soaked gauze, do not scrub clean Transport ASAP to closest appropriate facility IV access en route Treat other injuries per protocol Suction airway as needed ref. Fentanyl Monitor ABCs, VS, mental status, SpO2 Spinal Immobilization not routinely indicated for penetrating neck injury Penetrating injury is very rarely associated with unstable spinal column *Suspect laryngeal trauma with: Laryngeal tenderness, swelling, bruising Voice changes Respiratory distress Stridor 130 Approved January 23, 2017 Index 7035 Adult Spinal Trauma ref. General Trauma Care Full spinal immobilization if suspected spine injury Document neuro assessments before and after immobilization Rapid transport to appropriate Trauma Center Large bore IV and consider 2nd line If BP < 90 and/or signs of shock, resuscitate ref. Traumatic Shock Complete patient assessment Treat other injuries per protocol Monitor for status changes Monitor ABCs, VS, mental status, SpO2. ref. Fentanyl Approved January 23, 2017 Index 131 7040 Adult Selective Spinal Stabilization Mechanisms of injury that imply potential need for spinal stabilization and for whom stabilization should be considered include but are not limited to: MVC/MCC/Bicycle/Equestrian Accident Diving / Axial Load Fall from twice patient’s height o o o Establish manual in-line cervical stabilization Does the pt have /complain of any of the following? Clinical intoxication with ETOH or drugs Altered mentation Barrier to evaluate for spinal injury (e.g. language or development barrier) Distracting injury Midline C/T/L spine tenderness on palpation Subjective: (numbness, tingling, or weakness) Objective: (motor or sensory deficit) Yes No If NONE of above, spinal stabilization not indicated. Place appropriately sized c-collar or utilize improvised c-spine techniques if the rigid c-collar cannot be effectively utilized. * Obvious motor or sensory deficit on exam consisting of: Lack of Equal Bilateral grip, push/pull and/or Lack of Light touch sensation to extremity(s) No Yes Is pt able to cooperate and lay still? No Stabilize and secure torso/head utilizing scoop or backboard. Transport to closest Level I or Level II Trauma Center Yes Stabilize and secure torso/head utilizing scoop or backboard. Spinal stabilization is only indicated in penetrating trauma when there is obvious motor or sensory deficit on exam. Stabilize and secure unconscious blunt trauma patients Elderly patients are more susceptible to spinal injury Do not remove previously placed stabilization device(s). Manual in line stabilization may be released. Scoop/backboard NOT indicated. If the patient is capable, self-extrication is preferred. Place patient in position of comfort on gurney. 132 Approved January 23, 2017 Index 7045 Adult Chest Trauma ref. General Trauma Care Rapid transport to Trauma Center Are you able to oxygenate and ventilate effectively? No Airway management and assisted ventilations as indicated ref. needle thoracostomy Yes Penetrating trauma? Yes Rapid transport & stabilize in route Yes Splint with bulky dressing Occlusive dressings for sucking wounds No Large bore IV and consider 2nd line Flail Chest? Assess for need for assisted ventilations ref. Resp Distress as indicated ref. Resp Failure as indicated No SBP < 90 and/or shock? No Yes ref. traumatic shock enroute No ref. Fentanyl Monitor ABCs, VS, mental status, SpO2. 133 Approved January 23, 2017 Index 7045 Adult Chest Trauma Tension pneumothorax should be suspected with presence of the following: Unilateral absent breath sounds AND: JVD, hypotension, difficult/unable to ventilate Needle decompression is NEVER indicated for simple pneumothorax End points of fluid resuscitation should be improved mental status and pulses, not necessarily a normal blood pressure. This is especially true for penetrating chest trauma. 134 Approved January 23, 2017 Index 7050 Adult Abdominal Trauma ref. General Trauma Care Transport to closest appropriate Trauma Center IV access Consider 2nd line if MOI significant Penetrating trauma? Yes Cover wounds, viscera with saline moistened gauze dressing No Do not attempt to repack exposed viscera SBP < 90 and/or shock? Yes ref. Traumatic Shock No ref. Fentanyl Monitor ABCs, VS, mental status, SpO2. Approved January 23, 2017 135 7050 Adult Abdominal Trauma End points of fluid resuscitation should be improved mental status and pulses, not necessarily a normal blood pressure. This is especially true for abdominal trauma. Documentation MOI Time of injury Initial GCS Penetrating trauma Weapon/projectile/trajectory Blunt vehicular trauma Condition of vehicle Speed Ejection Airbag deployment Restraints, helmets Approved January 23, 2017 136 7055 Adult Burns ref. General Trauma Care Transport to Trauma Center Stop burning process: Remove clothes if not adhered to patient’s skin Flood with water only if flames/smoldering present Respiratory Distress? Yes O2 NRB 15 lpm ref. Resp Distress as indicated ref. Resp Failure as indicated No Evaluate degree and body surface area involved Critical Burn?* Yes No Start 2 large-bore IVs TKO 2º > 30% BSA 3º > 10% BSA Respiratory injury, facial burn Associated injuries, electrical or deep chemical burns, underling PMH (cardiac, DM), age > 50 If hypotensive ref. Shock IV NS TKO *Critical Burn: Remove rings, jewelry, constricting items Dress burns with dry sterile dressings Treat other injuries per protocol Cover patient to keep warm Ref. Fentanyl Monitor ABCs, VS, mental status, SpO2 Approved January 23, 2017 Index 137 7055 Adult Burns Document: Type and degree of burn(s) % BSA Respiratory status Singed nares, soot in mouth SpO2 PMH Confined space *Critical Burn: 2º > 30% BSA 3º > 10% BSA Respiratory injury, facial burn Associated injuries, electrical or deep chemical burns, underling PMH (cardiac, DM), age < 10 or > 50 yrs Types of Burns: Thermal: remove from environment, put out fire Chemical: brush off or dilute chemical. Consider HAZMAT Electrical: make sure victim is de-energized and suspect internal injuries Consider CO if enclosed space Consider CN if plastics, shock, pulseless arrest Designated Regional Burn Centers Consider direct transport of isolated burns if time and conditions allow Age ≤ 12 Children’s Hospital Colorado Age ≥ 13 University of Colorado Hospital 138 Approved January 23, 2017 Index 001p General Guidelines for Pediatric Patients General Guideline: A. Pediatric patients, defined as age < 12 years for the purpose of these protocols, have unique anatomy, physiology, and developmental needs that affect prehospital care. Because children make up a small percentage of total calls and few pediatric calls are critically ill or injured, it is important to stay attuned to these differences to provide good care. Therefore, CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) early for guidance when treating pediatric patients with significant complaints, including abnormalities of vital signs. Pediatric emergencies are usually not preceded by chronic disease. If recognition of compromise occurs early, and intervention is swift and effective, the child will often be restored to full health. Specific Considerations: A. The following should be kept in mind during the care of children in the prehospital setting: 1. Airways are smaller, softer, and easier to obstruct or collapse. 2. Respiratory reserves are small. A minor insult like improper position, vomiting, or airway narrowing can result in major deficits in ventilation and oxygenation. 3. Circulatory reserves are also small. The loss of as little as one unit of blood can produce severe shock in an infant. Conversely, it is difficult to fluid overload most children. You can be confident that a good hands-on circulation assessment will determine fluid needs accurately. 4. Assessment of the pediatric patient can be done using your knowledge of the anatomy and physiology specific to infants and children. 5. Listen to the parents' assessment of the patient's problem. They often can detect small changes in their child's condition. This is particularly true if the patient has chronic disease. 6. The proper equipment is very important when dealing with the pediatric patient. A complete selection of pediatric airway management equipment, IV catheters, cervical collars, and drugs has been mandated by the state. This equipment should be stored separately to minimize confusion. 139 Approved January 23, 2017 Index 002p Pediatric Assessment Airway / Appearance Abnormal: Abnormal or absent cry or speech. Decreased response to parents or environmental stimuli. Floppy or rigid muscle tone or not moving. Normal: Normal cry or speech. Responds to parents or to environmental stimuli. Good muscle tone. Moves extremities well. Work of Breathing Abnormal: Increased (nasal flaring, retractions or abdominal muscle use) OR Decreased/absent respiratory effort or noisy breathing Normal: Breathing appears regular without excessive respiratory muscle effort or audible respiratory sounds. Normal RR by age: neonates > 40, infants > 20, children > 12 Circulation / Color Abnormal: Cyanosis, mottling, paleness/pallor or obvious, significant bleeding. Unexplained tachycardia Normal: Color appears normal for racial group of child. No significant bleeding. Ref. Pediatric Field Guide and Refer to appropriate protocol. Approved January 23, 2017 Index 140 003p Pediatric Shock Ref. Oxygen Ref. Pediatric Field Guide Decompensated: Altered Mental Status Hypotensive2 Weak Femoral/Brachial Pulses Compensated: Normal Mental Status Tachycardia1 Normotensive2 Delayed Peripheral Cap. Refill Ref. IO Obtain IV access If unable to start IV after 2 attempts, Contact Base for ref. IO Pull / Push 20ml/kg NS bolus IV/ IO and begin transport Reassess Repeat 20ml/kg NS boluses up to 40ml/kg until goal met of: Threshold heart rate for age Normal Systolic Blood Pressure for age and Capillary refill < 2 seconds If patient is at risk for adrenal insufficiency, ref. Adrenal Insufficiency REFERENCE PEDIATRIC FIELD GUIDE FOR NORMAL VALUES 1 Tachycardia <1 y 1y-2y 2y-5y 5y-12y >12y 2 Hypotension for age: >160bpm >150bpm >140bpm >120bpm >100bpm <1 mo 1mo-1y 1y-10y >10y for age: <60mmHg <70mmHg <70+ (2 x age in years) <90mmHg Normal RR by age: neonates / infants = 40-60 per min children > 12 = < 20 breaths per minute 141 Approved January 23, 2017 Index 003p Pediatric Shock Specific Information Needed A. History: onset and progression of symptoms, frequency of vomiting and diarrhea, urine output, oral intake, recent trauma, possible drug ingestion B. Past medical history Document Specific physical findings A. B. C. D. E. F. General appearance: LOC, muscle tone, color ABCs and vital signs Skin: warmth of distal extremities, color, skin turgor, blood pressure, pulses Mucous membranes: wetness of mouth, presence of tears Musculoskeletal: evaluate for trauma The signs of dehydration are: 1. EARLY - tachycardia and tachypnea for age, decreased LOC, cool skin, mucous membranes dry, sunken eyes and fontanelle; 2. LATE - loss of skin turgor, diminished pulses, hypotension, and shock Treatment A. B. C. D. Use appropriate airway adjuncts as indicated. Ref. Oxygen Breathing: ventilation as indicated Circulation: 1. Establish pulse rate and blood pressure 2. Establish peripheral venous access. 3. Consider fluid bolus of normal saline 20cc/kg. 4. Do not delay transport for IV attempts. 5. The patient with simple dehydration is not a candidate for intraosseous infusion, CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) for approval of IO if shock is present. Specific Precautions A. Assessment of dehydration is primarily by physical exam. Vital signs may be abnormal, but they are nonspecific. B. Determination of tachycardia or hypotension is based on age. C. Monitor carefully for signs of decreased tissue perfusion (shock). Early shock is present if there are poor pulses, muscle tone and color, or decreased mental status. Decompensated shock is present if systolic BP is < normal for age Adrenal Insufficiency A. Patients at risk for adrenal insufficiency include: 1. Chronic steroid use 2. Addison’s disease 3. Congenital adrenal hyperplasia 4. Other patients identified as such by family, medical record, or physician note 142 Approved January 23, 2017 Index 004p General Guidelines: Transportation of the Pediatric Patient1 General Principles: For the purpose of the protocols, pediatric patients are defined as <12 years of age. The unique anatomy, physiology and developmental needs of children in this age range affect prehospital care. Several specific differences include: A. Airways are smaller, softer and easier to obstruct or collapse. Actions such as neck hyperflexion, hyperextension, or cricoid pressure may create an upper airway obstruction in a child B. Respiratory reserves are small, resulting in the possibility of rapid desaturation in the setting of increased demand. One of the earliest signs of physiologic stress in a child may be an unexplained increase in respiratory rate C. Infants and young children utilize their abdominal musculature to assist with respirations. Tight, abdominally-placed straps used to secure children to spine boards may result in onset of or worsening respiratory distress D. Circulatory reserves are small. The loss of as little as one unit of blood can produce severe shock in an infant. Conversely, it is difficult to fluid overload most children E. Pediatric medication dosing and equipment size recommendations vary by length and/or weight. As such, an assessment tool such as a length-based tape should be utilized on every pediatric patient to guide medication dosing and equipment size F. The developmental stage of a child impacts their ability to cooperate and their fear of strangers. The perception and memory of pain is escalated by anxiety. Discuss or forewarn of what will be done with any child over 2 years of age. Infants, especially those under 6 months of age, tolerate painful procedures better if allowed to suck on a pacifier (especially if dipped in D25W) during the procedure. Utilize the parent or familiar guardian whenever possible to distract/comfort (tell a story, sing a song, etc) for all pediatric patients during painful procedures. Approved January 23, 2017 Index 143 004p General Guidelines: Transportation of the Pediatric Patient cont. Specific Considerations: A. Transportation safety Children represent a unique challenge for safe transportation in emergency vehicles. The National Highway Traffic Safety Administration has established guidelines to ensure the safe restraint and positioning of children in emergency vehicles. Children should never be transported unrestrained or held in an adult’s arms. Transportation of children on the side bench seat in the rear compartment is also not recommended. The published goals are to prevent forward motion/ejection of the child, secure the torso, and protect the head, neck and spine in each of the following scenarios: 1. For a child who is uninjured/not ill, but requires transport to a facility If transport in a vehicle other than a ground ambulance is not possible, transport in a size-appropriate child restraint system in the front passenger seat (with air bags off) or rear-facing EMS provider’s seat in the ground ambulance 2. For a child who is injured/ill and whose condition does not require continuous monitoring or interventions: Transport child in a size-appropriate child restraint system secured appropriately on a cot (rear-facing) or in an integrated seat in the EMS provider’s seat. Do not use a rear-facing child restraint system in a rear-facing EMS provider’s seat. If no child restraint system is available, secure the child on the cot using three horizontal restraints across the child’s chest, waist and knees and one vertical restraint across each of the child’s shoulders. 3. For a child whose condition requires continuous or intensive monitoring or interventions: Transport child in a size-appropriate child restraint secured appropriately on a cot. If no child restraint system is available, secure the child on the cot using three horizontal restraints across the child’s chest, waist and knees and one vertical restraint across each of the child’s shoulders. 4. For a child whose condition requires spinal immobilization or lying flat Secure the child to a size-appropriate spineboard and secure the spineboard to the cot, head first, with a tether at the foot to prevent forward movement. Use three horizontal restraints across the chest, waist (not abdomen), and knees, and a vertical restraint across each shoulder. We do not recommend utilizing the child restraint system if spinal immobilization is required, as upright positioning places additional axial load on the patient’s neck and emergent airway intervention is not possible. 5. For a child requiring transport as part of a multiple patient transport (newborn with mother, multiple children, etc) If possible, transport each as a single patient. When available resources prevent single patient transportation, transport patients using safe, designated space available exercising extreme caution and driving at reduced speeds. For mother and newborn, the newborn should be transported in a rear-facing EMS provider seat using a convertible or integrated child restraint system. Do not use a rearfacing child restraint system in a rear-facing EMS provider’s seat. 144 Approved January 23, 2017 Index 004p General Guidelines: Transportation of the Pediatric Patient cont. B. Transportation of the child with special health care needs 1. Treat the child, not the equipment. Starting with the ABCs still applies to medically complicated or medical technology-dependent children. 2. The parent/guardian of a special needs child is the expert on that child and knows the details of that illness, typical responses, and baseline interactions better than anyone. Utilize and trust his/her knowledge and concerns. This may include vital signs, medication responses, or physical positioning (ie of contracted limbs) that may not be typical. 3. Medically complicated children are often given healthcare notes describing their unique medical history and emergency healthcare needs. Ask the parent/guardian for an emergency information sheet or emergency healthcare form 4. Ask the parent/guardian for the “go bag” for medical technology-dependent children. This will contain the child’s spare equipment and supplies that may be needed on scene, during transport or in the hospital 5. Transport the child to their medical “home” hospital whenever possible Approved January 23, 2017 Index 145 100p Pediatric Epistaxis Management Active Nosebleed ABCs Compress nostrils with clamp or fingers, pinching over fleshy part of nose, not bony nasal bridge for 10 minutes. Transport in position of comfort, usually sitting upright Tilt Head Forward Have pt blow nose to expel clots Spray both nares with ref. phenylephrine IV access and IV fluid bolus if signs of ref. hypoperfusion/shock based on age Approved January 23, 2017 146 Index 105p Pediatric Respiratory Failure / Arrest Requiring Assisted Ventilations In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible Ref. Pediatric Field Guide Begin BVM ventilations with OPA and capnography – use two rescuers If no indication for spinal immobilization, place towel roll under shoulders for pts <8 y.o. to optimize airway positioning BVM rate: o Neonates 30 - 40/min, o Infants 20-30/min o Children 12-20/min Signs of adequate oxygenation / ventilation? Examples include: Good CO2 Waveform Compliance with BVM Chest rise and fall Bilateral breath sounds Positive response to therapy Yes Complete assessment Transport No Reposition airway Ensure adequate mask seal Reassess airway adjunct (OPA/NPA/Mask size) Signs of adequate oxygenation / ventilation? Examples include: Good CO2 Waveform Compliance with BVM Chest rise and fall Bilateral breath sounds Positive response to therapy Yes No Ref FBAO Yes Possible FBAO? No Able to adequately oxygenate and ventilate with BVM?* Yes No Ref i-gel O2 Place i-gel ONLY if unable to adequately ventilate with BVM and oral airway* * Ref i-gel O2 in all cases of cardiac arrest. Approved January 23, 2017 Index 147 110p Pediatric Obstructed Airway: Conscious Patient Attempt to determine cause of obstruction Does patient show signs of choking? Assess severity of obstruction Severe or Complete Obstruction (mute, silent cough, severe stridor) INFANT (< 1 yr) 5 Back slaps, 5 Chest thrusts until object is expelled. Mild or Partial Obstruction (patient can speak / cry) Do not interfere with a spontaneously breathing or coughing patient Position of comfort Give high flow oxygen Suction if needed CHILD (> 1yr) Abdominal thrusts until object expelled. Is obstruction cleared? Is obstruction cleared? No Yes No Yes Ref. Pediatric Obstructed Airway: Unconscious Supportive care and rapid transport If patient deteriorating or develops worsening distress proceed as for complete obstruction Transport POC O2 via NRB 15 Lpm Monitor ABCs, SpO2, vital signs Suction PRN and be prepared for vomiting, which commonly occurs after obstruction relieved 148 Approved January 23, 2017 Index Index 111p Pediatric Obstructed Airway: Unconscious Patient If cause of airway obstruction is readily apparent, attempt removal Open airway with head tilt-chin lift If no indication for spinal immobilization, place towel roll under shoulders for pts < 8 y.o. to optimize airway positioning Open airway with jaw thrust if craniofacial trauma present / suspected Ventilate pt with BVM / capnography using two person technique. Ability to ventilate? Yes No Perform laryngoscopy Use McGill forceps to remove object if possible Ref. Pediatric Resp. Failure / Arrest Requiring Assisted Ventilation Ability to ventilate? No Yes 30 Chest compressions Ref. Pediatric Resp. Failure / Arrest Requiring Assisted Ventilation Open pt mouth and remove obstruction if seen. Open airway and ventilate pt with BVM / capnography using two person technique. Ability to ventilate? Yes Ref. Pediatric Resp. Failure / Arrest Requiring Assisted Ventilation Foreign body seen below vocal cords Use 3.5 or 6.0 ETT to push FB into right mainstem bronchus Withdraw ETT and reattempt to ventilate using BLS techniques No Perform direct visualization with laryngoscope Foreign body not seen Foreign body seen above vocal cords Remove laryngoscope and reattempt to ventilate using BLS techniques. Use McGill forceps to remove foreign body Reattempt to ventilate using BLS techniques Ability to ventilate? Yes No Transport Base Contact for consult Ref. Pediatric Resp. Failure / Arrest Requiring Assisted Ventilation Approved January 23, 2017 Index 149 115p Pediatric Respiratory Distress For all patients: While assessing ABCs: ref.O2, monitor vital signs, cardiac rhythm, and SpO2 NO Patent Airway? Ref. Pediatric Obstructed Airway YES Are ventilations adequate for age? NO Ref. Pediatric Respiratory Failure/Arrest YES Is anaphylaxis likely? YES ref. Pediatric Allergy/Anaphylaxis NO YES Is asthma likely? ref. Pediatric Asthma NO YES Is Croup likely? ref. Pediatric Croup NO Is Bronchiolitis likely? YES ref. Pediatric Bronchiolitis NO Transport • Provide supportive care • Maximize oxygenation and ventilation • CONTACT BASE if needed for consult 150 Approved January 23, 2017 Index 115p Pediatric Respiratory Distress General Assessment: Attempt to determine cause of respiratory distress based on clinical scenario, age, past history and exam Assess Airway, Breathing, perfusion and mental status in all patients Airway Assessment If obstructed, see Obstructed Airway Protocol Observe for stridor, hoarseness, drooling Consider foreign body if sudden onset stridor in young child Early suctioning of secretions may dramatically improve respiratory distress in bronchiolitis Breathing Assessment Note rate and effort (“work of breathing”) Listen for upper airway abnormal sounds which may mimic wheezing: stridor, hoarseness, barky cough (suggests croup) Note grunting, nasal flaring, head bobbing, chest wall movement, retractions, accessory muscle use Auscultate breath sounds for wheezing, crackles, decreased air movement (suggests bronchospasm) 151 Approved January 23, 2017 Index 120p Pediatric Asthma Ref. Pediatric Assessment Respiratory Distress Protocol and prepare for transport Severe Attack Grossly abnormal respiratory rate, loud wheezes, or so tight no wheezes are heard, anxiety, gray or ashen skin color, diaphoresis Moderate Attack Marked increase in respiratory rate, wheezes easily heard and accessory muscle breathing. ref. Albuterol + ref. Ipratropium ref. Epinephrine IM ref. Albuterol + ref. Ipratropium Adequate response to treatment? Adequate response to treatment? Yes No Yes Monitor response to treatment Continue cardiac monitoring and SPO2 en route Be prepared to assist ventilations as needed Transport Mild Attack Slight increase in respiratory rate, mild wheezes, good skin color. No ref. Epinephrine IM Adequate response to treatment? Yes Monitor response to treatment Continue cardiac monitoring and SPO2 en route Be prepared to assist ventilations as needed Transport Concern for impending respiratory failure? Worsening mental status Pt becoming tired (accessory muscle usage decreases) Ref. Pediatric Respiratory Failure/Arrest Start IV / ref. IO Contact Base Adequate response to treatment? Yes No ref. Magnesium IV ref. Methylprednisone IV 152 Approved January 23, 2017 Index 125p Pediatric Croup Ref. Pediatric Assessment Respiratory Distress Protocol and prepare for transport Transport in position of comfort appropriately secured ref.O2 Severe Symptoms? SpO2 < 90% despite O2 Stridor at rest Severe retractions Cyanosis Altered LOC No Monitor SPO2 en route Be prepared to assist ventilations as needed Transport Yes Mushroom tip Nasal suctioning if indicated Give nebulized racemic epinephrine Inadequate response to treatment? CONTACT BASE for consult Croup Age 6 months to 5 years w. stridor, barky cough, URI sx. Sx often rapid, nocturnal onset Consider pulmonary and non-pulmonary causes of respiratory distress in all cases: Common: croup, bronchiolitis, asthma. Less common: foreign body aspiration, allergic reaction, pneumonia. Rare: epiglottitis, bacterial tracheitis. Also: Congenital heart disease (CHF), sepsis, other metabolic acidosis (e.g.: DKA, inborn error of metabolism) 153 Approved January 23, 2017 Index 125p Pediatric Bronchiolitis Ref. Pediatric Assessment Respiratory Distress Protocol and prepare for transport Transport in position of comfort appropriately secured ref.O2 Severe Symptoms? SpO2 < 90% despite O2 Severe retractions Cyanosis Altered LOC No Monitor SPO2 en route Be prepared to assist ventilations as needed Transport Yes Mushroom tip Nasal suctioning if indicated Inadequate response to treatment? CONTACT BASE for consult Bronchiolitis Age < 2 yrs w. cough, fever, resp. distress, copious secretions, November-April Consider pulmonary and non-pulmonary causes of respiratory distress in all cases: Common: croup, bronchiolitis, asthma. Less common: foreign body aspiration, allergic reaction, pneumonia. Rare: epiglottitis, bacterial tracheitis. Also: Congenital heart disease (CHF), sepsis, other metabolic acidosis (e.g.: DKA, inborn error of metabolism) 154 Approved January 23, 2017 Index 130p Pediatric Allergy and Anaphylaxis Assess ABCs, ref.O2 If possible, determine likely trigger Determine PMH, medications, allergies Classify based on symptom severity and systems involved Other specific protocols may apply: e.g.: obstructed airway, bites & envenomations Generalized or Systemic Reaction Multisystem involvement: skin, lungs, airway, etc Does patient have any 2 of the following signs or symptoms of anaphylaxis? Hypotension for age Signs of poor perfusion Bronchospasm, stridor Altered mental status Urticaria No Localized Reaction Including isolated tongue, airway ref. diphenhydramine Airway involvement? Tongue or uvula swelling, stridor No Transport and reassess for signs of deterioration Yes Impending airway obstruction? Yes Yes No Immediately ref. epinephrine IM & manage airway ref. Ped respiratory failure ref. epinephrine IM, then: Start IV Ref. IO and give IV fluid bolus 20cc/kg NS ref. diphenhydramine ref. methylprednisolone ref. albuterol if wheezing Start IV / Ref. IO ref. diphenhydramine ref. methylprednisolone Monitor ABCs, SpO2, cardiac rhythm Reassess for signs of deterioration If persistent signs of severe shock with hypotension not responsive to IM epinephrine and fluid bolus: Repeat ref. epinephrine IM Contact Base 155 Approved January 23, 2017 Index 2000p Pediatric Cardiac Arrest – General Principles General Guideline: A. Pediatric cardiac arrest more frequently represents progressive respiratory deterioration or shock rather than primary cardiac etiologies. Unrecognized deterioration may lead to bradycardia, agonal breathing, and ultimately asystole. Resulting hypoxic and ischemic insult to the brain and other vital organs make neurologic recovery extremely unlikely, even in the doubtful event that the child survives the arrest. Children who respond to rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much more likely to survive neurologically intact. Therefore, it is essential to recognize the child who is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention before asystole occurs B. Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime before CPR and duration of CPR • Past History: medications, medical history, suspicion of ingestion, trauma, environmental factors (hypothermia, inhalation, asphyxiation) Penetrating and Blunt trauma arrest: Ref. Pediatric Trauma Arrest Cardiac arrest from the following causes should approached as a medical cardiac arrest: overdose, respiratory arrest, airway obstruction, asphyxiation, hanging and ref. Pediatric drowning Document Specific Objective Findings A. Unconscious, unresponsive B. Agonal, or absent respirations C. Absent pulses D. Any signs of trauma, blood loss E. Skin temperature General Treatment Guidelines A. Treat according to Pediatric BLS and ALS pulseless arrest algorithms B. Primary cardiac arrest from ventricular arrhythmia, while less common than in adults, does occur in children. If history suggests primary cardiac event (e.g.: sudden collapse during exercise), then rapid defibrillation is most effective treatment C. Most pediatric pulseless arrest is the result of primary asphyxial event, therefore initial sequence is chest compressions with ventilations, unlike adult pulseless arrest D. Call for ALS assistance if not already on scene or responding 156 Approved January 23, 2017 Index 2000p Pediatric Cardiac Arrest General Principles General Guidelines: Chest Compressions for 2 Rescuers Newborn (≤ 1 month old) A. 1 cycle of CPR = 3:1 chest compressions: breaths. Infant and Child (1 month to 12 years old) A. 1 cycle of CPR = 15:2 chest compressions: breaths B. Utilize CPR feedback device “puck” on all patients with a Broselow measurement of Purple or greater B. Push hard and fast at a compression rate of 100/minute C. Minimize interruption to chest compressions a. Continue CPR while defibrillator is charging, and resume CPR immediately after all shocks. Do not check pulses except at end of CPR cycle and if rhythm is organized at rhythm check b. Increase in compression interruption correlates with decrease in likelihood of successful defibrillation D. Ensure full chest recoil a. Represents diastolic phase for cardiac filling due to negative intrathoracic pressure E. Avoid hyperventilation a. Associated with barotrauma and air trapping b. Makes CPR less effective by inhibiting cardiac output by increasing intrathoracic pressure and decreasing venous return to the heart F. Rotate compressors every 2 minutes during rhythm checks General Guidelines: Defibrillation A. First shock delivered at 2 J/kg biphasic B. All subsequent shocks delivered at 4 J/kg biphasic General Guidelines: Ventilation during CPR A. Do not hyperventilate B. Contrary to adult cardiac arrest, pediatric arrest is much more likely to be from asphyxia. During this period, blood continues to flow to the tissues causing oxygen saturation to decrease and carbon dioxide to increase. Pediatric patients need both prompt ventilation and chest compressions. C. Hyperventilation decreases effectiveness of CPR and worsens outcome General Guidelines: Timing Of Placement Of Advanced Airway A. No intubation for cardiac arrest < age 12 B. i-gel O2 Airway preferred for all patients < 12 years old and should be placed according to ref. Pediatric Medical Arrest Core Competencies to allow for continuous chest compressions C. If advanced airway(i-gel O2) in place, ventilate continuously at 10 breaths/minute D. If no advanced airway (i-gel O2), alternate ventilations and compressions in 15:2 ratio E. Avoid hyperventilation General Guidelines: Pacing A. Effectiveness of transcutaneous pediatric pacing has not been established and is not Recommended General Guidelines: Transport A. Outcomes for non-shockable pulseless arrest are improved with timely transport. Approved January 23, 2017 Index 157 2000p Pediatric Cardiac Arrest General Principles Special Notes: Consider reversible causes of cardiac arrest (“Hs And Ts”): Hypovolemia = IV Fluid bolus Hypoxia = Ventilation Hydrogen Ion (acidosis) = Ventilation Hyperkalemia = Sodium bicarbonate Hypothermia = See hypothermia protocol Toxins: e.g.: opioid overdose = Naloxone 2mg IVP Tamponade (cardiac) Tension pneumothorax = Needle thoracostomy Thrombosis (coronary) Trauma 158 Approved January 23, 2017 Index 2010p Pediatric Pulseless Arrest BLS / AED Unresponsive and not breathing or only gasping Pulse > 60 Give 1 breath every 3 seconds Recheck pulse every 2 minutes Check pulse (< 10 sec) Is there a definite pulse? Pulse < 60 Infant/child: start CPR Age < 12: start CPR if signs of poor perfusion ref. Peds Bradycardia Definite Pulse Check Rate No Pulse Infant/Child (> 1 month) Neonate (< 1 month) Patient > 12 years Start CPR cycles in 15:2 Start CPR cycles in 3:1 ref. Newborn resuscitation Follow adult ref. Asystole / PEA or . VF / VT algorithm Apply AED/Defibrillator Use pediatric system if available for ages 1 year to 8 years Check Rhythm Shockable rhythm? Shockable Give 1 shock Resume CPR immediately for 2 minutes after shock Check rhythm every 2 minutes Use CPR feedback device “puck” for all patients with Broselow measurement of purple or greater. Approved January 23, 2017 Not Shockable Resume CPR immediately for 2 minutes Check rhythm every 2 minutes High quality CPR Rate > 100/min Compression depth 1 ½ inches in infants, 2 inches in children Allow complete chest recoil after compression Minimize interruptions of chest compressions Avoid excessive ventilation 159 Index 2020p Pediatric Pulseless Arrest – VF / VT Start chest compressions Consider circumstances of arrest: Witnessed by EMS = immediate rhythm check Unwitnessed by EMS = 2 minutes CPR o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator Routine medical assessment VF / VT Use CPR feedback device “puck” for all patients with Broselow measurement of purple or greater. SHOCK 2 min CPR Ref. Pediatric Respiratory Failure / Arrest ROSC Rhythm Check ASYSTOLE/PE A VF / VT DEFIB at Pediatric Field Guide Recommended Joules 2 min CPR ref. IO / IV ROSC A Rhythm Check ASYSTOLE/PE A VF / VT DEFIB at Pediatric Field Guide Recommended Joules 2 min CPR ref. Epinephrine q 4 min ROSC Rhythm Check ASYSTOLE/PE A VF / VT DEFIB at Pediatric Field Guide Recommended Joules Ref. PediatricROSC 2 min CPR ref. Amiodarone Ref. Asystole / PEA Go To Box “A” Approved January 23, 2017 After 15 minutes of ALS Care: Continue resuscitation and Transport Index Index 160 2021p Pediatric Pulseless Arrest Asystole / PEA Start chest compressions Consider circumstances of arrest: 2 minutes CPR o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator Routine medical assessment Treat reversible causes Use CPR feedback device “puck” for all patients with Broselow measurement of purple or greater. Asystole * / PEA 2 min CPR Ref. Pediatric Respiratory Failure / Arrest ROSC Rhythm Check VF / VT Asystole / PEA 2 min CPR ref. IO / IV ROSC A Rhythm Check VF / VT Asystole / PEA Ref. PediatricROSC 2 min CPR ref. Epinephrine q 4 min Ref. VF / VT Go To Box “A” After 15 minutes of ALS Care: 1. Asystole = CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for consideration of TOR at any point if continuous asystole. 2. PEA = Continue resuscitation and Transport * Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. The AFR incident number should be included on the strip. 161 Approved January 23, 2017 Index 2020p Pediatric Pulseless Arrest ALS CPR, Ventilation and Advanced Airway: • No intubation for cardiac arrest < age 12 • i-gel O2Airway preferred for all patients < 12 years old and should be placed as soon as possible to allow for continuous chest compressions • If advanced airway (i-gel O2) in place, ventilate continuously at 10 breaths/minute • If no advanced airway (i-gel O2), alternate ventilations and compressions in 15:2 ratio • Avoid hyperventilation Shock energy for defibrillation: • 1st shock 2 J/kg, or Broselow recommendation, subsequent shocks 4 J/kg, or Pediatric Field Guide recommendation Family Members • Family presence during resuscitation is recommended, unless disruptive to resuscitation efforts Reversible Causes: Hypovolemia Hypoxia H+ (Acidosis) Hypo/Hyperkalemia Hypothermia Tension Pneumothorax Tamponade (cardiac) Toxins Thrombosis: PE,AMI Index Approved January 23, 2017 162 2025p Pediatric Return of Spontaneous Circulation ROSC after Cardiac Arrest Transport patient to Children’s Hospital Colorado main campus Reassess ABCs Obtain baseline vitals Continuous cardiac monitoring Recurrent dysrhythmia? YES Treat per protocol Hypotension for age? Ref. Pediatric Field Guide Pull - Push 20ml/kg NS bolus IV/ IO Signs or symptoms of poor Reassess perfusion caused by bradycardia? (altered mental chest Repeat 20ml/kg NS boluses up tostatus, 40ml/kg until goal met of: Threshold heart rate for age pain, signs of shock) Normal Systolic Blood Pressure for age and Capillary refill < 2 seconds 163 Approved January 23, 2017 Index Index 2030p Pediatric Tachyarrhythmia Routine Medical Assessment Identify andBradycardia treat underlying cause HR ref.O2 < 60 and inadequate for clinical Monitor ECG: identify rhythm condition Start IV / ref. IO YES Search for and treat underlying cause: e.g.: dehydration, fever, hypoxia, hypovolemia, pain Bradycardia Probable Sinus Tachycardia HR < 60 and inadequate for Infants: rate usually < 220 clinical condition Children: rate usually < 180 NO Persistent tachyarrhythmia causing: (Any of the following) YES Hypotension for age, altered mental status or other signs of poor perfusion Contact base: Ref. Synchronized Cardioversion NO Wide QRS? > 0.09sec YES NO Valsalva maneuver ref. Adenosine if regular, narrow complex. Transport Monitor for deterioration Signs of Poor Perfusion: -Cool, pale extremities -Prolonged Cap Refill time (>2 sec) -Lethargy/ alt mental status -Hypotension Approved January 23, 2017 164 Index 2040p Pediatric Bradycardia Bradycardia HR < 60 and inadequate for clinical condition Maintain airway Bradycardia Assist breathing as needed HR <Ref. 60Oxygen and inadequate for Monitor ECG: identify rhythm clinical condition Start IV / Ref. IO Signs of Poor Perfusion: -Cool, pale extremities -Prolonged Cap Refill time (>2 sec) -Lethargy/ alt mental status -Hypotension Maintain airway Persistent bradyarrhythmia causing: Assist breathing as (Any of the following) needed Hypotension for age, altered mental Give oxygen status or other signs of Poor Perfusion No Monitor ECG: identify rhythm Start IV Yes Poor Perfusion Adequate Perfusion Yes Begin CPR Monitor and Transport No Monitor and Transport Persistent bradycardia? Yes Reminders: If pulseless arrest develops, ref. VF / VT or Asystole / PEA algorithm Search for possible reversible causes: “5Hs and 5 Ts” Increased Vagal Tone: -Child has increased ICP not responsive to Oxygen -Possible toxic ingestions ie: clonidine, digoxin, blood pressure medications, nitro, lithium, nasal spray decongestants (taken orally) Ref. epinephrine IV/IO Ref. atropine IV/IO For increased vagal tone or primary AV block For further considerations Contact Base Index Approved January 23, 2017 165 Pediatric Non-Traumatic Pulseless Arrest Dependent lividity Or Rigor mortis Or Decomposition Place patient on cardiac monitor Asystole* Not Asystole Advanced Directives indicating DNR Ref. VF / VT or Asystole / PEA algorithm CONTACT BASE for consideration of field pronouncement Cardiac arrest from the following causes should approached as a medical cardiac arrest: Overdose Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage * Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. The AFR incident number should be included on the strip. 166 Approved January 23, 2017 Index 2200p Newborn Resuscitation (< 24 Hours Old) Breathing and crying and good tone? Birth Routine Care: Warm Suction airway if necessary Dry Ongoing evaluation Yes No Warm, clear airway if necessary, dry, stimulate No 30 sec. HR < 100, gasping or apnea Labored breathing or persistent cyanosis? No Yes Yes BVM 40 – 60 / min (30 seconds) SpO2 monitoring Clear airway SpO2 monitoring 60 sec. No HR < 100 ? Supportive care Yes BVM 40 – 60 / min (30 seconds) SpO2 monitoring HR < 60 ? Treat reversible causes (Hs&Ts) No Yes CPR (1 minute) Ratio: 3 to 1 Depth: 1/3 depth of chest Rate: 120 per minute No REVERSIBLE CAUSES Cause Treatment Hypovolemia 30mL Saline Bolus Hypoxia Ventilation Hypothermia Warming Toxins CONTACT BASE Tension Pneumo Chest Decompression HR < 60 after 1 minute of CPR? Yes ref. Epinephrine DO NOT USE EZ IO Drill for newborns Pink EZ IO needle should be placed by hand. Full Resuscitation CPR (2 minute cycles) Ratio: 3 to 1 Depth: 1/3 depth of chest Rate: 120 per minute Transport to Children’s Hospital Colorado Approved January 23, 2017 Index 167 2200p Newborn Resuscitation General Considerations (From 2010 AHA Guidelines) • Newborn infants who do not require resuscitation can be identified generally based on 3 questions: • Term gestation? • Crying or breathing? • Good muscle tone? • If answer to all 3 questions is “yes” then baby does not require resuscitation and should be dried, placed skin-to-skin on mother and covered to keep warm • If answer to any of 3 questions is “no” then infant should receive 1 or more of following 4 categories of intervention in sequence: • Initial steps in stabilization (warm, clear airway, dry, stimulate) • Ventilation • Chest compression • Administration of epinephrine and/or volume expansion • It should take approx. 60 seconds to complete initial steps • The decision to progress beyond initial steps is based on an assessment of respirations (apnea, gasping, labored or unlabored breathing) and heart rate (>/< 100 bpm) Assisting Ventilations: • Assist ventilations at rate of 40-60 breaths per minute to maintain HR > 100 Chest compressions: • Indicated for HR < 60 despite adequate ventilation w. supplemental O2 for 30 seconds • 2 thumb – encircling hands technique preferred • Allow chest recoil • Coordinate with ventilations so not delivered simultaneously • 3:1 ratio of compressions to ventilations w. exhalation occurring during 1st compression after each ventilation 168 Approved January 23, 2017 Index 2200p Newborn Considerations General Considerations: A. Neonate/Newborn refers to a newly born child under the age of 30 days. While most neonates transition to post-natal life without difficulty, 10% will require medical assistance. Respiratory insufficiency is the most common complication observed in the newly born. B. Neonates born precipitously may exhibit signs of stress such as apnea, grunting respirations, lethargy or poor tone 1. Provide warmth, bulb suction mouth and then nose, and dry the infant 2. If breathing spontaneously, HR >100 and infant is vigorous, continue to monitor 3. If apneic, cyanotic, lethargic, or HR <100, provide 100% oxygen via BVM ventilations at a rate of 40-60 bpm 4. If HR < 60, begin CPR at 3:1 compression : ventilation ratio. C. For neonates who do not respond to initial interventions as above: 1. Obtain blood glucose level and if < 60, administer dextrose IV/IO (D10 5 mL/kg) 2. Administer epinephrine IV for persistent HR < 60 3. Consider hypovolemia and administer 10-20ml/kg NS over 5-10 minutes D. Neonates with congenital heart disease may not be detected prior to hospital discharge after delivery. Consider a cardiac cause of shock in the neonate who remains hypoxic or has persistent cyanosis despite 100% oxygen. These neonates may decompensate precipitously and fluid administration should be used judiciously (10ml/kg NS) E. Newborns are at high risk for hypothermia. Provide early warming measures, keep covered as much as possible (especially the head) and increase the temperature in the ambulance F. Acrocyanosis (cyanosis of only the hands and feet) is normal in newborns and does not require intervention G. Prolonged apnea without bradycardia or cyanosis may indicate respiratory depression caused by narcotics. However, naloxone should be avoided in infants of a known or suspected narcotic-addicted mother as this may induce a withdrawal reaction. Respiratory support alone is recommended H. Obtain pregnancy history, gestational age of the neonate, pregnancy complications, and any illicit drug use during pregnancy. 169 Approved January 23, 2017 Index 3000p Pediatric Syncope Specific Information Needed A. History of the event: onset, duration, seizure activity, precipitating factors. Was the patient sitting, standing, or lying? Pregnant? B. Past history: medications, diseases, prior syncope C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache, palpitations Specific Objective Findings A. B. C. D. Vital signs Neurological status: level of consciousness, residual neurological deficit Signs of trauma to the head or mouth or incontinence Neck stiffness Treatment A. Place patient in position of comfort: do not sit patient up prematurely; supine or lateral positioning if not completely alert B. Monitor vital signs and level of consciousness closely for changes or recurrence. C. Establish venous access and administer Normal Saline if indicated. D. Consider hypoglycemia. If signs of hypoglycemia are present ref. Pediatric Hypoglycemia E. If vital signs abnormal for age 1. Ref. Oxygen. 2. Keep patient supine. 3. Establish venous access. 4. Monitor cardiac rhythm (12-lead EKG) Specific Precautions A. Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the patient is still unconscious, treat as coma. If the patient is confused, treat according to Pediatric Altered Mental Status. B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes. Recumbent position should be sufficient to restore vital signs and level of consciousness to normal. C. Syncope that occurs without warning or while in a recumbent position is potentially serious and often caused by an arrhythmia. D. Patients with syncope, even though apparently normal, should be transported 170 Approved January 23, 2017 Index 3010p Pediatric Stroke POSSIBLE STROKE (Acute onset neurological deficit not likely due to trauma) Assess and stabilize ABCs, ref.O2 ref.O2 Start IV / ref. IO Assess Cincinnati Prehospital Stroke Scale (Presence of single sign sufficient) Rule out or treat ref. Ped hypoglycemia Determine when last KNOWN to be normal and document specific time “At 2:15 PM”, not “1 hour ago” Obtain medical history Document medications Identify family or friend who may assist with history and decision-making, get contact info and strongly encourage to come to ED as they may be needed for consent for treatments Start IV and draw blood Document cardiac rhythm Ensure full monitoring in place: cardiac, SpO2 Fully monitor patient and continually reassess: Improvement or worsening of deficit Adequacy of ventilation and oxygenation Cardiovascular stability Transport to Children’s Hospital Main Campus for pts < 12 years old. Notify receiving hospital of Stroke Alert 171 Approved January 23, 2017 Index 3020p Pediatric Altered Mental Status Assess ABCs ref. VF / VT or Asystole / PEA, respiratory distress or obstructed airway protocol as appropriate. Persistent AMS? Determine character of event Consider seizure, syncope and TIA Monitor and transport with supportive care No Yes Check BGL BGL < 60 mg/dL or clinical condition suggests hypoglycemia? Seizure activity present? Yes ref. Hypoglycemia protocol Yes ref. Seizure protocol No Perform rapid neurologic assessment including LOC and Cincinnati Prehospital Stroke Score (CPSS) Focal neuro deficit or positive CPSS? Yes ref. Stroke protocol No Consider other causes of AMS: ref. overdose, Shock, heat/cold emergency, EtOH Intoxication During transport: ref.O2 Start IV / ref. IO Monitor vital signs, airway, breathing, and ECG. Approved January 23, 2017 172 3030p Pediatric Seizure Support ABCs: ref.O2 Monitor BGL and ref. hypoglycemia Identify and treat reversible causes (see below) Actively Seizing? Yes No If seizure < 5 min medication not necessary If seizure > 5 min or recurrent sz, then treat as follows: Check pulse and reassess ABCs Give supplemental oxygen Transport and monitor ABCs, vital signs, and neurological condition Complete head to toe assessment ref. Midazolam via most readily available route (IN preferred) Actively Seizing? No Common Causes of Seizures Yes Start IV / ref. IO ref. Midazolam IV/ IM/ IN. IV preferred Actively Seizing? Epilepsy Febrile seizure Trauma/NAT Hypoglycemia Intracranial hemorrhage Overdose (TCA) Meningitis Stimulant use (cocaine, meth) No Yes CONTACT BASE 173 Approved January 23, 2017 Index 3030p Pediatric Seizure Seizure Precautions Ensure airway patency, but do not force anything between teeth. NPA may be useful Give oxygen Suction as needed Protect patient from injury Check pulse immediately after seizure stops Keep patient on side Document: Document: Seizure history: onset, time interval, previous seizures, type of seizure Obtain medical history: head trauma, diabetes, substance abuse, medications, compliance with anticonvulsants, pregnancy Approved January 23, 2017 174 Index 3050p Pediatric Alcohol Intoxication A. Minors that are clinically intoxicated should be transported for evaluation. a. Parents may wish to take their children home to “sleep it off”. The clinically intoxicated minor is at risk for adverse outcome and often benefits from evaluation of both medical and psychosocial concerns. b. The parent or guardian must speak with the base physician if he or she is refusing transport of the minor. 175 Approved January 23, 2017 Index 4010p Pediatric Abdominal Pain / Vomiting Abdominal pain and/or vomiting Assess ABCs ref.O2 Complete set of Vital Signs Physical exam Ref. Pediatric Shock as indicated ref.Ondansetron ref. Fentanyl Monitor and transport Frequent reassessment for deterioration and response to treatment 176 Approved January 23, 2017 Index Index 4020p Pediatric Overdose and Acute Poisoning PPE and decontaminate when appropriate ABCs ref.O2 Start IV / ref. IO monitor Need for airway management? ref. Naloxone Airway adjuncts and BVM ventilations as needed Yes ref. resp.failure protocol No Hypotension? Yes ref. dopamine if no response to 20cc/kg NS bolus IV / ref. IO fluid bolus ref. hypotension/shock protocol No Altered mental status? Yes Altered Mental Status Protocol Consider specific ingestions No Known Specific ingestion? No Monitor Transport Yes Stimulant Tricyclic antidepressant Organophosphate or nerve agent Calcium Channel Blocker Tachycardia, HTN, agitation, sweating, psychosis Wide complex tachycardia, seizure DUMBELS/SLUDGE syndrome Bradycardia, heart block, hypotension CONTACT BASE ref. Sodium bicarb ref.Atropine 20 cc/kg NS bolus Ref. Seizure ref.Nerve Agent Antidote Kit ß-Blocker Bradycardia, heart block, hypotension 20 cc/kg NS bolus ref.Dopamine ref. Calcium and ref.dopamine ref.Glucagon ref.Glucagon 177 Approved January 23, 2017 Index 4025p Pediatric Hypoglycemia Check blood glucose level in ANY patient with signs or symptoms consistent with hypoglycemia Examples: Altered MS, agitation, focal neurologic deficit, seizure, weakness, diaphoresis, decreased motor tone, pallor If hypoglycemia still most likely despite normal reading on glucometer, administer sugar while considering other causes of ref. altered mental status No Is BGL < 60? Yes Can the patient safely tolerate oral glucose? intact gag reflex, follows verbal commands Yes ref. Oral Glucose Reassess patient No ref. Glugacon IM ref. IO No Are you able to establish IV access? Yes Still symptomatic? No Yes ref. dextrose IV & reassess patient Symptoms resolved? No Recheck BGL and consider other causes of altered mental status Yes Monitor and transport or CONTACT BASE for refusal 178 Approved January 23, 2017 Index 4031p Pediatric Adrenal Insufficiency Patient at risk for adrenal insufficiency: Identified by family or medical alert bracelet Chronic steroid use Congenital Adrenal Hyperplasia Addison’s disease Assess for signs of acute adrenal crisis: Pallor, weakness, lethargy Vomiting, abdominal pain Hypotension, shock Congestive heart failure All symptomatic patients: Check blood glucose and treat hypoglycemia, if present Start IV / ref. IO / ref.O2 Give NS bolus IV 20 cc/kg up to 1 liter Does patient have hypotension and signs of poor perfusion? Altered mental status Tachycardia Cool, clammy skin Yes No Ref. Methylprednisolone 20 cc/kg NS bolus, as needed Continue to monitor for development of Hypoglycemia If otherwise considering administration of corticosteroid, CONTACT BASE for consult. Monitor 12 lead ECG q 5 min for signs of hyperkalemia 179 Approved January 23, 2017 Index 4031p Pediatric Adrenal Insufficiency Notes: If the patient is confirmed to have a disease (such as congenital adrenal hyperplasia or chronic use of systemic steroids) that could lead to acute adrenal insufficiency or Addisonian crisis, then the administration of steroids may be life-saving and necessary for reversing shock or preventing cardiovascular collapse. • Patients at risk for adrenal insufficiency may develop Addisonian crisis when under physiologic stress which would not lead to cardiovascular collapse in normal patients. Such triggers may include trauma, dehydration, infection, myocardial ischemia, etc. • If no corticosteroid is available during transport, notify receiving hospital of need for immediate corticosteroid upon arrival. 180 Approved January 23, 2017 Index 4040p Pediatric Drowning ABCs Ref. Spinal Immobilization before moving patient if trauma suspected Assess mental status Awake and alert Awake but altered LOC Remove wet garments, dry and insulate patient Transport, even if initial assessment normal Monitor ABC, VS, mental status Remove wet garments, dry and insulate patient Suction as needed Start IV, ref. IO, check BGL, ref.O2 Transport Monitor ABC, VS, mental status Comatose or unresponsive Pulse Present? No Yes Monitor cardiac rhythm Start CPR, attach AED/monitor/defibrillator and treat per Pediatric ref. VF / VT or Asystole / PEA algorithm If suspected hypothermia ref. Hypothermia Remove wet garments, dry and insulate patient Heimlich maneuver NOT indicated Consider all causes of Altered Mental Status Suction as needed Start IV, obtain BGL and give oxygen Monitor ABC, VS, mental status Monitor cardiac rhythm 181 Approved January 23, 2017 Index 4050p Pediatric Hypothermia Hypothermia and Frostbite Systemic hypothermia Presumed to be primary problem based on clinical scenario Localized cold injury Frostbite, frostnip Remove wet garments, dry and insulate patient Transport, even if initial assessment normal Monitor ABC, VS, mental status Dress injured area lightly in clean cloth to protect from further injury Do not rub, do not break blisters Do not allow injured part to refreeze. Repeated thaw freeze cycles are especially harmful Monitor for signs of systemic hypothermia High flow O2 ABCs Comatose or unresponsive Awake but altered LOC Remove wet garments, dry and insulate patient Suction as needed Start IV, ref. IO, BGL, oxygen Transport Monitor ABC, VS, Monitor cardiac mental status rhythm Start CPR, attach AED/monitor/defibrillator and treat ref. VF / VT or Asystole / PEA algorithm with following changes: Pulse Present? No Yes Remove wet garments, dry and insulate patient ref. Altered Mental Status Suction as needed Start IV, check BGL and give oxygen Transport Monitor ABC, VS, mental status ref. Resp Failure Monitor cardiac rhythm PEA Handle very gently Start IV w. warm IVF Insulate patient Asystole or V-fib/VT Single dose ref. Epinephrine IV/IO For Vfib/VT: single attempt defibrillation only ref. Resp Failure Monitor cardiac rhythm 182 Approved January 23, 2017 Index 4060p Pediatric Hyperthermia Hyperthermia Classify by clinical syndrome Consider non-environmental causes (see below) Heat Exhaustion Heat Cramps Normal or slightly elevated body temperature Warm, moist skin Generalized weakness Diffuse muscle cramping Heat Stroke Elevated body temperature Cool, diaphoretic skin Generalized weakness Anxiety Headache Tachypnea Possible syncope Very high core body temperature Hot, dry skin w. cessation of sweating Hypotension Altered mental status Seizure Coma Immediate Transport indicated 20cc/kg bolus NS Adequate airway and breathing? Monitor VS and transport No Yes Ref. respiratory failure Start IV. ref. IO, ref.O2, 20cc/kg bolus NS unless signs of volume overload Remove excess clothing For heat stroke, consider external cooling measures if prolonged transport ref. seizures, cardiac arrhythmias per protocol Monitor and transport 183 Approved January 23, 2017 Index Index 4070p Pediatric Insect/Arachnid Bite and Stings Protocol Initiate general care for bites and stings Assess for localized vs. systemic signs and symptoms and depending on animal involved Localized Symptoms: Pain, warmth and swelling Systemic Symptoms: Hives, generalized erythema, swelling, angioedema Hypotension Altered mental status Other signs of shock ref. Fentanyl for black widow spider and /or ref. diphenhydramine if needed for itching ref.O2 Start IV. ref. IO ref. allergy & anaphylaxis protocol Approved January 23, 2017 184 4080p Pediatric Snake Bite Assess ABCs, mental status ref.O2 Start IV, ref. IO Monitor Vital signs Remove patient from proximity to snake Remove all constricting items from bitten limb (e.g.: rings, jewelry, watch, etc.) Immobilize bitten part Initiate prompt transport • Do NOT use ice, refrigerants, tourniquets, scalpels or suction devices • Mark margins of erythema and/or edema with pen or marker and include time measured. Transport Assess for localized vs. systemic signs and symptoms Systemic Symptoms: • Metallic or peculiar taste in mouth • Hypotension • Altered mental status • Widespread bleeding • Other signs of shock Localized Symptoms: • Pain and swelling • Numbness, tingling to bitten part • Bruising/ecchymosis Immobilize bitten part Monitor pt and ref. Respiratory Distress as indicated ref. Fentanyl ref. Hypotension/Shock as indicated 185 Approved January 23, 2017 Index 4090p Pediatric Apparent Life Threatening Event (ALTE) DEFINITION: An infant < 1 year of age with episode frightening to the observer characterized by apnea, choking/gagging, color change or change in muscle tone Support ABCs as necessary Obtain detailed history of event and medical history Complete head-to-toe assessment Regardless of the infant’s appearance at the time of EMS assessment, the history of an apparent life-threatening event (ALTE) must always result in: A. Ambulance transport to an emergency department OR B. Base contact to consult with ER physician to discuss leaving patient on scene Against Medical Advice. 186 Approved January 23, 2017 Index 4090p Pediatric Apparent Life Threatening Event (ALTE) Clinical history to obtain from observer of event: Document observer’s impression of the infant’s color, respirations and muscle tone For example, was the child apneic, or cyanotic or limp during event? Was there seizure-like activity noted? Was any resuscitation attempted or required, or did event resolve spontaneously? How long did the event last? Past Medical History: Recent trauma, infection (e.g. fever, cough) History of GERD History of Congenital Heart Disease History of Seizures Medication history Examination/Assessment Head to toe exam for trauma, bruising, or skin lesions Check anterior fontanelle: is it bulging, flat or sunken? Pupillary exam Respiratory exam for rate, pattern, work of breathing and lung sounds Cardiovascular exam for murmurs and symmetry of brachial and femoral pulses Neuro exam for level of consciousness, responsiveness and any focal weakness 187 Approved January 23, 2017 Index 4095p Care Of the Child with Special Needs General Guideline: A. Children with special health care needs include those with chronic physical, developmental, behavioral or emotional health issues. These children often have complex medical needs and may be technology-dependent. Parents or caregivers for such children can be a wealth of knowledge about their child’s care and may carry a reference care sheet. CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for any concerns. Feeding Tubes: A. Feedings tubes are used for administration of medications and to provide feeds to children with an impaired ability to take oral feeds. Always ask caretaker the type of feeding tube (does the tube end in the stomach or jejunum?) and when it was placed B. Tubes may be placed through the nose, mouth or abdomen and end in the stomach or jejunum (upper intestine) C. Consider venting and/or gently aspirating the feeding tube in a child with respiratory or abdominal distress to allow removal of gastric contents and decompression D. Feeding tubes that have been placed less than 6 weeks ago are not well established and may close within 1 hour of tube removal. If transport time is prolonged, place an 8 Fr suction catheter tube 2 inches into the stoma to maintain patency. Do NOT use the tube. Tracheostomy: A. A tracheostomy is a surgical opening between the trachea and the anterior surface of the neck. Its purpose is to bypass the upper airway for chronically ventilated patients, upper airway obstructions, or to facilitate secretion removal in those with ineffective gag or swallow reflexes. B. Use bag-valve attached to the tracheostomy to assist ventilations if needed. May also attempt BVM with gloved finger over the tracheostomy C. Inability to ventilate and/or signs of respiratory distress (nasal flaring, retractions, hypoxia, etc) may indicate tracheostomy obstruction. Suction tracheostomy, passing the suction catheter no further than 6 cm. Limit suctioning time to minimum amount of time necessary to accomplish effective suctioning. Oxygenate between passes with the suction catheter. D. 0.5ml of saline may be instilled into the tracheostomy to assist suctioning of thick secretions E. If unable to ventilate through the tracheostomy tube and patient is apneic, bradycardic, or in pulseless arrest, remove tracheostomy tube and pass an appropriately sized endotracheal tube through the stoma approximately 1-2 inches, secure and ventilate. Appropriate depth must be based upon breath sounds, as right mainstem intubation is likely. F. Remember that caregivers are often the best people to change and suction a tracheostomy tube. Use them as your resource when possible. Central Venous Catheters (CVCs): A. Because of their size and location, a much greater risk of serious bacterial infections exist with CVCs compared to peripheral intravenous lines. Special care must be used when accessing such lines B. Prior to accessing a CVC, hands should be washed and gloves worn. Vigorously scrub the CVC hub with an alcohol swab. While alcohol possesses some antimicrobial properties, the friction produced by scrubbing is the most effective C. A port is an implanted venous central venous catheter (below the surface of the skin). These devices require a non-coring (e.g. Huber) needle for accessing and should not be accessed in the field Approved January 23, 2017 188 Index 5000p Pediatric Psychiatric / Behavioral Emergency Scene Safety A. Scene safety and provider safety are a priority. Consider police contact if scene safety is a concern. Specific Information Needed A. Obtain history of current event; inquire about recent crisis, toxic exposure, drugs, alcohol, emotional trauma, and suicidal or homicidal ideation. B. Obtain past history; inquire about previous psychiatric and medical problems, medications. Treatment A. Attempt to establish rapport B. Assess ABCs C. Transport to closest Emergency Department. D. Be alert for possible elopement. E. Consider organic causes of abnormal behavior (trauma, overdose, intoxication, hypoglycemia) F. Check blood sugar ref. Hypoglycemia G. If altered mental status or unstable vital signs: 1. Ref. Oxygen. 2. Establish venous access. 3. Refer to Altered Mental Status Protocol. Approved January 23, 2017 Index 189 7000p Pediatric General Trauma Care BSI Scene safety Consider mechanism Consider need for additional resources General impression ABCs and LOC Rapid Trauma Assessment Ref. Traumatic Pulseless Arrest Prepare for immediate transport SAMPLE history Give high flow oxygen ref. Resp Distress as indicated ref. Resp Failure as indicated Spinal immobilization if indicated Control exsanguinating hemorrhage: Direct pressure ref. Tourniquet protocol if indicated Pelvic stabilization if indicated Assess disability and limitation: Brief neuro assessment Ref. Extremity splinting if indicated Transport to closest appropriate facility Large bore IV, 2nd if unstable. ref. IO Consider fluid bolus 20cc/kg if unstable or suspected significant injuries. ref. Shock Monitor vital signs, ABCs, neuro status, GCS Ref. Fentanyl 190 Approved January 23, 2017 Index 7010p Pediatric Special Trauma Scenarios ref. General Trauma Care Sexual Assault Abuse/neglect Confine history to pertinent medical needs Observe pt’s behavior around caregivers Watch out for: Injury inconsistent with stated mechanism Delayed treatment Spreading blame Conflicting stories Prior/ healing injuries Respect patient’s emotional needs Don’t judge, accuse or confront victim Don’t judge, accuse or confront victim or suspected assailant Protect evidence: No washing or changing clothes Transport patient if suspected abuse or neglect, no matter how minor the injury may appear. Transport Notify Aurora Police Department of all suspected abuse / assault Request APD officer to respond to receiving facility if not on scene prior to patient transport. 191 Approved January 23, 2017 Index 7015p Pediatric Traumatic Pulseless Arrest 7015p Pediatric Traumatic Pulseless Arrest CPR until cardiac monitor applied Place pt on Cardiac Monitor1 Asystole*? No Yes CONTACT BASE for consideration of Field Pronouncement Immediate transport to closest appropriate trauma center Control life threatening external bleeding Continue chest compressions and ventilations as per AFR Pediatric Field Guide Ref. LMA Ref. bilateral needle thoracostomy on all traumatic arrests with trauma to trunk 1Load and go is always a reasonable approach to penetrating trauma arrest. IV. ref. IO access with NS bolus enroute Cardiac arrest from the following causes should be approached as a medical cardiac arrest: Overdose Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage Traumatic pulseless arrest is a unique situation. Do not apply “combo pads” Do Monitor not defibrillate cardiac Do not administer ACLS medications rhythm Do not treat as medical arrest * Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. Include the AFR incident number on the strip. Approved January 23, 2017 192 Index 7020p Pediatric Traumatic Shock Trauma w. suspected serious injury and/or signs of shock ref. General Trauma Care Pelvic sheet if indicated Administer oxygen Large bore IV 2nd IV preferred ref. IO Hypotension for age? Yes Ref. Intraosseous Access Pull / Push 20 cc/kg NS Bolus No Evaluate breath sounds, respiratory effort, and consider tension pneumothorax x Treat en route Keep patient warm Repeat Pull / Push NS bolus 20 cc/kg Reassess ref. needle thoracostomy if arrest or impending arrest Monitor: ABCs, VS, mental status Rapid transport to appropriate trauma center Monitor cardiac rhythm 193 Approved January 23, 2017 Index 7025p Pediatric Amputations ref. General Trauma Care Bleeding Controlled Uncontrolled Bleeding Control with direct pressure to bleeding area or vessel Large bore IV. ref. IO If hypotensive, ref. Shock Document neurovascular exam If bleeding not controlled with direct pressure, ref. Tourniquet Partial / NearAmputation Complete Amputation Amputated part: Cover with moist sterile dressing Splint near-amputated part in anatomic position Wrap in moist, sterile dressing Place in sealed plastic bag Place bag in ice water Do not freeze part Stump: Cover with moist sterile dressing covered by dry dressing ref. fentanyl Monitor and transport to appropriate Trauma Center Treat other injuries per protocol Approved January 23, 2017 194 Index 7029p Pediatric Head Trauma ref. General Trauma Care ref. Oxygen ref. Pediatric Spinal Immobilization as indicated ref. Pediatric Seizure as indicated ref. Pediatric Respiratory Failure / Arrest Requiring Assisted Ventilations as indicated Hypotension for age and / or definite signs of shock? Yes No Rapid Trauma Assessment Treat other injuries per protocol Watch for status changes Ref. Pediatric Traumatic Shock GCS < 8? Yes 0 Head of bed should be elevated 30 unless hypotensive for age. No IV Access Monitor cardiac rhythm Transport to Children’s Hospital Main Campus for pts < 12 years old. Continue to monitor for developing hypoxemia and shock Cushing’s Triad is a sign of increased intracranial pressure and consists of: Hypertension (often with a widening pulse pressure) Bradycardia Irregular respirations 195 Approved January 23, 2017 Index 7030p Pediatric Face and Neck Trauma ref. General Trauma Care Clear airway Rapid trauma assessment ref. Spinal immobilization ref. Resp Distress as indicated ref. Resp Failure as indicated Laryngeal trauma* Yes Transport No Severe airway Bleeding? Yes Direct pressure if appropriate No Complete neuro exam Asses for subcutaneous air Cover/protect eyes as indicated Do not try to block drainage from ears, nose Save avulsed teeth in saline-soaked gauze, do not scrub clean Transport ASAP to closest appropriate facility IV access en route. ref. IO Treat other injuries per protocol Suction airway as needed ref. Fentanyl Monitor ABCs, VS, mental status, SpO2 Approved January 23, 2017 196 Index Index 7035p Pediatric Spinal Trauma ref. General Trauma Care Full spinal immobilization if suspected spine injury Document neuro assessments before and after immobilization Rapid transport to appropriate Trauma Center If vital signs abnormal for age ref. Shock Large bore IV and consider 2nd line ref. IO Complete patient assessment Treat other injuries per protocol Monitor for status changes ref. Fentanyl Monitor ABCs, VS, mental status, SpO2. Approved January 23, 2017 197 7040p Pediatric Spinal Immobilization Considerations Spinal Immobilization A. Context/Special Considerations: B. 60-80% of spine injuries in children occur at the cervical level C. Children < 8 age year are more likely to sustain high C1-C3 injuries D. Less force is required to injure the cervical spine in children than adults E. Children with Down Syndrome are at risk for cervical spine injury F. Avoid strapping abdomen- children are abdominal breathers G. Use age/size appropriate immobilization devices H. Proper immobilization of pediatric patients should prevent: 1. Flexion/extension, rotation, lateral bending or axial loading of the neck (car seats do not prevent axial loading and are not considered proper immobilization technique) 2. Non-neutral alignment or alteration in normal curves of the spine for age (consider the large occiput) 3. Twisting, sliding or bending of the body during transport or care Spinal Immobilization criteria: A. Be conservative. Children are difficult to assess and “clinical clearance” criteria are not well established, as in adults B. Immobilize the following patients as well as any child you suspect clinically may have a spine injury: 1. 2. 3. 4. 5. 6. 7. 8. Mechanisms of injury that imply potential need for spinal stabilization and for whom stabilization should be considered include but are not limited to: MVC/MCC/Bicycle/Equestrian Accident Diving / Axial Load Fall > 3 feet Altered Mental Status (GCS < 15, AVPU < A, or intoxication) Barrier to evaluate for spinal injury (e.g. language or development barrier) Focal neurologic findings (paresthesias, loss of sensation, weakness) Non-ambulatory patient Any complaint of neck pain Torticollis (limited range of motion, difficulty moving neck in history or physical) Substantial torso Injury (thorax, abdomen, pelvis) Approved January 23, 2017 198 Index 7045p Pediatric Chest Trauma ref. General Trauma Care Rapid Transport to closest appropriate Trauma Center No Airway management and assisted ventilations as indicated Are you able to oxygenate and ventilate effectively? ref. needle thoracostomy Yes Penetrating trauma? Yes Occlusive dressings for sucking wounds Rapid transport & stabilize in route No Large bore IV and consider 2nd line ref. IO Flail Chest? Yes Assess for need for assisted ventilations Splint with bulky dressing ref. Resp Distress as indicated ref. Resp Failure as indicated No Vital signs abnormal for age? Yes ref. shock enroute No ref. Fentanyl Monitor ABCs, VS, mental status, SpO2. Index Approved January 23, 2017 199 7050p Pediatric Abdominal Trauma ref. General Trauma Care Rapid transport to closest appropriate Trauma Center IV access Consider 2nd line if MOI significant ref. IO Yes Cover wounds, viscera with saline moistened gauze dressing Penetrating trauma? Do not attempt to repack exposed viscera No Vital signs abnormal for age? Yes ref. Shock No ref. Fentanyl Monitor ABCs, VS, mental status, SpO2. Index Approved January 23, 2017 200 7055p Pediatric Burns ref. General Trauma Care Transport to Trauma Center Stop burning process: Remove clothes if not adhered to patient’s skin Flood with water only if flames/smoldering present Respiratory Distress? Yes O2 NRB 15 lpm ref. Resp Distress as indicated ref. Resp Failure as indicated No Evaluate degree and body surface area involved Critical Burn?* Yes Start 2 large-bore IVs 20 cc/kg NS bolus ref. IO No IV NS TKO Remove rings, jewelry, constricting items Dress burns with dry sterile dressings Treat other injuries per protocol Cover patient to keep warm ref, Fentanyl Monitor ABCs, VS, mental status, SpO2 *Critical Burn: 2º > 30% BSA 3º > 10% BSA Respiratory injury, facial burn Associated injuries, electrical or deep chemical burns, underling PMH (cardiac, DM), age < 10 Approved January 23, 2017 Index 201 ALBUTEROL SULFATE (PROVENTIL, VENTOLIN) Description Albuterol is a selective ß-2 adrenergic receptor agonist. It is a bronchodilator and positive chronotrope. Onset & Duration Onset: 5-15 min. after inhalation Duration: 3-4 hours after inhalation Indications Bronchospasm secondary to asthma, COPD or allergic reaction Contraindications Severe tachycardia is a relative contraindication Adverse Reactions Tachycardia Palpitations Dysrhythmias Drug Interactions Sympathomimetics may exacerbate adverse cardiovascular effects. ß-blockers may antagonize albuterol. How Supplied Pre-diluted nebulized solution: 2.5 mg in 3 ml NS (0.083%) Dosage and Administration Asthma Adult: Dose Albuterol sulfate solution 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5 to 15 minutes. May be repeated twice (total of 3 doses). Pediatric: Albuterol sulfate 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5-15 minutes. May be repeated twice during transport (total of 3 doses). Protocol Adult Asthma Adult COPD Pediatric Respiratory Distress Adult Allergy and Anaphylaxis Pediatric Asthma Pediatric Allergy and Anaphylaxis Special Considerations Consider inline nebs for patients requiring endotracheal intubation or CPAP. May precipitate angina pectoris and dysrhythmias Should be used with caution in patients with suspected or known coronary disease, diabetes mellitus, hyperthyroidism, prostatic hypertrophy, or seizure disorder Wheezing associated with anaphylaxis should first be treated with epinephrine IM. Index Approved January 23, 2017 202 ADENOSINE (ADENOCARD) Description Adenosine transiently blocks conduction through the AV node thereby terminating reentrant tachycardias involving the AV node. It is the drug of choice for AV nodal reentrant tachycardia (AVNRT, often referred to as “PSVT”). It will not terminate dysrhythmias that do not involve the AV node as a reentrant limb (e.g. atrial fibrillation). Onset & Duration Onset: almost immediate Duration: 10 sec Indications Stable, narrow-complex supraventricular tachyarrhythmia (suspected AVNRT) Contraindications Any irregular tachycardia. Specifically never administer to an irregular wide-complex tachycardia, which may be lethal Post cardiac transplant patients should not receive adenosine Adverse Reactions Chest pain Shortness of breath Diaphoresis Palpitations Lightheadedness Drug Interactions Methylxanthines (e.g. caffeine) antagonize adenosine, a higher dose may be required Dipyridamole (persantine) potentiates the effect of adenosine; reduction of adenosine dose may be required Carbamazepine may potentiate the AV-nodal blocking effect of adenosine Dosage and Administration Adult: 12 mg IV bolus, rapidly, followed by a normal saline flush. May repeat x 1. Total of 2 doses. For further considerations CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Pediatric: Reference Pediatric Field Guide 0.2 mg/kg IV bolus, Maximum single dose of 12mg, rapidly followed by normal saline flush. May repeat x 1. Total of 2 doses For further considerations CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Approved January 23, 2017 203 Index ADENOSINE (ADENOCARD) cont. Protocol Adult Tachyarrhythmia Pediatric Tacharrhythmia Special Considerations Reliably causes short lived but very unpleasant chest discomfort. Always warn your patient of this before giving medication and explain that it will be a very brief sensation May produce bronchospasm in patients with asthma Transient asystole and AV blocks are common at the time of cardioversion Adenosine is not effective in atrial flutter or fibrillation Adenosine is safe in patients with a history of Wolff-Parkinson-White syndrome if the rhythm is regular and QRS complex is narrow A 12-lead EKG should be performed and documented Adenosine requires continuous EKG monitoring throughout administration Print continuous EKG while administering adenosine and deliver to attending physician. 204 Approved January 23, 2017 Index AMIODARONE (CORDARONE) Description Amiodarone has multiple effects showing Class I, II, III and IV actions with a quick onset. The dominant effect is prolongation of the action potential duration and the refractory period. Indications Cardiac arrest in patients who continue to have VF/VT after CPR, epinephrine, and defibrillation Stable, wide complex tachycardia BASE CONTACT REQUIRED (AIP, Children’s, TMCA, CMP, SaddleRock) Precautions Wide complex irregular tachycardia Sympathomimetic toxidromes, i.e. cocaine or amphetamine overdose NOT to be used to treat ventricular escape beats or accelerated idioventricular rhythms Contraindications Hypotension Adverse Reactions Severe hypotension Bradycardia Dosage and Administration Adult: Max dose 450mg Pulseless Cardiac arrest in patients who continue to have VF/VT after CPR, epinephrine, and defibrillation Arrest (Refractory VT/VF) Initial 300 mg IV/IO bolus. Additional 150 mg IV/IO bolus in 4 minutes if pt continues to have VF/VT Wide Complex tachycardia with adequate perfusion CONTACT BASE REQUIRED for order (AIP, Children’s, TMCA, CMP, SaddleRock) 150 mg slow push Pediatric: Reference Pediatric Field Guide Pulseless Arrest (Refractory VT/VF) Cardiac arrest in patients who continue to have VF/VT after CPR, 2 doses of epinephrine, and defibrillation 5mg/kg IV/IO slow push. For additional doses CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock). Protocol Adult Pulseless Arrest Algorithm VF / VT Adult Pulseless Arrest Algorithm Asystole / PEA Pediatric Pulseless Arrest VF / VT Pediatric Pulseless Arrest Asystole / PEA Adult Tachycardia Special Considerations A 12-lead EKG should be performed and documented. Approved January 23, 2017 205 Index ASPIRIN (ASA) Description Aspirin inhibits platelet aggregation and blood clotting and is indicated for treatment of acute coronary syndrome in which platelet aggregation is a major component of the pathophysiology. It is also an analgesic and antipyretic Indications Suspected acute coronary syndrome. (chest pain, diaphoresis, dyspnea, etc) Contraindications Active gastrointestinal bleeding Aspirin allergy How Supplied Chewable tablets 81mg Dosage and Administration 324mg PO Protocol Adult Chest Pain Special Considerations Patients with suspected acute coronary syndrome taking warfarin (Coumadin) or clopidogrel (Plavix) may still be given aspirin Approved January 23, 2017 206 Index ATROPINE SULFATE Description Atropine is an endogenous antimuscarinic, anticholinergic substance. It is the prototypical anticholinergic medication with the following effects: Increased heart rate and AV node conduction Decreased GI motility Urinary retention Pupillary dilation (mydriasis) Decreased sweat, tear and saliva production (dry skin, dry eyes, dry mouth) Indications Adult Bradycardia with poor perfusion including: o 2nd and 3rd degree heart block Organophosphate poisoning Pediatric Bradycardia with Poor Perfusion associated with increased vagal tone or Primary AV Block Precautions Should not be used without medical control direction for stable bradycardias Closed angle glaucoma Adverse Reactions Anticholinergic toxidrome in overdose, think “blind as a bat, mad as a hatter, dry as a bone, red as a beet” Dosage and Administration Adult Bradycardia with Poor Perfusion Adult: Initial dose of 0.5 mg IV / IO bolus. Additional dose of 1.0 mg IV / IO bolus if needed at 4 minute interval, May repeat x 1. Total of 2.5mg (Stop at ventricular rate which provides adequate mentation and blood pressure) Pediatric Bradycardia with Poor perfusion associated with increased vagal tone or primary AV Block Reference Pediatric Field Guide 0.02mg/kg, IV/IO bolus. Minimum dose 0.1mg Maximum single dose is 0.5mg Maximum total dose 1.0mg Poisoning/Overdose For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Protocol Adult Bradycardia Pediatric Bradycardia Adult Overdose / Acute Poisoning Pediatric Overdose and Acute Poisoning Approved January 23, 2017 Index 207 CALCIUM GLUCONATE Description Cardioprotective agent in hyperkalemia. 10% calcium gluconate solution contains 1 g calcium gluconate per 10 mL, which is only 90mg of elemental calcium. Doses below refer to dose of calcium gluconate solution, not elemental calcium. Calcium chloride contains 3 times the concentration of elemental calcium compared to calcium gluconate. If calcium gluconate not available, calcium chloride is an acceptable substitution. Indications Not indicated for routine treatment of pulseless arrest Adult Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history o Calcium channel blocker overdose Calcium channel blocker overdose with bradycardia and hypotension/shock Contraindications Known hypercalcemia Suspected digoxin toxicity (i.e. digoxin overdose) Precautions Must flush IV / IO or give in separate line from Sodium bicarb to prevent precipitation/formation of calcium carbonate Extravasation may cause tissue necrosis In setting of digoxin toxicity, may worsen cardiovascular function Dosage and Administration Adult: Pulseless arrest assumed due to hyperkalemia: o To be administered before Sodium Bicarbonate Must flush IV/IO line between meds. o 1 g slow IV / IO push (10 mL of a 10% solution). Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) 1 g slow IV / IO push over 2-3 minutes. Dose may be repeated every 10 minutes for total of 3 doses (10 mL of a 10% solution). Pediatric: Reference Pediatric Field Guide Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Pulseless Arrest assumed due to hyperkalemia: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Index Approved January 23, 2017 208 CALCIUM GLUCONATE Protocol Adult Pulseless Arrest Algorithm VF / VT Adult Pulseless Arrest Algorithm Asystole / PEA Adult Overdose / Acute Poisoning Pediatric Overdose and Acute Poisoning 209 Approved January 23, 2017 Index CALCIUM CHLORIDE Description If calcium gluconate not available, calcium chloride is an acceptable substitution. Calcium chloride has 3 times the concentration of elemental calcium as calcium gluconate, so the volume given should be decreased. Calcium chloride is more likely to cause tissue necrosis in the event of extravasation and is therefore reserved for immediately lifethreatening conditions when given via peripheral line. Cardioprotective agent in hyperkalemia. Indications Not indicated for routine treatment of cardiac arrest Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history o Calcium channel blocker overdose Calcium channel blocker overdose with bradycardia and hypotension/shock Contraindications Known hypercalcemia Suspected digoxin toxicity (i.e. digoxin overdose) Precautions Must flush IV / IO or give in separate line from Sodium bicarb to prevent precipitation/formation of calcium carbonate Extravasation may cause tissue necrosis In setting of digoxin toxicity, may worsen cardiovascular function Dosage and Administration Adult: Pulseless arrest assumed due to hyperkalemia: o To be administered before Sodium Bicarbonate Must flush IV / IO line between meds. o 500 mg slow IV / IO push (5 mL of a 10% solution) Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock).500 mg slow IV / IO push over 2-3 minutes (5 mL of a 10% solution). Dose may be repeated every 10 minutes for total of 3 doses. Pediatric: Reference Pediatric Field Guide Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock). Pulseless Arrest assumed due to hyperkalemia: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock). Protocol Adult Pulseless Arrest Algorithm VF / VT Adult Pulseless Arrest Algorithm Asystole / PEA Adult Overdose / Acute Poisoning Pediatric Overdose and Acute Poisoning Approved January 23, 2017 Index 210 DEXTROSE 50% Description Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop in blood sugar level will result in disturbances of normal metabolism, manifested clinically as a decrease in mental status, sweating and tachycardia. Further decreases in blood sugar may result in coma, seizures, and cardiac arrhythmias. Serum glucose is regulated by insulin, which stimulates storage of excess glucose from the blood stream, and glucagon, which mobilizes stored glucose into the blood stream. Indications Hypoglycemia (BGL< 60 mg / dL) Not indicated for routine treatment of pulseless arrest Precautions None Dosage and Administration Adult: 25 gm (50 ml of a 50% solution) IV / IO bolus. May repeat if needed. Pediatric: Reference Pediatric Field Guide 1-8 years: 2 ml/kg IV/IO of a 25% solution <1 year: 5 ml/kg IV/IO of a 10% solution Protocol Adult Hypoglycemia Altered Mental Status Adult Seizures Pediatric Altered Mental Status Pediatric Seizures Overdose / Acute Poisoning Psych/Behavioral Newborn Resuscitation Pediatric Hypoglycemia Special Considerations Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to ensure route patency. Dextrose can be irritable to the vein and the vein should be flushed after administration. Dextrose should be diluted 1:1 with normal saline (to create D 25W) for patient 1-8 years old. Dextrose should be diluted 1:10 with normal saline (to create D10W) for patient < 1 year old. Index Approved January 23, 2017 211 DIPHENHYDRAMINE (BENADRYL) Description Antihistamine for treating histamine-mediated symptoms of allergic reaction. Also Anticholinergic and antiparkinsonian effects used for treating dystonic reactions caused by antiphsychotic and antiemetic medications (e.g.: haloperidol, droperidol, compazine, etc). Indications Allergic reaction Dystonic medication reactions or akathesia (restlessness) Precautions Asthma or COPD, thickens bronchial secretions Narrow-angle glaucoma Side effects Drowsiness Dilated pupils Dry mouth and throat Flushing Drug Interactions CNS depressants and alcohol may have additive effects. MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines. Dosage and Administration Adults: 50 mg IV / IO / IM Pediatrics: Reference Pediatric Field Guide 1 mg/kg slow IV /IO / IM (not to exceed 50 mg) Protocol Adult Allergy and Anaphylaxis Adult Insect / Arachnid Bite and Stings Pediatric Allergy and Anaphylaxis Pediatric Insect / Arachnid Bite and Stings 212 Approved January 23, 2017 Index DOPAMINE (INTROPIN) Description Endogenous catecholamine chemically related to epinephrine and norepinephrine. Increases blood pressure through combination of dopamine, alpha and beta receptor effects leading to increased heart rate, contractility and peripheral vasoconstriction. Indications Adult Hypotension refractory to adequate fluid resuscitation Adult Symptomatic bradycardia with signs of poor perfusion Contraindications Hypovolemia Hemorrhagic shock Adverse Reactions Tachydysrhythmias Hypertension Increased myocardial oxygen demand Dosage and Administration: CARRIED ONLY ON THE TRANSPORTING AMBULANCE CONTACT BASE FOR DIRECT PHYSICIAN ORDER (AIP, Children’s, TMCA, CMP, SaddleRock) Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of 1600 mcg/ml. Adult IV/IO: 2~20 mcg/kg/min, Start at 5 mcg/kg/min, Titrate dose up 5 mcg/kg/min every 5 min to a max of 20 mcg/kg/min to achieve desired effect. Pediatric: Reference Pediatric Field Guide 2~20 mcg/kg/min, Start at 5 mcg/kg/min, Titrate dose up 5 mcg/kg/min every 5 min to a max of 20 mcg/kg/min to achieve desired effect. Protocol Adult Medical Hypotension/Shock Protocol Adult Bradycardia Adult Overdose / Acute Poisoning Pediatric Overdose and Acute Poisoning Special Considerations May become ineffective if added to alkaline solution. Tissue extravasation at the IV site can cause skin sloughing due to vasoconstriction. Be sure to make Emergency Department personnel aware if there has been any extravasation of dopamine-containing solutions so that proper treatment can be instituted. Approved January 23, 2017 213 Index DOPAMINE (INTROPIN) cont. INTRAVENOUS DRIP RATES FOR DOPAMINE Concentration: 1600 mcg/ml Dose (mcg/kg/min) 5 10 15 20 50 kg 10 20 30 40 60 kg 10 25 35 45 70 kg 15 25 40 50 80 kg 15 30 45 60 90 kg 15 35 50 70 100 kg 20 35 55 75 110 kg 20 40 60 85 Weight microdrips/min Approved January 23, 2017 214 Index EPINEPHRINE (ADRENALIN) Description Endogenous catecholamine alpha, beta-1, and beta-2 adrenergic receptor agonist. Causes dose-related increase in heart rate, myocardial contractility and oxygen demand, peripheral vasoconstriction and bronchodilation. Indications Pulseless Arrest Anaphylaxis ( 2 or more of the following signs or symptoms) Hypotension Signs of poor perfusion Bronchospasm, stridor Altered mental status Urticaria Asthma Bradycardia with Poor Perfusion (symptomatic) (pediatric patients) Adverse Reactions Tachycardia and tachydysrhythmia Hypertension Anxiety May precipitate angina pectoris Drug Interactions Should not be added to sodium bicarbonate or other alkaloids as epinephrine will be inactivated at higher pH. Dosage and Administration Adult: Pulseless Arrest 1 mg (10 ml of a 1:10,000 solution), IV/IO bolus. Repeat every 4 minutes. o Only a Single Dose of Epi if suspected Systemic Hypothermia in Cardiac Arrest Asthma: 0.3 mg (0.3 ml of a 1:1,000 solution) IM. Anaphylaxis: 0.3 mg (0.3 ml of a 1:1,000 solution) IM. Repeat in 5 minutes X 1. 215 Approved January 23, 2017 Index EPINEPHRINE (ADRENALIN) cont. Pediatric: Reference Pediatric Field Guide Cardiac arrest: 0.01 mg/kg IV / IO (0.1 ml/kg of 1:10,000 solution). Repeat every 4 minutes. Bradycardia with Poor Perfusion for order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV / IO Asthma 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM Anaphylaxis 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM. May repeat in 5 minutes x 1. Newborn (< 24 hours old): (PINK EZ IO placed by hand NOT drill) Cardiac arrest: 0.3mL of 1:10,000 solution IO / IV Repeat every 4 minutes. Bradycardia (heart rate < 60 beats per minute after adequate positive pressure ventilation and chest compressions) 0.3mL of 1:10,000 solution IO / IV Protocol Adult Pulseless Arrest Algorithm VF / VT Adult Pulseless Arrest Algorithm Asystole / PEA Adult Hypothermia Pediatric Pulseless Arrest VF / VT Pediatric Pulseless Arrest Asystole / PEA Newborn Resuscitation Adult Allergy and Anaphylaxis Adult Asthma Pediatric Respiratory Distress Pediatric Asthma Pediatric Croup Pediatric Allergy and Anaphylaxis Pediatric Bradycardia Pediatric Hypothermia Special Considerations May increase myocardial oxygen demand and angina pectoris. Use with caution in patients with known or suspected CAD Only a single dose of Epi if suspected Systemic Hypothermia in Pulseless Arrest associated with Asystole, Vfib, VT Approved January 23, 2017 Index 216 FENTANYL (SUBLIMAZE) Description Potent synthetic opioid analgesic. Fentanyl is 100 times more potent than morphine. Onset & Duration Onset: Within 2~3 minutes Duration: 30 minutes Indications Moderate to severe pain The objective of pain management is not the removal of all pain. Use fentanyl to make the patient’s pain tolerable enough to allow for adequate assessment, treatment and transport Persistent chest pain that is not relieved by 3 doses of SL Nitroglycerine in non- inferior wall MIs and without prior Nitroglycerin in inferior wall MIs. For pain management during Transcutaneous Cardiac Pacing and Synchronized Cardioversion Contraindications Hypotension (<90mm Hg Systolic for Adult patients) (Age specific criteria for pediatrics) The use of parenteral narcotics in the presence of parenteral benzodiazepines is not allowed Side Effects Respiratory depression and apnea: May occur suddenly, and is more common in children and the elderly Hypotension, especially when used in combination with other sedatives such as alcohol or benzodiazepines. Can increase intracranial pressure Chest wall rigidity has been reported with rapid administration Pediatric patients may develop apnea without manifesting significant mental status changes Dosage and Administration Adult: IV route: 1-2 mcg/kg, SLOW IV bolus. Dose may be repeated after 5 minutes x 1 and titrated to clinical effect to a maximum cumulative dose of 300mcg. Consider lower dose of 0.5-1 mcg/kg in elderly pts over 65 years Any Additional dosing requires CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) IN route: 1-2 mcg/kg IN single dose. Additional dose only via IV route. May give 1 additional dose 5 minutes after initial IN dose up to a maximum cumulative dose of 300mcg. Consider lower dose of 0.5-1 mcg/kg in elderly pts over 65 years. Any Additional dosing requires CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Index Approved January 23, 2017 217 FENTANYL (SUBLIMAZE) cont. Pediatric (1-12 years): REFERENCE PEDIATRIC FIELD GUIDE IV route: 1 mcg/kg SLOW IV bolus. Dose may be repeated after 5 minutes and titrated to clinical effect to a maximum cumulative dose of 3 mcg/kg IN route: Requires CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) and approval for any indication other than isolated orthopedic injury or burns 2 mcg/kg IN single dose. Additional dose only via IV route. May give 1 additional dose 5 minutes after initial IN dose up to a maximum cumulative dose of 3 mcg/kg Pediatric < 1 year: REQUIRES CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) NOTE: IV route is preferred for more accurate titration. Continuous pulse oximetry is mandatory. Frequent evaluation of the patient’s vital signs is also indicated. Emergency resuscitation equipment and naloxone must be immediately available. Protocol Adult Extremity Injuries Adult Amputation Adult Chest Pain Adult Abdominal Pain / vomiting Adult Insect / Arachnid Bite and Stings Adult Snake Bite Adult Face and Neck Trauma Adult Spinal Trauma Adult Chest Trauma Adult Abdominal Trauma Adult Burns Synchronized Cardioversion Transcutaneous Pacing Pediatric Abdominal Pain/Vomiting Pediatric Insect / Arachnid Bite and Stings Pediatric Snake Bite Pediatric Amputations Pediatric Face and Neck Trauma Pediatric Spinal Trauma Pediatric Chest Trauma Pediatric Abdominal Trauma Pediatric Burns Index Approved January 23, 2017 218 GLUCAGON Description Increases blood sugar concentration by converting liver glycogen to glucose. Glucagon also causes relaxation of smooth muscle of the stomach, duodenum, small bowel, and colon. Onset & Duration Onset: variable Indications Hypoglycemia BGL < 60 mg/dL and IV access is unavailable. Hypotension, bradycardia from beta-blocker or calcium channel overdose. Side Effects Tachycardia Headache Nausea and vomiting Dosage and Administration Adult: Hypoglycemia 1.0 mg, IM Beta Blocker/Calcium Channel overdose for order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) 2.0 mg IV bolus Pediatric: Reference Pediatric Field Guide Hypoglycemia 0.1 mg/kg IM. Maximum dose 1.0 mg IM Beta Blocker/Calcium Channel overdose for order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) 2.0 mg IV bolus Protocol Adult Seizure Pediatric Seizure Adult Overdose / Acute Poisoning Adult Hypoglycemia Pediatric Overdose and Acute Poisoning Pediatric Hypoglycemia Approved January 23, 2017 Index Index 219 IPRATROPIUM BROMIDE (ATROVENT) Description Ipratropium is a anticholinergic antimuscarinic bronchodilator chemically related to atropine. Onset & Duration Onset: 5-15 min. after inhalation Duration: 6-8 hr. after inhalation Indications Bronchospasm secondary to asthma and COPD Contraindications Do not administer to children < 2 years Soy or peanut allergy is a contraindication to use of Atrovent metered dose inhaler, not the nebulized solution, which does not have the allergen contained in propellant Adverse Reactions Palpitations Tremors Dry mouth How Supplied Premixed Container: 0.5 mg in 2.5ml NS Dosage and Administration Not indicated for repetitive dose or continuous neb use Adult Mild- Mod- Severe Bronchospasm: Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer. Do not repeat. Child (2yrs – 12yrs) Mild- Mod- Severe Bronchospasm Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer. Do not repeat. Protocol Adult Asthma Adult COPD Pediatric Respiratory Distress Pediatric Asthma Index Index Approved January 23, 2017 220 MAGNESIUM SULFATE Description Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. In cardiac patients, it stabilizes the potassium pump, correcting repolarization. It also shortens the Q-T interval in the presence of ventricular arrhythmias due to drug toxicity or electrolyte imbalance. In respiratory patients, it may act as a bronchodilator in acute bronchospasm due to asthma or other bronchospastic diseases. In patients suffering from eclampsia, it controls seizures by blocking neuromuscular transmission and lowers blood pressure as well as decreases cerebral vasospasm. Indications Antiarrhythmic Torsade de pointes associated with prolonged QT interval Respiratory Severe bronchospasm secondary to asthma; unresponsive to all of the following: albuterol and ipratropium, continuous albuterol, and IM epinephrine. Obstetrics Pregnancy > 20 weeks gestational age with evidence of eclampsia Precautions Bradycardia Hypotension Respiratory depression Adverse Reactions Bradycardia Hypotension Respiratory depression Dosage and Administration Torsades de Pointes suspected caused by prolonged QT interval: 2 gm, IV / IO bolus. Refractory Severe Bronchospasm: For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 2 gm, slow IV push. Eclampsia: For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 2 gm, slow IV push. Pediatric: Reference Pediatric Field Guide For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Asthma 25-50mg/kg IV bolus. Maximum dose 2.0 grams Protocol Adult Pulseless Arrest Algorithm VF / VT Adult Asthma Adult Eclampsia Adult Seizure Pediatric Asthma 221 Approved January 23, 2017 Index METHYLPREDNISOLONE (SOLU-MEDROL) Description Methylprednisolone is a synthetic steroid that suppresses acute and chronic inflammation and may alter the immune response. In addition, it potentiates vascular smooth muscle relaxation by beta-adrenergic agonists and may alter airway hyperactivity. Indications Anaphylaxis Severe asthma COPD Shock with history of adrenal insufficiency Contraindications Evidence of active GI bleed Adverse Reactions Most adverse reactions are a result of long-term therapy and include: Gastrointestinal bleeding Hypertension Hyperglycemia Dosage and Administration Anaphylaxis, Severe Asthma, COPD: After primary treatment priorities are completed Adult: 125 mg, Slow IV Push Pediatric: Reference Pediatric Field Guide 2.0 mg/kg Slow IV Push, Maximum dose 60.0 mg Shock with history of adrenal insufficiency: Adult: 125 mg, Slow IV Push, IO slowly Pediatric: Reference Pediatric Field Guide 2.0 mg/kg Slow IV Push , IO slowly. Maximum dose 125mg Protocol Adult Asthma Adult COPD Adult Allergy and Anaphylaxis Adult Adrenal Insufficiency Pediatric Asthma Pediatric Allergy and Anaphylaxis Pediatric Adrenal Insufficiency 222 Approved January 23, 2017 Index METHYLPREDNISOLONE (SOLU-MEDROL) Special Considerations Must be reconstituted and used immediately The effect of methylprednisolone is generally delayed for several hours. Methylprednisolone is not considered a first line drug. Be sure to attend to the patient’s primary treatment priorities (i.e. airway, ventilation, beta-agonist nebulization, fluid bolus) first. If primary treatment priorities have been completed and there is time while in route to the hospital, then methylprednisolone can be administered. Do not delay transport to administer this drug 223 Approved January 23, 2017 Index MIDAZOLAM (Versed) Description Midazolam HCl is a water-soluble short acting benzodiazepine sedative-hypnotic. It is believed that benzodiazepines exert their effect on the GABA receptor to create anxiolysis, sedation and muscle relaxation. Indications Seizures > 5min or multiple seizures Eclampsia Sedation of the combative patient Sedation of the Excited Delirium patient Contraindications Hypotension (<90mm Hg Systolic for Adult patients) (Age specific criteria for pediatrics) Adverse Reactions Respiratory depression, including apnea Hypotension Sedative effect of midazolam may be heightened by associated use of opioids, alcohol, or other CNS depressants. Dosage and Administration Sedation of combative patient: Adult: A single dose of 2 mg IV or if no IV in place 5 mg IM / IN. In elderly pts over 65 years or small adults <50kg administer ½ dose. For repeat dose CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Pediatric: Reference Pediatric Field Guide For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Seizure / Eclampsia: Adult: 2 mg, IV may repeat x 1 in 5 minutes. Total of 2 doses. 5mg, IM / IN may repeat x 1 in 5 minutes. Total of 2 doses. For additional dosing CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Pediatric: Reference Pediatric Field Guide 0.1 mg/kg, IV / IM may repeat x1 in 5 minutes. Maximum single dose 2 mg. 0.2 mg/kg, IN (divided into each nare may repeat x1 in 5 minutes. Maximum single dose 5 mg. For additional dosing CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Excited Delirium: Adult: STANDING ORDER of: Initial dose of 2mg IV. REPEAT doses of 2mg IV in 5 minutes x 2 for a MAX of up to 6mg IV. OR Initial dose of 10mg IM / IN if no IV in place. Additional doses of 5mg IM / IN x 2. For MAX of up to 20mg IM / IN. Approved January 23, 2017 224 Index MIDAZOLAM (Versed) cont. Protocol Synchronized Cardioversion Adult Tachycardia Transcutaneous Pacing Adult Seizure Adult Eclampsia Pediatric Seizure Adult Combative Patient Excited Delirium Special Considerations Provide continuous cardiac and pulse-oximetry monitoring Have resuscitation equipment readily at hand. Due to increased risk of hypotension and respiratory depression, the use of parenteral benzodiazepines in the presence of parenteral narcotics is not allowed In elderly patients > 65 years old or small adults < 50kg, administer ½ dose. Approved January 23, 2017 Index 225 NALOXONE (NARCAN) Description Naloxone is a competitive opioid receptor antagonist Onset & Duration Onset: Within 5 minutes Duration: Approximately 1 hour Indications For reversal of suspected opioid-induced respiratory depression Not Indicated for routine treatment of Pulseless arrest Adverse Reactions Tachycardia Nausea and vomiting Pulmonary Edema Dosage and Administration Adult: 0.5 mg IV / IN / IO and titrate to desired effect, up to 2 mg total In Adult cases where IV / IN access is not feasible, 2 mg bolus IM is appropriate Pediatric: Reference Pediatric Field Guide 0.5 mg IV / IN / IO and titrate to desired effect, up to 2 mg total Protocol Altered Mental Status Adult Overdose / Acute Poisoning Pediatric Altered Mental Status Pediatric Overdose / Acute Poisoning Special Considerations Not intended for use unless respiratory depression or impaired airway reflexes are present. Reversal of suspected mild-moderate opioid toxicity is not indicated in the field as it may greatly complicate treatment and transport as narcotic-dependent patients may experience violent withdrawal symptoms Patients receiving EMS administered naloxone should be transported to a hospital. In the State of Colorado, bystanders, law enforcement, and other first responders can administer naloxone if they feel a person is experiencing an opiate-related drug overdose event (Colorado Revised Statutes §12-36-117.7). There are significant concomitant inherent risks in patients who have received naloxone, including: o Recurrent respiratory/CNS depression given short half-life of naloxone o Co-existing intoxication from alcohol or other recreational or prescription drugs o Acetaminophen toxicity from combination opioid/acetaminophen prescriptions o Non-cardiogenic pulmonary edema associated with naloxone use o Acute psychiatric decompensation, overdose, SI/HI or psychosis requiring ED evaluation o Sudden abrupt violent withdrawal symptoms which may limit decision making capacity (continued next page) Approved January 23, 2017 Index 226 Given the above risks, it is strongly preferred that patients who have received naloxone be transported and evaluated by a physician. However, if the patient clearly has decisionmaking capacity he/she does have the right to refuse transport. If adamantly refusing, patients must be warned of the multiple risks of refusing transport. If the patient is refusing transport contact base. If any concerns or doubts about decision-making capacity exist, err on the side of transport. 227 Approved January 23, 2017 Index NERVE AGENT KIT (DUODOTE) Description A streamlined, easy-to-use replacement for the Mark I™Kit. FDA approved for Emergency Medical Services (EMS) use in the treatment of organophosphorus nerve agent and organophosphorus insecticide poisoning. Contains two antidotes in 1 auto-injector; 2.1 mg of atropine in a 0.7-mL solution and 600 mg of pralidoxime chloride in a 2-mL solution. Delivered sequentially into separate areas of the muscle–Easy to use: only 1 injection with 1 needle Onset & Duration Onset: Within 5 minutes Duration: 1-4 hours Indications Treatment of poisoning by organophosphorus nerve agents as well as organophosphorus insecticides. Should be administered as soon as symptoms of organophosphorus poisoning appear. Adverse Reactions Tachycardia Nausea and vomiting Pulmonary Edema Dosage and Administration MILD symptoms: Blurred vision, miosis (excessive constriction of the pupils) Excessive, unexplained teary eyes Excessive, unexplained runny nose Increased salivation such as sudden drooling Chest tightness or difficulty breathing Tremors throughout the body or muscular twitching Nausea and/or vomiting Unexplained wheezing, coughing, or increased airway secretions Acute onset of stomach cramps Tachycardia or bradycardia Treatment for MILD Symptoms: FIRST DOSE: In the situation of known or suspected organophosphorus poisoning, administer one DuoDote™ injection into the mid-outer thigh if the patient experiences two or more MILD symptoms of nerve gas or insecticide exposure Wait 10 to 15 minutes for DuoDote™ to take effect. If, after 10 to 15 minutes, the patient does not develop any SEVERE symptoms, no additional DuoDote™ injections are recommended, but definitive medical care should ordinarily be sought immediately. ADDITIONAL DOSES: If, at any time after the first dose, the patient develops any SEVERE symptoms, administer two additional DuoDote™ injections in rapid succession, and immediately seek definitive medical care 228 Approved January 23, 2017 Index NERVE AGENT KIT (DUODOTE) cont. SEVERE Symptoms: Strange or confused behavior Severe difficulty breathing or copious secretions from lungs/airway Severe muscular twitching and general weakness Involuntary urination and defecation Convulsions Loss of consciousness Respiratory arrest (possibly leading to death) Treatment for SEVERE Symptoms: Immediately administer three DuoDote™ injections into the patient’s mid-outer thigh in rapid succession, and immediately transport. No more than 3 doses of DuoDote™ should be administered unless definitive medical care is available. Protocol Adult Overdose / Acute Poisoning Pediatric Overdose and Acute Poisoning Special Considerations Before injecting Tear open plastic pouch at any of the notches, and remove the DuoDote™ Auto-Injector Place DuoDote™ in your dominant hand and firmly grasp it, with the Green Tip pointing downward With your other hand, pull off the Gray Safety Release, taking care never to touch the Green Tip Keep fingers clear of both ends of the auto-injector You are now ready to inject Select site and inject The injection site is the mid-outer thigh area. You can inject through clothing, but make sure that pockets are empty Firmly push Green Tip straight down (at a 90ºangle) against mid-outer thigh, continuing to push firmly until you feel the auto-injector trigger After the DuoDote™ Auto-Injector triggers, hold it firmly in place against the injection site for 10 seconds After injecting Remove the DuoDote™ Auto-Injector from thigh and inspect the Green Tip; if the needle is visible, then the injection was successful If the needle is not visible, make sure the Gray Safety Release is removed and repeat the preceding injection steps Push the exposed needle against a hard surface until it bends back, then put the used auto-injector back in the plastic pouch Keep used auto-injector(s) with the patient so other medical personnel will be aware of how many injections were administered 229 Approved January 23, 2017 Index NITROGLYCERINE (NITROSTAT, etc) Description Short-acting peripheral vasodilator decreasing cardiac preload and afterload Onset & Duration Onset: 1-3 min. Duration: 20-30 min. Indications Pain or discomfort due to suspected Acute Coronary Syndrome Pulmonary edema due to congestive heart failure Contraindications SBP < 100 Recent use (48 hours) of erectile dysfunction (ED) medication (e.g. Viagra, Cialis) Patients with pulmonary hypertension who are taking Revatio. Inferior STEMI Pattern (ST elevation II, III, aVF) Adverse Reactions Hypotension Headache Syncope Dosage and Administration 0.4 mg (1/150 gr) sublingually or spray, every 4 minutes PRN up to a total of 3 doses Protocol Adult Chest Pain Adult CHF / Pulmonary Edema 230 Approved January 23, 2017 Index ONDANSETRON (ZOFRAN) Description Ondansetron is a selective serotonin 5-HT3 receptor antagonist antiemetic. Indications Nausea and/or vomiting Contraindications None Dosage and Administration Adult: 4 mg IV/IM/PO. May repeat x 1 dose as needed. Pediatric less than 4 years old: Reference Pediatric Field Guide 2 mg IV Pediatric greater than 4 years old: Reference Pediatric Field Guide 4 mg IV/IM/PO Protocol Adult Abdominal Pain/Vomiting Pediatric Abdominal Pain/Vomiting 231 Approved January 23, 2017 Index ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE) Description Glucose is the body's basic fuel and is required for cellular metabolism Indications Known or suspected hypoglycemia (BGL < 60 mg/dL) and able to take PO Contraindications Inability to swallow or protect airway Unable to take PO meds for another reason Administration One full tube 15 g buccal. Protocol Altered Mental Status Adult Hypoglycemia Pediatric Altered Mental Status Pediatric Hypoglycemia 232 Approved January 23, 2017 Index OXYGEN Description Oxygen added to the inspired air increases the amount of oxygen in the blood, and thereby increases the amount delivered to the tissue. Tissue hypoxia causes cell damage and death. Breathing, in most people, is regulated by small changes in the acid-base balance and CO2 levels. It takes relatively large decreases in oxygen concentration to stimulate respiration. Indications Low / Moderate flow O2 for the following: o All patients unable to achieve SpO2 > 90% on room air Titrate to goal of > 90% High flow O2 for the following: o BVM o Hypotension/shock states from any cause o Multi-systems Trauma o Suspected carbon monoxide poisoning o Obstetrical complications, childbirth o All patients unable to achieve SpO2 > 90% with low/moderate flow oxygen Titrate to goal of > 90% Administration Flow Low Flow Moderate Flow High Flow LPM Dosage 1-2 LPM 3-9 LPM 10-15 LPM Special Notes Do not use permanently mounted humidifiers. If the patient warrants humidified oxygen, use a single patient use device. Adequate oxygenation is assessed clinically and with the SpO2 while adequate ventilation is assessed clinically and with ETCO2. If the patient is not breathing adequately, the treatment of choice is assisted ventilation, not just oxygen. Do not withhold oxygen from a COPD patient out of concerns for loss of hypoxic respiratory drive. This is never a concern in the prehospital setting with short transport times 233 Approved January 23, 2017 Index PHENYLEPHRINE (INTRANASAL) Description Used for topical nasal administration, phenylephrine primarily exhibits alpha adrenergic stimulation. This stimulation can produce moderate to marked vasoconstriction and subsequent nasal decongestion. Indications Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa Nose bleed Precautions Avoid in pts with known CAD Avoid administration into the eyes, which will dilate pupil Dosage and Administration Instill two drops of 1% solution in the nostril prior to attempting nasotracheal intubation Administer 2 sprays in affected naris in patient with active nosebleed after having patient blow nose to expel clots. Protocol Nasotracheal intubation Adult Epistaxis Pediatric Epistaxis Approved January 23, 2017 234 Index RACEMIC EPINEPHRINE (VAPONEPHRINE) Description Racemic epinephrine is an epinephrine preparation in a 1:1000 dilution for use by oral inhalation only. Inhalation causes local effects on the upper airway as well as systemic effects from absorption. Vasoconstriction may reduce swelling in the upper airway, and ß effects on bronchial smooth muscle may relieve bronchospasm. Onset & Duration Onset: 1-5 minutes Duration: 1-3 hours Indications Stridor at rest Side Effects Tachycardia Palpitations Dosage and Administration 0.5 ml racemic epinephrine (acceptable dose for all ages) mixed in 2 ml saline, via nebulizer at 6-8 LPM to create a fine mist Protocol Pediatric Respiratory Distress Pediatric Croup Special Considerations Racemic epi is heat and photo-sensitive Do not confuse the side effects with respiratory failure or imminent respiratory arrest. Approved January 23, 2017 235 Index SODIUM BICARBONATE Description Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. Acids are increased when body tissues become hypoxic due to cardiac or respiratory arrest. Indications Not indicated for routine treatment of pulseless arrest Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history o To be administered after Calcium Gluconate or Calcium Chloride Must flush IV / IO line between meds. Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures Contraindications Metabolic and respiratory alkalosis Hypocalcemia Hypokalemia Adverse Reactions Metabolic alkalosis Hyperosmolarity may occur, causing cerebral impairment Dosage and Administration Adults Tricyclic OD with hypotension or prolonged QRS > 0.10 sec 1.0 mEq/kg slow IV/IO push Repeat if needed in 10 minutes. Pediatrics (>10kg) Reference Pediatric Field Guide (purple or larger) Tricyclic OD with hypotension or prolonged QRS > 0.10 sec 1.0 mEq/kg slow IV / IO push Repeat if needed in 10 minutes. Pediatrics (<10kg) Reference Pediatric Field Guide For Order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Requires Dilution Suspected hyperkalemia-related pulseless arrest in ADULT: To be administered after Calcium Chloride or Calcium Gluconate Must flush IV / IO line between meds 2 amps IV / IO Suspected hyperkalemia-related pulseless arrest in PEDIATRIC: For order CONTACT BASE (AIP, Children’s, TMCA) Index Approved January 23, 2017 236 SODIUM BICARBONATE Protocol Adult Pulseless Arrest Algorithm VF / VT Adult Pulseless Arrest Algorithm Asystole / PEA Adult Overdose / Acute Poisoning Pediatric Overdose and Acute Poisoning Drug Interactions May precipitate in calcium solutions. Alkalization of urine may increase half-lives of certain drugs. Vasopressors may be deactivated. Special Considerations Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a paradoxical intracellular acidosis. Sodium bicarb is no longer recommended for routine use in prolonged cardiac arrest. Its use in pulseless arrest should be limited to known or suspected hyperkalemia (e.g. dialysis patient). Index Approved January 23, 2017 237 TOPICAL OPHTHALMIC ANESTHETICS Description Used for topical administration as a pain reliever for eye irritation. Only proparacaine and tetracaine are approved for use. Indications Pain secondary to eye injuries and corneal abrasions Topical anesthetic to facilitate eye irrigation Contraindications Known allergy to local anesthetics Globe lacerations or rupture Precautions Transient burning/stinging when initially applied Dosage and Administration Instill two drops into affected eye. For repeat dose: required to CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Protocol May be used for the above listed indications as needed Special Considerations This is single patient use. Unused portions are to be discarded and only new bottles are to be used. Do not administer until patient consents to transport and transport has begun Topical ophthalmic anesthetics should never be given to a patient for self-administration Approved January 23, 2017 Index 238 Core Competency Adult Medical Arrest – Compressor Performance Criteria Skills Demonstration 0-2 MINUTES (BLS Airway) Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck. Compressor uses Q-CPR information displayed on MRx to give effective compressions At least 100 compressions per minute At least 2 inches deep Allow full recoil Once deployed, use Q-CPR for duration of the arrest Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task 2-4 MINUTES (ALS Airway) New Compressor uses Q-CPR information displayed on MRx to give effective compressions At least 100 compressions per minute At least 2 inches deep Allow full recoil Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task Approved January 23, 2017 239 Index Core Competency Adult Medical Arrest – Ventilator Performance Criteria Skills Demonstration 0-2 MINUTES (BLS airway) Correctly size and insert an OPA Connect ETCO2 to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique, give the pt 1 breath every 6 seconds First rescuer squeezes bag 1 breath every 6 seconds Second rescuer seals mask to pt’s face use “C-E” Technique 2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed (1 breath every 6 seconds) Verify effective ventilations using capnography Once i-gel O2 Airway is in place: Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds Second rescuer to set up IV/IO or other task as assigned by attending paramedic 4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using capnography 6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using capnography Approved January 23, 2017 Index 240 Core Competency Adult Medical Arrest – Lead Paramedic Performance Criteria Skills Demonstration 0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in medical arrest Delegates a rescuer to begin chest compressions Delegates 2 rescuers to begin ventilations Turn MRx energy level to 150J. Hand CPR puck to the Compressor Apply Combo Pads – If arrest witnessed by EMS, Correctly interpret and treat rhythm Verifies appropriate compressions and ventilations At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 2-4 MINUTES (Advanced Airway) Directs resumption of compressions and ventilations if needed Delegates or places i-gel O2 Airway and inserts suction catheter Connect ETCO2 to the i-gel O2 Airway Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 4-6 MINUTES (IV/IO access) Directs resumption of compressions and ventilations if needed Delegates or places IV/IO Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 6-8 MINUTES (Medication Administration) Directs resumption of compressions and ventilations if needed Delegates or administers indicated medication(s) Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm Approved January 23, 2017 241 Core Competency Adult Traumatic Arrest – Compressor Performance Criteria 0-2 MINUTES (BLS Airway) Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck. Pumper uses Q-CPR information displayed on MRx to give effective compressions At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 2-4 MINUTES (Advanced Airway) Continue using Q-CPR At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 4-6 MINUTES (IV/IO access) Continue using Q-CPR At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 6-8 MINUTES (Medication Administration) Continue using Q-CPR At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors Index Approved January 23, 2017 242 Core Competency Adult Traumatic Arrest – Ventilator Performance Criteria 0-2 MINUTES (BLS airway) Maintain manual in-line stabilization if indicated Correctly size and insert an OPA Connect ETCO2 to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique, give the pt 1 breath every 6 seconds First rescuer squeezes bag 1 breath every 6 seconds Second rescuer seals mask to pt’s face use “C-E” Technique 2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed (1 breath every 6 seconds) Verify effective ventilations using capnography Once i-gel O2 Airway is in place: Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds Second rescuer to set up IV/IO or other task as assigned by attending paramedic 4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilation using capnography 6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using capnography Approved January 23, 2017 Index 243 Core Competency Adult Traumatic Arrest – Lead Paramedic Performance Criteria 0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in traumatic arrest Delegates or controls life threatening external bleeding Delegates a rescuer to begin continuous chest compressions Delegates 2 rescuers to begin ventilations ( 1 breath every 6 seconds) with inline spinal immobilization if indicated Hand CPR puck to the Compressor Place patient on MRx (interpret EKG) Prepare for immediate transport or Contact Base if asystole Perform physical exam Address life threatening injuries Verify continuous compressions and ventilations ( 1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 2-4 MINUTES (Advanced Airway) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Direct or places i-gel O2 Airway with suction catheter Connect ETCO2 to i-gel O2 Airway Verify effective ventilations ( 1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors Address life threatening injuries 4-6 MINUTES (Needle Decompression if indicated) Directs resumption of continuous compressions and ventilations ( 1 breath every 6 seconds) Perform bilateral needle thoracostomy for trunk trauma At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 6-8 MINUTES (IV/IO) (Fluid Administration) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Directs or places IV/IO Directs or administers fluid bolus(s) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors Index Approved January 23, 2017 244 Core Competency Pediatric (<12years) Medical Cardiac Arrest - Compressor Performance Criteria 0-2 MINUTES (BLS Airway) Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck if indicated. Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task 2-4 MINUTES (Advanced Airway) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Switch to continuous compressions after advanced airway placement 4-6 MINUTES (IV/IO access) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task Approved January 23, 2017 245 Core Competency Pediatric (<12years) Medical Cardiac Arrest - Compressor 6-8 MINUTES (Medication Administration) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task Approved January 23, 2017 246 Index Core Competency Pediatric (<12years) Medical Cardiac Arrest - Ventilator Performance Criteria 0-2 MINUTES (BLS airway) Correctly size and insert an OPA Connect ETCO2 to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique Pt age >1 month to 12 years First rescuer uses 15:2 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique Pt age birth to 1 month First rescuer uses 3:1 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique 2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed Verify effective ventilations using capnography Once i-gel O2 Airway is in place: Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds Second rescuer to set up IV/IO or other task as assigned by attending paramedic 4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using capnography 6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM (1 breath every 6 seconds) Verify effective ventilations using capnography Approved January 23, 2017 Index 247 Core Competency Pediatric (<12years) Medical Cardiac Arrest – Lead Paramedic Performance Criteria 0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in medical arrest Delegates a rescuer to begin chest compressions (15:2) for pt 1month – 12 years Delegates a rescuer to begin chest compressions (3:1) for pt birth – 1 month Delegates 2 rescuers to begin ventilations (15:2)(3:1) Measure patient with Length Based Tape – Determine patient’s “color” Use AFD Pediatric Field Guide for appropriate interventions, therapies, etc Monitor turned on to appropriate energy level Hand CPR puck to the Compressor (Length Based Tape color “purple” or longer) Apply Combo Pads – Anterior / Posterior placement recommended Verifies appropriate compressions and ventilations At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 2-4 MINUTES (Advanced Airway) Directs resumption of compressions and ventilations (15:2)(3:1), if needed Delegates or places i-gel O2 Airway as indicated in AFD Pediatric Field Guide Connect ETCO2 to igel-O2 Airway. Verify effective ventilations Verifies switch to continuous compressions and appropriate ventilatory rate (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 4-6 MINUTES (IV/IO access) Directs resumption of compressions and ventilations, if needed Directs or places IV/IO Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 6-8 MINUTES (Medication Administration) Directs resumption of compressions and ventilations, if needed Directs or administers indicated medication(s) Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm Approved January 23, 2017 248 Core Competency Pediatric (<12years) Pediatric Trauma Arrest – Ventilator Performance Criteria Skills Demonstration 0-2 MINUTES (BLS airway) Correctly size and insert an OPA Connect ETCO2 to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique Pt age >1 month to 12 years First rescuer uses 15:2 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique Pt age birth -1 month First rescuer uses 3:1 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique 2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed Verify effective ventilations using capnography Once i-gel O2 Airway is in place: Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds Second rescuer to set up IV/IO or other task as assigned by attending paramedic 4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using capnography 6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM (1 breath every 6 seconds) Verify effective ventilations using capnography Index Approved January 23, 2017 249 Core Competency Pediatric (<12years) Pediatric Trauma Arrest – Compressor Performance Criteria 0-2 MINUTES (BLS Airway) Skills Demonstration Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck if indicated (please see AFD Pediatric Field Guide). Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task 2-4 MINUTES (Advanced Airway) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Switch to continuous compressions after advanced airway placement 4-6 MINUTES (Needle Decompression-if indicated) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task 6-8 MINUTES (Fluid Administration) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer) Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task Approved January 23, 2017 250 Index Core Competency Pediatric (< 12years) Pediatric Trauma Arrest – Lead Paramedic Performance Criteria Skills Demonstration 0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in traumatic arrest Delegates or controls life threatening external bleeding Delegates a rescuer to begin chest compressions Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio Delegates 2 rescuers to begin ventilations utilizing ETCO2. Maintain in line spinal stabilization if indicated Measure patient with Length Based Tape – Determine patient’s “color” Use AFD Pediatric Field Guide for appropriate interventions, therapies, etc Hand CPR puck to the Compressor (Length Based Tape color “purple” or longer) Place patient on MRx (interpret EKG) Prepare for immediate transport or Contact Base if asystole Perform physical exam Address life threatening injuries Verify continuous compressions and ventilations At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 2-4 MINUTES (Advanced Airway) Directs resumption of compressions and ventilations (15:2)(3:1), if needed Delegates or places i-gel O2 Airway as indicated in AFD Pediatric Field Guide Verifies that ETCO2 is being utilized with the i-gel O2 Verifies switch to continuous compressions and appropriate ventilatory rate (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors Address life threatening injuries 4-6 MINUTES (Needle Decompression if indicated) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Perform bilateral needle thoracostomy for trunk trauma At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 6-8 MINUTES (IV/IO) (Fluid Administration) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Directs or places IV/IO Directs or administers fluid bolus(s), bolus amount as indicated in the AFD Pediatric Field Guide. At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors Approved January 23, 2017 251