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
Pre-Hospital Treatment Protocols Version 10.0 This document has been approved by the Medical Director for Chaffee County Emergency Medical Services Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Table of Contents Acknowledgment Form Introduction Acts Allowed 6 7 8 Operating Policies Trauma Team Activation Roles and Responsibilities Standard of Care Operating Guidelines Patient Restraint Resuscitation and DNR Orders Field Pronouncement Guidelines 13 14 17 18 19 21 Treatment Protocols Cardiac Emergencies Cardiac Arrest, Medical Therapeutic Hypothermia Acute Coronary Syndrome STEMI Alert Thrombolytic Checklist Dysrhythmias Hypertension 22 26 27 28 29 31 36 Medical Emergencies Abdominal Pain Anaphylaxis Behavioral Disorders Cerebral Vascular Accident (CVA) CO Monitoring, Exposure, & Treatment Hyperglycemia Hypoglycemia Hyperthermia Hypothermia Generalized Hypothermia Localized Poisoning/Overdose Seizures Shock Septic Shock Alert Syncope Unconscious Patient Adrenal Insufficiency 37 38 39 40 43 44 45 46 47 48 49 52 53 54 57 58 66 2 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Treatment Protocols Pulmonary / Respiratory Emergencies Respiratory Distress, General Asthma CHF COPD Pediatric Dyspnea 59 60 61 62 63 Obstetrics / Gynecological Emergencies Childbirth Neonatal Resuscitation Pregnancy Induced Hypertension &Eclampsia Vaginal Bleeding 67 69 70 71 Trauma Emergencies Trauma Arrest Amputation Injuries Burns Chest Pain, Traumatic Fractures, Dislocations, and Sprains Head Trauma Hemorrhage Spinal Trauma Selective Spinal Immobilization Tool Crush Injury Drowning/Near Drowning 72 75 76 77 79 80 82 83 84 86 87 Procedure Protocols Airway OPA/NPA Extra-Glottic Airways Endotracheal Intubation, Nasal BAAM Endotracheal Intubation, Oral Endotracheal Intubation, RSI Awake Look Airway Assessment Failed Airway Percutaneous Cricothyrotomy Breathing Continuous Positive Airway Pressure Apneic Oxygen Chest Decompression 88 89 90 91 92 93 95 96 97 98 100 101 102 3 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols Circulation Peripheral IV Insertion Law Enforcement Blood Draw Venous Blood Draw External Jugular Cannulation Inter Osseous Cannulation January 1, 2016 Version 10 103 104 105 106 107 Cardiac Semi-Automated Cardiac Defibrillator Defibrillation Pacing Cardioversion 108 109 110 111 Skills and Monitoring Pulse Oxymetry Capnometry Automated Transport Ventilator Glucometer Pain Management Bandaging / Bleeding Control Splinting / Immobilization Selective Spine Immobilization Medication Administration Foley Catheter Placement NG / OG Tube Placement 114 115 116 127 128 129 130 132 134 136 137 Pharmacology / Medication Administration Protocols Assisted Medications Metered Dose Inhaler (MDI) EpiPen Nitroglycerine (NG) 139 140 141 Medications Acetylsalicylic Acid (ASA) Adenosine Albuterol Amiodarone Atropine Calcium Dextrose Diazepam Diltiazem Diphenhydramine Epinephrine Epinephrine Drip Fentanyl Furosemide Glucagon 142 143 144 145 146 147 148 149 150 151 152 154 156 157 158 4 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Glucose, Oral Hydromorphone Ketamine Ipratropium Lidocaine Magnesium Methylprednisolone Midazolam Morphine Naloxone Nitroglycerine Ondansetron Oxygen Phenylephrine Promethazine Sodium Bicarbonate Succinylcholine Tetracaine Vecuronium 159 160 161 162 163 164 165 166 167 168 169 170 172 173 174 175 176 177 178 Over the Counter Medications EMT-I Direct Order Exception Interfacility Transfer Medications Intravenous Solutions 179 180 181 185 Revisions from previous edition Critical Care Protocols 186 187 Addendum 5 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 CHAFFEE COUNTY EMERGENCY MEDICAL SERVICES MEDICAL PROTOCOL ACKNOWLEDGEMENT FORM I, _________________________________, acknowledge that I have received a copy of the Chaffee County Emergency Medical Services Medical Protocols version 10. I understand that I also have access to the Chaffee County Medical Protocols at either station, or in any ambulance, at any time. I have received the protocols in the form of: (Please circle one) Hard copy CD Electronic copy In addition, I agree to review these protocols and accept the responsibility for knowing and practicing as a provider in accordance with them, when appropriate. I further agree to review any additional additions and/or changes that may be made to the protocols as they are distributed. Name (Print):__________________________________________________ Signature: _______________________________ Date: _________________ Agency: ______________________________________________________ 6 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Introduction This manual is intended to outline the Standard of Emergency Medical Care for the personnel of Chaffee County Emergency Medical Services. As a Standard of Care, this manual is to be used by members certified at the EMT-Basic, EMT-Basic/IV, EMT-Intermediate, Paramedic, and Paramedic – Critical Care Endorsement levels, as a means of determining the level of care to be administered in any given situation. It is also the standard used by the Medical Director to evaluate and guide care throughout the system Not all medical skills, acts allowed, and medications are included in the initial education for various EMS provider levels. Every attempt will be made by Chaffee County Emergency Medical Services and the Medical Director to provide additional education, but it is the responsibility of the individual provider to seek additional education if it is needed. Each individual within the emergency medical services system is responsible for the following: Performing to the Standard of Care for his/her level of certification Obtaining additional training, beyond initial education, if needed Maintaining current certification Participating in continuing education These protocols are a guideline and are unable to account for every patient condition, patient presentation, and situation. Deviation from these protocols should be done only with the patient’s best interest in mind and backed with sound clinical judgment. Any deviation must be thoroughly documented and submitted for review If questions arise concerning a patient’s condition or treatment modalities, contact with the Base Physician should be initiated without hesitation 7 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Acts Allowed The Medical Director has determined the Acts Allowed for each certification level within Chaffee County Emergency Medical Services The Acts Allowed for EMT-B’s, EMT-B/IV’s, EMT-I’s, and Paramedics are accordance with the Acts Allowed as determined by the Colorado Department of Public Health and as outlined in Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter Two or through approved medical waivers. Providers must be certified to provide patient care in the state of Colorado Performing an Act that is beyond a provider’s Scope of Practice is considered “practicing without a license” and is not acceptable. Any provider that performs an Act that is beyond his/her Scope of Practice will be subject to disciplinary action that will be determined at the discretion of the Medical Director A provider may administer a medication that is beyond his/her Scope of Practice only under the direct visual supervision of a provider that has a Standing Order for that medication and to patients in extremis Certain procedures that are not covered in this document may be performed if adequate training has been obtained and with Base Physician approval. This does not apply to controlled medications Not all medical skills, acts allowed, and medications are included in the initial education for various EMS provider levels. Every attempt will be made by Chaffee County Emergency Medical Services and the Physician Medical Director to provide additional education, but it is the reasonability of the individual provider to seek additional education if it is needed X= Standing Order. Can be performed without on-line approval from the Base Physician or the provider of a higher level who has Standing Order allowance for the procedure/medication DO = Direct Order. Express verbal permission must be obtained from the Base Physician before performing procedure. A provider of a higher level, that has Standing Order allowance, may issue the Direct Order Procedures Level of Certification Patient Assessment EMT-B EMT-BIV EMT-I Paramedic x x x x x x x x x x Airway Management Suction (Powered or Manual) Pharyngeal suction Tracheal suction Extra-glottic device suctioning x x x x x x x x Basic Life Support Airways Oropharyngeal placement 8 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols Nasopharyngeal placement January 1, 2016 Version 10 x x x x x x x x x x Extra-Glottic Airways (King-LTD, King LTSD, LMA) Extra-Glottic Airways Endotracheal Intubation Oral intubation Nasal intubation x Rapid sequence intubation (Waivered) x Cricothyrotomy (Surgical, needle guided) x Oxygen Administration Nasal cannula (NC) x x x x Non-rebreather mask (NRB) x x x x Bag valve mask (BVM) x x x x Small volume nebulizer (SVN) DO DO x x Continuous positive airway pressure (CPAP) DO DO x x Blow-by oxygen x x x x x x Chest decompression (Needle) Circulation Management CPR x x x x Soft tissue management x x x x Fractures/dislocations x x x x Spinal immobilization x x x x Shock management x x x x Hemorrhage control Direct Pressure x x x x Bandaging x x x x Tourniquet x x x x Hemostatic Agents (Celox) x x x x x x x Intravascular Access IV initiation Peripheral IV 9 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols External jugular cannulation Saline lock January 1, 2016 Version 10 x x x x x Buritrol/Volutrol x x x Blood Y x x x x x x IV monitor/use/maintenance Peripheral IV External jugular IV x x Central venous catheter x x IV fluid administration Normal Saline x x x D5W x x x Medication drip DO x x x IO insertion Patient Monitoring Vital signs Non-invasive blood pressure x x x x Pulse rate x x x x Pulse oximetry x x x x CO monitoring & treatment x x x x End tidal C02 detection x x x x Temperature x x x x Glucometer x x x x Lactate monitor x x x x Miscellaneous Skills NG / OG tube placement x Foley catheter placement x Cardiac Management Automatic external defibrillation x x x x ECG/12 lead monitoring x x x x ECG/12 lead interpretation x x Manual defibrillation x x Transcutaneous cardiac pacing x x 10 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Synchronized cardioversion x Therapeutic hypothermia DO x Medication Administration Routes Nebulized (SVN) DO DO x /DO x Intra nasal (IN) x x x /DO x Intra muscular (IM) x /DO x Sub cutaneous (SC) x /DO x x /DO x x /DO x Intra venous x Intra osseous Oral/Buccal/Lingual x/DO x/DO x/DO x Medication Administration Medication: Assisted medications: EpiPen/EpiPen Jr DO DO DO x MDI DO DO DO x NTG DO DO x x Acetylsalicylic acid/Aspirin x x x x Adenosine/Adenocard DO x Albuterol DO x Amiodarone DO x Atropine DO x Calcium Dextrose 10% Diazepam/Valium Diltiazem/Cardizem Diphenhydramine/Benadryl Dopamine/Inotropin Epinephrine DO DO x x x x DO x x DO x x x/DO x Epinephrine drip DO x Fentanyl/Sublimaze DO x Furosemide/Lasix DO x Glucagon/Glucogen x/DO x 11 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols Ipratropium bromide/Atrovent Ketamine/Ketalar Lidocaine/Xylocaine (Bolus for procedure) Lidocaine/Xylocaine (Antidysrhythmic) Magnesium Sulfate January 1, 2016 Version 10 DO x x x x DO x DO(OB) x Methylprednisolone/SoluMedrol DO x Midazolam/Versed DO x Morphine DO x Naloxone/Narcan x x Nitroglycerine/Nitrostat x/DO x Ondansetron/Zofran x x DO(ODT) DO(ODT) x x Oral glucose x x x x Oxygen x x x x Phenylephrine/Neosynephrine Promethazine/Phenergan Vecuronium Bromide Sodium Bicarbonate Succinylcholine Chloride Tetracaine/Opthaine Specified OTC medications x DO x x DO x/DO x x x x x x x Interfacilty Transport - Procedures Chest tube monitoring x Ventilator – Automated Transport Ventilator x IV Pump x x Interfacility Transport - Medications See Specific Protocol 12 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Trauma Team Activation The Trauma Team at Heart of the Rockies Regional Medical Center consists of the ED physician, trauma surgeon, EDRN, respiratory therapy technician, radiology technician and laboratory technician The emergency department, prior to the arrival of patients who meet the criteria listed, will notify the team. Any pre-hospital provider, EDRN, MD, EDMD or surgeon may activate the Trauma Team for patients who meet criteria. The trauma surgeon, when available for consult, will respond within 10 minutes of the arrival of the patient who meets activation criteria Trauma Team Activation – Major o GCS <13 due to trauma o o o o o o o o o BP <90 systolic, or pulse >120 in an adult patient BP <70, or pulse >150, or capillary refill time >3 seconds in an pediatric patient (0-12 yrs old) Respiratory rate <10 or >29 Flail chest Penetrating injury to neck, chest, or abdomen Spinal cord injury with neurological deficit Multisystem injury (>2 systems injured) Burns >15% TBSA and/or associated injury including inhalation potential Falls >20 feet Trauma Team Activation – Minor o o o o o o o o o GCS <14 due to trauma Pulseless extremity High speed MVA w/ significant vehicle damage Unrestrained occupant of MVC Auto vs. pedestrian / bicycle at speeds >20mph or thrown > 15 feet Separation from conveyance (Includes: horse, ATV, snowmobile, bicycle etc) Death of same car occupant Lightning or electrical injury Contra lateral fractures A trauma team activation may be called at the pre-hospital provider’s discretion even if a patient does not meet the above stated criteria ***Please note that the Trauma Team Activation with surgeon applies only when the trauma surgeon is on call and present for consultation in our facility. All other times, State Trauma Protocol for Trauma and Transfer criteria takes precedence *** 13 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Roles and Responsibilities The Board of Medical Examiners has promulgated Rule 800 which allows EMS workers to function under the license of a physician who is termed a Medical Director. Each Medical Director is responsible for preparing local protocols to govern field performance according to Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter 2. Chapter 2 defines the roles and responsibilities of Medical Directors and describes the Acts Allowed by EMT-B’s, EMTBIV’s, EMT-I’s, and Paramedics It is important for all providers to remember that they are required to work under a physician’s license. Personnel who do not comply with any portion of this policy shall have their patient care privileges suspended until further notice Emergency Medical Technician - Basic (EMT-B) Providers certified at EMT-B level may be responsible for rendering care in conjunction with providers of a higher certification level or as a sole provider. Requirements to provider care in Chaffee County include: Maintain current certification in BLS for the Health Care Provider Completion of a recognized EMT-Basic course Colorado EMT-B certification Continuing education as required to maintain certificate Provide copies of all certifications Sponsorship from the Medical Director IV Certifications by EMT-B’s Providers certified at the EMT-B level may obtain an IV certification. In addition to the above requirements, the following are required for an EMT-B to start IV’s within Chaffee County: Present proof of completion of a recognized initial IV training course Maintain documentation of a minimum of six (6) successful IV starts every six (6) months. IVs may be started on patients in the field, on colleagues during training sessions, or at clinical sessions in a hospital setting. IV starts must be documented by an R.N., MD/DO, EMT-B, EMT-BIV, EMT-I or Paramedic Emergency Medical Technician – Intermediate /99 (EMT-I) Providers certified at EMT-I level may be responsible for rendering care in conjunction with providers of a higher certification level or as a sole provider. Requirements to provider care in Chaffee County include: Completion of a recognized initial EMT-I course Colorado EMT-I certification Continuing education as required to maintain certificate Provide copies of all certifications Current CPR for the Health Care Provider certification Current ACLS certification Current PEPP or PALS certification Sponsorship from the Medical Director Emergency Medical Technician – Paramedic/EMT-Intermediate Trainee (Paramedic/EMT-I Trainee) A Paramedic/EMT-Intermediate Trainee is defined as a provider who is presently in Paramedic or EMT- Intermediate school and has sufficiently progressed with the didactic and field education so that the individual can efficiently operate in the field as an ALS provider. The transition from EMT- Basic to Paramedic/EMT-Intermediate Trainee is generally at the time at which the individual has completed the didactic portion of the program. Requirements to provider care in Chaffee County as a Trainee include: Currently attending an approved Paramedic or EMT-Intermediate school Have authorization from the clinical coordinator of the school the Trainee is attending 14 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Sponsorship from the Medical Director Work with a Paramedic at all times in order to operate as a Trainee A Trainee may perform all of the skills of a Paramedic/EMT-Intermediate under supervision of an approved Paramedic Paramedic Providers certified at Paramedic level may be responsible for rendering care in conjunction with providers of a higher certification level or as a sole provider. Requirements to provider care in Chaffee County include: Completion of a recognized initial Paramedic course Colorado Paramedic certification Continuing education as required to maintain certificate Provide copies of all certifications Current CPR for the Health Care Provider certification Current ACLS certification Current PEPP or PALS certification Sponsorship from a Medical Director Medical Director The Board of Medical Examiners and the State Health Department define the roles of the Medical Director. The following description is taken from the State of Colorado Board of Medical Examiners Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter Two, Section 4 A medical director shall possess the following minimum qualifications: Be a physician currently licensed to practice medicine in the State of Colorado Be trained in Advanced Cardiac Life Support. Physicians acting as medical directors for Department-recognized EMS education programs must possess authority under their licensure to perform any and all medical acts to which they extend their authority to EMS Providers, including any and all curricula presented by EMS education programs The duties of a medical director shall include: Be actively involved in the provision of emergency medical services in the community served by the EMS Service Agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director, but does require such involvement during the time that he or she acts as a medical director. Active involvement in the community could include, by way of example and not limitation, those inherent, reasonable and appropriate responsibilities of a medical director to interact with patients, the public served by the EMS Service Agency, the hospital community, the public safety agencies, and the medical community, and should include other aspects of liaison oversight and communication normally expected in the supervision of EMS Providers Be actively involved on a regular basis with the EMS Service Agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director, but does require such involvement during the time that he or she acts as a medical director. Involvement could include, by way of example and not limitation, involvement in continuing education, audits, and protocol development. Passive or negligible involvement with the EMS Service Agency and supervised EMS Providers does not meet this requirement Notify the Department on an annual basis of the EMS Service Agencies for which medical control functions are being provided in a manner and form as determined by the Department Establish a medical continuous quality improvement (CQI) program for each EMS Service Agency being supervised. The medical continuous quality improvement program shall assure the continuing competency of the performance of that agency’s EMS Providers. This medical continuous quality improvement program shall include, but not be limited to, appropriate protocols and Standing Orders and provision for medical care audits, observation, critiques, continuing medical education and direct supervisory communications 15 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Submit to the Department an affidavit that attests to the development and use of a medical continuous quality improvement program for all EMS Service Agencies supervised by the medical director. As set forth below in section 4.3, the Department may review the records of a medical director to determine compliance with the CQI requirements in these rules Provide monitoring and supervision of the medical field performance of each supervised EMS Service Agency’s EMS Providers. This responsibility may be delegated to other physicians or other qualified health care professionals designated by the medical director. However, the medical director shall retain ultimate authority and responsibility for the monitoring and supervision, for establishing protocols and Standing Orders and for the competency of the performance of authorized medical acts Ensure that all protocols issued by the medical director are (1) appropriate for the certification and skill level of each EMS Provider to whom the performance of medical acts is delegated and authorized, and (2) compliant with accepted standards of medical practice Be familiar with the training, knowledge and competence of EMS providers under his or her supervision and ensure that EMS providers are appropriately trained and demonstrate ongoing competency in all skills, procedures and medications authorized Be aware that certain skills, in procedures and medication authorized may not be included in the national EMS educations standards and ensure appropriate additional trains Is provided to supervised EMS providers Ensure that any data and/or documentation required by these rules are submitted to the Department Notify the Department within fourteen business days excluding state holidays prior to his or her cessation of duties as medical director Notify the Department within fourteen business days excluding state holidays of his or her termination of the supervision of an EMS Provider for reasons that may constitute good cause for disciplinary sanctions pursuant to the Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter One. Such notification shall be in writing and shall include a statement of the actions or omissions resulting in termination of supervision and copies of all pertinent records Physicians acting as medical directors for EMS education programs recognized by the Department that require clinical and field internship performance by students shall be permitted to delegate authority to a student-in-training during their performance of program-required medical acts and only while under the control of the education program Abuse/Neglect Reporting Any employee of Chaffee County Emergency Medical Services, as described in C.R.S. 19-3-304, is by law a mandatory reporter if they suspect child or elder abuse or neglect. This applies if: Provider has reasonable cause to know or suspect that a child or elderly person has been subjected to abuse or neglect Provider observed the child or elderly person being subjected to circumstances or conditions that would reasonably result in abuse or neglect The mandatory reporter shall immediately upon receiving such information report to the Chaffee County Department of Human Services, the local law enforcement agency, or through the child abuse reporting hotline system. If appropriate, law enforcement should be called to the scene Child Abuse Hotline: 1-844-264-5437 16 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Standard of Care Policy o o o The Standard of Care is defined as "The minimum acceptable care, based on state laws and the protocols set forth by the Chaffee County Medical Director” The Standard of Care will be used to determine which Acts are to be allowed for each level of certification. It will also allow the individual to understand what is expected of him or her These Protocols are to be used as guidelines not “the law”. Each emergency is different and requires a provider to make judgments and decisions that may not fit directly into one specific protocol. Knowing this, the protocols should be used as guidelines and a tool to help the EMS personnel provide medical care to their patients Provision of care o EMS personnel are expected to perform to the level of their training at all times. Care will not be modified or altered based on the patient's race, religion, beliefs, or medical prognosis or condition unless the patient is refusing care due to personal or religious beliefs and the patient is determined to be mentally competent o Responsibility for patient care is delegated to the individual with the highest level of medical training. The hierarchy of medical control on scene is as follows: First Aid/ Wilderness First Aid First Responder/Wilderness First Responder Emergency Medical Responder Emergency Medical Technician - Basic (EMT-B) Emergency Medical Technician – Basic with IV certification (EMT-BIV) Advanced Emergency Medication Technician Emergency Medical Technician - Intermediate (EMT-I) Emergency Medical Technician – Paramedic (EMT-P) Paramedic Paramedic with Critical Care Endorsement Medical Director or Base Physician The patient should receive the most appropriate level of care available in all situations. Denying a patient Advanced Life Support in favor of Basic Life Support care in an Advanced Life Support situation constitutes an act of willful negligence and is not in the best interests of the patient's welfare. Knowingly withholding or denying advanced levels of care is a serious act. Failure to abide by this policy will result in immediate corrective action The patient should be evaluated by the personnel on scene who has the highest level of training. The ultimate responsibility of patient care falls upon the highest level medical provider on scene Under no circumstances, (except when ALS care is not available), is a patient who falls under the ALS category to be solely attended by or transported by BLS personnel. This is detrimental to the patient's wellbeing and places the EMS personnel and the medical director in legal jeopardy This policy has not been designed to stifle, limit or curtail the experiences of BLS personnel. Our primary goal is to ensure that optimal patient care is being rendered. With this in mind, we encourage BLS personnel to be as involved with the delivery of ALS care or act as primary attended when deemed appropriate. This enhances their learning experience and improves their EMS skills In some cases, it is feasible for a BLS unit to transport a patient to a medical facility. This can be very perilous if the patient should deteriorate en-route and ALS care is not available. The decision to bypass ALS care should be made by the primary attendant. If questions arise, contact the ALS unit or Base Physician 17 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Patient Restraint It may be necessary to restrain a patient to ensure the safety of the patient and the EMS personnel Your personal safety is of paramount importance and is the first priority Use chemical restraint when appropriate The type of physical restraints used should restrict the movement of the patient without causing injury. Types of acceptable methods include Kerlix and soft restraints Have enough resources available. Call for additional resources if they are needed Do not use excessive force in restraining a patient Once restraints have been applied, it is important to constantly monitor the patient. An attendant must be physically present with the patient at all times while the patient is restrained. Distal circulation must be checked and documented every 15 minutes if extremities are restrained Many patients with abnormal behavior have an organic etiology. Do not overlook the possibility of head injuries, hypoxia, drug ingestion, hypoglycemia, or neurological disorders by assuming the patient's only problem is a psychiatric one Always check the patient for weapons. Keep in mind that just about anything can be a weapon such as cowboy boots, jewelry, belt buckles, flashlights, etc Document the reason for restraining a patient, the location and the type of restraints used. Documentation should also reflect the inadequacies of less restrictive means of control such as medication or verbal interaction Avoid transporting the patient prone due to possibility of respiratory effort being impaired If a patient is handcuffed during transport, a law enforcement officer must be present during transport Criteria to necessitate patient restraint: Patient is a danger to themselves or others o Threat of self-harm o If patient is a danger to others, law enforcement assistance must be requested Patient is a minor with potentially life threatening injury or illness, with no guardian present o If patient is a minor with potential life threatening injury or illness, and a guardian is refusing care, request law enforcement involvement and consult Base Physician Patient is mentally incompetent to refuse treatment Always consult Base Physician prior to restraining a patient unless there is a threat of immediate harm to the patient or the provider. Law enforcement involvement strongly encouraged 18 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 DNR Orders A DNR Order is a written document in which the physician, in the best interest of the patient, and after consultation with the patient and/or family, has deemed it appropriate that the patient should not be resuscitated in the setting of a cardiopulmonary arrest A signed, valid, DNR must be present to withhold resuscitation efforts Bracelets, necklaces, or other DNR notification devices can be acknowledged as valid DNR orders Verbal DNR orders from a family member or medical power of attorney require Base Physician contact prior to withholding resuscitation efforts or termination of efforts The following procedures should NOT be performed on DNR patients who are in cardiopulmonary arrest: o CPR o Intubation o Defibrillation o "CORE" drug administration o Cardiac pacing o IV/IO placement Contact with Base Physician should be made to confirm DNR order or if questions arise A DNR may be revoked at any time by the patient or the patient’s healthcare power of attorney Living Wills A Living Will is a document that expresses the patient’s wishes concerning what medical care should be render if the patient is rendered incapable of doing so. Most Living Wills will specifically express what procedures may or may not be performed Some Living Wills will state “Comfort measures only”. The following procedures may be performed depending upon clinical judgment and consultation with the patient, the private physician, or the Base Physician Position of comfort Airway control such as manual positioning and use of bag valve mask. Intubation and extra-glottic devices are specifically excluded Suction IV line for hydration Foley catheter for urinary retention Oxygen for dyspnea and hypoxia Treatment of injuries or illness that are not a cardiac arrest situation Analgesics and sedatives Treatment of acute injury or illness 19 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Candidates for Resuscitation: All patients in cardiac and/or pulmonary arrest without a valid DNR order will be resuscitated with the following exceptions: Those patients who are obviously dead and beyond any chance of resuscitation. This includes patients who are pulseless, apneic and, but not limited to: o Are decapitated o Have rigor mortis o Tissue decomposition o Massive blunt trauma o Dependent lividity o Third degree burns to 90% of the body o Extended down time without CPR The safety of the EMS personnel must also be taken into consideration if the resuscitation attempt might endanger the rescue personnel Upon a verbal order from an attending physician who is present at the time. You must be able to verify that this person is, in fact, the attending physician who knows this patient well. Should there be any question concerning this physician, you should proceed with resuscitation and immediately contact the Base Physician at Heart of the Rockies Regional Medical Center Cardiac arrest due to trauma: Current data shows that a number of victims of penetrating trauma to the neck or torso, who are found without signs of life, may be successfully resuscitated. Therefore, resuscitation should be initiated on all patients found in full arrest secondary to penetrating trauma. Exceptions may exist in the following circumstance: Patients found pulseless and apneic with penetrating or blunt trauma if the provision of ALS has been unavailable for at least 10 minutes proceeding the time EMS personnel initiate on-scene assessment Multi-causality incidents when there are more viable patients that require care 20 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Field Pronouncement Guidelines A patient may be pronounced in the field under the following circumstances: Valid DNR order Obvious death Blunt traumatic arrest Medical arrest when: o Patient has received 30 minutes of ALS care with no return of spontaneous circulation with no treatable or reversible causes identified o Patient has received 30 minutes of BLS measures with AED present and no shocks have been delivered o Patient has received extended BLS care and providers are not able to continue efforts until an AED or ALS is available due to, but not limited to, fatigue, adverse/dangerous conditions, etc. The following patients found pulseless and apneic warrant resuscitation efforts beyond 30 minutes and should be transported: o Hypothermic or cold water drowning (H2O temp <50 deg F.) with core temperature of <91F that preceded the cardiac arrest o Pregnant and estimated to be 20 weeks or later in gestation o A reversible cause has been identified that may not be rectified in the field In the case of an obviously deceased patient, or if an arrest is called in the field, the Chaffee County Coroner's Office asks the following: Do not run an ECG strip on obviously deceased patients Do not remove any medical devices from the body. This includes endotracheal tubes, NG tubes, IV lines, combo pads, etc. Be aware of the scene and the surroundings. Do not destroy, tamper with, or remove anything from the scene. This is considered evidence and will be used in the investigation Do not change the location or position of the body if there are signs of obvious death, or after the resuscitation efforts have been terminated Under no circumstances is the deceased patient to be used for practice procedures Base Physician contact is required to terminate resuscitation efforts, accept a DNR Order, or to withhold resuscitation efforts 21 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Cardiac Arrest - Medical This protocol serves as a guide in the treatment of a patient in cardiac arrest from a medical cause Procedure EMTB EMTBIV EMTI Paramedic Initiate CPR (Follow current AHA guidelines) x x x x Ventilate with BVM and high flow O2 x x x x Suction as needed x x x x Insert OPA/NPA x x x x Monitor cardiac rhythm and if the patient is in a shockable rhythm: Consider 2min of CPR prior to defibrillation x x x x Defibrillate manually or with AED (Certification level dependent) x x x x x x x x x x x x IV: 1-2 IV with Normal Saline 20ml/kg IO if unable to obtain IV with Normal Saline 20ml/kg Administer medications as indicated Insert advanced airway: Extra-glottic Device or Oral ETT (Do not stop compressions to insert an advanced airway) x x x x Consider and treat reversible causes of cardiac arrest x x x x If ROSC: Begin transport x x x x Monitor vital signs x x x x Perform 12-lead ECG x x Treat hypotension and arrhythmias as indicated x x Begin passively cooling if indicated DO x Consider sedation if advanced airway is in place and the patient shows signs of neurologic function DO x x x Notes: See Hypothermia, Traumatic Cardiac Arrest, and Neonate Resuscitation for specific Protocol Prioritize treatments during cardiac arrest. Do not interrupt compressions unnecessarily. Advanced airway insertion allows continuous compressions Swap compressors every two minutes, if possible If ROSC occurs, consider an appropriately extended scene time to ensure that all needed interventions are complete; and that enough personnel are present if the patient rearrests to provide needed treatments 22 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 23 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 24 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 25 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Targeted Temperature Management Authorizations: Protocol: EMT-I, and Paramedic Paramedic - Standing Order EMT-I – Direct Order Targeted Temperature Management is the process of preventing fever in a patient who had a Return of Spontaneous Circulation following treatment per ACLS guidelines. Indications: Patients who have ROSC after cardiac arrest and: o Non-traumatic cardiac arrest o ROSC within 60min o GCS <8, no withdrawal from painful stimuli o Intubated Contraindications: Active bleeding or suspicion of internal hemorrhage Evidence of intracranial hemorrhage Active, life-threatening arrhythmias Refractory hypotension Sepsis Pregnancy Age < 12 y/o Hypothermia < 89.6F Precautions: Monitor for hyperkalemia Procedure: Document time of ROSC and time cooling is initiated Obtain core temperature (If time permits or the patient may be hypothermic) Obtain IV/IO access if not already obtained Place cold packs on neck, axilla, and groin Reassess temperature every 15m o Temperature goal: 34-36C (93.2 – 96.8F) Sedate as indicated Prevent shivering as indicated Notes: Initiate for witness and unwitnessed cardiac arrests that meet the indications Efforts should be limited to passive, external cooling only 26 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Acute Coronary Syndrome This protocol serves as a guide to the treatment of a patient who is having cardiac, or suspected cardiac, chest pain or other signs/symptoms associated with Acute Coronary Syndrome Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive, or titrated to SPO2 ≥ 94% x x x x Monitor vital signs x x x x Administer Aspirin as indicated x x x x Continuously monitor cardiac rhythm (EMT-B, EMT-BIV noninterpretive) x x x x Serial 12-lead ECGs with consideration of right-sided or posterior leads as indicated x x Determine if the patient meets STEMI Alert criteria x x x x x x x DO/x x (Assisted DO) x x Administer opioid of choice as indicated DO X Treat dysrhythmias as indicated DO X IV: 1-2, and draw blood if possible (Dark green top) x IO if unable to obtain IV and the patient is unstable Maintain systolic BP ≥ 90mmHg with fluid or a vasopressor as indicated Administer Nitroglycerine as indicated Notes: Consider BGL evaluation as well as bi-lateral blood pressure determination Appropriate pain and anxiety control may significantly improve patient outcomes 27 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 ST segment Elevation Myocardial Infarction (STEMI) Alert This criteria is to determine when to call a Cardiac/ STEMI Alert Indication (All criteria must be met): Noted 1mm or more of ST segment elevation in two or more anatomically contiguous leads on the 12 lead ECG (ST elevation that does not meet this criteria may suffice if the provider is familiar with more subtle MI patterns that may present) Patients presenting with active chest pain/ discomfort or other symptoms consistent with Acute Coronary Syndrome (Optional criteria) Corresponding reciprocal depression in opposite or nearby leads on the 12 lead ECG. Reciprocal changes may be noted in the following locations: o Anterior MI: Posterior leads o Inferior MI: High-lateral leads o High/Low-lateral MI: Inferior leads o Posterior MI: Anterior leads Contraindications: Presence of Left Bundle Branch Block o Unless provider is comfortable applying modified Sgarbossa’s Criteria ≥ 1mm concordant ST elevation in two or more anatomically contiguous leads or ≥ 1mm concordant ST depression in V1, V2, or V3 Ventricular paced rhythms Procedure: Treat the patient according to the Acute Coronary Syndrome Protocol Contact receiving hospital and request a “STEMI Alert” o Provide call in patient care report Complete Thrombolytic Checklist if time permits STEMI Mimics: Left Ventricular Hypertrophy (LVH) o Choose largest S wave in V1 or V2 add it to the largest R wave in V5 or V6. o If >35mm = LVH o Strain indicated by a ST segment slanting the opposite direction as the R or S wave deflection Hypothermia o Osborne waves Pericarditis o Global or near global ST segment elevation and PR segment depression Early Repolarization o ST segment elevation with no reciprocal changes o J-point notching o PR depression o Concave ST segment elevation o Normal R wave progression o 12-lead does not change over time Ventricular paced rhythms Hyperkalemia Interventricular conductions delays/defects 28 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Thrombolytic Checklist: This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions should be NO * * * * * Remove sheet and provide to receiving hospital * * * * * Chest pain <15min or >12hrs Systolic BP > 180mmHg Diastolic BP > 110mmHg Right arm vs. Left arm BP difference > 15mmHg systolic History of structural CNS disease Head/Facial trauma within 3mos Major trauma, surgery, GI bleed within 6wks Taking blood thinners Coagulopathy Pregnancy CPR > 10min Advanced cancer, severe liver or renal disease Patient Name Date of Birth Age Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Time of onset? ___ Systolic BP? ___ Diastolic BP? ___ If “Y”, see below Duration of CPR if performed? ___ Weight (kg) Medications: Medical History: Allergies: Other: 29 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Thrombolytic Checklist: This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions should be NO * * * * * Remove sheet and provide to receiving hospital * * * * * Chest pain <15min or >12hrs Systolic BP > 180mmHg Diastolic BP > 110mmHg Right arm vs. Left arm BP difference > 15mmHg systolic History of structural CNS disease Head/Facial trauma within 3mos Major trauma, surgery, GI bleed within 6wks Taking blood thinners Coagulopathy Pregnancy CPR > 10min Advanced cancer, severe liver or renal disease Patient Name Date of Birth Age Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Time of onset? ___ Systolic BP? ___ Diastolic BP? ___ If “Y”, see below Duration of CPR if performed? ___ Weight (kg) Medications: Medical History: Allergies: Other: 30 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Dysrhythmias This protocol serves as a guide to the treatment of a patient who is experiencing cardiac dysrhythmias Procedure EMTB EMTBIV EMT-I Paramedic Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive, or titrated to SPO2 ≥ 94% x x x x Monitor vital signs and cardiac rhythm x x x x x x x x x x x x x x x x/DO x IV: 1- 2, and draw blood if possible (Dark green top) IO if unable to obtain IV and the patient is unstable See Acute Coronary Syndrome Protocol if signs of ACS x If unstable with systolic BP ≤ 90mmHg: Consider fluid bolus Administer appropriate pharmacological intervention, if indicated Synchronized cardioversion if indicated Overdrive pacing x x x x x x/DO x If stable with systolic BP > 90mmHg: Consider fluid bolus Administer appropriate pharmacological intervention, if indicated Consider synchronized cardioversion if indicated Consider overdrive pacing x x x x Notes: Consult Base Physician for advice if needed Wide complex tachycardias can be very difficult to differentiate. If unable to differentiate and perfusion is adequate, administer Adenosine first. If this is not effective, treat the dysrhythmia as ventricular tachycardia. If the patient is hypotensive with associated signs/symptoms, synchronized cardioversion is indicated If pulses are not palpable and the patient is unconscious, begin CPR and treat accordingly Many dysrhythmias are caused by or enhanced by hypoxia. Be sure that the patient is receiving high flow O2 and ventilating adequately 31 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Adult Tachycardia (With pulse) 32 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Adult Bradycardia (With pulse) 33 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pediatric Tachycardia (With pulse) 34 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pediatric Bradycardia (With pulse) 35 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hypertension This protocol serves as a guide to the treatment of a patient who is hypertensive Procedure EMTB EMTBIV EMT- I Paramedic Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs x x x x x x x x x IV : 1-2, and draw blood if possible IO if unable to obtain IV and the patient is unstable Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Perform stroke evaluation x x x x If systolic BP > 200mmHg or diastolic BP > 130mmHg, and symptomatic, without stroke like symptoms: Consider Diltiazem Consider Morphine x DO x Notes: Hypertension secondary to stress or pain will usually have high systolic pressures but not high diastolic pressures. These rarely need to be treated in the field Causes of hypertension include: pulmonary edema, CHF, CVA, hypoglycemia, myocardial infarctions, head injuries, seizures, drugs or stress. Treat the underlying cause first if possible Using a BP cuff that is too small can give false elevations When attempting to lower the diastolic blood pressure, the goal is a range of 90-100mmHg Prior to therapeutic intervention, the blood pressure should be auscultated multiple times, on both sides, to ensure that the hypertension was not a transient event Hypertension secondary to a CVA or head injury should not be treated in the field. Elevated BP in these instances is a compensatory response to maintain blood flow to the brain, lowering the blood pressure will worsen cerebral ischemia 36 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Abdominal Pain This protocol serves as a guide to the treatment of a patient who has abdominal pain Procedure EMTB EMTBIV EMT-I Paramedic Place the patient in position of comfort (See Pregnancy Protocol or Acute Coronary Syndrome Protocol as indicated) x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive, titrated to SPO2 ≥ 94%, or if significant bleeding is present x x x x Monitor vital signs x x x x x x x x x x x DO x x x IV : 1-2, and draw blood if possible IO if unable to obtain IV and the patient is unstable Continuously monitor cardiac rhythm (EMT-B, EMT-BIV noninterpretive) x x Opioid of choice as indicated If unstable with systolic BP ≤ 90mmHg: Fluid bolus to maintain systolic BP ≥ 90mmHg: x Notes: 37 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Allergic Reaction, Anaphylaxis, and Anaphylactic Shock This protocol serves as a guide to the treatment of a patient who is experiencing an allergic reaction, anaphylaxis, or anaphylactic shock Procedure EMT-B EMT-BIV EMT-I Paramedic Remove injection mechanism if a bee or wasp sting x x x x Remove the patient from allergen or allergen from the patient x x x x Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive, or titrated to SPO2 ≥ 94% x x x x Monitor vital signs x x x x x x x x x IV :1-2, and draw blood if possible IO if unable to obtain IV and the patient is unstable Allergic Reaction (Localized reaction with no airway or vascular involvement) Diphenhydramine (Consider IM administration while obtaining IV/IO access) DO x Solu-Medrol DO x Anaphylaxis (With airway or vascular compromise) Albuterol Epinephrine (Consider IM administration while obtaining IV/IO access) DO DO DO x Assisted DO Assisted DO DO x Diphenhydramine (Consider IM administration while obtaining IV/IO access) DO x Solu-Medrol DO x x x x Assisted DO DO x Anaphylactic Shock (Hypotension due to anaphylaxis) Fluid bolus as indicated Epinephrine (Consider IM administration while obtaining IV/IO access) Diphenhydramine (Consider IM administration while obtaining IV/IO access) DO x Solu-Medrol DO x Consider Glucagon administration Assisted DO x 38 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Behavioral and Psychiatric disorders This protocol serves as a guide to the treatment of a patient who has suffering, or potentially suffering, from a behavioral or psychiatric disorder Procedure EMTB EMTBIV EMT- I Paramedic Place the patient in position of comfort x x x x Restrain if necessary (Refer to Patient Restraint Protocol) x x x x DO/x x Consider administration of Diazepam or Midazolam as indicated Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs x x x x x x x x x If unstable or potentially unstable: IV :1-2, and draw blood if possible IO if unable to obtain IV and the patient is unstable Continuously monitor cardiac rhythm (EMT-B, EMT-BIV noninterpretive) x x x x Check blood glucose level (Glucometer) x x x x x x x x x x x x x x x Administer Oral Glucose if indicated Administer Dextrose if indicated Administer Glucagon if indicated Consider Narcan administration x x Notes: Psychiatric patients and/or patients with abnormal behavior may have an organic etiology. Do not overlook the possibility of head injuries, hypoxia, hypoglycemia, drug ingestion, or neurological disorders by assuming that it is just a psychiatric disorder If the patient is suicidal, do not leave them alone. Either remove dangerous objects or have someone else remove them. Keep in mind, just about anything can be a weapon 39 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Cerebral Vascular Accident – Stroke and Stroke Alert This protocol serves as a guide to the treatment of a patient who has suffering, or potentially suffering, from cerebral vascular accident Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs x x x x x x x x x IV : 1-2, and draw blood if possible IO if unable to obtain IV and the patient is unstable Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Check blood glucose level (Glucometer) x x x x x x x x x x x x x x x Administer Oral Glucose if indicated Administer Dextrose if indicated Administer Glucagon if indicated Notify receiving facility of Stroke Alert and complete Thrombolytic Checklist x x Notes: HRRMC is now using tPA for patients that meet strict criteria. With suspected CVA the highest prehospital priorities should include treatment of life threats, immediate transport, and a obtaining a thorough history. Immediate transport is important because if tPA is to be used it must be given within 3 hours of the onset of the CVA. If the patient exhibits symptoms suggestive of a CVA do not delay transport to obtain a patient history, however when dealing with an aphasic patient, a few minutes spent on scene obtaining a description of events and last time the patient was normal from family or bystanders is important and may save time in the long run in terms of patient care If the patient requires artificial ventilation, do not hyperventilate the patient. Hyperventilation will decrease the patient’s level of carbon dioxide and cause cerebral vasoconstriction and further ischemia. Alert HRRMC that you are en-route with a potential stroke patient as soon as possible. Even if the patient has been symptomatic for up to 12 hours, they may be eligible for interventions If the CVA causes an increase in intracranial pressure, the signs and symptoms will mimic a closed head injury. These patients will present the same as a patient suffering from a traumatically induced injury by displaying possible combativeness, posturing, and Cushing's triad. Refer to "Head Injury Protocol" for additional information Do not treat hypertension of suspected CVA patient The ultimate goal with a CVA patient is to get the patient to definitive care while protecting the airway and increasing cerebral oxygenation 40 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Thrombolytic Checklist: This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions should be NO * * * * * Remove sheet and provide to receiving hospital * * * * * Chest pain <15min or >12hrs Systolic BP > 180mmHg Diastolic BP > 110mmHg Right arm vs. Left arm BP difference > 15mmHg systolic History of structural CNS disease Head/Facial trauma within 3mos Major trauma, surgery, GI bleed within 6wks Taking blood thinners Coagulopathy Pregnancy CPR > 10min Advanced cancer, severe liver or renal disease Patient Name Date of Birth Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Time of onset? ___ Systolic BP? ___ Diastolic BP? ___ If “Y”, see below Duration of CPR if performed? ___ Age Medications: Medical History: Allergies: Other: 41 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Thrombolytic Checklist (Duplicate): This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions should be NO * * * * * Remove sheet and provide to receiving hospital * * * * * Chest pain <15min or >12hrs Systolic BP > 180mmHg Diastolic BP > 110mmHg Right arm vs. Left arm BP difference > 15mmHg systolic History of structural CNS disease Head/Facial trauma within 3mos Major trauma, surgery, GI bleed within 6wks Taking blood thinners Coagulopathy Pregnancy CPR > 10min Advanced cancer, severe liver or renal disease Patient Name Date of Birth Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Time of onset? ____ Systolic BP? ____ Diastolic BP? ____ If “Y”, see below Duration of CPR if performed? ___ Age Medications: Medical History: Allergies: Other: 42 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Carbon Monoxide Monitoring, Exposure, and Treatment This protocol serves as a guide to the treatment of a patient who is suffering from Carbon Monoxide poisoning Procedure EMT-B EMT-BIV EMT -I Paramedic Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 via NRB if symptomatic x x x x Monitor Carboxyhemoglobin level if available x x x x If the patient is asymptomatic and reading: o 0-5%: No further medical evaluation needed o >5%: Administer oxygen and reassess after 15min. Consult Base Physician if reading remains >5% If the patient is symptomatic: Treat and transport the patient If the patient is pregnant or could be pregnant and reading >5%: Treat and transport the patient Monitor vital signs x x x x Continuously monitor ECG x x x x DO DO x x x x x x x CPAP if symptomatic and/or >20% IV :1-2, and draw blood if possible IO if unable to obtain IV and the patient is unstable Notes: The fetus of a pregnant woman is at high risk when exposed to carbon monoxide. Fetal hemoglobin has a greater affinity for CO than adult hemoglobin. A pregnant woman maybe asymptomatic while the fetus may be in danger or distress. Classifications of CO Poisoning: <15-20% Headache, nausea, vomiting, dizziness, blurred vision 21-40% Confusion, syncope, chest pain, dyspnea, tachycardia, tachypnea, weakness 41-59% Dysrhythmias, hypotension, cardiac ischemia, palpitations, respiratory arrest, pulmonary edema, seizures, coma, cardiac arrest >60% Fatal 43 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hyperglycemia This protocol serves as a guide to the treatment of a patient who is hyperglycemic Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive or titrated to SPO2 ≥ 94% x x x x Monitor vital signs x x x x x x x x x IV: 1-2, and draw blood if possible IO if unable to obtain IV and the patient is unstable Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Check dextrose level (Glucometer) x x x x x x x Fluid bolus as indicated Notes: Hyperglycemia is often a slow onset. It usually develops over a period of days, not hours The buildup of ketones can sometimes be detected on the patient's breath. There may be an odor of acetone or fruity smell Because of the dehydration, DKA and HHNK patients may have a rapid, weak pulse, decreased blood pressure, orthostatic changes, and dry, flushed, warm skin Be aware of the upper limits of glucometer. If reading is above that limit, glucometer may read “Hi” Slightly elevated blood glucose levels may be due to any hypermetabolic state or sympathetic response The determination between HHNK and DKA can only be made with blood chemistry and is unimportant in the field If possible, attempt to determine the cause of hyperglycemia, such as an acute infection 44 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hypoglycemia This protocol serves as a guide to the treatment of a patient who is hypoglycemic Procedure EMTB EMT – BIV EMT – I Paramedic Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs x x x x Check blood glucose level (Glucometer) x x x x x x x x Establish IV and draw blood if possible x x x Administer D50%, D25%, or D10% as indicated x x x Consider Glucagon administration x x IO if the patient condition does not change with Glucagon x x x x If the patient is hypoglycemic: Administer oral glucose if indicated If unable to establish IV: Recheck blood glucose stick after Dextrose or Glucagon administration x x Notes: Infiltration of IV Dextrose will cause severe tissue necrosis. Dilution of D50% is required Hypoglycemia can present as: seizures, coma, diaphoresis, chest pain, behavioral disorders, alcohol intoxication, confusion or stroke-like with neurological deficits (particularly in elderly patients). Patients who are elderly or who have been hypoglycemic for prolonged periods of time may be slower to regain normal mental status Administration of dextrose in the malnourished patient with depleted thiamine stores may precipitate Wernicke's or Korsakoff's syndrome. However, do not withhold dextrose from a patient who is hypoglycemic Do not give to possible CVA or head injury patients without documented hypoglycemia Patients who are on oral hypoglycemic medications should be transported. Patients who do not have a responsible party present should be transported. The medication/reason that the patient’s blood glucose level is below acceptable limits may cause a second drop in blood glucose Hypoglycemia is considered to be any reading <50mg/dL, approximately, in a newborn BGL may not raise, or may have a secondary drop, after Glucagon administration 45 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hyperthermia This protocol serves as a guide to the treatment of a patient who is hyperthermic due to an environmental cause Procedure EMTB EMTBIV EMTI Paramedic Remove from hot environment and place the patient in a position of comfort x x x x Remove clothing as needed. Cool with cool water or cold packs in the groin, neck and armpits. Be careful not to chill the patient. Fan the patient if needed x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive, titrated to SPO2 ≥ 94% x x x x Monitor vital signs, including temperature x x x x Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x DO x x x IV: 1-2 and draw blood if possible IO if unable to obtain IV and the patient is unstable Normal Saline bolus as indicated x Treat seizures with benzodiazepine of choice Check blood glucose level x x Notes: Do not let cooling in the field delay your transport When cooling a patient, be careful not to chill him/her. Shivering will increase the body temperature and exacerbate the problem Heat Cramps is due to electrolyte imbalance causing muscle spasms in the legs and abdomen. Severe pain nausea and vomiting are normal. Patient will not be hypotensive and have a normal core temperature Heat Exhaustion is an emergency and is the result of depletion of water and salt resulting in hypovolemic shock; monitor for signs of shock. Pale and diaphoretic skin, dilated pupils, headache, nausea, and altered level of consciousness are normal symptoms. Temperature will be between 98.6F and 104F. Treat patient for shock and cool Heat Stroke is due to failure of the normal cooling mechanisms failing. Skin may be hot, dry, and flushed. Patient may have mental status changes, nausea, vomiting, seizures, and hypotension. Temperature will be greater than 104F. Treat the patient for shock and cool aggressively. Treat for seizures as needed Hyperthermia should only be treated with cooling if due to environmental or exertional causes 46 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hypothermia This protocol serves as a guide to the treatment of a patient who is hypothermic Procedure EMTB EMTBIV EMTI Paramedic x x x x Re-warm the patient passively. Cover with warm blankets, place in warm environment, and consider heat packs on the chest, abdomen, axilla, neck, or groin areas x x x x Start CPR if pulses are not palpable x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive, or titrated to SPO2 ≥ 94% x x x x Monitor vital signs, including core temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x DO x x x Remove from cold or windy environment and remove wet clothing Limit defibrillation to 1 shock Extend period between drug administrations and limit to 2 rounds Refer to specific cardiac arrest protocol for additional information IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Treat seizures with benzodiazepine of choice Monitor blood glucose level Notes: x x Mild hypothermia: 90 - 95F Moderate hypothermia: 82 - 89.9F Severe hypothermia: < 82F Shivering will stop when the body temperature drops below 90F It is crucial that the patient be handled gently. The heart becomes very irritable when it is cold and will fibrillate easily. It is most likely to fibrillate between 84-88F and does not convert readily until the patient's temperature is above 86F (30C) When possible, rewarming should be left for the hospital setting Successful resuscitation has been documented in a patient with a core temperature as low as 64.4F. When in doubt, begin CPR and be prepared for extended resuscitation times. All patients with a core temperature <91F should be transported unless cardiac arrest preceded the hypothermia or obvious signs of death are present 47 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hypothermia – Frost Bite This protocol serves as a guide to the treatment of a patient who has frost bite Procedure EMT-B EMT-BIV EMT-I Paramedic Remove from cold or windy environment and remove wet clothing x x x x Protect areas from pressure, trauma or friction. Do not break any blisters present. Do not allow the patient to ambulate if possible. Do not attempt to rewarm in the field x x x x DO DO DO x Cover the patient with warm blankets, place in warm environment, and consider heat packs on the chest, abdomen, axilla, neck, or groin areas x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, titrated to SPO2 ≥ 94% x x x x Monitor vital signs, including core temperature x x x x Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x DO x Under extenuating circumstances, such as prolonged or complicated transport, rewarm by submersion in warm water (100 degrees) for 20 minutes IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Monitor blood glucose level Treat pain as indicated with opioid of choice x x Notes: Do not allow a limb to thaw if there is a danger it will refreeze. Partial rewarming or refreezing will cause further tissue damage. Thawing should only be done under controlled conditions Patients with frostbite will often be hypothermic Signs of cold injury to an extremity range from red skin to completely frozen tissue 48 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Poisons and Overdoses This protocol serves as a guide to the treatment of a patient who has suffered an overdose or poisoning Procedure EMT-B EMT-BIV EMT- I Paramedic Remove contaminate from the patient if possible/safe to do so x x x x Place the patient in position of comfort x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath, hypotensive or titrated to SPO2 ≥ 94%. If the patient has been exposed to a simple or chemical asphyxiant, administer high-flow O2 x x x x Monitor vital signs including, but not limited to: BP, ECG, SPO2, SPCO, BGL, and core temperature x x x x x x x x x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Treat specific poising/overdose/exposure as indicated x x x x Obtain information on specific treatment if needed x x x x Notes: POISON CONTROL CENTER TELEPHONE NUMBER: (303) 629-1123 or (800) 222-1222 Ensure that scene is safe during all overdoses, poisoning, and exposures If the patient has intentionally overdosed or poisoned themselves, strongly consider transport for a mental health evaluation Many poisonings, overdoses, and exposures are treated symptomatically with airway, breathing, and circulatory support Do not induce vomiting or administer an antidote unless instructed to do so by Poison Control or the Base Physician Specific emergencies Type of exposure General information Signs/symptoms Treatment Alcohol overdose CNS depressant, chronic use causes GI bleeds, liver failure, and cerebral degeneration Slurred speech, decreased respirations, altered LOC, nausea, vomiting, and coma Support airway, breathing, and circulation Alcohol withdrawal Occurs 12-24 hours after last ingestion Seizures, tremors, coma, and hallucinations Support airway, breathing, and circulation. Treat seizures with benzodiazepine of choice Aspirin (salicylate acid) Over the counter analgesic and antiinflammatory Ringing in the ears, lethargy, nausea, GI bleeding, Support airway, breathing, and circulation. Consider Sodium 49 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 hyperventilation, seizures, coma, metabolic acidosis, and pulmonary edema Bicarbonate for acidosis. Consider Benzodiazepine of choice for seizures Acetaminophen Over the counter analgesic and sleep medication Nausea, vomiting, diaphoresis, RUQ pain, and liver failure Support airway, breathing, and circulation Barbiturates CNS depressant, sedation, deep coma, anticonvulsant medication Slurred speech, altered LOC, dilated pupils, decreased respirations, pale, cool skin. Support airway, breathing, and circulation Benadryl Over the counter antihistamine Dry mouth, dilated pupils, flushed dry skin, tachycardia, and anticholinergic effects Support airway, breathing, and circulation Benzodiazepine CNS depressant and tranquilizer Sedation, coma, anticonvulsant, slurred speech, altered LOC, dilated pupils, decreased respirations, pale, cool skin. Support airway, breathing, and circulation Beta Blocker or Calcium Channel Blocker Negative inotrope and negative chronotrope Decreased LOC, hypotension, bradycardias, and pulmonary edema. Support airway, breathing, and circulation. Consider Glucagon, Dopamine, and/or Epinephrine drip. Consider TCP Carbon Monoxide CO binds to the hemoglobin in the blood and causes cellular asphyxia Headache, dyspnea, angina, syncope, seizures, coma, cherry red skin. Support airway, breathing, and circulation. Administer high-flow oxygen. See specific protocol Cocaine/ CNS stimulants Vasoconstrictor, and CNS stimulation Euphoria, agitation, psychosis, seizures, MIs, CVAs, dyspnea, increased HR and BP, dilated pupils. Support airway, breathing, and circulation. Consider Benzodiazepine of choice. Do not administer antiarrhythmics. Caustics The caustics will burn soft tissue 1st, 2nd and 3rd degree burns to any tissue contacted Support airway, breathing, and circulation Hallucinogens Causes auditory and visual hallucination. Psychosis, dilated pupils, headache, secondary trauma. Support airway, breathing, and circulation. Consider Benzodiazepine of choice. Opioids Analgesic that acts as a CNS depressant Sedation, pinpoint pupils, respiratory depression, Support airway, breathing, and circulation. 50 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 bradycardia, pulmonary edema Consider Narcan administration Tricyclic anti-depressant Prescription antidepressant Anticholinergic response, tachycardia, dry, flushed skin, dilated pupils, coma, seizures, hypotension, wide-complex QRS. Support airway, breathing, and circulation. Consider Sodium Bicarbonate and Dopamine administration Anticholinergic toxidrome Antihistamines, TCA, phenothiazines, Nightshade, Mandrake, Moonflower Flushed skin, psychosis, hyperthermia, dry mucosa, dilated pupils, and tachycardia Support airway, breathing, and circulation. Consider Benzodiazepine of choice administration Cholinergic toxidrome Organophosphates Salivations, lacrimation, urination, defecation, bronchosecretions, bronchoconstriction, and bradycardia Support airway, breathing, and circulation. Consider Atropine administration 51 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Seizures This protocol serves as a guide to the treatment of a patient who has suffered or is suffering a seizure Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively seizing, administer high flow O2 x x x x Continuously monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Consider specific cause of seizure and attempt to reverse if possible x x x x Consider spinal immobilization if injuries are consistent w/ spinal immobilization criteria x x x x Check blood glucose level (Glucometer) x x x x DO x x x If seizure activity persists (status): Administer Benzodiazepine of choice Consider endotracheal intubation Notes: Control of the airway can be very difficult during a seizure because the jaws are often closed. Do not attempt to force the teeth open. This can cause oral trauma and bleeding which will obstruct the airway. NPAs and nasal intubation are useful in this situation. In addition, consideration should be given to Rapid Sequence Intubation Protect the patient from harm during the seizure. Restrain the patient only if needed to prevent injury A patient who has a first time seizure should be transported by ambulance A pediatric patient who has suffered a suspected febrile seizure should be transported by ambulance Causes of seizures include: hypoxia, hypotension, hypoglycemia, CVA, fever, pregnancy (hypertension), medication overdose, medication under dosage, ETOH withdrawal, tumor, and epilepsy 52 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Shock This protocol serves as a guide to the treatment of a patient who is in a state of inadequate perfusion Procedure EMTB EMT-BIV EMTI Paramedic Control bleeding x x x x Place the patient in position of comfort/indicated position x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Monitor blood glucose level x x x IV: 1-2 with Normal Saline bolus as indicated x x x x x x x x x (Fluid Bolus) x/DO x IO if unable to obtain IV and the patient is unstable Consider spinal immobilization if indicated x Treat for specific type of shock Consider repeated fluid boluses and vasopressor of choice for septic/distributive shock Consider Epinephrine infusion for cardiogenic shock Control bleeding, warm, and transport for hemorrhagic shock. Consider fluid boluses to systolic BP 80mmHg Needle decompression for obstructive shock due to a tension pneumothorax x x x x x x x Notes: Hypotension should be treated. Attempt to maintain a systolic blood pressure of 90mmHg or MAP of ≥ 65mmHg Hypotension is a late sign of shock. Monitor for: altered mentation, agitation, restlessness, unexplained, or tachycardia. Consider history and assessment Consider the cause of rales/rhonchi prior to withholding fluid bolus. A patient with pneumonia may have isolated, unilateral, rales; in this patient fluid is safe, if indicated 53 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Septic Shock Alert This criteria has been developed in conjunction with Heart of the Rockies Regional Medical Center to assist in the early recognition and goal directed therapy in the treatment of patients who are in septic shock Inclusion criteria (All three criteria must be present): Suspected infection Systemic Inflammatory Response Syndrome (SIRS) criteria: o Must have 2 or more of the following: Temperature ≥ 100.9F or ≤96.8F Heart rate ≥90/min Respiratory rate ≥20/min Signs of hypoperfusion: o Venous lactate ≥4.0mmol/L o Systolic blood pressure <90mmHg o MAP <65mmHg If the patient meets criteria for a Septic Shock Alert: Notify receiving facility as early as possible Maximize oxygenation by providing supplemental oxygen (NC 4-6lpm or NRB 10-15lpm) Established vascular access and begin Normal Saline administration to 20mL/kg regardless of BP if breath sounds/fluid status permits If MAP <65mmHg after initial fluid bolus, administer Epinephrine infusion to maintain MAP ≥65mmHg Complete checklist/information sheet if time permits Treat other signs, symptoms, and conditions as indicated 54 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Septic Shock Alert Checklist: * * * * * Remove sheet and provide to receiving hospital * * * * * Suspected infection Systemic Inflammatory Response Syndrome (SIRS) criteria: o Must have 2 or more of the following: Temperature ≥ 100.9F or ≤96.8F Heart rate ≥90/min Respiratory rate ≥20/min Signs of hypoperfusion: o Venous lactate ≥4.0mmol/L o Systolic blood pressure <90mmHg o MAP <65mmHg Patient Name Possible location/cause of suspected infection? _______________ Date of Birth Age Temperature in *F? ________ Heart rate? _______________ Respiratory rate? __________ Venous lactate? ___________ Blood pressure? ____________ MAP? ____________________ Weight (kg) Medications: Medical History: Allergies: Other: 55 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Septic Shock Alert Checklist: * * * * * Remove sheet and provide to receiving hospital * * * * * Suspected infection Systemic Inflammatory Response Syndrome (SIRS) criteria: o Must have 2 or more of the following: Temperature ≥ 100.9F or ≤96.8F Heart rate ≥90/min Respiratory rate ≥20/min Signs of hypoperfusion: o Venous lactate ≥4.0mmol/L o Systolic blood pressure <90mmHg o MAP <65mmHg Patient Name Possible location/cause of suspected infection? _______________ Date of Birth Age Temperature in *F? ________ Heart rate? _______________ Respiratory rate? __________ Venous lactate? ___________ Blood pressure? ____________ MAP? ____________________ Weight (kg) Medications: Medical History: Allergies: Other: 56 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Syncope This protocol serves as a guide to the treatment of a patient who has suffered a syncope event Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort x x x x Consider spinal immobilization if indicated x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Monitor blood glucose level x x x IV: 1-2 with Normal Saline bolus as indicated x x x IO if unable to obtain IV and the patient is unstable x x Obtain 12-lead if syncope is suspected of being cardiac in origin x x Treat dysrhythmias as appropriate x x x x Treat hypotension as appropriate x x x x Treat underlying cause as indicated x x x x Notes: Syncope by definition is a transient state of unconsciousness from which the patient regains consciousness Syncope that occurs when the patent sits up or stands up is often due to hypovolemia such as a GI bleed or dehydration. Syncope at rest or while recumbent is often caused by cardiac arrhythmias 57 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Unconscious Patient This protocol serves as a guide to the treatment of a patient who is unconscious upon arrival of EMS Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Consider specific cause of unconsciousness and attempt to reverse if possible x x x x Consider spinal immobilization if injuries are consistent w/ spinal immobilization criteria x x x x Notes: Attempt to determine cause of unconsciousness so that treatment can be focused If no cause can be determined, continue supportive treatment and transport 58 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Respiratory Distress - General This protocol serves as a general guide to the treatment of a patient with respiratory distress Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs including: HR, BP, ETCO2, SPO2, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Consider specific cause of shortness of breath and treat per protocol x x Notes: Consider and treat specific cause if possible 59 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Respiratory Distress - Asthma This protocol serves as a general guide to the treatment of a patient with respiratory distress due to asthma Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Remove extrinsic stressor if possible x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs including: HR, BP, SPO2, ETCO2 x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x IV: 1-2 with NS x x x Consider administration of Normal Saline bolus to help thin secretions x x x x x DO x Consider Atrovent (May mix with Albuterol) DO x Consider Solu-Medrol if more than one Albuterol treatment is needed DO x Consider Epinephrine when asthma is refractory to inhaled bronchodilators DO x x x IO if unable to obtain IV and the patient is unstable Consider Albuterol Consider CPAP DO DO DO DO Consider Magnesium Sulfate in severe cases Monitor for pneumothorax x x x x x Notes: Asthma consists of three components: spasms of the bronchial smooth muscles, increased mucous secretions and inflammation of the bronchial tissue 60 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Respiratory Distress - Congestive Heart Failure This protocol serves as a general guide to the treatment of a patient with respiratory distress due to congestive heart failure Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway (Upright with legs dependent, if possible) x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs including: HR, BP, SPO2, ETCO2 x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Treat cardiac arrhythmias as indicated x x 12- Lead ECG if indicated x x x x x x DO x x x IV: 1-2 with buff cap, D5W, or NS TKO x IO if unable to obtain IV and the patient is unstable Consider Nitroglycerine administration Consider CPAP DO DO Consider Dopamine administration if the patient is hypotensive x Consider Morphine administration DO x Consider Lasix administration DO x Consider Albuterol administration if significant, documented, bronchospasm is present and pulmonary edema is treated DO x Notes: 61 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Respiratory Distress - COPD This protocol serves as a general guide to the treatment of a patient with respiratory distress due Chronic Obstructive Pulmonary Disease Procedure EMTB EMT-B IV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Remove extrinsic stressor if possible x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs including: HR, BP, SPO2, ETCO2 x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x IV: 1-2 with NS x x x Consider administration of NS to help thin secretions x x x x x DO x Consider Atrovent (May mix with Albuterol) DO x Consider Solu-Medrol if more than one Albuterol treatment is needed DO x Consider Epinephrine when bronchoconstriction is refractory to inhaled bronchodilators DO x x x IO if unable to obtain IV and the patient is unstable Consider Albuterol Consider CPAP DO DO DO DO Consider Magnesium Sulfate in severe cases Monitor for pneumothorax x x x x x Notes: 62 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pediatric Respiratory Distress This protocol serves as a general guide to the treatment of a pediatric patient with respiratory distress due to some common causes Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Avoid stressing the patient if possible x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs including: HR, BP, SPO2, ETCO2, temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x x x DO x DO x DO x Bronchiolitis IV: 1-2 with NS if the patient is unstable IO if unable to obtain IV and the patient is unstable Assist ventilations with BVM if needed x x Consider intubation for patients in profound distress or near respiratory failure Consider nebulized Racemic Epinephrine Consider nebulized saline, and/or Albuterol(Limited effectiveness) Consider Atrovent (Limited effectiveness) DO DO Consider Magnesium Sulfate (Limited effectiveness) Consider Solu-Medrol administration if IV/IO has been previously established x DO x Notes: Bronchiolitis is a viral infection of the bronchioles. It is caused primarily by the Respiratory Syncytial Virus (RSV) but influenza and the Rhino virus can also be the cause Children <6mo old that are exposed to other children, like a day care environment, are at the greatest risk. Other risk factors include: premature delivery, exposure to smoke and congenital abnormalities. Signs and symptoms include: low grade fever, tachypnea, tachycardia, dyspnea, and runny nose 63 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols Procedure January 1, 2016 Version 10 EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Avoid stressing the patient if possible x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs including: HR, BP, SPO2, ETCO2, temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Assist ventilations with BVM if needed x x x x x x x x x x Epiglottitis Consider intubation for patients in profound distress or near respiratory failure and BVM ventilation is ineffective (Oral). If intubation fails (cricothyrotomy) Extra glottic airways will not be effective and should not be attempted IV: peripheral access with Normal Saline if the patient is unstable IO if unable to obtain IV and the patient is unstable x Notes: Epiglottitis is a life threatening bacterial infection of the upper airway causing the Epiglottis to swell and occlude the larynx. Is most commonly caused by the Haemophilus Influenza Type B (Hib) but can be caused by other bacterial and viral infections as well as trauma related causes. Children 2-6yrs are most commonly affected, but any may occur at any age. Due to pediatric vaccinations Epiglottitis is becoming less frequent but it remains a concern. Risk factors include: weakened immune systems, crowded conditions such as day care, and congenital abnormalities Signs and symptoms include: High fever, sore throat, painful swallowing, dyspnea, drooling, and cyanosis Palliative treatment is the preferred pre-hospital course of action. Invasive procedures such as IV, and advanced airway management should be a last resort and performed by the most proficient provider on scene. Typically the provider will only have one chance at an advanced airway and extra-glottic devices will be ineffective Nebulized medications can be detrimental and are rarely effective 64 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols Procedure January 1, 2016 Version 10 EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/position to best maintain airway x x x x Avoid stressing the patient if possible x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x DO x Croup Nebulized Racemic Epinephrine (If the patient has stridor at rest) Monitor vital signs including: HR, BP, SPO2, ETCO2, temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x x x DO x IV: with NS if the patient is unstable IO if unable to obtain IV and the patient is unstable Assist ventilations with BVM if needed x x Consider intubation for patients in profound distress or near respiratory failure Consider Solu-Medrol if IV/IO has been previously established Consider nebulized NS (Limited effectiveness) Consider nebulized Albuterol (Limited effectiveness) Consider nebulized Atrovent (Limited effectiveness) x x x x DO DO DO x DO x Notes: Croup, laryngotracheobronchitis, is caused by a viral infection typically the parainfluenza virus, and is usually not serious Children <5yrs are the most commonly affected with the most severe cases in children <3yrs. Premature deliveries are at a greater risk due to their smaller airways Signs and Symptoms of Croup include: Barking cough (Seal Bark), high fever >103f, dyspnea, and difficulty swallowing 65 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Adrenal Insufficiency This protocol serves as a guide to the treatment of a patient who has suspected adrenal insufficiency Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort/Indicated position x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Monitor blood glucose level and treat as indicated x x x IV: 1-2 with Normal Saline bolus as indicated x x x x x DO x x x IO if unable to obtain IV and the patient is unstable Consider Solu-Medrol administration Monitor for hypotension and hyperkalemia. Treat as indicated x x Notes: Patients at risk include: Addison’s Disease, Chronic Adrenal diseases, and chronic steroid use Hypotension is a late sign of shock. Monitor for: altered mentation, agitation, restlessness, unexplained, or tachycardia. Consider history and assessment 66 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Childbirth This protocol serves as a general guide to the treatment of a female patient with imminent childbirth and neonatal care Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort x x x x If delivery is not imminent, transport immediately with the patient on her left side x x x x Obtain prenatal and maternal history. Consider immediate transport if pregnancy has complications x x x x Support airway and breathing as indicated x x x x Administer O2 to achieve SPO2 100% (NC as NRB will probably not be tolerated) x x x x Monitor vital signs including: HR, BP, and SPO2 x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x x IV: 1-2 with NS TKO IO if unable to obtain IV and the patient is unstable Treat maternal bleeding, hypotension, chest pain, decreased level of consciousness, respiratory distress, or any other condition/symptom as indicated x If delivery is imminent, (crowning, feeling of a bowel movement, or urge to push): Warm ambulance/delivery area x x x x Place the patient on her back with knees flexed x x x x Remove clothing to waist and establish clean delivery area x x x x Prepare neonatal resuscitation and delivery equipment x x x x Visualize vaginal opening and identify presenting part c x x x x x x x x x x x x x x x o Cord prolapse o One foot or one arm presentation o Place mother in a knee to chest/face down position and begin immediate transport. Attempt to manually relieve pressure on the cord to maintain fetal perfusion Place mother in a knee to chest/face down position and begin immediate transport Breach: Buttock, both arms, or both legs presenting Begin immediate transport. Urge mother not to push, but assist with delivery if delivery proceeds. 67 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Presentation complicates delivery, but field delivery is possible o Cephalic presentation o x x x x x x x x Proceed with field delivery. Assess for nuchal cord as soon as possible Additional complications: Nuchal cord: Attempt to remove cord from neck. If unable to do so, clamp thr cord and cut it Cephalopelvic disproportion/Shoulder dystocia: Attempt McRobert’s Maneuver To perform field delivery: Support the infant’s head as it emerges, using gentle pressure, prevent the infant from an explosive delivery x x x x Wipe mouth and nose. Have bulb suction available x x x x Support infant as it rotates to allow shoulder delivery x x x x When infant is delivered, clamp cord in two places x x x x o Approximately 8-10 inches from the infant and cut the cord in between. Use only sterile materials Dry and stimulate the infant. Place in blanket and place cap on infant. DO NOT ALLOW INFANT TO BECOME HYPOTHERMIC x x x x Place infant on mother's chest to warm and allow it to nurse (May not be realistically achieved during transport) x x x x Prepare for multiple deliveries if needed x x x x Placenta normally delivers within 30 minutes. Do not delay transport or attempt to force delivery of the placenta See neonatal resuscitation flow chart if infant does not begin spontaneous breathing, spontaneously crying, has decreased level of responsiveness, or is distressed Use bulb suction only if infant has respiratory distress x x x x Note meconium if present. Suction only if infant has respiratory distress x x x x x (IV) x x Asses BGL and administer D10% through IV or IO if indicated. Reassess BGL frequently in distressed infants Administer Narcan if indicated (Consider IN administration) x x x x Ensure infant is kept warm x x x x Notes: Withhold supplemental oxygen, from the infant, during routine deliveries DO NOT pull on the cord; it may cause the placenta to abrupt or the cord may tear loose from the placenta and either condition may cause catastrophic hemorrhage Babies are slippery. It is unacceptable to drop one 68 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 69 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pregnancy Induced Hypertension and Eclampsia This protocol serves as a general guide to the treatment of a female patient with pre-eclampsia or eclampsia Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort x x x x Attempt to remove all stimuli: Dim lights, do not use siren, allow mother to cover her eyes, keep the patient calm and relaxed x x x x Transport the patient on her left side x x x x Obtain prenatal and maternal history x x x x Support airway and breathing as indicated x x x x Administer O2 to achieve SPO2 100% (NC as NRB will probably not be tolerated) x x x x Monitor vital signs including: HR, BP, ECG and SPO2 x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x Administer Benzodiazepine of choice DO x Administer Magnesium Sulfate DO x IV: 1-2 with NS TKO IO if unable to obtain IV and the patient is unstable If the patient experiences a seizure: Support airway and breathing x x Notes: Pre-eclampsia is a pregnancy-induced hypertension. The patient will have a history of a rapid weight gain in the second and third trimester. Hypertension of greater than 140/100 will be present in these patients Eclampsia is the onset of seizures. These are often set off by loud noises and bright flashing lights. Be sure to turn off the emergency lights on the ambulance and rescue vehicles 70 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Vaginal Bleeding This protocol serves as a general guide to the treatment of a female patient with vaginal bleeding Procedure EMTB EMTBIV EMTI Paramedic Place the patient in position of comfort x x x x If pregnant and >20wks gestation, transport the patient on her left side x x x x Obtain prenatal and maternal history x x x x Support airway and breathing as indicated x x x x Administer O2 to achieve SPO2 100% (NC as NRB will probably not be tolerated) x x x x Monitor vital signs including: HR, BP, ECG and SPO2 x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x DO x IV: 1-2 with NS TKO IO if unable to obtain IV and the patient is unstable Administer fluid bolus as indicated Administer Fentanyl as indicated x Notes: Always consider pregnancy as a cause of vaginal bleeding Ectopic pregnancies can be life threatening. If it is located in the fallopian tubes, rupture of the tube and peritoneal hemorrhage will usually occur 3-8 weeks after conception Consider placenta previa and placenta abruptio as a possible causes of vaginal bleeding Absorb blood but do not pack the vagina 71 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Cardiac Arrest - Trauma This protocol serves as a guide in the treatment of a patient in cardiac arrest Procedure EMTB EMTBIV EMTI Paramedic Perform triage as indicated x x x x Determine patient viability (Field Pronouncement Guidelines. <10min since loss of vital signs/signs of life x x x x Established manual/spinal immobilization x x x x Initiate CPR ( Follow current AHA guidelines) x x x x Ventilate with BVM and high flow O2 x x x x Suction as needed x x x x Insert OPA/NPA x x x x Monitor cardiac rhythm and if the patient is in a shockable rhythm: Consider 2min of CPR prior to defibrillation x x x x Defibrillate manually or with AED (Certification level dependent) x x x x x x x x x x Perform bilateral needle decompression IV: 1-2 IV with Normal Saline 500-1000mL x IO if unable to obtain IV with Normal Saline 500-1000mL Administer medications as indicated x x x x Insert advanced airway: Extra-Glottic or Oral ETT ( Do not stop compressions to insert an advanced airway) x x x x x x If there is no response to treatment, consult Base Physician and terminate resuscitation efforts If ROSC: Begin transport x x x x Monitor vital signs x x x x Treat hypotension and arrhythmias as indicated x x x x Notes: Swap compressors every two minutes, if possible Trauma arrests carry over 99% mortality. Blunt trauma carries 100% mortality If there are multiple patients, these patients should be bypassed in order to treat viable patients. Triage should not be circumvented or delayed by focusing on traumatic arrests 72 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 73 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 74 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Amputation Injuries This protocol serves as a guide in the treatment of a patient who has suffered an amputation injury Procedure EMTB EMTBIV EMTI Paramedic Control bleeding x x x x Place the patient in position of comfort/indicated position x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Bandage wound with sterile, moistened, gauze x x x x Preserve amputated tissue by wrapping in moist gauze and keeping cool x x x x x x x x x x x Consider pain control as indicated with opioid of choice DO x Consider anxiety control as indicated with benzodiazepine of choice DO x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Consider spinal immobilization if indicated x x Notes: Time is of great importance in attempts to reattach the severed part. If transport time will be delayed, consider sending the amputated part to the hospital ahead to be prepared for reattachment Partial amputations should be dressed and splinted in anatomical position to insure optimal blood flow. Avoid twisting or crushing the damaged parts. 75 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Burns This protocol serves as a guide in the treatment of a patient who has suffered a burn injury Procedure EMT-B EMT-BIV EMT-I Paramedic Remove source of burn and any clothing/jewelry that is removable x x x x Place the patient in position of comfort/indicated position x x x x Support airway and breathing as indicated x x x x Administer high flow O2 x x x x Keep the patient warm and cover with sterile dressing x x x x If burn is <10% TBSA: A moist dressing may be used x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Preserve amputated tissue by wrapping in moist gauze and keeping cool x x x x x x x x x x x x x x x x/DO x DO x IV: 1-2 IO if unable to obtain IV and the patient is unstable Begin fluid resuscitation at : 500ml/hr if age >14yrs 250ml/hr for age 3-14yrs 125ml/hr if age <3yrs Determine age as close as possible Consider spinal immobilization if indicated Consider pain control as indicated with opioid of choice Consider anxiety control as indicated with benzodiazepine of choice x Notes: Burn patients with airway injury are at risk for obstruction due to edema. Consider early airway control if: stridor/wheezing is present, significant airway/facial burns or noted, or time is extended from time of burn injury Consider carbon monoxide and other poisonous gas inhalation if burns occurred during a fire in a confined space Consider MIs in firefighters or patients who have collapsed during a fire Consider helicopter transport for critical or pediatric burns 76 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Chest Pain - Traumatic This protocol serves as a guide in the treatment of a patient who is suffering chest pain from a traumatic injury Procedure EMTB EMTBIV EMTI Paramedic Control bleeding x x x x Place the patient in position of comfort/indicated position x x x x Consider spinal immobilization if indicated x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Assess anterior and posterior breath sounds x x x x Seal open chest/neck wounds with chest seal x x x x x x x x x x x Consider pain control as indicated with opioid of choice DO x Consider anxiety control as indicated with benzodiazepine of choice DO x x x Consider chest decompression for tensions pneumothorax DO x If ventricular ectopy is present due to possible cardiac contusion, consider antiarrhythmic of choice DO x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Stabilize fractured ribs as indicated Impaled objects should be stabilized in place unless that interfere with the airway x x x x Notes: Consider rapid transport to nearest trauma center and limit scene time if possible 77 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Specific emergencies Type of injury Signs/symptoms Vital signs/ breath sounds Specific Treatment Rib fractures: fractures can be linear, or comminuted. Localized pain that increases on respiration and palpation. Vital signs are often elevated due to the pain, breath sounds shallow. Stabilize injury, control pain with opioid of choice, assess for further injury Flail segment: 2 or more ribs broken in 2 or more places. Localized pain that increases on respiration, paradoxical movement. Vital signs are often elevated due to pain, breath sounds shallow. Stabilize injury, control pain with opioid of choice, assess for further injury Pneumothorax: air from either an internal or external wound fills the pleural space. Shortness of breath, dyspnea, breath sounds will be diminished on the effected side. Vital signs elevated due to increased respiratory effort. Stabilize injury, control pain with opioid of choice, assess for further injury Tension pneumothorax: Dyspnea, jugular venous distension, tracheal shift (late signs). HR: increased Needle thoracotomy, stabilize injury, control pain with opioid of choice, assess for further injury Hemothorax: Blood in the pleural space causes dyspnea and hypovolemia. Dyspnea, vitals signs will indicate shock. no JVD will be present HR: increased Pulmonary contusion: bruising to the lung tissue causes it to swell and interferes with gas exchange. Dyspnea, chest wall pain on respiration, low pulse ox readings. BS: rales present over injured area. Control pain with opioid of choice, assess for further injury Cardiac contusion: HR: varies bruising to the heart tissue. Chest pain, symptoms similar to MI. signs of chest wall trauma. Control pain with opioid of choice, assess for further injury, consider antiarrhythmic of choice Pericardial tamponade: Fluid present in the sac surrounding the heart. Dyspnea, jugular venous distention, narrowing of pulse pressures. HR: rapid and weak Traumatic asphyxia: JVD, bulging eyes and tongue, facial cyanosis. Usually presents as a cardiac arrest. Treat as indicated by patient condition Dyspnea, air bubbles or air movement present in wound. Vital signs are often elevated due to the increased effort of respirations. Monitor for tension pneumothorax, seal chest wound with occlusive dressing Crushing forces prevent respiration. Sucking chest wound: External wound in chest wall allows air to flow through it BP: decreased BS: decreased or absent over the effected side. BP: decreased BS: diminished over effected side. BP: varies BS: clear BP: decreased Stabilize injury, control pain with opioid of choice, assess for further injury and shock. Fluid bolus as indicated Transport and treat for shock as indicated BS: clear 78 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Fractures, Dislocations, and Sprains This protocol serves as a guide in the treatment of a patient who has suffered an injury to a bone or joint Procedure EMTB EMTBIV EMTI Paramedic Consider spinal immobilization if indicated x x x x Control bleeding x x x x Place the patient in position of comfort/indicated position x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Assess for circulation and neurologic function in extremity. Reposition as needed to restore circulation if absent x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x Apply sterile dressing to open fractures or open wounds x x x x Splint injured extremity x x x x Elevate and apply ice packs x x x x x x x x x Consider pain control as indicated with opioid of choice DO x Consider anxiety control as indicated with benzodiazepine of choice DO x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Notes: Do not apply ice or cold packs directly to skin or use them under bandages as this will cause tissue damage Fractures do not necessarily lead to loss of function. For example, impacted fractures may cause pain but little or no loss of function. When splinting, evaluate the patient's pulse, movement and sensation before and after applying the splint. Document findings Fractures should be splinted in the position they are found unless there is diminished distal circulation or the position prevents transportation. If an angulated fracture is to be realigned, gentle traction should be used to return it to the anatomical position. Document the neurovascular exam before and after the realignment. Dislocations should not be relocated in the field. If the distal circulation is impaired, contact the Base Physician for advice. 79 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Head Trauma This protocol serves as a guide in the treatment of a patient who has suffered a traumatic injury to the head Procedure EMTB EMTBIV EMTI Paramedic Consider spinal immobilization if indicated x x x x Control bleeding x x x x Place the patient in position of comfort/Indicated position x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94% x x x x Monitor vital signs including: HR, BP, ECG, BGL, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x DO x X x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Consider benzodiazepine of choice if the patient experiences a seizure or is combative Monitor blood glucose level X X Notes: Ventilate the patient at a rate to achieve EtCO2 of 35-45mmHg if the patient requires ventilation. Do not hyperventilate unless the patient exhibits signs of herniation; then ventilate to 30mmHg EtCO2 Early signs of increased intracranial pressure include: confusion, restlessness, anxiety, combativeness, headache and nausea. Late signs are changes in vital signs, posturing and changes in pupils. Do not wait until the patient is unconscious before you suspect a head injury If a patient has trauma to the head, and is taking Coumadin or another blood thinner, the patient should be encourage to consent to transport. An AMA refusal must be obtained if the patient refuses transport. 80 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Specific emergencies Type of injury Signs/symptoms Vital signs Special considerations Concussion: temporary loss of neurological function, no tissue damage. Loss of consciousness, amnesia, headache, altered mentation. Vital signs will not be affected and should be within normal limits. All signs and symptoms should be resolved within 24 hours. Contusion: bruising to the brain results in swelling of the tissue. Loss of consciousness, amnesia, headache, altered mentation. If ICP increases: bradycardia, hypertension, abnormal respirations, posturing and pupil changes. Severe swelling can result in brain damage and death. Epidural hematoma: arterial bleed occurs in the epidural space. Associated with skull fractures. Associated with a “lucid interval” followed by a loss of consciousness, amnesia, headache, altered mentation. If ICP increases: bradycardia, hypertension, abnormal respirations, posturing and pupil changes. Associated with skull fractures, especially in the temporal and sphenoid area. Carries a high mortality rate. Subdural hematoma: venous bleed occurs in the subdural space. Loss of consciousness, amnesia, headache, altered mentation, dilated pupils, and hemiparesis. If ICP increases: bradycardia, hypertension, abnormal respirations, posturing and pupil changes. Can be acute, or chronic as seen in the elderly and alcoholics. Subarachnoid hematoma: bleeding occurs in the subarachnoid space. Loss of consciousness, amnesia, headache, altered mentation, neck or back stiffness or pain. If ICP increases: bradycardia, hypertension, abnormal respirations, posturing and pupil changes. CSF is found in the subarachnoid space. Blood will irritate the meninges causing neck or back pain. Basilar skull fracture: the base of the skull is broken. Head pain, raccoon's eyes, battle signs, CSF in ears, nose or mouth. Vital signs may vary. Open skull fracture: brain matter will be visible in the wound. Associated with large amounts of bleeding. Vital signs may vary. Keep any exposed brain tissue covered with a sterile dressing moistened with Normal Saline. Depressed skull fracture: bone in which fragments are driven into the brain. Depressed deformity to skull, often a comminuted fracture. Vital signs may vary. Do not use direct pressure to control bleeding on these areas. 81 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hemorrhage This protocol serves as a guide in the treatment of a patient who has suffered an injury and is bleeding Procedure EMTB EMTBIV EMTI Paramedic Consider spinal immobilization if indicated x x x x Control bleeding with: x x x x Direct pressure and bulky dressing x x x x If bleeding persists, apply tourniquet x x x x Consider a hemostatic agent if it is not possible to control bleeding with a tourniquet x x x x Bandage wounds and splint as needed x x x x Ensure the patient does not become hypothermic x x x x Place the patient in position of comfort/indicated position x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x Consider pain control as indicated with opioid of choice DO x Consider anxiety control as indicated with benzodiazepine of choice DO x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Notes: The vast majority of hemorrhage will be controlled with aggressive direct pressure to the injury. If the initial dressing soaks through continue with pressure and add more dressing. Ten minutes or more may be required for an adequate clot to form Patients taking ASA, anti coagulants or with coagulopathy may need longer periods of direct pressure or more aggressive control techniques 82 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Spinal trauma This protocol serves as a guide in the treatment of a patient who has suffered a spinal injury Procedure EMTB EMTBIV EMTI Paramedic Manually stabilize cervical spine x x x x Move the patient to supine if indicated x x x x Apply cervical collar and maintain manual stabilization as indicated x x x x Support airway and breathing as indicated x x x x Restrict spinal movement as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x Consider pain control as indicated with opioid of choice DO x Consider anxiety control as indicated with benzodiazepine of choice DO x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Consider antiemetic administration DO Notes: Be prepared to tip the entire board to the side if the patient begins to vomit. The patient must be secured to the board or scoop with straps across the torso 83 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Selective Spinal Immobilization Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-I, and Paramedic - Standing Order EMT-B, EMT-BIV - Direct Order Introduction: Scientific evidence has shown limited, if any, benefit from the use of spinal immobilization devices in traumatically injured patients; evidence has shown potential harm from spinally immobilizing patients The tool provided below will assist providers in deciding when or when not to immobilize a patient. If at any time a provider is uncomfortable withholding immobilization, immobilization should be performed and the situation documented in the PCR for review Implementation: Determine required immobilization technique using tool provided below or determine that no immobilization is indicated If full spinal immobilization is indicated: o Immobilize the patient on a Long Spine Board, Scoop Board, or Vacuum Mattress o Place properly sized C-collar o Ensure that the patient is adequately padded to avoid further injury If a C-collar is to be placed: o Place properly sized C-collar o Coach the patient to restrict spinal movement. o If the patient is ambulatory, assist patient in moving to the gurney. If the patient is able to selfextricate after a MVC, this is acceptable and preferred o If the patient is not ambulatory, a Scoop Board should be used to facilitate movement to the gurney If no C-collar or immobilization is indicated: o Treat patients injures and conditions as indicated, but do not spinally immobilize the patient General: Log rolling patients should be avoided unless the patient is found in a prone position or there is suspected injury to the posterior aspect of the patient Withhold C-collar placement if it is difficult to place, poorly fitting, or might impair airway management. Other methods of cervical immobilization may be used Risk of aspiration should be considered prior to fully immobilizing a patient. Prophylactic antiemetic administration may be used A properly padded Scoop Board may be left in place during transport to HRRMC to facilitate movement of the patient. If padding is not used, Scoop Board should be removed prior to transport Forcefully restraining a patient to initiate spinal immobilization may cause more harm than forgoing immobilization. Sedation may be used if needed (Refer to Patient Restraint Protocol). Base Physician contact should be initiated Properly securing a patient to the gurney is mandatory. Seatbelts should be implemented for adults, and proper pediatric restraint devices for pediatric patients 84 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Selective Spinal Immobilization Flow Chart Clinical assessment suggests the potential for spinal injury? Yes Patient is unconscious, has significantly altered mental status, or unable to follow commands due to acute No condition? No Yes Patient does not require placement on a long spine board Harm likely Consider harm vs. benefit to providing full spinal immobilization: Patient will resist immobilization Extended transport time No significant harm likely Does the patient: Have CTLS spine pain Have neurologic deficits Have distracting injuries No Yes Immobilize with LSB/Scoop/Vacuum Mattress & C-collar & Spider Straps & Head blocks Place on gurney with C-collar in place and coach patient to restrict movement No C-collar or immobilization indicated 85 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Crush Injury This protocol serves as a guide in the treatment of a patient who has suffered a traumatic crush injury Procedure EMTB EMTBIV EMTI Paramedic Control bleeding as indicated x x x x Place the patient in position of comfort/indicated position x x x x Consider spinal immobilization if indicated x x x x Support airway and breathing as indicated x x x x Administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x x x Consider pain control as indicated with opioid of choice DO x Consider anxiety control as indicated with benzodiazepine of choice DO x DO DO DO x IV: x 2 IO if unable to obtain IV Fluid bolus of 20ml/kg x If the patient has: Compression of a full upper or lower extremity for greater than 4 hours Compression of chest or abdomen for greater than 4 hours Has signs of hyperkalemia Administer 1meq/kg Sodium Bicarbonate diluted in 250mL D5W just prior to extrication Administer 5mg Albuterol DO DO Consider Calcium Chloride Treat hypotension as indicated. Control airway and breathing as indicated x x x x x Notes: Contact Base Physician for all crush injuries Avoid Succinylcholine administration 86 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Drowning / Near Drowning This protocol serves as a guide in the treatment of a patient who has drowned or had a near drowning event Procedure EMTB EMTBIV EMTI Paramedic Manually stabilize cervical spine if indicated x x x x Immobilize as indicated x x x x Initiated CPR if needed: Refer to Cardiac Arrest Protocol x x x x Support airway and breathing as indicated x x x x Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If the patient is actively bleeding or hypotensive, administer high flow O2 x x x x Monitor vital signs including: HR, BP, ECG, and temperature x x x x Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive) x x x x x x x x x IV: 1-2 with Normal Saline bolus as indicated IO if unable to obtain IV and the patient is unstable Monitor for hypothermia: Refer to Hypothermia Protocol x x x x Consider CPAP administration x x x x Notes: Consider transport of all near-drowning patient. Even if the patients initially appear fine, they can deteriorate Beware of neck injuries - they often go unrecognized Under current ACLS standards, Heimlich maneuver is not indicated Contact Medical Control Via Cell phone or radio if service is available. See “Field Pronouncement” protocol for further guidelines. 87 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pharyngeal Airways – Oral and Nasal Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order Placement of airway adjuncts in the nasopharynx or oropharynx to displace the soft tissues of the pharynx and ease ventilation. An oropharyngeal (OPA) airway can be placed in a patient who is unconscious without a gag reflex. Nasopharyngeal airways (NPA) can be placed in patients who are conscious and/or have a gag reflex Indications: To ease spontaneous respiration by a patient that is semi-conscious To assist oxygenation and ventilating a patient To prevent gastric distention Contraindications: OPA – known intact gag reflex Precautions: Insert airways gently to avoid airway trauma NPA –Basilar skull fractures Procedure: OPA placement o Size the OPA from the corner of the mouth to the angle of the jaw o Place the patient with the head in midline, neutral position. (Cervical collar may be in place) o Introduce the OPA into the mouth upside down or sideways (Pediatrics: sideways) When the tip of the OPA reaches the back of the throat, insert the OPA into the pharynx with a twisting corkscrew motion o If the patient begins to gag, immediately remove the OPA NPA placement o Size the NPA from the corner of the nares to the angle of the jaw o Lubricate the NPA with a water soluble lubricant if needed o With gentle steady pressure, advance the NPA through the nares into the posterior pharynx. The beveled edge should be against the nasal septum, to avoid trauma to the turbinates o If the patient begins to gag, withdraw the NPA a few centimeters Notes: Never force the placement of an airway adjunct. 88 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Extra-Glottic Airways Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic-Standing Order To improve ability to ventilate and provide a more secure airway than OPA/NPA in patients that require ventilation Indications: Patients: o With no intact gag reflex o Who require ventilation o When Bag-Valve-Mask ventilation is not adequate or indicated Back up airway after endotracheal intubation is unsuccessful in RSI Cardiac arrest when an endotracheal tube can not be placed without interruption in chest compressions Contraindications: Intact gag reflex Known esophageal disease Ingestion of caustic substances Upper airway obstruction See manufactures recommendations Procedures: Maintain C-spine immobilization if needed Preoxygenate/ventilate the patient Prepare equipment including suction Test cuffs by inflating to full volume and inspect for leaks Place head should be in neutral position Perform tongue-jaw lift Choose appropriate size of tube for patient, per manufacture recommendations Insert tube per manufacture recommendations Inflate balloons/cuffs Confirm tube placement with continuous waveform capnography (Mandatory) Secure tube Maintain continuous waveform capnography, upload to report, and asses for breath sounds Notes: • Chaffee County Emergency Medical Services currently carries King-LT/LTDs and LMAs. 89 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Endotracheal Intubation - Nasotracheal Authorization: Protocol: Paramedic Paramedic - Standing Order This procedure is to serve as a guide to the placement of an endotracheal tube to protect a patient’s airway and ensure ventilation Indications: To secure and protect the airway in a compromised patient who has an intact gag reflex and is spontaneously breathing Contraindications: Suspected basilar skull fracture Apnea Precautions: The head must be midline for successful intubation May cause bleeding and thus complicate patient care Procedure: Ventilate the patient prior to starting intubation if spontaneous ventilations are inadequate or oxygenate Place phenylephrine into the nares Lubricate tube and/or nares with viscous Lidocaine Choose endotracheal tube size based on size of nares Consider the use of a BAAM or ETCO2 detector to assist with placement Place the patient with the head in midline, neutral position. (Cervical collar may be placed) With gentle steady pressure, advance the tube through the nares into the posterior pharynx. The beveled edge should be against the nasal septum to avoid trauma to the turbinates. Pass the tube along the floor of the nasopharynx, perpendicular to the head Keeping curve of tube exactly in midline, continue advancing slowly, listening for air exchange through the tube Wait for an inhalation, exhalation, or cough to advance the tube through the glottis into the trachea. A slight resistance will be felt just before entering the trachea Advance about 1" further, then inflate cuff Ventilate and check for breath sounds bilaterally. Confirm endotracheal tube placement Continuous capnography after placement is mandatory and must be uploaded to report Secure tube Notes: Consider other means of airway management 90 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Beck Airway Airflow Monitor (BAAM) Authorization: Protocol: Paramedic Paramedic - Standing Order The BAAM is a plastic cap that when placed on an endotracheal tube will be activated by the patient’s respirations and magnify airway airflow sounds facilitating blind nasotracheal intubation Indications: Assist nasotracheal intubation placement Contraindications: None during nasotracheal intubation Precautions: A BAAM can only be used in a patient who has spontaneous respirations with a tidal volume strong enough to create airflow through the device The BAAM will only confirm placement in the bronchial tree, it will not determine if the tube tip is placed at the carina or in a bronchial main stem An unobstructed endotracheal tube with its tip located in the pharynx can produce the whistle sound. It is important to know the length of the endotracheal tube within the patient Procedure: Connect the BAAM to a 15 mm endotracheal connector. When the tube is advanced into the posterior nasopharynx, the patient's breathing will activate the BAAM and a whistling sound will be produced with inhalation and exhalation The tube is then advanced into the larynx and trachea, which will increase the intensity and pitch of whistling sound Deviation out of the airflow tract, esophageal intubation will result in immediate diminution or loss of the whistle sound. The tube should be withdrawn until the whistle sound is audible, and the tube should be redirected and reinserted Once tube is thought to be placed, remove BAAM and confirm correct tracheal intubation Notes: A BAAM is single-use only 91 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Endotracheal Intubation - Orotracheal Authorization: Protocol: EMT-I and Paramedic EMT-I and Paramedic - Standing Order This procedure is to serve as a guide to the placement of an endotracheal tube to protect a patient’s airway and ensure ventilation Indications: To secure and protect the airway in a patient without a gag reflex To allow continuous compressions during CPR Contraindications: Patient has intact gag reflex Precautions: Never use intubation as a primary treatment of respiratory arrest in the field. Airway management should be accomplished with BVM ventilation and pharyngeal airways Patients with suspected neck injuries. If oral intubation is attempted, the head should be held in midline position with manual traction. However, airway management takes precedence over everything, including spinal immobilization Do not pry the laryngoscope against the teeth Procedure: Ventilate the patient Assemble the equipment: Tube, syringe, suction, laryngoscope, ect. Choose the appropriate tube size (see following Notes) Position the patient. Pad under shoulders/head as needed Insert laryngoscope and place endotracheal tube Ensure SPO2 is adequate during attempt Inflate cuff with 5 - 10 cc of air and remove the stylette if used Place capnography detector and: listen to breath sounds, listen to the epigastrum, and check for chest rise during ventilation Continuous ETCO2 monitoring is mandatory and must be uploaded to report Secure endotracheal tube Notes: Esophageal intubation should be avoided by using direct visualization of the vocal cords if possible Consider using a Bougie Flex-Tip ET tube inducer Intubation of the right main stem bronchus is very common. If there are not any breath sounds on the left or they are diminished, withdraw the tube slightly until bilateral breath sounds are heard To determine tube size in children: Utilize Broselow tape (Another "rule of thumb" is to use the tube with a diameter nearest to the diameter of the patient's little finger.) If there is a question as to the placement of the tube, remove it and re-intubate. Do not ever leave a tube in place that is questionable. 92 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Endotracheal Intubation – Rapid Sequence Intubation Authorization: Protocol: Paramedic Paramedic - Standing Order The use of sedative and paralytic medications to facilitate direct laryngoscopy and orotracheal intubation Indications: In a patient with an intact gag reflex that: o Is unable to protect their own airway o Will potentially be unable to protect their own airway without intervention o Who is at risk for airway swelling and obstruction without intervention o Airway compromise with trismus Contraindications: Patients <12yrs Patients who can be adequately oxygenated/ventilated by less invasive means with no potential for airway compromise Precautions: RSI is a procedure that has a high potential for significant complications. This procedure should be reserved patients who have, or will most likely develop, airway compromise that cannot be adequately managed by other means A adequate number of personnel should be on hand to assist Procedure: Ensure that indications are present for RSI Asses for predicated difficult BVM, intubation, EGD, and cricothyrotomy: o Consider an “Awake Look” utilizing atomized Lidocaine o Sedation with Versed may be used if needed Obtain BP and continuous SPO2, ECG, and ETCO2 (If indicated) Place a nasal cannula on patient for apneic oxygenation, even if patient is on a NRB Established IV/IO Prepare intubation equipment, extra-glottic device, and cricothyrotomy equipment Consider premedication with: Fentanyl - 3µg/kg Lidocaine for head injury – 1.5mg/kg For patients with increased ICP, CAD, or vascular disease Administer induction agent: Ketamine - 1.5mg/kg If the patient is hypotensive consider 1mg/kg ----------OR--------- Midazolam - 0.3mg/kg Administer paralytic of choice: Succinylcholine - 1.5mg/kg ----------OR--------- Veccuronium - 0.1mg/kg Attempt endotracheal intubation with VL or DL technique Ensure that adequate SPO2 is maintained during/between attempts. If endotracheal intubation is unsuccessful, the patient desaturates with inability to ventilate with a BVM, or after 3 intubation attempts, place extra-glottic device if indicated. (See Failed Airway) 93 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Verify endotracheal tube placement Continuous ETCO2 monitoring is mandatory and must be uploaded to report Secure endotracheal tube Maintain sedation: Versed and/or Ketamine Maintain pain control: Fentanyl The need for re-paralysis should only be considered once adequate sedation and analgesia have been ensured Veccuronium – 0.1mg/kg IV Place NG or OG tube Complete all documentation per agency and state requirements and submit for review within 24hrs Notes: If the patient is hypotensive or at risk to become hypotensive, have vasopressor of choice available and attempt to correct hypotension prior to induction If the patient is hypoxic and unable to correct prior to induction and paralysis, consider placement of an EGD with oral ETI at a later time If the patient is acidotic, consider placement of an EGD with oral ETI at a later time. Ensure ETCO2 does not rise from pre-induction value Plan in place? (RSI, Awake, RSA) Consider increased/decreased BP/SP02/pH Intubation equipment ready Suction on and available Asses for EGD placement/ready Asses for cricothyrotomy. Mark/ready Preoxygenate/denitrogenate NC for apneic oxygenation in place Pre-treatment with Fentanyl Ketamine drawn up Paralytic drawn up Post intubation medications drawn up Vasopressor available Patient monitors in place Position patient: ramp/ear to sternal notch with proper lighting Team briefed on plan, roles and back up plans 94 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Awake Look - Laryngo-Tracheal Mucosal Atomization Device Authorization: Protocol: Paramedic Paramedic - Standing Order Should be used to assist in oral intubation if the patient has an intact gag reflex Indications: In a patient with an intact gag reflex that: o Is unable to protect their own airway o Will potentially be unable to protect their own airway without intervention o Is determined to be, or potential be, a difficult intubation Contraindications: Patient does not require intubation See Lidocaine Protocol Precautions: See Lidocaine Protocol Only to be used in patients that require endotracheal intubation and are determined to have or potential have a difficult airway The patient must be able to gag, cough, and protect their airway Procedure: Explain procedure to the patient Obtain BP and continuous SPO2, ECG, and ETCO2 (If indicated) Established IV/IO Prepare intubation equipment including suction Assemble atomization device and draw up 2% Aqueous Lidocaine Preoxygenate the patient Have the patient open mouth and pass device as far posterior and inferiorly as the patient will allow. Consider the use of a tongue depressor Firmly press syringe to spray Lidocaine on the mucosa o Numbing the posterior tongue and then re-administering posteriorly may be needed Once the patients gag reflex is no longer intact, pass the laryngoscope, preferably video laryngoscope, gently into the patient’s mouth and attempt to visualize the vocal cords If the patient will allow, gently place an endotracheal tube. See Endotracheal intubation – Oral for further procedure and confirmation procedure If endotracheal tube is placed, consider sedation and paralyzation If endotracheal tube is not placed, consider RSI or alternate means of airway control as indicated If sedation is need to reduce anxiety during “Awake Look”, consider dose of sedative of choice 95 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Airway Assessment Authorization: Protocol: EMT-B, EMT-BIV, EMT-I and Paramedic EMT-B, EMT-BIV, EMT-I and Paramedic - Standing Order This protocol is a tool that can be used by all providers to evaluate a patient’s airways for difficulty in performing procedures LEMONS for intubation: L = “Look” – Look at body habitus, neck, beard & clinical situation E = “Evaluate” - 3:3:2 Rule o Can 3 of the patient’s fingers fit in the mouth opening o Is the hyomental distance greater than 3 of the patient’s fingers o Is the thyrohyoid distance greater than 2 of the patient’s fingers M = “Mallampatti” – Classify the oropharynx. O = “Obstruction” – Check for airway obstruction (Teeth, blood, edema ect.) N = “Neck” Immobility – Known or expected S = “Saturation” – Check ability to oxygenate blood prior to procedure MOANS for ventilation: M = “Mask” – Evaluate for beard, difficult anatomy, or other feature that might impair mask seal O = “Obstruction” A = “Age” N = “No” (teeth (replace dentures for Bag Valve Mask ventilation) S = “Stiff” lungs requiring increased ventilatory pressures (Asthma, COPD, ARDS, term pregnancy) SHORT for cricothyrotomy: S = “Surgery” distorting the airway and tracheal access H = “Hematoma”, infection or mass in the path of the cricothryotomy O = “Obesity” or fixed flexion deformity of the neck R = “Radiation” to the neck T = “Tumors” involving the airway or in vicinity RODS for extra-glottic airway placement: R = “Restricted” mouth opening O = “Obstruction” of the upper airway or larynx D = “Distorted” or disrupted airway S = “Stiff” lungs requiring increased ventilatory pressures (Asthma, COPD, ARDS, term pregnancy) 96 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Failed Airway Unable to intubate the patient with RSI, unable to oxygenate/ventilate, or unable to intubate the patient after three attempts Place extra-glottic device Assess for adequate oxygenation/ventilation Ventilation compliance Waveform capnography SpO2 monitoring Auscultation of breath sounds If oxygenation/ventilation is inadequate or extra-glottic device is/may become inadequate to protect airway Perform Percutaneous Cricothyrotomy 97 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Percutaneous Cricothyrotomy Authorization: Protocol: Paramedic Paramedic - Standing Order Percutaneous Cricothyrotomy is the establishment of an airway through the cricothyroid membrane Indications: The inability, or potential inability, to oxygenate or ventilate a patient by other means Contraindications: Ability to oxygenate or ventilate the patient by less invasive means Precautions: Bleeding is likely, be prepared to perform the procedure “blind” Subcutaneous air may indicated improper placement or tracheal damage Procedure should be performed in a well-lit and stable environment Procedure: Needle cricothyrotomy (Patient < 4yrs of age) Ensure that procedure is indicated. See Failed Airway Protocol Position the patient in a supine position, with in-line spinal immobilization if indicated Cleanse the site Choose 16ga or 14ga angiocatheter as appropriate Insert chosen needle through the cricothyroid membrane in a caudal direction at a 45-degree angle Procedure until a “pop” is felt or air is readily aspirated. Advance needle a short distance more, and advance catheter Remove syringe or needle and syringe as indicated Place a 2.5mm ETT/BVM adapter onto the angiocatheter Ventilate with BVM and 100% oxygen Confirm placement with continuous waveform capnography Secure catheter Allow longer exhalation period to avoid barotrauma Surgical cricothyrotomy (Patient >4yrs of age) Ensure that procedure is indicated. See Failed Airway Protocol Position the patient in a supine position, with in-line spinal immobilization if indicated Cleanse the site and consider marking the location Open package, maintaining asepsis Inflate cuff with 10mL of air. Deflate fully Locate landmark over cricothyroid membrane digitally Make vertical incision with scalpel Performing blunt or digital dissection Perforate cricothyroid membrane with scalpel or use forceps Insert tracheotomy hook and secure tracheal ring caudally from incision site Or Insert Gum Elastic Bougie in a caudal direction Insert provided endotracheal tube into incision or over Bougie in a caudal direction approximately ½ to 1inch Inflate cuff with 5-10mL of air 98 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Ventilate with BVM and 100% oxygen Confirm placement with continuous waveform capnography Secure tube and control bleeding as needed Notes: Identifying landmarks to locate the cricothyroid membrane is difficult, especially in the female and pediatric patient If landmarks can be identified, a stabbing motion with the scalpel is preferred It is recommended to stabilize the instrument hand on the sternum of the patient It may be helpful to identify structures in a downward direction using the “handshake” method: o Hyoid Bone o Thryroid cartilage o Cricoid membrane o Cricoid cartilage The reason for performing this procedure must be documented and submitted for review to the Medical Director or designee within 24 hours 99 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Continuous Positive Airway Pressure (CPAP) Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-I, and Paramedic - Standing Order EMT-B, and EMT-BIV – Direct Order CPAP provides constant pressure during exhalation and inhalation. This provided benefits through “splinting” of the small airways and increased intraaveolar pressure Indications: Shortness of breath due to: o Congestive heart failure o Pulmonary edema o COPD o Pneumonia o Near drowning Caron Monoxide poisoning with levels >20% or symptomatic RSI preoxygenation Contraindications: Patient unable to protect airway Apnea Hypotension (Systolic < 90mmHg) Dyspnea secondary to trauma, pneumothorax, or penetrating injury Nausea and vomiting or other risk of aspiration Precautions: Cardiac chest pain Altered level of consciousness Inability to achieve mask seal Procedure: Explain the procedure to the patient Monitor the patient’s vital signs: HR, BP, ECG, SPO2, and ETCO2 Attach device to oxygen with flow rate of 15/lpm Place mask on the patient’s face and secure with harness if tolerated Ensure mask seals to patient’s face Continue to coach the patient to keep mask in place and readjust as needed Treat medically as indicated Advise receiving facility of CPAP initiation If respiratory status deteriorates or does not improve, remove device and consider intermittent positive pressure ventilation via BVM and/or advanced airway placement Notes: A patient that requires CPAP is a mandatory ALS if an ALS personnel is available CPAP therapy needs to be continuous and should not be removed unless the patient deteriorates or other complications develop Watch the patient for gastric distention 100 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Apneic Oxygenation Authorization: Protocol: EMT-I, and Paramedic EMT-I, and Paramedic - Standing Order Apneic oxygenation is the process of introducing oxygen into the pharynx via the nasopharynx. Due to oxygen absorption at the alveolar level and the created negative pressure, oxygen is drawn into the alveoli and made available for absorption Indications: RSI preoxygenation through apneic period Any apneic patient as an adjunct until definitive ventilation and airway control can be obtained Contraindications: None Precautions: Apneic oxygenation does not remove CO2. Great caution should be taken to ensure that hypercarbia will not harm the patient Does not eliminate the need for airway or ventilatory control Procedure: Place an ETCO2 Nasal Cannula on the patient Set flow rate to 10-15lpm Notes: Apneic oxygenation throughout the apneic period during an RSI has become the standard of care and should be utilize on all patients 101 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Chest Decompression Authorization: Protocol: EMT-I and Paramedic EMT-I and Paramedic - Standing Order A needle is introduced into the pleural space to allow the escape of air that has built accumulated secondary to a break in the chest wall or integrity of the lungs Indications: Tension pneumothorax (Pneumothorax with signs of obstructive shock) Hypotensive patient with multisystem trauma and no apparent hypovolemia Contraindications: Simple pneumothorax without signs of shock Precautions: Tension pneumothorax is a rare condition, but can occur either traumatically or spontaneously. If it is present, it may rapidly lead to death if left untreated Procedure: Expose the chest There are two sites that can be used; however the lateral location is preferred: o The second or third intercostal space on the anterior midclavicular line o The third or fourth intercostal space on the mid-axillary line Clean the site to be used vigorously Using a 14 gauge or a 10-gauge angiocath, insert the needle into the pleuritic cavity over the top of the rib If the air is under tension, air will vent out of the angiocath. Advance the catheter and remove the needle Secure catheter Procedure may be performed multiple times as indicated Notes: Complications include: creation of a pneumothorax if one did not exist previously, laceration of blood vessels and nerves, and infection The procedure may be painful, especially when piercing the pleura. Even so, if indicated, the procedure should be done as soon as possible A tension pneumothorax can be precipitated by sealing a sucking chest wound. If the patient deteriorates after a dressing is in place on an open chest wound, remove the dressing and have the patient cough. This will relieve the pressure The use of positive pressure ventilation will rapidly accelerate the development of tension pneumothorax if there is a simple pneumothorax present due to lung injury. Therefore, monitor closely for the development of a tension pneumothorax any time you use positive pressure ventilation especially in the trauma setting 102 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Peripheral IV Insertion Authorization: Protocol: EMT-BIV, EMT-I, and Paramedic EMT-BIV, EMT-I, and Paramedic IV access allows a blood draw to be obtained, and fluid/medications to be administer or potentially administered Indication: Any patient requiring or potentially requiring: o A blood draw o Fluid administration o Medication administration Contraindications: None Precautions: Do not start an IV distal to a fracture site or through skin damaged with more than erythema or superficial abrasions Make certain the IV solution on hand is the desired solution Check expiration dates and clarity of fluid Do not delay maintaining Airway, Breathing, or other methods of maintaining Circulation to attempt IV access Procedure: Explain the procedure to the patient Prepare the equipment o Determine correct fluid to be administered o Choose correct administration set or extension set o If possible, use extension set when using an administration set o Assemble equipment per accepted procedure ensuring asepsis Cleanse site Once venous cannulation is achieved, perform Venous Blood Draw if indicated Attach administration set and/or extension set Administer fluid at appropriate rate Notes: IV’s in patients younger than 12 should be run through a volumetric infusion device (i.e., Volutrol, Buretrol) to prevent fluid overload or use an extension set alone Pyrogenic reactions due to contaminated fluids become evident in about 30 minutes after starting the IV. The patient will become febrile. Chills, vomiting, nausea, headache, backache and general malaise are indications. If observed, stop and remove IV and immediately save the solution so it may be cultured Complications: hematoma formation, infection, thrombosis, phlebitis, skin necrosis, sepsis, pulmonary embolus, catheter fragment embolus, fluid overload, pulmonary edema, cardiac failure, fiber embolus from solution in IV The incidence of phlebitis is particularly high in the leg. Avoid use of lower extremity if possible. 103 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Law Enforcement Blood Draw Authorization: Protocol: EMT-BIV, EMT-I, and Paramedic EMT-BIV, EMT-I, and Paramedic – Standing Order Blood draw to obtain samples of venous blood to be used by a law enforcement agency Indications: At the request of the Colorado State Patrol At the request of the Chaffee County Sheriff’s Office At the request of the Salida Police Department At the request of the Buena Vista Police Department Contraindications: None Precautions: May be performed on a patient that is not transported Do not delay treatment/transport of a critically ill or injured patient to obtain blood draw Procedure: Assemble equipment from seal package provided by the law enforcement officer Cleanse site with iodine. Do not use alcohol Obtain blood samples Remove needle, if used, and hold pressure. Apply bandage if needed Complete required paperwork Notes: The required paperwork includes the following questions o Does the person want any medical care or treatment from CCEMS personnel? o Is the person voluntarily consenting to having g their blood drawn by CCEMS personnel? o Was the sealed venipuncture kit(s) provided by the requesting officer? o Was the blood drawn using all of the materials from the sealed kit(s)? o Was the venipuncture site(s) cleaned using only non-alcoholic antiseptic wipe(s) from the provided kit? o Blood specimen obtained using: o Did you witness the sealing of each blood tube? o Did you witness the initialing of all seals? o How many venipuncture attempts were made? o Home many kits were use? o Venipuncture site Obtain officer’s signature 104 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Venous Blood Draw Authorization: Protocol: EMT-BIV, EMT-I, and Paramedic EMT-BIV, EMT-I, and Paramedic – Standing Order A blood draw obtains samples of venous blood, in various tubes, that can be used for testing at the receiving hospital Indications: Any patient who receives a peripheral IV or EJ in the field o A blood draw may be forgone altogether or withheld until a second IV is place at the providers discretion Contraindications: None Precautions: Treatment of unstable patients should not be delayed to obtain blood samples Procedure: After initiating an IV and removing the needle, attach the vacutainer holder to the hub of the IV catheter. (This is accomplished using the Luer adaptor attached to the vacutainer holder.) Fill all the desired blood tubes in appropriate order per system requirements Tubes should be gently inverted. Do not shake the tube, as this could cause hemolysis, which could interfere with test results Tubes should be placed in bag and kept with the patient Provide tubes to receiving facility Notes: Pediatrics receiving an IV should have at least a red tube and lavender top tube drawn. The red top may be filled only halfway and the lavender only 1/4 of the way to do the needed tests. If available, red and lavender pediatric tubes may be used The blue top tube must be filled exactly to be usable; the amount of vacuum in the tube is pre-established to draw the proper amount of blood into the tube. 105 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 External Jugular IV Insertion Authorization: Protocol: EMT-I, and Paramedic EMT-I, and Paramedic - Standing Order Indications: Provider choice when peripheral IV access is not obtainable Contraindications: Hematoma, trauma, or other abnormality over site Patient does not require an IV Precautions: Complications from an EJ attempt can be severe Consider IO placement Procedure: Position the patient: supine with the patient's head turned to opposite side from procedure. Cleanse the site with alcohol prep Align the cannula in the direction of the vein with the point aimed toward the ipsilateral shoulder (on same side) Make the puncture midway between the angle of the jaw and the midclavicular line, tamponade the vein lightly with one finger above the clavicle Attach IV tubing to catheter Secure tubing to patient's neck with tape. Notes: Complications: hematoma formation, infection, thrombosis, phlebitis, skin necrosis, punctures of internal jugular vein or carotid artery, sepsis, pulmonary embolus, catheter fragment embolus, fiber embolus from solution in IV This should never be attempted as a “blind stick” 106 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Intraosseous Cannulation Authorization: Protocol: EMT-I, and Paramedic EMT-I, and Paramedic - Standing Order A metal catheter is placed into a bone, usually the tibia or humeral head, so that fluids or medications can be infused into the bone marrow Indications: Any situation in which IV/IO access is needed and IV access is unobtainable or will require extended time to establish Contraindications: Fracture of same bone Patient is stable, with no indication of potential instability Replacement of joint on side of procedure Precautions: Limit IO attempt to only one per extremity Conscious patients require Lidocaine administration for local anesthetic Osteoporosis (Insecure placement) Procedure: Assemble equipment If the patient is conscious, flush extension set with Lidocaine and attach to flushed drip set, if a drip set is needed Choose appropriate IO cannula Locate landmarks for the tibial (Preferred) or humeral insertion sites Scrub the insertion site with Iodine and then alcohol prep Insert the needle through the skin at a 90 degree angle on the tibial plateau or at the greater tubercle of the humeral head Place needle into the marrow cavity with gentle, constant pressure. If drill slows, too much pressure may being applied There will be a slight "pop" when the needle goes into the marrow cavity. Stop as soon as the needle flange contacts the patient’s skin or a sudden decrease in resistance is felt as the needle enters the medullary canal Attach extension set and/or administration set Ensure adequate flow with no extravasation of fluid. IO should be be flushed to ensure flow or pressure infuser may be used Secure IO cannula Notes: Refer to IV Infusion or specific treatment protocol for more information At this time, any drug that may be given IV may also be given IO and have the same efficacy 107 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Semi-Automated External Defibrillator Authorization: Protocol: EMT-B, EMT-BIV EMT-I, and Paramedic with current SAED authorization EMT-B, EMT-BIV EMT-I, and Paramedic - Standing Order The SAED analyses cardiac rhythm for the presence of ventricular fibrillation or rapid ventricular tachycardia, charges to preset energy levels, and allows the user to deliver a defibrillation shock. The user must follow strict patient selection criteria. The user must be currently authorized as an AED provider Indications: A patient found unresponsive, apneic, and pulseless Contraindications: Do note place on the patient that: o Is breathing o Is responsive o Has a pulse ALS providers should use Manual Defibrillation to avoid delays is defibrillation Precautions: Everyone must be clear of physical contact with the patient during analysis and defibrillation. Patients who are wet or are in any form of water must be moved to a dry surface and the chest must be dried prior to application of electrode patches. All medication patches (such as nitroglycerin) should be removed from the patient's chest prior to defibrillation Patients with suspected hypothermia resulting in cardiac arrest may only be given one shock, then must be transported with continuous CPR to a hospital for re-warming before further defibrillation attempts If devices, such as implanted pacemaker or ICD is visualized, place SAED electrodes so as to avoid shocking through the device Procedure: Each provider must be familiar with the operation of the SAED that their agency carries Provide CPR per current AHA recommendations Operate SAED per manufacture recommendations Notes: Unless the SAED is analyzing or a shock is being delivered, someone must be doing chest compressions 108 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Manual Defibrillation Authorization: Protocol: EMT-I and Paramedic EMT-I and Paramedic - Standing Order Passage of electrical current through the heart tissue to cause a uniform depolarization to occur and the normal intrinsic pacers of the heart to resume at normal rates and sequences Indications: Ventricular fibrillation in a pulseless and apneic patient Ventricular tachycardia in a pulseless and apneic patient Uncontrolled A-Fib with suspected WPW (Wide complex, and irregularly irregular tachycardia) Contraindications: Patient condition does not meet indications Precautions: Do not treat the monitor strip alone - treat the entire the patient! A patient who is talking to you is not in ventricular fibrillation, whatever the monitor shows. Check another lead and confirm that the electrodes are attached Ensure that chest is clean and dry Avoid any direct physical contact with the patient during defibrillation Defibrillation may not be successful in ventricular fibrillation due to hypothermia until core temperature is above 88F (31C) Defibrillation is not the first treatment in fibrillation due to hypovolemia (trauma situation). CPR and fluids take precedence Do not defibrillate over any medication patch. Remove the patch first Do not defibrillate over any implanted pacemaker or defibrillator. Move pad/paddle one inch from device Procedure: Perform CPR per ACLS guidelines. Refer to the specific Cardiac Arrest Protocol Attach ECG limb leads and multi-function pads. Correct pad placement will increase chance of successful conversion. Hard paddles can also be used if needed Defibrillate per manufacture recommendations Notes: ALS providers should use Manual Defibrillation, not SAED mode to avoid long pauses in chest compressions Remember that the hypoxic or acidotic heart may not respond to defibrillation. Chest compressions will, to some degree, reverse hypoxia and acidosis. Any underlying condition should be treated appropriately Do not forget to start CPR by preoccupation with defibrillation. Continue compressions while charging 109 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Transcutaneous Cardiac Pacing Authorization: Protocol: EMT-I and Paramedic EMT-I and Paramedic – Standing Order An externally applied electrical current is passed through the heart tissue causing cardiac depolarization Indications: Symptomatic bradycardias when Atropine is ineffective or contraindicated Tachycardia that cannot be treated by pharmacological means (EMT-Intermediate) Contraindications: None Precautions: Capture may not be possible with severe ischemia and necrosis Patients who are conscious will experience discomfort. Consider benzodiazepine or opioid administration Procedure: Place limb leads on the patient and multi-function pads on the chest Turn the pacer on Set initial energy setting to 60mA and the rate at 80 BPM Increase energy setting in 10 mA increments until capture occurs up to 200 mA. Once capture occurs, check for a femoral pulse. If it is not present, consider a fluid challenge, attempt to increase by 10mA, or begin vasopressor of choice Place pleth wave in one channel of Life Pak and press print to document pulse Notes: An Epinephrine drip or Dopamine drip can be administered while TCP is being performed if indicated The figures below are example of pacing artifact. Figures are copied from a Medtronic user manual 110 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Synchronized Cardioversion Authorization: Protocol: Paramedic Paramedic - Standing Order Passage of electrical current through the heart tissue to cause a uniform depolarization to occur and the normal intrinsic pacers of the heart to resume at normal rates and sequences Indications: Unstable cardiac tachy-dysrhythmias Cardiac tachy-dysrhythmias when pharmacological treatment is not indicated Contraindications: Sinus tachycardia Precautions: All of the precautions for defibrillation apply Patients that are stable, with a tachydysrhythmia, should be treated with medication, first if indicated Patients with a-fib, and a ventricular response <140bpm, will not cardiovert easily and are almost certainly decompensated for another reason Sinus tachycardia is a symptom of an underlying problem. The patient must be treated for the underlying cause. Initial treatment should be for shock if perfusion is poor. Cardioversion is not indicated Digitalis toxicity Procedure: Apply limb leads and multi-function pads onto chest. Correct pad placement may increase chance of achieving conversion Press “Sync” o If the Sync function will not mark each QRS complex, try selecting a different lead or turning up the QRS amplitude o Ensure that each QRS complex is marked with a marker (Not T-waves, ect.) Set desired Joules. Follow current AHA recommendations. A default 200j for adult patients may be used Consider sedation with benzodiazepine of choice prior to cardioversion Press “Charge” Clear the patient Hold “Shock” until synchronizer discharges o If the Sync function does not function properly, deactivate and consider unsynchronized cardioversion at a higher energy setting Notes: If sinus rhythm is achieved only transiently with cardioversion, subsequent cardioversion at a higher energy setting will be of no additional value. Leave the energy setting the same and consider alteration of other variables. If V-Fib occurs, see Defibrillation protocol Cardioversion is rarely indicated in children. Ventricular fibrillation and asystole are rare as complications of cardioversion and usually occur in the setting of a digitalis-toxic patient 111 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 112 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 113 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pulse Oximetry Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order Pulse oximetry combines the principles of optical plethysmography (light absorption), and spectrophotometry to determine the percentage of arterial hemoglobin oxygen saturation (SaO2). The actual measurement is the percent of hemoglobin that is bound. The machine cannot differentiate between what gas the hemoglobin is bound with Indications: Routine assessment on every patient Contraindications: None Precautions: Use plethwave to determine quality of reading; patient motion can interfere with the signal giving a false low reading Poor perfusion caused by hypoperfusion, vasoconstriction, or cold extremities may not generate an acceptable waveform Dyshemoglobinemias will give false high readings. This occurs when another molecule such as carbon monoxide binds to the hemoglobin. Carboxyhemoglobin and methemoglobin will both render the pulse oximeter readings inaccurate Anemia is the result of low hemoglobin or RBC levels. The pulse oximeter will give inaccurate or misleading readings Procedure: The probe from the pulse ox unit must be placed in an area where the red and infrared light emissions can pass through a vascular bed into a light sensor. The most commonly used sites are digits such as fingers or toes, ear lobes or the bridge of the nose Sensor may function on a heel or forehead The pulse oximeter unit must indicate that it is sensing adequate amplitude of a pulsating waveform otherwise the readings are inaccurate. Nail polish should be removed prior to application of the probe Titrate oxygen administration to a saturation of 94-99% if indicated Special Notes: A probe that is too tight, either too small or taped/strapped on, can impeded venous circulation and cause venous pulsations that will give a false low readings Often a patient in respiratory distress will have normal or elevated oxygen saturation due to the hyperventilation and increased tidal volume. Treat the patient and not the pulse oximeter 114 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 End-Tidal CO2 Waveform Capnography Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic – Standing Order Waveform capnography provides vital tool in the evaluation of metabolism, circulation, and respiration. Also provide almost absolute confirmation of tube placement during endotracheal intubation, extra-glottic airway use, and cricothyrotomy Indications: Confirmation of advanced airway placement Detect ROSC during CPR Any metabolic/respiratory acidosis or alkalosis Overdose Respiratory distress or respiratory depression Contraindications: None Precautions: Numerical value must be evaluated in context with the patient’s condition Airway secretions can block detector causing a loss of wave form. Replace detector if this occurs Procedure: Choose side stream or inline detector as indicated Attach orange connector to port on LP-12 Place cannula on the patient or adapter on 15mm connecter Use selector knob dial to the third channel of the home screen and push in selector knob Select “Waveform” then “Source” and “ETCO2”. Press “Home” to exit After intubation/extra-glottic placement, use BVM to ventilate for six breaths. Assure corresponding waveform and numerical equivalent Continuous waveform capnography is mandatory after advanced airway placement Notes: After six breaths a positive waveform is 100% confirmation of correct advanced airway placement The loss of wave form requires a cause be identified If no waveform or number appears on home screen check all connections. If it is determined that the equipment is working correctly, consider esophageal intubation and remove advanced airway Do not withhold oxygen to place cannula detector; use a non-rebreathing mask instead or a nasal cannula with oxygen can be placed in the patient’s mouth. Some nasal cannula CO2 detectors have an O2 attachment. Be familiar with the equipment and alternatives Normal end-tidal CO2 readings are 35-45mmHg Head injury patients should be ventilated to 30mmHg 115 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Automated Transport Ventilator Authorization: Protocol: Paramedic Paramedic - Standing Order May be used for any patient during an interfaculty transport that requires mechanical ventilation Indications: Any patient that requires ventilator support for an extended period of time Contraindications: Patient <12yrs Precautions: Patient should have NG/OG tube in place Patient should be stable prior to transport Side effects: Ventilator associated pneumonia Barotrauma Hypotension Procedure: Ensure that adequate high pressure oxygen is available for transport, that the ventilator battery is charge, that the AC adapter is present, and that the ventilator is properly set up and ready for use A ventilator circuit should be pre-made with a: o Double male connector o Circuit – Either adult or pediatric o Suction adapter with sterile suction catheter o Inline EtCO2 collector o Flex fitting All paperwork must be present prior to transport, to include, but not limited to: o Face sheet o EMTALA Form o Physician certified statement o Patient chart and medication record o Current labs and ABG o Radiographic studies as appropriate Perform a physical assessment and record: o Assessment findings o Vital signs o Ventilator settings o Medication drips including rate and dose –confirm how/when to titrate or discontinue medications drips if needed Ensure that the patient has at least two points of IV access, with one currently open for medication administration Label each line at point of entry with medication being administered and ensure compatibility/proper infusion method Determine Predicted Ideal Body Weight and Initial Tidal Volume using chart or formula o Males = 50 + 2.3 [height (inches) - 60] o Females = 45.5 + 2.3 [height (inches) -60] 116 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Place ventilator on test lung to facilitate setup Place ventilator in Assist/Control Mode and adjust settings as described in flow chart Place the patient on the Automated Transport Ventilator and allow 5-10min to ensure that settings are adequate/appropriate prior to transport. Consult sending physician/RT as needed All medication infusions except Normal Saline, Lactated Ringers, and blood products must be on placed on an IV infusion pump provided by the sending facility Move the patient to gurney and place head of gurney at a minimum of a 30 degree angle, with NG/OG tube in place, and suction oral secretions as needed to prevent ventilator associate pneumonia Secure the patient as appropriate Empty urinary catheter and transfer remaining pumps/equipment Ensure that all equipment is functioning correctly each time the patient is moved Monitor endotracheal tube cuff during transport for appropriate pressure Administer medications as indicated/ordered Document vital signs, medications, and setting s at a minimum every 15min Patient should be administered 1-2 mcg/kg of Fentanyl every 60 minutes and 0.1mg/kg Versed every 30 minutes as blood pressure allows. If patient HR or BP increase, or patient discomfort is noted, the interval between administrations should be shortened or doses increased. Only administer paralytics during transport after assuring adequate analgesia and sedation needs are met. Notes: Every patient will require different treatment and their condition may change during transport. This protocol serves as a guide to assist in proper treatment, not an absolute list of rules This protocol cannot account for every eventuality that may be encountered 117 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Obstructive Ventilator Strategy The obstructive ventilator strategy should be employed when obstructive lung disease is present in the patient being ventilated. These conditions include, but are not limited to: COPD, Asthma, and Emphysema Set initial Tidal Volume (Vt) 8ml/kg (PBW) May lower to 4-6ml/kg if pPlat >30cmH2O Set Respiratory Rate (RR) Calculate ideal RR: 120mL/kg/min. (Example: 120x PBW in kg / Vt) May lower to 60ml/kg/min to achieve adequate exhalation time Titrate respiratory rate to maintain baseline EtCO2. Patients with COPD live in a hypercapnic state. Hypercapnea is permissible Under direct supervision of RT: Lower inspiratory time if needed to achieve I:E ratio of at least 1:4-5 Set initial % Oxygen (FiO2) Start at 40% Titrate up as needed to maintain SPO2 92-99% Set PEEP 0-2cmH2O. Do not raise above 2cmH2O Set sensitivity: Set sensitivity as high as needed to avoid triggering due to movement Set alarms: High pressure: 10cmH2O greater than average PIP Low pressure: 10cmH2O less than average PIP Use Inspiratory Hold to asses Peak Plateau Pressure (pPlat): pPlat should be <30cmH2O If >30cmH2O o Lower Vt to 6ml/kg o Decrease RR o Lower Vt to 4ml/kg o Asses for other cause of increased pPlat Provide appropriate medical interventions as needed. (Drips, infusions, nebulizers, etc.) 118 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Injury Ventilator Strategy The injury ventilator strategy should be used for any patient that does not have an obstructive pulmonary disease Set initial Tidal Volume (Vt) 8ml/kg (PBW) May lower to 4-6ml/kg if pPlat >30cmH2O Set Respiratory Rate (RR) Calculate ideal RR: 120mL/kg/min. (Example: 120 x PBW in kg / Vt) Titrate respiratory rate to an EtCO2 of 35-45cmH2O In setting of acute metabolic acidosis (pH <7.30) due to ketoacidosis, severe lactic acidosis, ingestion, etc. Double calculated ideal RR above Titrate respiratory rate to an EtCO2 25-30cmH2O or baseline if lower Under direct supervision of RT: Lower inspiratory time to achieve I:E ratio of 1:2-3 Set initial % Oxygen (FiO2) Start at 40% Titrate up with PEEP, per chart, to maintain SPO2 of 92-99% Set PEEP 5cmH2O Titrate up with FiO2, per chart, to maintain SPO2 of 92-99% Set sensitivity: Set sensitivity as high as needed to avoid triggering due to movement Set alarms: High pressure: 10cmH2O greater than average PIP Low pressure: 10cmH2O less than average PIP Use Inspiratory Hold to asses Peak Plateau Pressure (pPlat): pPlat should be <30cmH2O If >30cmH2O o Lower Vt to 6ml/kg o Decrease RR o Lower Vt to 4ml/kg o Asses for other cause of increased pPlat Provide appropriate medical interventions as needed. (Drips, infusions, nebulizers, etc.) 119 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Injury Ventilator Strategy – FiO2 and PEEP Chart Titrate up/down as needed to maintain SPO2 of 92-99% FiO2 30% 40% 40% 50% 50% 60% 70% 70% 70% 80% 90% 90% 90% 100% PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 Acidosis/Alkalosis Guide Remember that electrolyte concentrations will change with changes in pH, and vice versa. Particularly, if pH decreases, serum K+ will increase. If pH increases, serum K+ will decrease. 120 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Predicted Body Weight and Tidal Volume - Males 121 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Predicted Body Weight and Tidal Volume - Females 122 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols Time @ sending Time January 1, 2016 Version 10 Record every 15 minutes during transport or every time a change is made SPO2 EtCO2 HR BP RR Temp Vt FiO2 pPlat Fentanyl Versed Vecc 1-2mcg/kg/hr 0.1mg/kg or 5mg q 30min 0.1mg/kg Age and Sex: If needed DOB: Weight in Kg: Height in Inches: Predicted Body Weight in Kg: ¼ q 15min PEEP Name: Medication Infusions and Notes: 123 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Patient condition declining potentially due to ventilator or increased PIP/pPlat Assess Peak Inspiratory Pressure (PIP) PIP Decreased: Leak Dislodgment Decreased BP PIP Increased: PIP No Change: Low O2 pressure Pulmonary embolus Assess pPlat pPlat No Change: Mucus plug Kink Asynchronous breathing Bronchoconstriction pPlat Increased: Auto PEEP Pneumothorax ARDS Pulmonary edema Gastric distension Asynchronous breathing Bronchoconstriction 124 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 125 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Alarms APNEA XX bpm (Should not occur in Assist/Control Mode) APNEA BAT EMPTY BATTERY LOW DISC/SENSE HIGH PRES Vent INOP LOW MIN VOL Time since last breath exceeds the set Apnea Interval Reevaluate the patient’s condition An Apnea Alarm has occurred and cleared Battery charge is critically low Battery charge is low Patient curciut has become dissconected, pinched, or occluded Reevaluate the patient’s condition The circuit sense lines may be pinched or occulded Refference troubleshooting flow chart Occurs when ventilator is switched on, or ventilator is innoperable Exhaled minut volume is less than the Low Minute Volume alarm LMV OFF Low Minute Volume alarm is off LOW PRES Possible leak in the circuit Sense lines pinched or occluded POWER LOST Occurs when the extenal power and voltage drops below the usable level Occurs when the extenal power and voltage drops to the low leve POWER LOW Attach AC or DC power Attach AC or DC power Check cuciut for discconects Check sense lines for occulsions Check circuit and sense lines for occlusions or pinch If occurs during operation, remove the patient for the ventilator Check all connections Check sense lines Is setting appropriate for patient? Reevalutate the patient’s condition Set Low Minute Volume alarm, or ignore Check all connections Check sense lines Is setting appropriate for patient? Reevalutate the patient’s condition Attach AC or DC power Attach AC or DC power Definitions PIP MAP PEEP f Vte VE I:E Vcalc Vt SIMV Peak Inspritory Pressure Mean Airway Pressure Positive End Expritory Pressure Total Breath Rate Exhaled Tidal Volume Exhaled Minute Volume Inspritory/Expritory Ratio Calculated Peak Flow Tidal Volume Synchornized Intermittent Mandatory Ventilation 126 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Diagnostic Capillary Blood Tests – Blood Glucose & Blood Lactate Authorization: Protocol: Glucose - EMT, EMT-BIV, EMT-I, and Paramedic Lactate – EMT-I, and Paramedic Glucose - EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order Lactate – EMT-I, and Paramedic – Standing Order Indications: Blood Glucose o Any patient who: Has a history of diabetes Has suffered a possible CVA Is unconscious Has a decreased LOC Is suspected to be under the influence of any intoxicating substances Has abnormal respiratory patterns (Kussmaul) with other signs and symptoms of hyperglycemia o Any critically ill or injured pediatric patient o Any patient whose condition could alter their blood glucose level significantly Blood Lactate o Any patient that may be in a state of decreased cellular perfusion or be producing lactate Contraindications: None Precautions: Ensure test strips are not expired and that the machine is calibrated to the strip Do not rely solely on diagnostic tests to direct treatment of patient Procedure: Place sample strip in machine making sure calibration number on machine matches number on strip container Using aseptic technique, obtain blood sample with lancet from patient’s distal tip of finger or forearm. It is also acceptable to obtain drop of blood from IV catheter after obtaining IV access, blood draw hub, or other aseptic source Place drop of blood on end of strip, allowing blood to soak up into test area After reading number, dispose of strip, lancet, hub or other sharp in a sharps container Notes: 127 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pain Management Authorization: Protocol: EMT-I, and Paramedic EMT-I, and Paramedic – See specific medication protocol A bandage is used to protect and control the bleeding of injuries to the soft tissue Indications: Any patient experiencing pain from: o Traumatic injury o Acute Coronary Syndrome o Abdominal pain o Other painful conditions or procedures Contraindications: None Precautions: Ensure proper blood pressure, ventilation, and oxygenation are maintained Procedure: Obtain a full set of vital signs as indicated including: SPO2, HR, BP, and ETCO2 Monitor at a minimum: SPO2, HR, and BP. If situation allows, monitor continuous ETCO2 Administer indicated analgesia via appropriate route Administer oxygen as indicated to maintain SPO2 >92% Notes: In adult patients, use and document pain on a 0-10 scale. In pediatrics, a Faces or other scale can be used to indicate level of discomfort In general, all patients that are in moderate to severe pain should receive adequate analgesia to reduce pain to a tolerable level. In adults, this is usually a 2-3/10 or until patient states that they require no further analgesia If continuous ETCO2 cannot be monitored, such as in a backcountry setting, careful administration of analgesics is acceptable if resuscitation equipment and reversal medications are available and close monitoring of the patient is feasible Each medication has a specific dose, considerations, and precautions 128 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Bandaging/Bleeding Control Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order A bandage is used to protect and control the bleeding of injuries to the soft tissue Indications: Wounds should be bandage to protect the injury from further damage or contamination and to control bleeding Contraindications: None Precautions: Ensure proper BSI Procedure: Bandaging o Evaluate the site and expose the area o Choose the appropriate dressing material: sterile 4x4s, trauma dressing etc o Place the dressing over the wound. o Secure the dressing with Kerlix and tape o Moisten the dressing for burns (Less than 10% TBSA), eviscerations and abrasions. This will prevent the tissue from drying and adhering to the wound o Ensure that circulation is not impaired due to bandaging Bleeding control o Attempt direct pressure to control bleeding o In bleeding cannot be controlled with direct pressure, place tourniquet o Consider hemostatic agent if a tourniquet cannot be placed Notes: Cold packs and elevation will slow the swelling process. Use care with cold packs so that the soft tissue is not damaged by the cold 129 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Splinting/Spinal Immobilization Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic Standing Order A splint is a device that immobilizes an injury to the musculoskeletal system Indications: Pain, edema or deformity in the skeletal system which includes the extremities, head, torso and spine should be splinted to decreases the pain and protect the blood vessels, nerves, and soft tissue from further trauma Contraindications: None Precautions: Splinting in multisystems trauma, or critical patients, should be done with a long spine board. Splinting of individual injuries should not delay transport Spinal immobilization can cause the patient harm. Do not immobilize the patient unless it is indicated Procedure: Splinting extremities o Expose the injured site o Check for distal pulse, movement, and sensation o Dress and bandage any wounds prior to splinting o Severely angulated fractures may need to be straightened if there are no distal pulses present or if the position prevents extrication or transportation o Joint injuries should be immobilized in the position found o Retraction of bone ends in open fractures is not advisable but may be unavoidable o Immobilize the joint above and below the fracture site o There are a variety of splints that can be used. The type of splint will be dependent on the type and location of the fracture. o The splint should be secured. It should be secure enough to immobilize the limb but not impair circulation. o After the splint has been applied, the patient should be evaluated for distal pulse, movement and sensation Traction splints (Kendrick, HARE, or Slishman) o Ensure that fracture is closed midshaft femur without fractures to the pelvis or lower leg o Expose the fracture site o Check for distal pulse, movement and sensation o Dress and bandage any wounds prior to splinting o Place splint according to manufacturer’s recommendations o Secure the leg straps. Avoid placing straps over the fracture site or the knee o After the splint has been applied, the patient should be evaluated for distal pulse, movement and sensation o Consider immobilization of the spine Spinal immobilization o See Selective Spinal Immobilization Protocol o Apply manual stabilization to the head and neck as soon as possible o Check distal circulation, motor and sensation o Place a cervical collar of the appropriate size 130 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols o o o o o January 1, 2016 Version 10 Pad voids and behind the patient’s head Place the patient onto the long spine board or a scoop with method indicated (Standing placement, logroll, ect.) Attach the torso to the board with straps Attach the head and cervical spine to the board with head rolls and tape. Do not use sand bags Check distal circulation, motor, and sensation Notes: Cold packs and elevation will slow the swelling process. Use care with cold packs so that the soft tissue is not damaged by the cold 131 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Selective Spinal Immobilization Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-I, and Paramedic - Standing Order EMT-B, EMT-BIV - Direct Order Introduction: Scientific evidence has shown limited, if any, benefit from the use of spinal immobilization devices in traumatically injured patients; evidence has shown potential harm from spinally immobilizing patients The tool provided below will assist providers in deciding when or when not to immobilize a patient. If at any time a provider is uncomfortable withholding immobilization, immobilization should be performed and the situation documented in the PCR for review Implementation: Determine required immobilization technique using tool provided below or determine that no immobilization is indicated If full spinal immobilization is indicated: o Immobilize the patient on a Long Spine Board, Scoop Board, or Vacuum Mattress o Place properly sized C-collar o Ensure that the patient is adequately padded to avoid further injury If a C-collar is to be placed: o Place properly sized C-collar o Coach the patient to restrict spinal movement. o If the patient is ambulatory, assist the patient in moving to the gurney. If the patient is able to selfextricate after a MVC, this is acceptable and preferred o If the patient is not ambulatory, a Scoop Board should be used to facilitate movement to the gurney If no C-collar or immobilization is indicated: o Treat the patient’s injures and conditions as indicated, but do not spinally immobilize the patient General: Log rolling patients should be avoided unless the patient is found in a prone position or there is suspected injury to the posterior aspect of the patient Withhold C-collar placement if it is difficult to place, poorly fitting, or might impair airway management. Other methods of cervical immobilization may be used Risk of aspiration should be considered prior to fully immobilizing a patient. Prophylactic antiemetic administration may be used A properly padded Scoop Board may be left in place during transport to HRRMC to facilitate movement of the patient. If padding is not used, Scoop Board should be removed prior to transport Forcefully restraining a patient to initiate spinal immobilization may cause more harm than forgoing immobilization. Sedation may be used if needed (Refer to Patient Restraint Protocol). Base Physician contact should be initiated Properly securing a patient to the gurney is mandatory. Seatbelts should be implemented for adults, and proper pediatric restraint devices for pediatric patients 132 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Selective Spinal Immobilization Flow Chart Clinical assessment suggests the potential for spinal injury? Yes Patient is unconscious, has significantly altered mental status, or unable to follow commands due to acute No condition? No Yes Patient does not require placement on a long spine board Harm likely Consider harm vs. benefit to providing full spinal immobilization: Patient will resist immobilization Extended transport time No significant harm likely Does the patient: Have mid-line CTLS spine pain Have lateral cervical spine pain Have neurologic deficits Have distracting injuries No Yes Immobilize with LSB/Scoop/Vacuum Mattress & C-collar & Spider Straps & Head blocks Place on gurney with C-collar in place and coach patient to restrict movement No C-collar or immobilization indicated 133 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Medication Administration Authorization: Protocol: Refer to individual route Refer to individual route Medication can be administered in a variety of methods: intramuscular (IM), intravenous (IV), by mouth (PO), intraosseous (IO), intranasal (IN), underneath the tongue (SL), onto the tongue (L), or onto the cheek (Buccal) An EMT-B, EMT-BIV, or EMT-I may administer a medication, which is not in his/her Scope of Practice, under the direct supervision of a provider that has Standing Order or Direct Order authorization for that medication if the patient is in cardiac arrest or extremis via the IV or IO route. The EMT-B, EMT-BIV, or EMT-I must have been trained in the administration of the medication they are to administer and may only administer the medication at the discretion of the provider that has authorization for that medication Indications: Any illness or injury, which requires medication to improve or maintain the patient's condition Contraindications: See each individual route of administration Precautions: Certain medications can be given by only one route, others by several. If you are uncertain about the drug you are giving, consult the specific protocol or consult the Base Physician Certain medications require a different concentration/dilution for each route. Consult the specific protocol or consult the Base Physician if questions arise Make certain that the medication you want to give is the one in your hand. Always double check the medication and the concentration before administration PO, IM, and SQ routes are unpredictable and the medication is absorbed erratically via these routes; or may not be absorbed at all if the patient is seriously ill Procedure: Draw medication: o Use syringe just large enough to hold appropriate quantity of medication, unless further dilution is required o Attach a needle to the syringe. If a large volume is being drawn up, use an 18ga needle o Break ampule (With 4x4 or alcohol prep), open cap, or cleanse multi-dose vial with alcohol prep o Using sterile technique, draw up the appropriate amount of medication into syringe o When using a medication from an ampule, a filter needle should be used to draw the medication from the ampule o Dispel air from syringe and ensure that appropriate dose is still present o Cover needle with safety as appropriate o Consider labeling syringe with name of medication and dose Alternate methods: o Assemble CarpuJect as recommended by manufacture and expel air o Remove cap from pre-filled syringe and expel air o Assemble luerjet as recommended by manufacture and expel air Intravenous technique (EMT-BIV, EMT-I, and Paramedic): o Draw appropriate medication, dose, and expel air o Check the medication: confirm medication, indications, no contraindications, dose, concentration and amount o Cleanse the IV tubing injection port with alcohol 134 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols o o o o o January 1, 2016 Version 10 Attach syringe to IV set at needleless port Pinch the IV tubing closed between IV bag and the syringe Consider allowing IV to flow during administration if further dilution is required Inject at rate appropriate for medication and condition of the patient Remove syringe and release tubing to restore flow Record the medication given, dose, effects and time Sublingual/Buccal/Lingual technique (EMT-B, EMT-BIV, EMT-I, and Paramedic): o Check the medication: confirm medication, indications, no contraindications, dose, concentration and amount o Have the patient open their mouth o Place the medication in the mucosa at base of tongue, onto the tongue, or onto the cheek as indicated o Have the patient lower their tongue and close their mouth o Record medication given, dose, effects and time Intramuscular technique (EMT-I, and Paramedic) o Draw appropriate medication, dose, and expel air o Check the medication: confirm medication, indications, no contraindications, dose, concentration and amount o Use 21-22 gauge needle, which is long enough to reach the muscle (1 to 1.5 inches) o Select injection site: Vastus lateralis in adult and pediatric patients Deltoid in adults patients Other site as indicated o Cleanse the site with alcohol prep o Stretch the skin over the injection site o Insert the needle at a 90 degree angle through the skin into the muscle. o Pull back on the syringe to aspirate and, if there is not a blood return, inject the medication. o Remove the needle and put pressure over injection site with sterile swab o Record the medication given, dose, effects and time Intra Nasal technique (EMT-B, EMT-BIV, EMT-I, and Paramedic) o Draw appropriate medication, dose, and expel air o Check the medication: confirm medication, indications, no contraindications, dose, concentration and amount o Attach MAD (mucosal atomizing device) to syringe o Insert MAD into patient’s nares and aggressively depress plunger to deliver ½ the dose o Repeat in the other nares for second ½ of dose Intraosseous technique (EMT-I, and Paramedic): o Draw appropriate medication, dose, and expel air o Check the medication: confirm medication, indications, no contraindications, dose, concentration and amount o Cleanse the IV tubing injection port with alcohol o Attach syringe to IV set at needleless port o Pinch the IV tubing closed between IV bag and the syringe Consider allowing IV to flow during administration if further dilution is required o Inject at rate appropriate for medication and condition of the patient o Remove syringe and release tubing to restore flow o Record the medication given, dose, effects and time 135 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Assist with Urinary Catheter Placement Authorizations: Protocol: Paramedic Paramedic - Standing Order A urinary catheter should be placed to assist a patient with urination or to control flow of urine Indications: Assist the patient with a pre diagnosed need for catheterization Contraindications: Obstruction or resistance during procedure or history of difficult catheter insertion Blood present in the urethral meatus in the trauma patient Scene conditions that do not facilitate the performance of a sterile procedure Precautions: Close proximity to definitive care facility Procedure: Utilize only intact kit maintaining sterility Follow standard of practice for catheterization utilizing one sterile hand and one “dirty” hand Clean the urethral opening and surrounding tissue with provided iodine utilizing circular motion in the male patient and anterior to posterior motion in the female patient Insert catheter until urine “flash” is observed Insert catheter fully and inflate cuff, gently withdraw cuff until resistance is felt and catheter is “seated” Secure catheter to the patient’s leg and document initial output of urine Consider the use of viscous Lidocaine as a topical analgesic Notes: Monitor for hypovolemia, hypotension, or bradycardia if patient’s urine output is ≥ 1000mL 136 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 NG / OG tube Insertion Authorization: Protocol: Paramedic Paramedic - Standing Order NG/OG tubes should be utilized to decompress gastric distention thus minimizing the risk of airway compromise due to vomiting and decrease intrathoracic pressure during/post cardiac arrest Indications: Patients requiring reduction of gastric distention o Prolonged Bag-Valve-Mask ventilations o During or post cardiac arrest Patients with advanced airways placed o Endotracheal intubation or extra-glottic device Patients at risk of aspiration from emesis o Paralyzed patients (induced or caused by injury o Overdose/poisoned patients o Patient with decreased level of consciousness Prior to interfacility transport when patient is on ATV Contraindications: NG placement should not be performed in the patient with maxial facial injury (LaFort Fracture) or evidence of basilar skull fracture OG placement should not be performed on patient’s with an intact gag reflex Precautions: None Procedure: 137 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Prepare equipment o Suction equipment, lubricant, Neo-Synephrine, and cloth tape Measure tube for proper placement o Place the distal tip of the NG/OG tube at the distal tip of the xyphoid process, lay the tube up the sternum and around the patient’s ear, extend the tube from the superior aspect of the auricle to the tip of the nose (NG) or to the lips (OG). Mark this location with tape or marker NG placement o Pre medicate the larger naris with Neo-Synephrine o Lubricate distal 4cm of tube with lubrication jelly or viscous Lidocaine o Place the patient in a neutral position or with slight flexion of neck o Insert tube into naris directly posteriorly or with a slight caudal angle, pass tube through the upper airway and have the patient “swallow” if possible. Pass tube to the depth of your mark and secure. o Test tube by aspiration of gastric contents, auscultation, and relief of distention o If tube gets “hung up”, the patient experiences coughing or tube is seen in the mouth, remove tube, reposition the patient and retry placement OG placement o Place the patient in a neutral position or with slight flexion of neck o Insert tube into the mouth, or suction port on extra glottic device, and pass posteriorly with a slight inferior angle. Pass the tube to the depth of your mark and secure o Test tube by aspiration of gastric contents, auscultation, and relief of distention Notes: 138 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Assisted Medication Administration – Albuterol Prescribed Inhaler Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic Paramedic - Standing Order EMT-B, EMT-BIV, and EMT-I - Direct Order Albuterol is a beta-adrenergic agent that stimulates the Beta 2 receptor sites of the sympathetic nervous system. This causes smooth muscle dilation, which relieves bronchospasms General Information: EMT-B, and EMT-B/IV may provide assistance in the administration of a patient own physician prescribed Metered Dose Inhalers (MDI) in situations where the patient is unable to self-administer the medication due to circumstances including lack of training, poor understanding of prescription use or lack of physical access to the medication. Providers may not initiate administration of MDI’s administer medication that is not specifically prescribed for the patient or administer MDI’s to patients who do not meet the criteria listed below Effects: Bronchodilation Indications: Respiratory distress due to asthma, or COPD Contraindications: None Precautions: Use with care in patients who are hypertensive, severely tachycardic, or have coronary artery disease, CHF or a known sensitivity to beta agonist. Bronchoconstriction secondary to pulmonary edema may cause wheezing. Albuterol can be detrimental to these patients Side effects: Slight increase in heart rate and blood pressure Anxiety Dose/Administration: Check medication, assure medication is prescribed for the patient, and check the expiration date Call Base Physician for Direct Order Shake the inhaler vigorously Instruct the patient to exhale deeply and place their lips around the spacer or MDI mouthpiece Fully depress the inhaler and instruct the patient to breathe deeply and hold their breath for 1-2secs Document time, dose, base Physician and response to the inhaler Repeat as instructed by Base Physician Notes: Albuterol must reach the alveoli in order to be absorbed. Patients who are in severe distress and have low or minimal tidal volume will not benefit from Albuterol since the drug cannot reach the alveoli Do not delay transport/ALS rendezvous to administer Beta blocker use may limit effectiveness Pregnancy category: C 139 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Assisted Medication Administration – Epinephrine (Adrenaline, EpiPen) Auto Injector Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order General Information: Epinephrine is an endogenous catecholamine that is secreted by the adrenal medulla, which has potent alpha and beta adrenergic effects. Effects: Vasoconstriction Bronchodilation Indications: Anaphylaxis, with airway involvement, and Anaphylactic shock Contraindications: None Precautions: MAOI use Cardiac/ Coronary artery disease Hypertension Advanced age Increased cardiac oxygen demand can precipitate angina and/or an MI in susceptible individuals Should be used with caution in patients with peripheral vascular/cerebral vascular insufficiency Hyperthyroidism Side effects: Tachydysrhythmias Angina/MI Hypertension Anxiety and nausea/vomiting Dose/Administration: Check medication for name, expiration date, cloudiness Remove safety cap and place tip of injector firmly against the mid-lateral thigh until the mechanism activates (up to 10 seconds) Remove needle from site and inspect injector to insure medication was delivered. Place in sharps container Document injection, time, response, and initiate transport Notes: Epinephrine may have serious side effects and should only be used on patients experiencing lifethreatening implications of a serious anaphylactic reaction. Airway management, oxygenation, ventilation, circulatory support and rapid transport should not be be delayed in favor of epinephrine autoinjector Should not be used for allergic reactions unless circulatory or respiratory compromise is present Wheezing in an elderly patient is often pulmonary edema or a pulmonary embolus. Thoroughly evaluate the patient and remember that epinephrine’s side effects, especially in the elderly, can be severe Beta blocker use may limit effectiveness Pregnancy category: C 140 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Assisted Medication Administration - Nitroglycerin Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-I, and Paramedic - Standing Order EMT-B, and EMT-BIV - Direct Order Nitroglycerine is a prodrug that metabolizes into nitric oxide. Exact mechanism of action is not well understood General Information: EMT-B/BIVs may provide assistance in the administration of a patient’s own physician prescribed sublingual Nitroglycerine in situations where the patient is unable to self-administer the medication due to circumstances including lack of training, poor understanding of prescription use or lack of physical access to the medication. EMT-B/BIVs may not initiate administration of Nitroglycerine, administer medication that is not specifically prescribed for that patient, or administer Nitroglycerine to patients who do not meet the criteria listed below Effects: Vasodilation including coronary arteries Decreased preload and afterload Indications: Cardiac chest pain Contraindications: Hypotension (Systolic BP < 90mmHg) HR > 100bpm or < 50bpm Phosphodiesterase 5 inhibitor use: o Viagra (sildenafil), Levitra (vardenafil), or Stendra (avanafil) within 24hrs o Cialis (tadalafil) within 48hrs o Other PDE5 inhibitors are currently in clinical trials and may become available in the USA Precautions: Inferior wall MI Side effects: Hypotension and tachycardia Headache Dose/Administration: Establish IV with Normal Saline (EMT-BIV and above only) Check medication, assure medication is prescribed for the patient, check expiration date Blood pressure must be taken and recorded before and after administration Call Base Physician for Direct Order Administer 0.4mg sublingual nitroglycerin by tablet or spray o May repeat after 5min to a total of 3 doses or until pain is relieved, BP decreases or ALS arrives Repeat vital signs every 5min after administration Document indications, Base Physician, all vital signs, and response to medication on patient report Notes: Do not delay transport/ALS rendezvous to administer Onset within 2min and duration of 30min Pregnancy category: C 141 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Aspirin (Acetylsalicylic acid /ASA) Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order ASA inhibits the formation Cyclooxygenase, thus inhibiting the formation of Thromboxane A2 and Prostaglandins Effects: Inhibition of platelet aggregation Indications: Acute Coronary Syndrome Symptoms suspected of being Acute Coronary Syndrome in origin Contraindications: Contraindicated in patients allergic to ASA or ASA products Precautions: Active GI bleeding or other severe bleeding Use with caution in patients with asthma Not to be given for analgesic purposes such as headaches or orthopedic injuries Use with caution in patients with liver dysfunction and impaired renal function Side Effects: May precipitate an asthma attack in patients with asthma May cause GI upset Dose/Administration: 324mg (PO) o Administer 4 chewable 81mg aspirin (PO), if the patient is able to protect his or her own airway o If patient has taken ASA, for the event, prior to EMS arrival, supplement patient dose up to 324mg Notes: Patients who normally take regular doses of ASA or ASA compounds can have gastrointestinal disorders such as GI hemorrhage Patients taking warfarin (Coumadin), clopidogrel (Plavix), or other anti-coagulant/antiplatelet medications may be given ASA Pregnancy category: D 142 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Adenosine (Adenocard) Authorization: Protocol: EMT-I and Paramedic Paramedic - Standing Order EMT-I – Direct Order Adenosine in an endogenous nucleoside that is used to treat reentry supraventricular tachycardias by slowing conduction through the AV node Effects: Interrupts reentry pathway abnormalities in AVNRT, AVRT, SNRT, and allows the normal sinus pathway to function by slowing conduction at the AV node Interrupts SA node function Indications Paroxysmal supraventricular tachycardias (AVNRT, AVRT, SNRT) Tachycardias that are: Undifferentiated, wide-complex, monomorphic, and regular Contraindications: Contraindicated in hypotensive or unstable patients Contraindicated in patients with known history of 2nd degree block, 3rd degree block, or sick sinus syndrome, without a functioning pacemaker in place Atrial fibrillation is an absolute contraindication. Rhythm must be regular to administer Tachycardias secondary to sympathomimetic/CNS stimulant use Precautions: Known hypersensitivity to Adenosine Do not re-administer if an arrhythmia other than PSVT persists Patients on Dipyridamole (Permole, Persantine) for cardiac and vascular disease should be given ¼ of the normal dose since a full dose will cause prolonged adverse effects Dose/Administration: 12mg repeated in 1 - 3min if rhythm has not converted o Each bolus of Adenosine is administered as a fast push and flushed with a 20mL Normal Saline bolus o 24mg max dose Pediatric dose: 0.1mg/kg (IV, IO). Repeat x2 at 0.2mg/kg in 1-3min if rhythm has not converted o Max single dose not to exceed adult dose o Each bolus of Adenosine is administered as a fast bolus and flushed with Normal Saline Side effects: Side effects should quickly pass and include: HA, anxiety, chest pain, hypotension, and arrhythmias Notes: Patients who take Methylxanthine compounds, such as caffeine or Theophylline, will require higher doses to achieve conversion Safe in WPW (AVRT) with either antidromic or orthodromic conduction Will not convert A-flutter or most VT Pregnancy category: C 143 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Albuterol (Proventil, Ventolin) Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic Paramedic - Standing Order EMT-B, EMT-BIV, and EMT-I – Direct Order Albuterol is a beta-adrenergic agent that stimulates the Beta 2 receptor sites of the sympathetic nervous system. This causes smooth muscle dilation, which relieves bronchospasms Effects: Bronchodilation Indications: Respiratory distress due to pneumonia, asthma, anaphylaxis or COPD Suspected hyperkalemia (Paramedic only) Contraindications: None Precautions: Use with care in patients who are hypertensive, severely tachycardic, have coronary artery disease, CHF or a known sensitivity to beta agonists. Bronchoconstriction secondary to pulmonary edema may cause wheezing. Albuterol can be detrimental to these patients Side effects: Slight increase in heart rate and blood pressure Anxiety Dose/Administration: 2.5mg (SVN) o Set the O2 at 6-8 liters/minute o May repeat as needed or provide continuous nebulization o May use inline nebulizer on CPAP, ETT, or extra-glottic device Pediatric dose: 2.5mg (SVN) o Max: 10mg Notes: Albuterol must reach the alveoli in order to be absorbed. Patients who are in severe distress and have low or minimal tidal volume will not benefit from Albuterol since the drug cannot reach the alveoli. Consider epinephrine IM or IV Coach patient to breathe deeply and hold their breath as long as possible. Consider having the patient rinse mouth with water if previous treatments have been administered Beta blocker use may limit effectiveness Pregnancy category: C 144 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Amiodarone (Cordarone) Authorization: Protocol: EMT-I and Paramedic Paramedic - Standing Order EMT-I - Direct Order Amiodarone has Class I, II, III and IV antiarrhythmic properties Effects: Prolongation of the action potential duration and the refractory period Indications: Pulseless VT or VF refractory to defibrillation Stable VT or wide complex tachycardias (Rapid infusion method) or symptomatic runs of VT Following successful defibrillation/synchronize cardioversion if tachyarrhythmias or ectopy persist Contraindications: None in cardiac arrest with VF or VT 2nd or 3rd degree AV block Sick Sinus Syndrome Cardiogenic shock/Hypotension Bradycardia (Including ventricular escape beats of IVR/AIVR) Tachycardias secondary to sympathomimetic/CNS stimulant use Precautions: Wide complex, irregular rhythms (With pulse) Side effects: Hypotension and bradycardia o Treat initially by slowing the infusion rate but may require Atropine, pacing, vasopressors, and volume expansion. These side effects are usually rate of infusion, not dose related Dose/Administration: 300mg (IV, IO) bolus in cardiac arrest o May administer 150mg (IV, IO) bolus after 3-5min if VT/VF refractory Pediatric cardiac arrest: 5mg/kg (IV, IO) bolus. Contact Base Physician for additional dose 150mg (IV, IO) over 10min for stable wide complex tachycardias, runs of VT, or post arrest, after successful conversion, if ectopy/tachyarrhythmias persist o May repeat 150mg dose o Rapid infusion over 10min: 150mg in 100mL NS run @ 100 macro gtts/min or dilute in syringe and administer in flowing (IV,IO) over 10min Pediatric stable wide complex tachycardia, runs of VT, or post arrest after successful conversion: 5mg/kg (IV, IO) over 20-60min o Place in 100mL NS run @ 15-60 macro gtts/min. Contact Base Physician for additional doses Notes: Compatible at the Y-site with the following ACLS drugs: Dopamine, and Nitroglycerine Do not administer in same line as Sodium Bicarbonate 12-lead should be performed when applicable Pregnancy category: D 145 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Atropine Sulfate Authorization: Protocol: EMT-I and Paramedic Paramedic - Standing Order EMT-I - Direct Order Atropine is an acetylcholine antagonist that inhibits the effects of the parasympathetic nervous system by blocking muscarinic receptors Effects: Increases SA and AV node conduction Reduces the motility of the GI tract Reduces the action of the urinary system Causes pupil dilation Dries mucosal membranes Dilation of the bronchioles Indications: Symptomatic bradycardia Improve the conduction in 2nd Degree Type I AV blocks Reverse effects from organophosphate and nerve gas poisonings Contraindications: A-Fib and A-Flutter Precautions: Bradycardias in the setting of a myocardial infarction Do not treat bradycardias unless the patient is symptomatic to the bradycardia: chest pain, hypotension, altered LOC, or other symptom Closed angle glaucoma Side effects: Anticholinergic toxidrome HA Altered vision Dose/Administration: Bradycardia: 0.5 - 1.0mg (IV, IO) bolus o Repeat every 5min to a max dose of 3mg Organophosphate and nerve gas poisonings: 2-4mg (IV, IO) bolus o Repeat every 5min until patient is no longer symptomatic Pediatric dose: 0.02mg/kg (IV, IO) o Repeat at 0.04mg o Pediatric: Min single dose 0.1mg. Max dose not to exceed adult dose Notes: Small doses or slow administration may cause a paradoxical bradycardia Pregnancy category: C 146 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Calcium Chloride Authorization: Protocol: Paramedic Paramedic - Standing Order Each gram of CaCl² contains 273mg of elemental calcium. Calcium stabilizes the myocardial cells and will improve inotropy Effects: Increased inotropy Stabilization of the myocardial cell membrane (Mechanism in hyperkalemia) Indications: Cardiac arrest potentially caused by hyperkalemia Calcium channel or beta blocker overdose Hyperkalemia causing widening QRS or bradycardia with AV blocks Hydrofluoric acid exposure Contraindications: Digitalis use Non-patent IV line Precautions: Will cause severe tissue necrosis if infiltration occurs. Ensure that line is patent and use the most proximal line possible Pediatric patients Do not use in same line as Sodium Bicarbonate Side effects: There is little potential for severe side effects if used in a patient that is unstable or in cardiac arrest Dose/Administration: 1gm (IV,IO) over 2-10 minutes o Ensure that line is patent and dilute during administration Pediatric: 20mg/kg (IV,IO) over 2-10 minutes Notes: Calcium Chloride is supplied as 10mL of a 10% solution. Each 10mL contains 1 gram of Calcium Chloride Effectiveness when administered for a calcium channel blocker overdose may be limited; do not forgo other treatments if indicated Calcium Chloride is not indicated for use in routine cardiac arrest ECG changes that may be seen during hyperkalemia include: widened QRS, sinusoidal waveform, symmetrically peaked T-waves, AV blocks, escape rhythms, V-fib, and asystole. Patient history should indicated a potential for hyperkalemia due to highly variable ECG findings Pregnancy category: C 147 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Dextrose Authorization: Protocol: EMT-BIV, EMT-I, and Paramedic EMT-BIV, EMT-I, and Paramedic - Standing Order Dextrose is a 6-carbon sugar, which is the principle form of carbohydrates used by cells for energy Effects: Raise blood glucose level Lower blood potassium level (Paramedic only. Limited effectiveness) Indications: Hypoglycemia Unconscious patients (Consider obtaining BGL reading prior to administration) Medical cardiac arrest (Consider obtaining BGL reading prior to administration) Hypothermia (Consider obtaining BGL reading prior to administration) Hyperkalemia (Paramedic only) Contraindications: Non-patent IV line Precautions: Ensure IV is patent before and during administration Use with caution in patients with suspected hypokalemia Chronic malnutrition (Wernicke’s and Korsakoff’s) Side effects: Tissue necrosis with extravasation Vascular necrosis Dose/Administration: 25g (250mL of D10%) (IV, IO) slow infusion o Administer through IV or IO until patient mentation returns or 250mL administered o Recheck blood glucose level o Stop administration when patient mentation returns to desired level o If infiltration does occur, stop administration immediately and notify receiving facility Pediatrics dose: o Newborn – 12yrs: 2-4mL/kg D10% Use buretrol or administer with a syringe to allow proper dosing Notes: Patient may require repeat doses Frequently asses BGL on pediatric patients that are distressed. Their BGL may lower quickly Hypoglycemia is considered to be any reading <50mg/dL, approximately, in a newborn Pregnancy category: C 148 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Diazepam (Valium) Authorization: Protocol: EMT-Iand Paramedic Paramedic - Standing Order EMT-I - Direct Order* (*EMT-I – May be administered under Standing Order when the safety of the patient or the EMT is at risk) Valium is a member of the Benzodiazepine family. Effects are due to an increase of GABA activity in the brain Effects: Anxiolytic Skeletal muscle relaxant Sedation and amnesia Suppresses the spread of seizure activity within the motor cortex of the brain Indications: Status epilepticus Major motor seizures Anxiolysis prior to procedure: cardioversion and external cardiac pacing Relieve muscle spasm Relieve anxiety Sedation secondary to behavioral emergencies Contraindications: None Precautions: Respiratory depression Hypotension Opioid administration Side effects: Respiratory depression Hypotension Sedation Agitation Dose/Administration: 2.5-10mg slow (IV, IO). Repeat every 5 - 15min as needed. Max dose 20mg o Administer over 2-5min Pediatric dose: 0.1mg/kg slow (IV, IO) o Administer over 2-5min Notes: IM administration should be avoided due to slow/inconsistent absorption Most likely to produce respiratory depression in patients who have taken other sedative drugs, especially alcohol and barbiturates Pregnancy category: D 149 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Diltiazem (Cardizem) Authorization: Protocol: Paramedic Paramedic - Standing Order Diltiazem is a non-dihydropyridine, Class IV antiarrhythmic, which is relatively selective to cardiac Ca++ channels Effects: Decreased heart rate (Decreased chronotropy) Decreased rate of conduction (Decreased dromotropy) Decreased force of contractility (Decreased inotropy) Indications: Hypertensive crisis (Systolic pressure > 200 or diastolic blood pressure >130, without stroke like symptoms) Symptomatic, stable, narrow complex, A-Fib and A-Flutter with ventricular response >150bpm Stable, regular, monomorphic PSVT refractory to Adenosine Thyroid Storm Contraindications: Hypersensitivity Sick Sinus Syndrome 2nd or 3rd degree AV blocks (Unless an artificial pacemaker is in place) Blood pressure <90mmHg systolic History of recent MI or congestive heart failure Use of Rifampin (Antitubercular) Wide complex, irregular rhythms Tachycardias secondary to sympathomimetic/CNS stimulant use Precautions: Hepatic or renal impairment (use a ½ dose) Pregnant, lactating, or pediatric patients Use of other antihypertensives Use of beta blockers, digoxin, or phenytoin Accessory cardiac pathways Side effects: Bradycardia AV heart blocks Hypotension Anxiety Headache and dizziness Dose/Administration: 5mg (IV, IO) over 2-5min o Repeat dose every 5-10min as needed up to 0.25mg/kg o If patient becomes hypotensive or bradycardic at any time, discontinue administration Pediatric dose: Contact Base Physician Notes: Monitor ECG, blood pressure, and lung sounds Pregnancy category: C 150 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Diphenhydramine (Benadryl) Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I – Direct Order Diphenhydramine is an inverse H1 agonist that has antimuscarinic, antiparkinsonian, and serotonin reuptake inhibitor properties Effects: Antihistamine CNS depressant (Sometimes CNS stimulant) Decrease GI motility Antiparkinsonian Indications: Anaphylaxis Severe allergic reactions Counteract acute dystonic reactions due to antipsychotic drugs Sedation (Paramedic only) Antiemetic (Paramedic only) Contraindications: None Precautions: May have synergistic effect with alcohol or other CNS depressants Asthma and COPD (Will dry bronchosecretions) Glaucoma Pregnancy MAOI use may prolong/intensify anticholinergic effects Side effects: Sedation Anticholinergic effects Hypotension Dose/Administration: 25-50mg (IV, IO) slow push or deep (IM) injection Pediatric dose: 2mg/kg (IV, IO) slow push or deep (IM) injection Notes: Diphenhydramine is not the first-line drug for anaphylaxis/anaphylactic shock Treats dystonic reactions, including, oculogyric crisis, acute torticollis, and grimacing; Can be caused by certain antipsychotic drugs known as phenothiazines (Such as Haldol, Thorazine, and Compazine) Pregnancy category: B 151 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Epinephrine (Adrenaline) Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I - Cardiac arrest Standing Order, all other indications by Direct Order Epinephrine is an endogenous catecholamine that is secreted by the adrenal medulla, which has potent alpha and beta adrenergic effects. Effects: Increased heart rate (Increased chronotropy) Increased rate of conduction (Increased dromotropy) Increased force of contractility (Increased inotropy) Vasoconstriction Bronchodilation Indications: Pulseless cardiac arrest including: Ventricular fibrillation, Asystole, and PEA Anaphylaxis, with airway or circulatory compromise, and Anaphylactic shock Asthma refractory to Albuterol Pediatric Dyspnea with stridor at rest Obstructive pulmonary disease refractory to inhaled bronchodilators (Use cautiously in elderly patients) Contraindications: None Precautions: MAOI use Cardiac/ coronary artery disease Hypertension Advanced age Increased cardiac oxygen demand can precipitate angina and/or an MI in susceptible individuals Should be used with caution in patients with peripheral vascular/cerebral vascular insufficiency Hyperthyroidism Side effects: Tachydysrhythmias Angina/MI Hypertension Anxiety Nausea/vomiting Dose/Administration: Cardiac arrest: 1mg (10mL of 1:10,000 solution) (IV, IO) every 3- 5min Obstructive pulmonary/anaphylaxis/anaphylactic shock: 0.3mg (0.3mL of 1:1,000 solution) (IM) or 0.3mg (3mL of 1:10,000 solution) (IV, IO) o Consider further dilution prior to (IV,IO) administration o Consider Epinephrine Drip if condition is refractory or requires continuous treatment Pediatric dose for cardiac arrest: 0.01mg/kg (0.1mL/kg of 1:10,000 solution) (IV, IO) every 3- 5min 152 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Pediatric dose for obstructive pulmonary/anaphylaxis/anaphylactic shock: 0.01mg/kg (0.01mL/kg of 1:1,000 solution) (IM) or 0.01mg/kg (0.1mL/kg of 1:10,000 solution) (IV, IO) o Max single pediatric dose not to exceed adult dose o Consider further dilution prior to (IV,IO) administration o Consider Epinephrine Drip if condition is refractory or requires continuous treatment Pediatric dyspnea with stridor at rest: 0.5mL via SVN of racemic epinephrine Notes: Should not be used for allergic reactions unless circulatory or respiratory compromise is present Wheezing in an elderly patient is often pulmonary edema or a pulmonary embolus. Thoroughly evaluate the patient and remember that epinephrine’s side effects, especially in the elderly, can be severe Inactivated by alkaline solutions and exposure to light. Do not mix with Sodium Bicarbonate Beta blocker use may limit effectiveness Pregnancy category: C 153 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Epinephrine Drip/Push Dose Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I – Direct Order Effects: See Epinephrine protocol Indications: Symptomatic bradycardia refractory to Atropine Symptomatic bradycardia in patients when Atropine is contraindicated Symptomatic bradycardia in patients that capture is not obtained during TCP Maintenance treatment of bronchospasm (Status asthmaticus, anaphylaxis, COPD, etc.) o Patient should be refractory to inhaled bronchodilators Obstructive pulmonary/anaphylaxis/anaphylactic shock that is refractory to other treatments or requires continuous treatment Cardiogenic shock Distributive shock Contraindications: See Epinephrine protocol Hypovolemic shock Precautions: Use judiciously as a vasopressor due to the Beta adrenergic effects of epinephrine. See Epinephrine protocol Side effects: See Epinephrine protocol Dose/Administration: 2-10mcg/min continuous infusion or slow IV/IO push o Mix 4mg Epinephrine 1:1000 (4mL) into 250mL D5W to achieve a concentration of 16mcg/mL A higher dose of 0.1-0.5mcg/kg/min may be needed o Mix 4mg Epinephrine 1:1000 (4mL) into 250mL D5W to achieve a concentration of 16mcg/mL Pediatric: 0.1-0.5mcg/kg/min Drip 16mcg/ml Micro drops/minute Dose/minute 7gtts/min 2mcg/min 15gtts/min 4mcg/min 22gtts/min 6mcg/min 30gtts/min 8mcg/min 37gtts/min 10mcg/min 154 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Push Dose This method should only be used as a temporary measure until a vasopressor drip can be established or in cases when hypotension is expected to resolve quickly Discard 9mL of Epinephrine 1:10,000. Draw 9mL of NS into the medication syringe. This will produce Epinephrine 1:100,000 with a concentration of 10mcg/ml Administer via slow IV/IO push 0.1-0.5 (Desired dose) x Patient weight in kg x 60 (Drip factor) = gtts/min 16 (Concentration) Epinephrine Infusion (gtts/min) 16mcg/mL Concentration Desired Dose Weight in Kilograms 20 kg 30 kg 40 kg 50 kg 60 kg 70 kg 80 kg 90 kg 100 kg 0.1 mcg 7.5 11.25 15 18.75 22.5 26.25 30 33.75 37.5 0.2 mcg 15 23 30 37.5 45 52.5 60 67.5 75 0.3 mcg 22.5 24.25 45 56.25 67.5 78.75 90 90.25 112.5 0.4 mcg 30 46 60 75 90 105 120 135 150 0.5 mcg 37.5 47.75 75 93.75 112.5 131.25 150 157.75 187.5 Notes: Should be considered primary vasopressor in anaphylactic shock. Epinephrine also stabilizes mast cells and basophils, which can be beneficial in the setting of anaphylactic shock AHA recommends TCP, a Dopamine drip, or an Epinephrine drip for symptomatic bradycardia that is refractory to Atropine or if Atropine is contraindicated. AHA currently does not prefer one treatment over another. The provider’s choice should be guided by patient assessment, ECG, and patient history Peak action is delayed up to 20min 155 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Fentanyl Citrate Authorization: Protocol: EMT-I and Paramedic Paramedic - Standing Order EMT-I - Direct Order Fentanyl is an opioid analgesic Effects: Analgesia Decrease sympathetic tone Indications: Pain relief due to stable traumatic or medical causes (Cardiac chest pain, extremity trauma, acute abdomen, etc.) Premedication for RSI / post intubation analgesia (Paramedic only) Blunt sympathetic response during Acute Coronary Syndrome (Paramedic only) During ventilation with ATV (Paramedic only) Contraindications: Myasthenia Gravis Precautions: CNS and respiratory depression Hypotension Closed head injury Side effects: Hypotension Respiratory depression Sedation Bradycardia Chest wall rigidity (Rapid administration) Dose/Administration: 1-2mcg/kg (IV, IO, IN, IM, SVN) Repeat as indicated o Administer over 2-5min (IV, IO) Pediatric Dose: 1-2mcg/kg (IV, IO, IN, IM, SVN) Repeat as indicated o Administer over 2-5min (IV, IO) (IN, IM, SVN) dosing of Fentanyl requires close monitoring of vital signs Notes: Effects increased by other CNS depressants (Alcohol, benzodiazepines, muscle relaxants, opiates, etc.) Continuous patient monitoring is required. Frequent evaluation of the patient’s vital signs is also recommended Patients may develop apnea without manifesting significant mental status changes Fentanyl does not cause a histamine reaction Pregnancy category: C 156 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Furosemide (Lasix) Authorization: Protocol: EMT-I and Paramedic EMT-P - Standing Order EMT-I – Direct Order Furosemide is a potassium wasting, loop diuretic that inhibits sodium reabsorption Effects: Diuretic Vasodilation Indications: Acute pulmonary edema Congestive heart failure with pulmonary edema Contraindications: Pneumonia Hypotension Shock Pregnancy/ breast feeding Precautions: Contact Base Physician if urine is bloody. Trauma to the kidneys and urinary system makes the use of Furosemide hazardous Age <12yrs Side effects: Hypotension Hypovolemia Hyponatremia/hypokalemia Hearing loss (Rapid administration) Dose/Administration: 20-40mg (IV, IO) over 2min o Patients on home Lasix may require higher doses. Double home dosage Pediatric dose: Contact Base Physician Notes: A majority of patients experiencing acute, cardiogenic, pulmonary edema are euvolemic and will not require diuresis. Other pharmacological treatment may be preferable Induced hypokalemia is of significant concern in digitalized patients and particularly those who have digitalis toxicity Patient must be placed on a cardiac monitor prior to administration If the patient is unconscious, a urinary catheter must be placed Onset 30-60min, duration 2hrs Pregnancy category: C 157 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Glucagon Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I – Hypoglycemia by Standing Order, beta/Ca++ blocker overdose by Direct Order Glucagon is a hormone that stimulates the liver to release glycogen, thus raising the level of glucose in the blood and causes smooth muscle relaxation. At higher doses, increases inotropy and chronotropy due to increase in cAMP Effects: Increase blood glucose level Smooth muscle relaxation Increased heart rate (Increased chronotropy) Increased force of contractility (Increased inotropy) Indications: Symptomatic hypoglycemia when IV access is unsuccessful Symptomatic beta-blocker or calcium channel blocker overdose unresponsive to Normal Saline bolus Esophageal spasm (Paramedic only) Anaphylaxis (Paramedic only) Contraindications: Known hypersensitivity to this drug Precautions: Use with caution in patients with a history of cardiovascular disease, renal disease, pheochromocytoma or insulinoma Side effects: Tachycardia Headache Nausea/vomiting Hyperglycemia Dose/Administration: Hypoglycemia: o Adult dose 1mg (IM, IN) o Pediatric dose: 0.1mg/kg (IM, IN) Single dose should not exceed adult dose Beta blocker/Ca++ channel blocker OD and anaphylaxis: o Adult dose: 2mg (IV, IO) repeat as needed o Pediatric dose: 0.1mg/kg (IV, IO) repeat as needed Single dose should not exceed adult dose Esophageal Spasm: 1mg (IV, IO, IM, IN). Over 2min Notes: In the presence of beta blocker and Ca++ blocker overdose, Glucagon has limited effectiveness. Other treatments should be used concomitantly. Use in refractory anaphylaxis may improve patient condition Pregnancy category: B 158 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Glucose, Oral Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order Oral glucose is a simple sugar will raise the blood glucose level Effects: Hypoglycemia Indications: Hypoglycemia with blood sugar of 70mg/dl or less with signs and symptoms of hypoglycemia Contraindications: Dysphagia Inability to swallow Inability to protect airway Patient who has decreased level of consciousness Precautions: Can cause choking/aspiration if the patient unable to protect airway Side effects: See precautions Dose/Administration: 15g (PO) Pediatric dose: 15g (PO) Squeeze tube, releasing a reasonable amount of medication towards inside of cheek. Give the patient a chance to swallow medication and repeat until tube is empty Notes: Make sure that the patient is sitting in an upright position to help protect airway Re-check blood sugar after administration Sugary foods/drinks, such as soda, may be of benefit and contain higher amounts of sugar Will raise blood glucose level slowly 159 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Hydromorphone (Dilaudid) Authorization: Protocol: Paramedic Paramedic – Standing Order Dilaudid is semi-synthetic opioid analgesic Indications: Pain relief due to isolated, traumatic, injuries Contraindications: Hypotension Multisystem trauma Precautions: Head injury Renal impairment (2-fold effect) Hepatic impairment (4-fold effect) Side effects: Hypotension Respiratory depression Dose/Administration: Adult: 0.5(IM, IN, IV, IO) May repeat as needed Notes: 1mg Dilaudid has, approximately, the same effectiveness as 10mg of Morphine Caution should be exercised to avoid causing respiratory depression. Narcan or resuscitative equipment should be available prior to administration Consider dilution prior to (IV) administration Dilaudid has been shown to be as effective (IN) as it is (IV) Onset 5min, peak 15-60min, duration 1-4hrs Pregnancy category: C 160 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Ketamine Authorization: Protocol: Paramedic Paramedic – Standing Order Ketamine is a variety of effects, including: anesthesia, analgesia, hallucinogen, and sympathetic stimulation. The exact mechanism of action is unknown Effects: Sedation Analgesia Indications: Induction agent for RSI Post intubation sedation (Critical Care only) Contraindications: Patient <12yrs Precautions: Pregnancy Significant hypotension (Decrease dose by ½) Side effects: Hallucinations Increased airway secretions Dose/Administration: 1.5mg/kg (IV, IO, IM, IN) Notes: Safe in patients who are: hypotensive, septic, hypovolemic and who have increased ICP Onset 30-45secs, duration 10-20min Pregnancy category: B 161 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Ipratropium Bromide (Atrovent) Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I – Direct Order Antagonist of the muscarinic acetylcholine receptors in the bronchi/bronchioles Effects: Bronchodilation Anticholinergic Indications: Bronchospasm due to asthma, and COPD Contraindications: Hypersensitivity to this drug, Atropine (Anticholinergics), or bromide Precautions: Children < 2yrs Use cautiously in patients with coronary artery disease Use cautiously in patients with glaucoma Pneumonia Side effects: Tachycardia Headache Anxiety Dry mucus membranes Can cause paradoxical bronchospasm. If this occurs, discontinue treatment Dose/Administration: 0.5mg ( > 2yrs) (SVN) Pediatric (< 2yrs) dose: 0.25mg (SVN) o Draw 1.25mL into a syringe and place into SVN Dose may be repeated after 20min May be administered as Duo-Neb in conjunction with Albuterol Notes: Pulse, blood pressure, and ECG must be monitored Soy and peanut allergy applies to MDI use and does not apply to SVN Ipratropium Bromide Pregnancy category: B 162 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Lidocaine (Xylocaine) Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I –Direct Order Lidocaine is a Class IB antidysrhythmic that blocks the fast sodium channels. This shortens the action potential and stabilizes the cell membrane. Lidocaine also has local anesthetic effects Effects: Antidysrhythmic Local anesthetic Indications: Intraosseous cannulation in a conscious patient Nasal intubation (Viscous Lidocaine. Paramedic only) Oral intubation – “Awake Look” (Paramedic only) Premedication in RSI (Paramedic only) Contraindications: Hypotension High degree AV blocks Bradycardia IVR or ventricular escape rhythms Precautions: AV blocks Liver disease Side effects: Seizure Neurologic changes (Alterations in speech, tingling, visual changes, etc.) AV blocks Hypotension (At toxic doses) Dose/Administration: IO infusion analgesic: 18mg bolus. May repeat x1 o Flush saline lock with Lidocaine prior to attaching to IO o Currently our extension sets hold 0.9mL. 0.9mL of 2% Lidocaine is 18mg Pediatric dose for IO infusion: 0.5mg/kg. Max not to exceed adult dose. May repeat x1 Oral intubation: 1mg/kg up to 50mg (Atomized). May repeat dose up to total of 1.5mg/kg Nasal intubation: 1-2mL in each naris and lubricate ETT with Viscous Lidocaine Notes: Effect of bolus will last 20minutes ½ dose in liver disease, CHF, or over the age of 70 Seizures due to Lidocaine toxicity usually resist treatment Pregnancy category: B 163 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Magnesium sulfate Authorization: Protocol: EMT-I and Paramedic Paramedic - Standing Order EMT-I – Direct Order for Eclampsia Magnesium is an electrolyte that has a variety of effects including smooth muscle relaxation, calcium channel blockage, CNS depression, prolongs action potential, and shortens the QT interval Effects: Bronchodilation Decrease blood pressure and relieve cerebral vasospasm Shorten QT interval Indications: Seizures secondary to eclampsia Polymorphic Ventricular Tachycardia (Paramedic only) Cardiac arrest due to hypomagnesaemia (Paramedic only) Status asthmaticus (Refractory to other treatments) (Paramedic only) Contraindications: AV heart blocks (Except in Torsade’s and cardiac arrest) Precautions: Hypotension Respiratory depression Bradycardia CNS depression Digitalis toxicity Renal failure Side effects: See precautions AV heart blocks Flushing/sweating Dose/Administration: Cardiac: 2g (IV, IO) over 2-5min Eclampsia: 4g (IV, IO) o Mix in 100mL Normal Saline. Drip over 20-30min o With 10gtt set, administer at 30-50gtts/min Respiratory: 2g (IV, IO) over 2-5min Pediatric dose: 25-50mg/kg. Drip over 20-30min Notes: Be prepared to assist ventilations Monitor for hypotension. Discontinue administration if hypotension occurs Pregnancy category: A 164 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Methylprednisolone (Solu-Medrol) Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I – Direct Order Methylprednisolone is a synthetic steroid that stimulates the increased release of anti-inflammatory mediators and decreases the production of pro-inflammatory mediators. Also decreased the degranulation of mast cells/ the lysis of other leukocytes Effects: Anti-inflammatory Suppresses the immune/allergic response Indications: Anaphylaxis Asthma/COPD Croup/Bronchiolitis – If IV/IO previously established Suspected Addisonian crisis (Cardiovascular collapse in patient at risk for adrenal insufficiency) Acute mountain sickness (When rapid descent is not achievable) Contraindications: Hypersensitivity to methylprednisolone Active GI bleeding Precautions: None with short-term treatment/use History of diabetes – Will increase blood glucose levels Side effects: None with short-term treatment/use Dose/Administration: 125mg (IV, IO, IM) o Use promptly after reconstitution Pediatric dose: 2mg/kg (IV, IO, IM) Notes: Be aware that the effect of methylprednisolone is generally delayed for approximately 1hr. Administer as early in the course of treatment as appropriate, but do not delay transport or other treatments to administer Avoid routine administration for croup/bronchiolitis. The effect of stressing the child due to a needle may outweigh the benefit of administration in the pre-hospital setting Pregnancy category: C 165 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Midazolam (Versed) Authorization: Protocol: EMT-I and Paramedic Paramedic - Standing Order EMT-I - Direct Order* (*EMT-I – May be administered under a standing order when the safety of the patient or the EMT is at risk) Versed is a benzodiazepine that increases GABA activity in the brain Effects: Inhibit neuronal excitability Sedation Anxiolysis Skeletal muscle relaxation Indications: Chemical restraint for combative patients Rapid Sequence Intubation maintenance or if Ketamine is contraindicated/unavailable for induction (Paramedic only) Seizures Relief of muscle spasm Anxiolysis Contraindications: Hypotension (Except for prior to procedure) Respiratory depression (Except for prior to procedure/RSI, or if unable to establish airway control due to combativeness) Precautions: Age > 70yrs ( Consider lower dose) CNS/respiratory depression Hypotension Side effects: Hypotension Respiratory depression Dose/Administration: RSI induction adult: 0.3mg/kg (IV, IO) o Maintenance: 1-5mg (IV,IO) repeat as needed All other indications adult: 1-5mg (IV, IO, IN, IM) o Use lower dosage for (IV, IO) administration All other indications pediatric: 0.05-0.1mg/kg (IV, IO, IN, IM) o Use lower dosage for (IV, IO) administration Notes: Onset 2-5min, duration 15-90min IN administration of Versed has shown to be very effective in the treatment of seizures Pregnancy category: D 166 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Morphine sulfate Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I - Direct Order Morphine is an opiate analgesic. Morphine has vasodilatory properties due to release of histamine after administration Effects: Narcotic analgesic Peripheral vasodilatation Decreased myocardial oxygen demand and decreased cardiac workload Indications: Cardiac chest pain Extremity fractures Pulmonary edema Severe pain of non-traumatic origin (Back spasms or kidney stones) Contraindications: Hypotension Hypovolemia or severe bleeding Head, chest or abdominal injures Undiagnosed abdominal pain Precautions: CNS/respiratory depression Liver disease Side effects: Hypotension CNS/respiratory depression Nausea/vomiting Dose/Administration: 2-4mg (IV, IO, IM) over 2min o May repeat after 5min as needed o Max dose: 30mg Pediatric dose: 0.1mg/kg (IV, IO, IM) over 2min o Max single dose should not exceed adult dose Notes: Morphine has limited effectiveness in the treatment of pulmonary edema Diphenhydramine may be administered to counteract the symptoms of the histamine release that may occur after Morphine administration Pregnancy category: C 167 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Naloxone (Narcan) Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order Competitive opioid antagonist Effects: Reversal of opioid effects Indications: Narcotic/suspected narcotic overdose Catapres (Clonidine) overdose (Paramedic only) Contraindications: None Precautions: Narcotic addiction/abuse Chronic pain – If used in a patient who is habituated to narcotics, the patient may develop condition consistent with narcotic withdrawal Side effects: Sudden narcotic withdrawal o Nausea/vomiting o Combativeness o Pulmonary edema Soreness/headache (If narcotics are not present) Dose/Administration: 2mg (IV, IN, IO, IM) repeat as needed o Consider dilution and titration if the patient is not in respiratory arrest Pediatric dose: 0.1mg/kg (IV, IN, IO, IM) repeat as needed o Max single pediatric dose not to exceed adult dose Titrate dose to reverse respiratory depression, not to achieve full reversal of effects Notes: The duration of some narcotics is longer than Narcan (1-4hrs). Repeated doses of Narcan may be required Patients who have received this drug must be transported Large doses (16-20mg) may be needed to reverse Propoxyphene (Darvon) overdose Demerol (Meperidine) will not cause pupillary constriction The number of opioid analgesics, and medications that include an opioid, is extensive. Physical exam and patient assessment is the most useful tool in determining whether or not a patient might have overdosed on an opioid Catapres (Clonidine) is an A2 adrenergic agonist whose effects will be reversed with Narcan administration Pregnancy category: C 168 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Nitroglycerine Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I - Cardiac chest pain by Standing Order, Direct Order for all other indications Nitroglycerine is a prodrug that metabolizes into nitric oxide. Exact mechanism of action is not well understood Effects: Vasodilation (Including coronary arteries) Decreased preload and afterload Generalized smooth muscle relaxation Indications: Cardiac chest pain Pulmonary edema Esophageal spasm (Paramedic only) Contraindications: Hypotension (Systolic BP < 90mmHg) Right ventricular MI Phosphodiesterase 5 inhibitor use: o Viagra (sildenafil) within 24hrs o Cialis (tadalafil) within 48hrs o Levitra (vardenafil) within 24hrs o Stendra (avanafil) within 24hrs o Other PDE5 inhibitors are currently in clinical trials and may become available in the USA Precautions: Inferior MI (V4R or right-sided 12-lead required prior to administration) HR >100 or <60bpm Side effects: Hypotension and tachycardia Headache Dose/Administration: 0.4mg (1/150gr) (SL, lingual, buccal) o May repeat every 5min as long as the systolic BP is >90 mmHg o Time between doses may be shortened when administered for CHF as needed and as BP allows o Administration is still allowed, if indicated, even if the patient has taken prior to our arrival Notes: Blood pressure should be taken and recorded before and after each administration Nitroglycerine is thought to have a cumulative effect Onset 2min, duration 30min Pregnancy category: C 169 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Ondansetron (Zofran) Authorization: Protocol: EMT-I and Paramedic EMT-I, Paramedic - Standing Order Blocks serotonin receptors in the chemoreceptor trigger zone that is located in the medulla oblongata Effects: Antiemetic Indications: Nausea and/or vomiting Potential for nausea and/or vomiting Contraindications: Hypersensitivity Precautions: Children < 3yrs Pregnancy/breast feeding Side effects: Headache Dizziness Fatigue Dose/Administration: 4mg (IV, IO, IM, IN) Pediatric dose: 0.15mg/kg (IV, IO, IM, IN) o Max pediatric dose not to exceed adult dose Note: Usually will not cause sedation Pregnancy category: B 170 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Ondansetron (Zofran) ODT Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-I, Paramedic - Standing Order EMT-B, and EMT-BIV – Direct Order Blocks serotonin receptors in the chemoreceptor trigger zone that is located in the medulla oblongata Effects: Antiemetic Indications: Nausea and/or vomiting Potential for nausea and/or vomiting Contraindications: Hypersensitivity Children <3yrs Precautions: Pregnancy/breast feeding Side effects: Headache Dizziness Fatigue Dose/Administration: 4mg (ODT) o May repeat once as needed by ODT or use parenteral Zofran Note: Usually will not cause sedation Effect may be delayed over parenteral administration Pregnancy category: B 171 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Oxygen Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order Required by for aerobic metabolism Effects: Saturate hemoglobin with oxygen Hasten disassociation of CO from hemoglobin Indications: Hypoxia (SPO2 < 94%) Shortness of breath Hypotension/shock states Significant bleeding Pregnancy with complications and during childbirth CO/suspected CO poisoning Poisonous inhalation Contraindications: None Precautions: MI/stroke with SPO2 > 94% and no shortness of breath Patients with COPD/other chronic lung disease may have “normal” SPO2 < 94% Side effects: Drying of nasal mucosa Dose/Administration: Nasal cannula: 1-6L/min o 4-6L/min will quickly dry mucosa. Consider NRB use instead of NC o 15L/min for apneic oxygenation during RSI Non-rebreather mask: 10-15L/min o Ensure that reservoir is full prior to placement on the patient o >15L/min for denitrogenation during RSI Bag-valve-mask: 10-15L/min o Ventilate at appropriate rate o Used with mask, endotracheal tube, or extra glottic device Small volume nebulizer: 6-8L/min o EMT-BIV, EMT-I, and Paramedic only. See specific protocol o Use same volume/min of oxygen when SVN on mask. Ensure that one-way valves are removed CPAP: 15L/min o EMT, EMT-BIV, EMT-I, and Paramedic only. See specific protocol Automated transport ventilator: high pressure oxygen required o Paramedic only Notes: Oxygen supports combustion. Be aware of possible sources of ignition 172 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Phenylephrine (Neo-Synephrine) Authorization: Protocol: Paramedic Paramedic - Standing Order Alpha1 adrenergic agonist Effects: Vasoconstriction Nasal decongestion Indications: Prior to nasal intubation May relieve ear blockage and pressure/pain associated with altitude changes Epistaxis (Patient should be transported) Contraindications: None Precautions: Hypertension Hyperthyroidism Cardiovascular disease Side effects: Hypertension Dose/Administration: 0.5 - 1 .0mL in each nares (One to two sprays) Pediatric dose: 0.5mL in each nares (One spray) Notes: When used to relieve otitic barotrauma, the best results are from pretreatment before descending from altitude Pregnancy category: C 173 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Promethazine (Phenergan) Authorization: Protocol: EMT-I and Paramedic Paramedic – Standing Order EMT-I - Direct Order Phenothiazine with H1 antagonist and anticholinergic properties Effects: Antiemetic Sedation (Particularly when administered with opioids) Indications: Nausea and/or vomiting Potential for nausea and/or vomiting Contraindications: CNS depression Hypersensitivity to “sulfite” (Not sulfa drugs) Children < 2yrs of age Precautions: Acutely ill or dehydrated patients Age > 70yrs Pregnancy/breast feeding Side effects: Use in children may cause paradoxical hyper-excitability and apnea Sedation Hypotension Confusion Tissue necrosis (With extravasation) Dose/Administration: 6.25 mg (IV, IO) over 2min. May repeat every 15min o Dilution is required prior to (IV/IO) administration – See note o IV must be patent 6.25mg (IM). May repeat every 15min Pediatric dose (2yrs < - <12yrs): Consult Base Physician Notes: (IV /IO) Promethazine is highly damaging to tissue with/without extravasation. It is currently recommended that single doses not exceed 6.25mg, the dose be pushed over 2 minutes, and the dose be diluted with Normal Saline. Dilution may be done in a syringe and/or by running saline wide open through drip set during administration IM administration may cause local irritation and pain Pregnancy category: C 174 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Sodium Bicarbonate Authorization: Protocol: EMT-I and Paramedic Paramedic – Direct Order for crush injury, Standing Order for all other indications EMT-I - Direct Order Sodium Bicarbonate is an alkalotic sodium solution that binds to hydrogen ions to become carbonic acid. Carbonic acid readily disassociates into CO2 and water. Sodium Bicarbonate will increase the pH of the urine and increase serum sodium Effects: Increase sodium concentration in the blood Minimal increase in serum pH Indications: Cardiac arrest preceded/potentially preceded hyperkalemia Known hyperkalemia (Paramedic only) Tricyclic antidepressant overdoses with QRS >0.12ms, dysrhythmias, ectopy, or hypotension (Paramedic only) Massive crush injuries (Paramedic only) Contraindications: Metabolic alkalosis Respiratory acidosis Precautions: Routine use Side effects: Metabolic alkalosis Paradoxical cerebral/intracellular acidosis Dose/Administration: 1mEq/kg (IV, IO) o Repeat dose of 0.5mEq/kg after 15min if indicated Pediatric dose: 1mEq/kg (IV, IO) diluted by 50% with D5W o Repeat dose of 0.5mEq/kg diluted by 50% with D5W after 15min if indicated Crush injury o 1mEq/kg (IV,IO) diluted in 250mL D5W administered over 10min Notes: Avoid mixing with Normal Saline for drip administration Per the American Heart Association, "The value of Sodium Bicarbonate is questionable during cardiac arrest, and it is not routinely recommended for the routine cardiac arrest sequence." Adequate and effective ventilation is the mainstay of treatment for acidosis Carbon dioxide is generated after administration. Effective ventilation is essential to remove the CO2 from the body Must be administered in separate line than catecholamines and Calcium Chloride Pregnancy category: C 175 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Succinylcholine Chloride Authorization: Protocol: Paramedic Paramedic - Standing Order Depolarizing acetylcholine nicotinic receptor antagonist Effects: Paralysis Indications: RSI Contraindications: Known hyper-sensitivity to any component Personal or family history of malignant hyperthermia Acute narrow angle glaucoma or penetrating eye injuries Inability to ventilate/oxygenate the patient if intubation is not successful Patient <12yrs Precautions: Known or potential hyperkalemia or metabolic acidosis Pregnancy/breast feeding Burns Liver disease Anemia Malnutrition Quinidine or Digitalis use Increased dose may be needed if the patient is hypotensive Side effects: Hyperkalemia Muscle fasciculation Arrhythmias (Particularly pediatric patients) Dose/Administration: 1.5mg/kg (IV, IO) o Use RSI cards for assistance with dosing Notes: Succinylcholine Chloride does not affect pain or anxiety – administer sedative first Onset within 30secs, duration 4-6min Pregnancy category: C 176 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Tetracaine/Opthaine Authorization: Protocol: EMT-I and Paramedic EMT-I and Paramedic – Standing Order Tetracaine inhibits sodium influx through neuronal cell membranes Effects: Topical ophthalmic analgesic Indication: Pain caused by superficial trauma to the eyes Provide analgesia to facilitate flushing after chemical or foreign body UV burn to the eye Contraindications: Penetrating trauma to the eye Globe not intact Precautions: Patient must be transported Side effects: Tearing Transient burning sensation Blurred vision Dose/Administration: 1-2 drops in to the affected eye o Medication may be administered prior to flushing eye with Normal Saline or sterile water o Cover both eyes, after administration, to reduce movement of globe Notes: Pregnancy category: B 177 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Vecuronium Bromide Authorization: Protocol: Paramedic Paramedic - Standing Order Non-depolarizing, nicotinic, acetylcholine receptor antagonist Effects: Paralysis Indications: Maintenance of chemical paralysis after RSI RSI if Succinylcholine is contraindicated/unavailable Contraindications: Inability to ventilate/oxygenate if intubation is unsuccessful Patient <12yrs Precautions: Inability to oxygenate/ventilate the patient Increased dose may be needed if the patient is hypotensive Side effects: None Dose/Administration: 0.1mg/kg (IV, IO) o See RSI cards for assistance with dosing Notes: Onset is within 1min, duration is up to 45min Continuous end tidal CO2 and pulse oximetry monitoring is mandatory Does not provide analgesia or sedation Consider withholding long term paralysis if the patient condition warrants. Ensure that appropriate sedation and analgesia are provided Pregnancy category: C 178 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Over-the-Counter Medications Authorization: Protocol: EMT-B, EMT-BIV, EMT-I, and Paramedic EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order Overview: This protocol has been established to outline a basic guideline for when and under what circumstances a provider may administer an over-the-counter medication to a patient that is under his/her care Circumstances: Over the counter medications may only be administered under the following circumstances: In a “wilderness” setting. Defined as: o No access by 2-wheel drive vehicle o Extended access by 4-wheel drive vehicle o Access only by ATV, motorcycle, or snowmobile o Access only by foot or other non-mechanized means of conveyance When access to the other medications covered in these protocols are not available or not appropriate When deemed, by the provider, that the patient requires the medication to: o Relieve swelling from isolated extremity injuries in stable patients o Reduce pain from isolated extremity injuries in stable patients o Treat MI o Treat an allergic reaction Medications: Only commonly available, over-the-counter, medications may be administered. Use of a prescription medication by a person other than the person that the medication is prescribed for is illegal and strictly forbidden Pain relief/swelling reduction o NSAIDs Aspirin, Ibuprofen, or Naproxen Generic, Advil, Motrin, Aleve, Ascriptin, Bayer, or Ecotrin o Acetaminophen Tylenol or Generic Treat MI o Aspirin Allergic reaction o Benadryl or generic Diphenhydramine Doses: Aspirin for MI o Adult: 324mg (PO) All other medications should be given as instructed on the label. Do not deviate from the recommended dosing Pediatric patients may be given the medications that have a specific pediatric use and dose on the label Notes: Myocardial infarction, cardiac chest pain, allergic reactions, multisystem trauma, long bone fractures and other serious trauma/medical are extremely serious conditions. Transfer to definitive care should not be delayed and helicopter use should be strongly considered Medications should only be used if they are in their original packaging with instructions, dosing information, and drug information readily available 179 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 EMT – Intermediate Direct Order Exception Authorization: Protocol: EMT-I EMT-I - Standing Order This protocol serves to allow an EMT-Intermediate that had received adequate training and education, and is currently employed with Chaffee County Emergency Medical Services, to administer certain medications, in certain situations, without a verbal Direct Order from the receiving physician 6 CCR 1015-3, Chapter Two. Section 14.22 allows “…specific exception criteria are established by the supervising physician. Exception criteria may include, but are not limited to, cardiac arrest, behavioral management, or communications failure. “ The following are the specific exception criteria. Providers should reference specific protocols for further information Communications Failure An EMT-I may administer any medications that they feel is appropriate for the patient condition, and have Direct Order authorization for, under a Standing Order if: o Communication with the Base Physician via radio has failed o Communication with the Base Physician via phone has failed o The patient’s life may be threatened if the EMT-I withholds the medication Communication with the Base Physician should be established as soon as possible after the administration and the communications failure be thoroughly documented in the patient care report Fentanyl Citrate An EMT-I may administer Fentanyl Citrate (Sublimaze) under Standing Order if the following criteria are met: o The patient has suffered an isolated traumatic injury or has pain likely due to Acute Coronary Syndrome o All Contraindications for Fentanyl Citrate (Sublimaze) are absent o All Precautions for Fentanyl Citrate (Sublimaze) have been considered This protocol only allows an exception for the Direct Order for Fentanyl Citrate (Sublimaze), under the above conditions, no other component of any other protocol Benzodiazepine – Midazolam (Versed) or Diazepam (Valium) An EMT-I may administer Midazolam (Versed) or Diazepam (Valium) under Standing Order if the following criteria are met: o The patient or provider’s well-being is at risk if medication administration is delayed o All Contraindications for the selected Benzodiazepine are absent o All Precautions for the selected Benzodiazepine have been considered 180 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Interfacility Transfer Medications Authorization: Protocol: EMT-I and Paramedic EMT-I and Paramedic - Direct Order by sending physician Purpose: Some patients will require the administration of medications that are only allowed to be administered under the following conditions: During a ground, interfacility transport, when other transfer options are not available Under the direct, written, order of a sending physician When specifically allowed below General Procedures: The following apply to each medication or infusion covered in this protocol: o Providers certified as FA/CPR, FR, EMT-B, and EMT-BIV may not be the sole attendant when a medication is being infused o Only medication infusions approved below may be maintained by Chaffee County Emergency Medical Services EMT-I’s and Paramedics o EMT-I may only maintain medications specifically approved o A provider may not initiate administration of these medications unless specifically authorized in other sections of this Protocol Manual (i.e. dopamine) o IV/IO medications must be administered via an infusion pump. Other routes of administration must comply with physician order. Blood products do not require the use of an infusion pump o If any adverse reactions/conditions occur, discontinue administration and contact sending physician The following apply to prior/during/after transport: o The EMT-I or EMT-P must ensure the patency of the IV/IO o A second route of access should be established, if it has not already, prior to leaving sending facility o The patient must be placed on the cardiac monitor o The concentration of the drug solution must be recorded and documented o The infusion rate and dose must be recorded and documented o Vital signs must be obtained and recorded at least every 15min o If an IV/IO infiltration occurs during infusion, reinitiate the infusion through an available access point and notify the sending physician immediately Approved Medications and Blood Products: Diltiazem HCI (Paramedic) Heparin (Paramedic) Nitroglycerin (Paramedic) Blood/Blood products (Paramedic) Solu-Medrol (Paramedic) Vitamins (EMT-I, and Paramedic) Electrolytes (Paramedic) o Magnesium sulfate - Maximum rate of 4g/hr o Potassium chloride - Maximum rate of 10mEq/hr Lidocaine (EMT-I, and Paramedic) Dopamine (Paramedic) Amiodarone (EMT-I, and Paramedic) Antibiotic infusions (EMT-I, and Paramedic) Mannitol (Paramedic) Oxytocin (Paramedic) Total Parenteral Nutrition (EMT-I, and Paramedic) 181 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Glycoprotein Inhibitors (Paramedic) Nicardipine (Paramedic) Magnesium (Paramedic) Sodium Bicarbonate (Paramedic) Insulin (Paramedic) Methylprednisolone (Paramedic) Octreotide (Paramedic) Pantoprazole (Paramedic) Specific Procedures and Precautions: Diltiazem HCL (Cardizem) o Indications: See protocol o Contraindications: See protocol o Precautions: See protocol o Complications: See protocol o Procedure: Follow the sending physician’s orders o Usual dose: 5-15 mg/hr. Maximum rate of 15mg/hr Heparin o Indications: Heparin is frequently administered as an anticoagulant to prevent blood clotting in the setting of ischemic coronary disease, pulmonary embolism, or peripheral vascular conditions o Contraindications: Severe thrombocytopenia and active bleeding o Precautions: o Complications: Hemorrhage from any site may occur, or hypersensitivity reaction o Procedure: Usually 20,000 to 40,000 units of Heparin are added to 1000cc NS. o Usual dose: 1,000units/hr in adults Insulin o Indication: Insulin is used to treat patients with diabetic ketoacidosis or hyperglycemia. It may also be used with dextrose solutions to treat patients with hyperkalemia o Contraindications: Hypoglycemia, or hypokalemia. o Precautions: Alcohol and salicylates may potentiate the effects of insulin. o Complications: Attention must be paid to any signs of hypoglycemia (diaphoresis, weakness, tachycardia, confusion, nausea). The transporting ambulance must have a functional Glucometer for evaluation of blood sugar during transport o Procedure: Document on the patient care report if the patient received (and how much) a loading dose of insulin. Blood glucose checks are mandatory every 30 minutes during transport. A decrease in blood sugar of 3-50 mg/dl/hr should be anticipated on average o Usual dose: 0.1 units/kg/hour Nitro glycerin o Indications: Ischemic coronary state and hypertension o Contraindications: Hypotension and shock o Precautions: The patient should be observed clinically for pain relief, blood pressure changes, and other signs of poor perfusion. Decrease the infusion rate by half if signs of poor perfusion (pallor, sweating, decreased capillary refill, or mental alertness) occur in conjunction with systolic BP<100. Notify the sending physician immediately. Rapid withdrawal of nitroglycerin infusion may result in worsening of ischemia and should be avoided. Infusion rates may be increased only through direct, sending physician, order if the patient develops worsening ischemic chest pain or hypertension o Complications: Nitroglycerin absorbs into plastic IV tubing, so the dose that the patient receives maybe be lower than the dose shown on the IV pump o Procedure: A dilution of 50 – 100 mcg/ml is typical 182 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols o January 1, 2016 Version 10 Usual dose: 50-200mcg/min Blood/Blood Products o Indications: Hemorrhage and certain anemic states and for other disorders of the hematologic system o Contraindications: The sending physician will have considered the contraindications to blood transfusion o Precautions: Some patients may object to the transfusion of blood products for religious reasons. For problems, contact the sending physician o Complications: Transfusion reactions and hypersensitivity reactions can occur after the onset of blood product infusion. Symptoms may include fever, restlessness, anxiety, flushing, chest or lumbar pain, tachycardia, tachypnea, nausea, and shock. Occasionally bleeding from coagulopathy may develop. If any of the signs or symptoms listed above develop after the onset of the transfusion, the transfusion should be discontinued and the sending physician be contacted immediately o Procedure: Maintain infusion rate as indicated by the sending physician. All blood products should be administered through tubing with a blood filter. Document blood product number (with pen or sticker) to permanent medical record and pre-hospital trip sheet left at receiving facility o Usual dose: Determined by sending physician Solu-Medrol/Methylprednisolone o Indications: See protocol. In addition, may be administered in patients with spinal cord injury o Contraindications: See protocol. In addition, premature infants o Precautions: o Complications: Rare instances of bronchospasm, bradycardia, and other cardiac arrhythmias have been reported after large rapid IV administration. If complications develop, discontinue the infusion and notify the sending physician immediately o Procedure: o Usual dose: 5.4 mg/kg/hr for 23 hours Vitamins/Electrolytes o Indications: Vitamins or electrolytes may be infused when there is a confirmed or suspected deficiency. Most commonly, multivitamin infusions (MVI) will be given to patients suspected of being malnourished (e.g. chronic alcoholics) o Contraindications: These will have been previously considered by the sending physician o Precautions: None o Complications: Exceeding the prescribed rate of potassium solutions may result in cardiac conduction abnormalities. Infusion rate should be slowed if any burning or irritation occurs at the infusion site and sending physician should be contacted immediately o Procedure: All patients being given IV Potassium must be on a cardiac monitor o Usual dose: Varies with vitamin/electrolyte Lidocaine o Indications: See protocol o Contraindications: See protocol o Precautions: CHF, liver disease, bradycardia, and AV heart blocks. Lidocaine may speed the ventricular rate in patients with atrial fibrillation. o Complications: Signs and symptoms of Lidocaine toxicity include dizziness, tinnitus (ringing in the ears), tremulousness, seizures, agitation, and exacerbation of heart block, hypotension, and bradycardia. In cases of Lidocaine toxicity the medication drip should be discontinued immediately and the patient should be treated with supportive measures (e.g., Atropine in the case of heart block, diazepam in the case of seizure) and contact sending physician immediately 183 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols o o January 1, 2016 Version 10 Procedures: Typically a maintenance infusion of Lidocaine is 1 gram or Lidocaine in 250cc of D5W Usual dose: 1-4mg/min Amiodarone o See individual drug protocol Dopamine o Indications: Hypotension, bradycardia, or renal protection o Contraindications: Hypovolemia (relative) o Precautions: MAOI use, tachyarrhythmias, infusion should be decreased or stopped o Procedure: Usually premixed, use infusion pump to administer 2-20mcg/kg/minute o Dose: 2-10mcg/kg/min (IV, IO) drip for cardiogenic shock and bradycardia 10-20mcg/kg/min (IV, IO) drip for distributive shocks Mannitol o Indications : Treatment of increased intraocular or intracranial pressure o Contraindications :Hypersensitivity, anuria, dehydration, or active intra cranial bleeding o Precautions: Pregnancy o Complications: Hypotension, confusion, headache, nausea, vomiting, blurred vision, rhinitis, or electrolyte imbalance o Procedure: Usually premixed. Must be administered through filter set and warm o Usual dose: 0.25 – 2 g/kg over 30-60min Nicardipine o Indications: Hypertension and BP management in CVA / hemmorhage o Contraindications: Aortic stenosis o Precautions: Pregnancy class C. Monitor BP closely o Complications: Hypotension, headache, weakness, flushing o Usual dose: 5mg /hr slow infusion (IV, IO). May be increased by 2.5mg/hr every 15 minutes. Do not exceed 15mg/hr Oxytocin o Indications: Control of post-partum hemorrhage o Contra indications: Hypersensitivity, or non vaginal delivery o Precautions: o Complications: Coma, seizure, or hypotension o Procedure: o Usual dose: 0.5 – 2 milliunits/min. Max dose of 20 milliunits/min 184 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 IV/IO Solutions Authorization: Protocol: EMT-BIV, EMT-I and Paramedic EMT-BIV, EMT-I and Paramedic - Standing Order Chaffee County Emergency Medical Services currently carries two crystalloid IV/IO solutions General: Normal Saline – Contains Na+, and Cl- and is isotonic Primary IV fluid for resuscitation purposes D5W – Contains 5% dextrose in water and is hypotonic D5W diffuses into the tissue three times faster than NS and is inefficient as a volume expander. Should be used for drip medication administration and in patients that circulatory overload is a concern Precautions: In hemorrhagic shock, volume expansion with crystalloid solutions is efficient in raising intravascular volume but does not increase oxygen carrying capacity. Can be used temporarily to maintain blood pressure Volume overload is a constant danger. Ensure that the IV/IO is at the desired rate throughout transport. Excess fluid can be detrimental Do not use D5W in suspected Cerebral Vascular Accidents Administration: Establish an IV or IO line using technique outlined in each specific protocol Use either a macro drip set, micro drip set, or saline lock as appropriate Rate should always be set at a TKO rate unless a fluid bolus is indicated The rate that fluid can be infused is dependent on the diameter and length of the catheter used o A 24 gauge is the smallest and a 14 gauge is the largest that can be used in the field o For volume expansion, a large catheter should be used, such as a 16 or 14 gauge o Aim for security and accuracy, not size. Do not try to force a large bore needle into a small vein Notes: Administer boluses in small increments, such as 250mL, up to 20mL/kg, assessing breath sounds, changes in vital signs, and patient condition frequently. May repeat as indicated Be careful of administering large amounts of fluid (>2 liters) as circulator overload may develop o Signs and symptoms of overload include dyspnea, orthopnea, rales, JVD, polyuria and hypertension o If fluid overload occurs, immediately turn the IV to a slow TKO and advise the Base Physician o The elderly, pediatrics, and those with kidney and heart problems are particularly vulnerable to fluid overload Refer to the individual protocol to determine in which situations an IV/IO should be initiated and what patient conditions might require fluid administration 185 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Revisions Version 10 Calcium Chloride added - Page #147 Dextrose changed from D50% to D10% for all ages - Page #148 12mg Adenosine – Removed 6mg dose for adults - Page #143 200J – Optional starting point for all cardioversion/defibrillation of adult patients - Page #111 SPO2 added to TCP – To prove capture with pulse - Page #110 Sepsis protocol updated with new criteria - Page #54 Dopamine moved to IFT and removed from prehospital protocols Critical care protocols added - Page #188 Nicardipine added to transfer medications - Page #182 Ketamine modified for CC paramedics - Page #161 Added consider lidocaine to RSI protocols - Page #93 Removed TIH and added TTM – Page #26 Apneic Oxygen – Page #101 Pain control protocol - Page #128 186 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Critical Care Protocols Requires Critical Care Endorsement in the state of Colorado 187 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Acetylcysteine (Mucomyst) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Acetylcysteine is used in the treatment of acetaminophen overdose. Acetylcysteine maintains and/or replenishes depleted glutathione reserves in the liver which inactivates hepatotoxic metabolites of acetaminophen metabolism Effects: Protects the liver against toxic metabolites of acetaminophen toxicity Mucolytic agent for use in cystic fibrosis Indications: Acetaminophen overdose Mucolytic therapy Contraindications: Allergy (relative) – treat with diphenhydramine and continue infusion if benefit > risk Precautions: Can cause bronchospasm Increase in bronchial secretions Side effects: May cause rash, urticaria and pruritus Nausea Dose/Administration: Adult and Pediatric dose IV/IO: o Loading Dose: 150 mg/kg in 200 mL of 5% dextrose intravenously over 60 minutes (maximum: 15 g) o Second Dose: 50 mg/kg in 500 mL 5% dextrose intravenously over 4 hours (maximum: 5 g) o Third Dose: 100 mg/kg in 1000 mL of 5% dextrose intravenously over 16 hours (maximum: 10 g) Notes: Use may be dictated by the Rumack-Matthew nomogram (See next page) If plasma levels cannot be obtained it is reasonable to treat based on suspected acetaminophen overdose Some formulations of acetaminophen may be extended release Pregnancy category: B 188 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 189 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Dobutamine (Inotropin) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Dobutamine increases inotropy by stimulation of β1 Effects: Increases cardiac output via increased inotropy Indications: Cardiogenic shock Need for increased inotropy As an adjunct to other vaso-active medications Contraindications: Dobutamine hydrochloride is contraindicated in patients with idiopathic hypertrophic subaortic stenosis and in patients who have shown previous manifestations of hypersensitivity to dobutamine injection Precautions: Increase in myocardial oxygen demand Side effects: Hypertension Angina Arrhythmia. May cause rapid ventricular response in patients with atrial fibrillation Nausea Dose/Administration: Adult and Pediatric 2.5 - 20 mcg/kg/min (IV, IO) Notes: Pregnancy category: B 190 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Esmolol (Brevibloc) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Esmolol is a selective β1 blocker that will decrease inotropy, HR, and BP Effects: Slows Ventricular rate Decreases Blood Pressure Indications: SVT (including atrial fib / atrial flutter / Non-Compensatory sinus tach (Ex: POTS) Hypertension Contraindications: Severe sinus bradycardia Heart block greater than first degree Sick sinus syndrome Decompensated heart failure Cardiogenic shock Co-administration of IV cardiodepressant calcium-channel antagonists (e.g. verapamil) in close proximity to BREVIBLOC injection Pulmonary hypertension Known hypersensitivity to esmolol Precautions: Use with caution in patients with reactive airway diseases May raise serum potassium Avoid in Prinzmetal’s angina as it may cause unopposed alpha stimulation Not recommended for sympathomimetic overdose Side effects: Hypotension Bradycardia Heart blocks Dose/Administration: Supraventricular tachycardia (SVT) or noncompensatory sinus tachycardia • Optional loading dose: 500 mcg per kg infused over one minute •Then 50 mcg per kg per minute for the next 4 minutes • Adjust dose as needed to a maximum of 200 mcg per kg per minute. Notes: Pregnancy category: C 191 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Fosphenytoin (Cerebyx) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Fosphenytoin is an anticonvulsant drug that is believed to work by sodium channel blockade The dose, concentration, and infusion rate of CEREBYX should always be expressed as phenytoin sodium equivalents (PE). There is no need to perform molecular weight-based adjustments when converting between fosphenytoin and phenytoin sodium doses. CEREBYX should always be prescribed and dispensed in phenytoin sodium equivalent units (PE Effects: Anti-convulsant Seizure prophylaxis Indications: Control and prevention of seizures Contraindications: Hypersensitivity Sinus bradycardia AV blocks (type 1-3) Adams-Stokes syndrome Precautions: May cause hypotension May cause arrythmias, maintain continuous ecg monitoring Side effects: Hypotension Arrhythmias Purple glove syndrome Ataxia / stupor Dose/Administration: ALL DOSES ARE IN PE UNITS. Prior to IV infusion, dilute CEREBYX in 5% dextrose or 0.9% saline to a concentration of 1.5 to 25 mg PE/mL. The loading dose of CEREBYX is 15 to 20 mg PE/kg administered at 100 to 150 mg PE/min Because of the risk of hypotension, CEREBYX should be administered no faster than 150 mg PE/min Maintenance dose is 4 – 6 mg PE/kg/day in divided doses Notes: Always dilute before administration All doses expressed in phenytoin equivalents (PE) Pregnancy category D 192 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Labetalol (Normodyne) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Labetalol is a mixed α and β adrenergic antagonist that is used to treat hypertension. Effects: Lowered BP by α and β blockade Indications: Hypertension Pheochromocytoma Contraindications: Hypersensitivity Precautions: Use with caution in the presence of severe reactive airway disease Side effects: Nausea Bradycardia Side effect Dose/Administration: Initial dose 20 mg (0.25 mg/kg) by slow IV injection over a 2 minute period Continuous infusion (dilute to 1 - 1.5mg/ml ) administer @ 1mg/minute -2mg/minute Notes: Pregnancy category: C 193 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Levitiracetam (Keppra) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Levitiracetam is an anticonvulsant drug believed to work by blocking pre-synaptic calcium channels Effects: Anti-convulsant and seizure prophylaxis Indications: Seizures Prophylaxis of seizures Contraindications: Hypersensitivity Adjust dose if patient has renal impairment Precautions: Dosing adjustments required for patients with impaired renal function MUST BE DILUTED IN 100ML OF NS Side effects: Somnolence Dose/Administration: MUST BE DILUTED IN 100ML OF NS 500 – 1500 mg (IV, IO) over 15 minutes BID Pediatric dose: o 1 month to < 6 months Initiate at 7 mg/kg twice and day and titrate to 21 mg/kg twice a day o 6 months to 4 years Initiate at 10 mg/kg twice and day and titrate to 25 mg/kg twice a day o 4 year to 16 years initiate 20 mg/kg in 2 divided doses (10 mg/kg twice daily) Notes: Pregnancy class: C 194 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Metoprolol (Lopressor) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Metoprolol is β1 selective antagonist that lowers blood pressure and slows heart rate Effects: Lowers blood pressure Lowers heart rate Decreases myocardial oxygen demand Indications: Hypertension Tachycardias Myocardial infarction Hyperthyroid / Thyroid storm Angina Pectoris Contraindications: Hypersensitivity Cardiogenic shock Sick sinus syndrome, Bradycardia / AV blocks in absence of pacemaker Precautions: May worsen heart failure May effect reactive airway disease Do not use in Cocaine overdose Do not use in untreated pheochromocytoma Side effects: Bradycardia Wheezing Fatigue Dose/Administration: 3 IV boluses of 5 mg each at 2-minute intervals. Pediatric dose: safety and efficacy not established in children Notes: Pregnancy category: C 195 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Norepinephrine (Levophed) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Norepinephrine is an α and β agonist that increases inotropy and causes vasoconstriction Effects: Vasoconstriction Increased cardiac output Indications: Hypotension Contraindications: Hypersensitivity Do not give in the same IV line as NaHCO3 (sodium bicarbonate) Precautions: Use with extreme caution in concurrent MAOI use May cause arrhythmias Side effects: Bradycardia (not an issue in hypotensive patients, bradycardia points to over-medication) Nausea Dose/Administration: Hypotension 2-30mcg/minute Pediatric dose: 0.05 – 0.1mcg/kg/minute (max 1-2mcg/kg/minute) Notes: Pregnancy category: C Frequent checks for extravasation required 196 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Phenytoin (Dilantin) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order Phenytoin is an anticonvulsant Effects: Anti-epileptic Seizure prophylaxis Indications: Seizures Seizure prophylaxis Indication Contraindications: Hypersensitivity AV block (type II and type III) Adams-Stokes syndrome Sinus bradycardia Precautions: Administration should not exceed 50 mg/minute in adults or 1 to 3 mg/kg/minute May Cause Hypotension Side effects: Hypotension Bradycardia Nystagmus / visual disturbance Dose/Administration: 10 to 15 mg/kg IV loading dose (at a rate not exceeding 50 mg/minute) Pediatric dose: same as adult Notes: Pregnancy category: D 197 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 Propofol (Diprivan) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic– Standing Order Propofol potentiates GABA receptors, sodium channel receptors and other receptors to cause sedation and amnesia Effects: Sedation Amnesia Indications: Mechanically ventilated patients Contraindications: Allergy to eggs Allergy to Soy Not for use in pediatric patients Precautions: May cause pain at injection site May lower blood pressure Prolonged high dose infusions may cause Propofol infusion syndrome. Abrupt discontinuation may cause anxiety and agitation Side effects: Possible hypotension Propofol infusion syndrome Dose/Administration: Notes: Maintenance of sedation in adults: 5mcg/kg/minute – 50mcg/kg/minute titrated to effect (IV, IO) For induction: 1.5mg/Kg – 3Mmg/Kg IV Push Pregnancy category: B Consider lower dose in hemodynamically compromised patient. 198 Table of Contents Chaffee County Emergency Medical Services Pre-Hospital Treatment Protocols January 1, 2016 Version 10 tPA (Alteplase) Authorization: Protocol: Critical Care Paramedic Critical Care Paramedic – Standing Order tPA is an enzyme that aids in dissolution of blood clots Effects: Converts plasminogem in to plasmin aiding in clot breakdown Indications: Ischemic stroke Contraindications: See tPA screening checklist Precautions: See tPA screening checklist Side effects: Bleeding, especially from gums / nose Intracerebral hemorrhage Dose/Administration: The recommended dose is 0.9 mg/kg (max, 90 mg) infused over 60 min with 10% of the total dose administered as an initial IV bolus over 1 min Notes: Pregnancy category: C 199 Table of Contents