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PRIDEMARK PARAMEDIC SERVICES & DENVER METROPOLITAN PREHOSPITAL PROTOCOLS These protocols are effective January 31st, 2008 These protocols are considered property of the Denver Metro EMS Medical Directors and Pridemark Paramedic Services, LLC. as well as contributors listed below. They may be utilized and edited by others as long as the Denver Metro EMS Medical Directors and Pridemark Paramedic Services are credited. We also ask to be notified at: Pridemark Paramedic Services 6385 W. 52nd Ave. Arvada, CO 80002 Return to Table of Contents Introduction At first glance, these protocols appear a bit unusual. They are in that they are a hybrid of the Denver Metro Protocols that the majority of agencies in our area utilize, Boulder County Protocols and the Pridemark Protocols. By allowing the documents to compliment each other, this allows us to practice at the regional standard as set by the Denver Metro EMS Medical Directors as well as utilize the protocols that we have developed in house that are specific to the needs of Pridemark. If you have practiced in the Metro area before coming to Pridemark, much of what you have utilized still apply, however, you will find some differences in ways that hopefully will make your job easier. This document is separated into different sections addressing different items. There are no page numbers—this is by design to allow easy introduction / retirement of protocols so the entire book doesn't need to be printed. Pridemark specific protocols are noted by a Pridemark Logo in the header area of the page. In the event of discrepancies or conflicts between the Pridemark and Denver Metro Protocols, Pridemark protocols are to be followed. Please remember that it is impossible to write a protocol or guideline to cover every eventuality. Use good judgment, always act in the patient's best interest and document well. Help is only a phone call away. Return to Table of Contents PRIDEMARK PREHOSPITAL PROTOCOL MANUAL ACKNOWLEDGEMENT OF RECEIPT AND PROVIDER PRACTICE EXPECTATIONS The completed information below verifies that the Pridemark Prehospital Protocol Manual has been received and that the recipient accepts the responsibility for knowing and practicing as an EMT and/or paramedic in accordance with these protocols. ______________________________________________________________ Name of Recipient (please print) Date Received ______________________________________________________________ Signature of Recipient Date ___________________________________________ Agency For office and administrative use only: Protocol Examination Results: (90% or higher required to pass on all tests) Mapping and Radios: ______________________________________________________________________ Combination Analgesia: ______________________________________________________________________ Cardiology: ______________________________________________________________________ Operations: ______________________________________________________________________ Final Protocol Test: ______________________________________________________________________ Notes: _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Return to Table of Contents ACKNOWLEDGEMENTS This version of the Denver Metro Emergency Medical Services Medical Directors protocols has been produced based on previous protocols produced by the following. The Denver Metropolitan Physician Advisor Group F. Keith Battan, M.D. Mark Kozlowski, M.D. Christopher Colwell, M.D. Donald Massey, D.O. James Cusick, M.D. David McArdle, M.D. Eugene Eby, M.D. Gilbert Pineda, M.D. James Hogan, M.D. John Riccio, M.D. Benjamin Honigman, M.D. Ray Rossi, M.D. Arthur Kanowitz, M.D. W. Peter Vellman, M.D. Ron Keller, M.D. Special thanks and recognition to: Mike Armacost, MS, EMT-P Wilson Lindquist Eric Bettinger, EMT-P Rick Lindsey, EMT-P Michael Bilo, EMT-P Robert Marlin, EMT-P Marilyn Bourn, RN, MSN, EMT-P Kathy Mayer, RN, MSN Colleen Bruntz Bill Mayfield, RN Thomas Candlin, III, EMT-P Ron McCuiston Jami Mari Cavos Lee Meyer, B.S., EMT-P Anne Clouatre, MHS, EMT-P David Patterson, EMT-P Jim Cloud Randy Pennington, EMT-P Tracy Collins, RN Scott Phillips, EMT-P Ray Coniglio, RN Lorna Prutzman Brian Daley, EMT-P Ron Quaife, RN, EMT-P David Day, EMT-P Joe Rockwell, EMT-P Jean Distretti David Sanko, BA, EMT-P Jeff Fletcher, BS, EMT-P Mike Shabkie, EMT-P Douglas Frosh, BS, EMT-P Bill Spialek, EMT-P John Glenn, EMT-P Tracy Thomas, EMT-P Craig Gravitz, RN, EMT-P Thomas Tkach, EMT-P Garet Hickman, EMT-P Ted Hockenberry, EMT-P Carol Hurdelbrink, RN Patricia Tritt, RN, MS Carol Jenks Ted Vargas Jacob Johnson, EMT-P Sam Walters Kathee Johnson Danny Willcox, EMT-P Timothy Keane, EMT-P Jean Zambrano, EMT-P These protocols have been developed specifically for the Denver metropolitan community. They represent consensus amongst all of the Denver metropolitan EMS agency Medical Directors. The protocols express a commitment to a consistent approach to quality patient care. Return to Table of Contents The process that has been initiated in the construction of this revised set of metro-wide protocols will remain in place. The authors will continue to edit and revise the protocols Dedicated to Carol J. Shanaberger, Esq., EMT-P. May her memory be eternal. Acknowledgments The process behind managing protocols is a daunting one in that the document is truly living. What may be standard-of-care today could possibly be extinct as early as tomorrow. Many people have spent hundreds of hours on protocol development and maintenance. The following people are thanked in the first version of the Pridemark Protocols: Christina Crumpecker, EMT-Paramedic Arthur Kanowitz, MD FACEP Jeff Flasschoen, EMT-Paramedic along with the Protocol Development committee: Tori Ainlay, EMT Chris Naig, EMT-Paramedic Bruce Amdahl, EMT-Paramedic Thomas F. Pedigo, PA-C Chantel Benish, EMT-Paramedic David Pace, EMT-Paramedic Matthew Bergland, EMT-Paramedic Ray Bondi, EMT-Paramedic Jamie Bosten, EMT-Paramedic Christopher Carleton, EMT-Paramedic Alice "Twink" Dalton, RN EMT-Paramedic Julia Davis, EMT Eammonn Dolan, EMT-Paramedic Bryan DeWolfe, EMT-Paramedic Cameron Duran, EMT-Paramedic Sarah Duran, EMT Simon Edwards, PA-C Pam Evans, EMT-Paramedic David Fending, EMT-Paramedic Wes Filener, EMT-Paramedic Chris Galton, EMT-Paramedic Faith Goodrich, EMT-Paramedic Robert Greenlee, EMT-Paramedic Terry Halford, EMT-Paramedic Bryan Handwork, EMT-Paramedic Chris Hendricks, EMT-Paramedic Hollis Hopkins, EMT-Paramedic Megan Huffman, EMT-Paramedic Scott Kittredge, EMT-Paramedic Steve Koniezny, EMT-Paramedic Pam Howes, EMT-Paramedic Paul Johnson, EMT-Paramedic Brendan Kelly, EMT_Paramedic William H. Kraft, EMT-Paramedic Chris Mulberry, EMT-Paramedic Melissa Lunt, EMT-Paramedic Return to Table of Contents Table of Contents I. Introduction II. Confidentiality / HIPAA III. Consent IV. Physician on scene V. DNR/ Advanced Directives Protocol Protocol Title Last Revision Date Number 1000 Airway V. Airway Go to Table of Contents 4012 Coma 4013 Seizure 4014 Syncope 4020 Allergies & Anaphylaxis 4030 Abdominal (including GI/GU) 4031 Vomiting 4040 Poisoning & Overdose 4050 Environmental 4051 High Altitude 4052 Drowning/Near Drowning 4053 Cold Emergencies 4054 Heat Emergencies 4055 Bites & Stings/ Snake Bites 4056 Snake Bites 4060 Shock-Medical 4070 Psychiatric/ Behavioral Emergencies 4080 Obstetrics/ Gynecological Emergencies 4090 Excited Delirium 5000 Trauma 5010 Trauma Arrest 5020 Amputations 5030 Head Trauma 5040 Face & Neck Trauma 5050 Spinal Trauma 5055 Selective Spinal Immobilization 5060 Chest Injury 5070 Abdominal Trauma 5080 Extremity Injuries 5090 Burns 5100 Taser 5200 Boulder Specific Trauma Activation Criteria SOP Tourniquet Procedure Located with SOP's 6000 General Guidelines for Pediatrics 6010 Infant and Child Resuscitation 6020 Sudden Infant Death Syndrome 6030 Pediatric Dehydration 6040 Pediatric Respiratory Distress 6050 Pediatric Seizures 7000 Pharmacology. Medication Administration 7010 Medication Administration 7020 Medication Administration (Parental) 7030 Medications Adenosine (Adenocard) Albuterol Sulfate (Proventil, Ventolin) Amiadorone (Cordarone) Aspirin Atropine Sulfate Diltiazem (Cardizem) Dextrose Return to Table of Contents Diazepam (Valium) Diphenhydramine (Benadryl) Dopamine (Intropin) Epinephrine (Adrenalin) Epinephrine Auto-Injector (Epi-pen, Epi-pen Jr.) Fentanyl Furosemide (Lasix) Glucagon Haloperidol (Haldol) Ipratropium Bromide (Atrovent) IV Solutions Lidocaine 2% Solution Lidocaine Gel (Xylocaine) Magnesium Sulfate Mark I Nerve Agent Antidote Kit Metered Dose Inhaler (MDI) Methylprednisolone (Solu-Medrol) Midazolam (Versed) Morphine Sulfate Naloxone (Narcan) Nitroglycerine (Nitrostat, Nitroquick, etc.) Ondansetron (Zofran) Oral Glucose (Glutose, Insta-Glucose) Oxygen Phenylephrine (Intranasal) Promethazine (Phenergan) Racemic Epinephrine (Vaponephrine) Sodium Bicarbonate Topical Ophthalmic Anesthetics Interfacility Transfer Formulary Protocols Antibiotics Heparin Drip Nitro Drip 8000 System Specific Medical Procedures & Operations Guidelines Procedures Bandaging Procedures Capnography Procedures Cardioversion Procedures Combination Analgesia Procedures Continuous Positive Airway Pressure (CPAP) Procedures Field Drawn Blood Samples Procedures Blood Draw for Law Enforcement Procedures Percutaneous Cricothyrotomy Procedures Pneumatic Anti-Shock Garment (PASG) Procedures Restraints Procedures Splinting: Axial Procedures Splinting: Extremity Procedures Tension Pneumothorax: Needle Decompression Return to Table of Contents Procedures Transcutaneous Cardiac Pacing Procedures Transport of the Handcuffed Patient Procedures Vascular Access Devices Procedures Venous Access Technique-General Principle Procedures Venous Access Technique-Saline Lock Procedures Vascular Access Technique-External Jugular Vein Procedures Venous Access Technique-Extremity Procedures Venous Access Technique-Intraosseous Infusion Assessment Assessment/ MOI Assessment History Assessment Documentation Assessment Commonly Accepted Abbreviations Operations Combined Advanced Directives Operations Communication Operations Destination Policy Operation Destination Policy: Divert Operations Incident Command System Operations START Triage Operations Hazardous Materials / WMD Operations Infectious Diseases Operations Non-Transport of Patients Operations Non-Transport of Patients: Refusals Operations Non-Transport of Patients: Field Pronouncements Miscellaneous Lab Values Miscellaneous 12-Lead EKG Landmarks & Infarct Patterns 9000 Pridemark Paramedic Services Clinical SOP's SOP BLS Transport SOP Certification Requirement SOP QA/QI Guidelines SOP Protocol Violations SOP Narcotic Storage and Administration SOP FI Process SOP Paramedic School Sponsorship SOP Firefighter or Emergency Event Rehab SOP Pridemark TB Screening Policy/Procedure SOP Disposition of ETOH Patients Return to Table of Contents INTRODUCTION The following PROTOCOLS define the rules of medical care by EMS Providers. These protocols delineate the expected practice, actions and procedures of EMS providers in the field. They have been developed in conjunction with and are sanctioned by the Denver Metro EMS Medical Directors (DMEMSMD). Deviation from the protocols is occasionally necessary due to the vast array of complex clinical presentations. It should always be done with the patient's best interest in mind and backed with documentable and defendable clinical reasoning and judgment. When protocol variance occurs it should be approached in a logical and knowledgeable manner, done in the best interests of the patient, and well documented. In essence it should be done "in good faith." Deviation from standing order protocols should be done with the support of online medical control and/or reported to the agency's Medical Director for offline medical control and review. The prehospital protocols are categorized in accordance with the National Standard curriculum and further broken down by sub-categories within a section. Advanced procedures are those techniques that require physician direction in teaching, skill maintenance, and use. Some procedures are suitable for a standing order while others are categorized as a direct order that requires base contact. A number of treatment, medication, procedure, and operational guidelines protocols require base contact for specific circumstances. A list of protocols that require base contact can be found in the appendix. Please remember that protocols define process; people provide care. PROTOCOL KEY The following symbols denote assessments and treatments that are limited to a certain level of prehospital provider: EMT with IV certification IV P Paramedic Advanced Practice Paramedic The following symbol denotes assessments and treatments that are specific to prehospital pediatric care. Pediatric Care Go to Table of Contents CONFIDENTIALITY A. The patient-physician relationship, the patient-registered nurse relationship, and the patient-EMT relationship are recognized as privileged. This means that the physician, nurse, or EMT may not testify as to confidential communications unless: • the patient consents or • the disclosure is allowable by law (such as Medical Board or Nursing Board proceedings, or civil litigation in which the patient's medical condition is in issue) B. The patient's medical information must be kept confidential by the prehospital provider as private information in medical care. The patient likely has an expectation of privacy and trusts that personal, medical information will not be disclosed by medical personnel to any person not directly involved in the patient's medical treatment. Exceptions A. The patient is not entitled to confidentiality of information that does not pertain to the medical treatment, medical condition, or is unnecessary for diagnosis or treatment. B. The patient is not entitled to confidentiality for disclosures made publicly. C. The patient is not entitled to confidentiality with regard to evidence of a crime. Additional Considerations A. Any disclosure of medical information should not be made or allowed unless necessary for the treatment, evaluation or diagnosis of the patient. B. Any disclosures made by any person, medical personnel, the patient, or law enforcement should be treated as limited disclosures and not authorizing further disclosures to any other person. C. Any discussions of prehospital care by and between the receiving hospital, the crew members in attendance, or at in-services or audits are done strictly for educational purposes. Further disclosures are not authorized. D. Radio communications should not include disclosure of patient names. E. This procedure does not preclude or supersede your agency's HIPAA policy and procedures. Go to Table of Contents CONSENT General Principles: Adults A. An adult in the State of Colorado is 18 years of age or older. B. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient. C. A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, i.e., the patient: 1. Understands the nature of the illness/injury or risk of injury/illness; 2. Understands the possible consequences of delaying treatment/refusing transport; and 3. Given the risks and options, the patient voluntarily refuses or accepts treatment/transport. D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, and treat to the extent possible. E. The odor of alcohol on a patient's breath does not, by itself, prevent a patient from refusing treatment. Refer to letter C above. F. Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening injuries/illnesses. G. Involuntary Consent: In rare circumstances, consent may be authorized by a person other than the patient (such as a court order [guardianship], from a peace officer for prisoners in custody or detention, and persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled). Procedure: Adults A. Consent may be inferred by the patient's actions or by express statements. If you are not sure that you have consent, clarify with the patient or CONTACT BASE. This may include consent for treatment decisions or transport/destination decisions. B. Determining whether or not a patient has decision-making capacity to consent or refuse medical treatment in the prehospital setting can be very difficult. Every effort should be made to determine if the patient has decision-making capacity, as defined above under C. C. For patients who do not have decision-making capacity, CONTACT BASE. D. If the patient lacks decision-making capacity and the patient's life or health is in danger, and there is no reasonable ability to obtain the patient's consent, proceed with transport and treatment of life-threatening injuries/illnesses. If you are not sure how to proceed, CONTACT BASE. E. For patients who refuse medical treatment. F. If you are unsure whether or not a situation of involuntary consent applies, CONTACT BASE. Go to Table of Contents General Principles: Minors A. A parent, including a parent who is a minor, may consent to medical or emergency treatment of his/her child. There are exceptions: 1. Neither the child nor the parent may refuse medical treatment on religious grounds if the child is in imminent danger as a result of not receiving medical treatment, or when the child is in a life-threatening situation, or when the condition will result in serious handicap or disability. 2. The consent of a parent is not necessary to authorize hospital or emergency health care when an EMT-P in good faith relies on a minor's consent, if the minor is at least 15 years of age and emancipated or married. 3. Minors may seek treatment for abortion, drug addiction, and venereal disease without consent of parents. Minors > 15 years may seek treatment for mental health. B. When in doubt, your actions should be guided by what is in the minor's best interests and base contact. Procedure: Minors A. A parent or legal guardian may provide consent to or refuse treatment in a non- life-threatening situation. B. When the parent is not present to consent or refuse: 1. If a minor has an injury or illness, but not a life-threatening medical emergency, you should attempt to contact the parent(s) or legal guardian. If this cannot be done promptly, transport. 2. If the child does not need transport, they can be left at the scene in the custody of a responsible adult (e.g., teacher, social worker, grandparent). It should only be in very rare circumstances that a child of any age be left at the scene if the parent is not also present. 3. If the minor has a life-threatening injury or illness, transport and treat per protocols. If the parent objects to treatment, CONTACT BASE immediately and treat to the extent allowable, and notify police to respond and assist. Return to Table of Contents PHYSICIAN AT THE SCENE/MEDICAL DIRECTION Purpose A. To provide guidelines for prehospital personnel who encounter a physician at the scene of an emergency General Principles A. The prehospital provider has a duty to respond to an emergency, initiate treatment, and conduct an assessment of the patient to the extent possible. B. A physician who voluntarily offers or renders medical assistance at an emergency scene is generally considered a "Good Samaritan." However, once a physician initiates treatment, he/she may feel a physician-patient relationship has been established. C. Good patient care should be the focus of any interaction between prehospital care providers and the physician. Procedure See algorithm. Special notes A. Every situation may be different, based on the physician, the scene, and the condition of the patient. B. CONTACT BASE when any question(s) arise. NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMTs THANK YOU FOR OFFERING YOUR ASSISTANCE. The prehospital personnel at the scene of this emergency operate under standard policies, procedures, and protocols developed by their physician advisor. The drugs carried and procedures allowed are restricted by law and written protocols. After identifying yourself by name as a physician licensed in the State of Colorado and providing identification, you may be asked to assist in one of the following manners: 1. Offer your assistance or suggestions, but the prehospital care providers will remain under the medical control of their base physician or 2. With the assistance of the prehospital care providers, talk directly to the base physician and offer to direct patient care and accompany the patient to the receiving hospital. Prehospital care providers are required to obtain an order directly from the base physician for this to occur. THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY. Medical Director Agency Go to Table of Contents PHYSICIAN AT THE SCENE/MEDICAL DIRECTION ALGORITHM EMT arrives on scene EMS attempts patient care Physician reports on patient. Physician wants to help or is Relinquishes patient care. involved in patient care and will not relinquish patient care Provide care per protocol Prehospital provider identifies self and level of training Physician wishes to just help Physician requests or performs out care inappropriate or inconsistent with protocols Provide general instructions Prehospital care provider shares and utilize physician assistance Physician at the Scene/Medical Direction note with physician. Advise physician of your responsibility to patient Physician does not relinquish Physician complies patient and continues care inconsistent with protocols Contact base physician Continue per patient protocol Follow base physician's direction Document patient care on run report. Document difficulties or problems on the unusual circumstance report. Return to Table of Contents RESUSCITATION AND FIELD PRONOUNCEMENT GUIDELINES Purpose A. To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the prehospital setting General Principles A. Agency policy determines base contact requirements for patients for whom resuscitative efforts are being withheld. B. All patients found pulseless and apneic are to be resuscitated, except patients found in any of the following conditions: 1. Decapitation or 2. Decomposition or 3. Third degree burns over more than 90% of the total body surface area or 4. Dependent lividity or rigor mortis or 5. A valid CPR directive present with the patient or 6. Evidence of massive blunt head, chest, or abdominal trauma Special Considerations in Resuscitation Decisions: A. All cases described below require contact with a base physician to approve termination of treatment. 1. Blunt Trauma: Resuscitative efforts may be withheld or terminated in patients found apneic and pulseless with: a. Blunt trauma to the head, neck or torso; and b. No spontaneous pulse or respirations following appropriate medical interventions, which include, for example: ensuring a patent airway or chest decompression. (The majority of injuries sustained by these patients are not compatible with life. "Appropriate" interventions will vary and should be dictated by guidance from the base.) 2. Penetrating Trauma: a. Research data shows that a significant number of victims of penetrating trauma to the neck or torso, who are found without signs of life, may be successfully resuscitated. Therefore, resuscitation and rapid transport to a trauma facility should be initiated on all patients found in full arrest secondary to penetrating trauma. Exceptions may exist in the following circumstance: i. Patients found pulseless and apneic with penetrating trauma if the provision of ALS (EMT-Intermediate or EMT-Paramedic or emergency department) has been unavailable for at least 10 minutes from the time EMS personnel initiate on-scene assessment. (Some of the injuries sustained by these patients may be compatible with life. "Appropriate" interventions will vary and should be dictated by guidance from the base physician.) ii. However, if there is any doubt about duration of the arrest, then resuscitation and rapid transport should be initiated. 3. Medical Patients (i.e., no evidence of trauma and presumed medical arrest) should receive resuscitative treatment until there is: Go to Table of Contents a. No return of spontaneous pulse or respirations during 15 minutes of CPR (after successful intubation and medications) and no reversible causes have been identified; or b. Continuous asystole for at least 10 minutes in the adult patient, and 30 minutes in a pediatric patient (after successful intubation and medications), and no reversible causes have been identified c. The following patients found pulseless and apneic warrant resuscitation efforts beyond 30 minutes and should be transported: i. Hypothermic; or ii. Drowning with submersion less than 60 minutes (with hypothermia); or iii. Pregnant and estimated to be 20 weeks or later in gestation 4. After pronouncement, do not alter condition in any way or remove equipment (lines, tubes, etc.) as the patient is now a potential coroner's case. Advance Medical Directives A. There are several types of advance medical directives (documents in which a patient identifies the treatment to be withheld in the event the patient is unable to communicate or participate in medical treatment decisions). B. Do not resuscitate (DNR) orders are generally intended to be written by a physician for a patient whose medical condition is such that commencement of resuscitation efforts would be futile. C. A Colorado living will ("Declaration as to Medical or Surgical Treatment") requires a patient to have a terminal condition, as certified in the patient's hospital chart by two physicians. For the document to become operative, the patient must be unresponsive because of a terminal condition for a period of seven days. D. Other types of advance directives may be a "Durable Medical Power of Attorney," or "Health Care Proxy" (the CPR Directive is covered separately. Each of these documents can be very complex and require careful review and verification of validity and application to the patient's existing circumstances. Therefore, the consensus is that resuscitation should be initiated until a physician can review the document or field personnel can discuss the patient's situation with the base physician. E. Resuscitation may be withheld from or terminated for a patient who has a valid, written do not resuscitate order or other advance medical directive. 1. The document is clear, unequivocally to the prehospital provider that CPR, intubation and defibrillation are refused by the patient or by the patient's attending physician who has signed the document; and 2. Base physician has approved of withholding or ceasing resuscitative efforts; and 3. There is no apparent indication of suicidal gesture or intent by the patient. F. If there is disagreement at the scene about what should be done, the base should be contacted immediately for guidance. G. Prehospital providers presented with equivocal DNR orders or advance medical directives should proceed with resuscitation and establish base contact for guidance on treatment and transport. 1. If the directive document is long and detailed, then it is probably more reasonable for resuscitation to be initiated and the patient to be transported so that the base physician can review the document and possibly contact the patient's attending physician. Return to Table of Contents 2. The duration of the resuscitation should be guided by the same factors of any medical cardiac arrest. H. Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family or an attending physician directs resuscitation be ceased, the prehospital provider should immediately CONTACT BASE. The prehospital provider should accept verbal orders to cease resuscitation only from the base physician. I. There may be times in which the prehospital provider feels compelled to perform or continue resuscitation, such as a hostile scene environment, family members adamant that "everything be done," or other highly emotional or volatile situations. In such circumstances, the prehospital provider should attempt to confer with the base for direction and if this is not possible, the prehospital provider must use his or her best judgment in deciding what is reasonable and appropriate, including transport, based on the clinical and environmental conditions, and establish base contact as soon as possible. Additional Considerations: A. Mass casualty incidents are not covered in detail by these guidelines. (See Colorado State Unified Disaster Tag and Triage System: A Guide to MCI). B. These guidelines apply to both adult and pediatric patients. C. If the situation appears to be a potential crime scene, EMS providers should disturb the scene as little as possible. D. ALS personnel should document asystole for 10 seconds in at least two leads prior to withholding or terminating resuscitative efforts. However, base physicians and prehospital providers must use discretion when considering the need for a rhythm strip (i.e., monitor strips are not necessary in patients found decapitated, decomposed or with dependent lividity or rigor mortis). E. Mechanism for disposition of bodies by means other than EMS providers and vehicles should be prospectively established in each county or locale. 1. In all cases of unattended deaths occurring outside of a medical facility, the coroner should be contacted immediately. 2. Patients with valid DNR orders or advance medical directives should receive medical treatment and supportive or comfort care prior to cardiac arrest. Return to Table of Contents 1000 AIRWAY & VENTILATION GENERAL PRINCIPLES The following protocols are recommended as a guide for approaching difficult medical and trauma airway problems. They assume that the responder is skilled in the various procedures, and will need to be modified according to training level. Advanced procedures should only be attempted if simpler ones fail and if the technician is qualified. Individual cases may require modification of these protocols. All patients require continuous monitoring of their airways to ensure airway patency. Wherever the term "Monitor airway" is used throughout these protocols, the following elements shall be utilized: • Position of the patient's head • Need for airway adjuncts • Need for oropharyngeal suctioning; • Need for Advanced Life Support airway management techniques • Use of Pulse Oximetry (SpO2), if available • Use of secondary form of Endotracheal Tube confirmation (Example: End Tidal Capnography (ETCO2). Secondary confirmation devices are not a substitute for primary confirmation techniques that rely upon direct visualization and auscultation, but serve as an additional method of documenting proper endotracheal tube placement. Definitions Respiratory distress – Signs and symptoms may include increased respiratory effort, peripheral cyanosis, tachypnea, accessory muscle use, anxiety and adventitious lung sounds upon auscultation. Respiratory insufficiency/failure – signs and symptoms include the above with central cyanosis and insufficient air exchange, tiring, and inability to speak in complete sentences. Pediatric respiratory distress is characterized by increased respiratory effort with peripheral cyanosis, i.e. anxiety, tachypnea, nasal flaring and intercostal retractions. Respiratory failure in a child is characterized by ineffective respiratory effort with central cyanosis, i.e. agitation or lethargy, severe dyspnea or labored breathing, bobbing or grunting, and marked intercostal and parasternal retractions. Use appropriate airway adjuncts as indicated – These are devices that are approved for the level of the provider and by the agency's Medical Director. NOTE: Bradycardia is an ominous sign that indicates hypoxic cardiac arrest may be imminent Go to Table of Contents METHODS OF OPENING THE AIRWAY HEAD TILT-CHIN LIFT: Technique: From beside head, place one hand on forehead. Grasp lower edge of chin with fingers of other hand and lift chin forward. Teeth may come together. Indications: Medical patient. May require less neck extension than head tilt. Useful with dentures. May be used without head tilt in trauma victims. JAW THRUST: Technique: Position yourself above patient. Place fingers of each hand under angle of jaw, just below ears. Lift jaw, using forearms to maintain head alignment. Indications: Trauma victim or medical patient, where neck extension is not possible. Another rescuer must do BVM ventilation, and this is a fatiguing method. May be used with dentures in place. Providers are reminded that aggressive treatment is indicated for better outcomes. Return to Table of Contents 1010 OBSTRUCTED AIRWAY Indications A. Complete or partial obstruction of the airway due to a foreign body. B. Complete or partial obstruction due to airway swelling from anaphylaxis, croup, or epiglottitis. C. Patient with unknown illness or injury who cannot be ventilated after procedures of previous protocol: Opening the Airway. Precautions A. Perform chest thrusts only in visibly pregnant patients, obese patients, and in infants. B. Patients with partial airway obstruction can be very uncomfortable and vociferous. Abdominal or chest thrusts will not be effective and may cause injury to the patient who is still breathing. Be ready to intervene promptly if arrest occurs. C. Hypoxia from airway obstruction can cause seizures. Chest or abdominal thrusts may not be effective until the patient becomes relaxed after the seizure is over. Technique A. COMPLETE AIRWAY OBSTRUCTION: 1. Open airway using head tilt-chin lift or jaw thrust. 2. Attempt to ventilate using BVM ventilations or mouth to mask. 3. If unable to ventilate, reposition airway and reattempt ventilations. 4. If airway remains obstructed, visualize with laryngoscope and remove any IN obvious foreign body. 5. If unable to ventilate, administer 5 subdiaphragmatic abdominal thrusts. 6. Reposition the airway and reattempt to ventilate. 7. Consider percutaneous cricothyrotomy if obstruction is above the cords P unrelieved or unusable to ventilate adequately with bag-valve. See Appendix for more information. 8. When obstruction is relieved: a. Keep patient on side, sweeping airway to remove debris. b. Administer high flow oxygen via reservoir mask. c. Assess adequacy of ventilation, and support as needed. d. Suction aggressively. e. Restrain if combative . B. PARTIAL AIRWAY OBSTRUCTION: 1. Have patient assume most comfortable position. 2. Administer high flow oxygen by non-rebreather mask. 3. Attempt suctioning of upper airway. 4. If patient is unable to move air, confused, or otherwise deteriorating, visualize airway, remove foreign body or perform abdominal thrusts as noted above. Go to Table of Contents Complications A. Hypoxic brain damage and death from unrecognized or unrelieved obstruction. B. Trauma to ribs, lung, liver and spleen from chest or abdominal thrusts (particularly when forces are not evenly distributed). C. Vomiting and aspiration after relief of obstruction. D. Creation of complete obstruction after blind incorrect finger probing. E. Tonsillar or pharyngeal laceration from over vigorous finger sweep. Return to Table of Contents 1020 CLEARING AND SUCTIONING THE AIRWAY Indications A. To remove foreign material that can be removed by a suction device. B. To remove excess secretions or pulmonary edema fluid in upper airway or lungs (with endotracheal tube in place). C. To remove meconium or amniotic fluid in mouth, nose and oropharynx of newborn Technique A. Turn patient on side if possible, to facilitate clearance. B. Open airway and inspect for visible foreign material. C. Remove large or obvious foreign matter with gloved hands. Use padded tongue blade or oropharyngeal airway (do not pry) to keep airway open. Sweep finger across posterior pharynx and clear material out of mouth. D. Suction of oropharynx: 1. Attach tonsil tip (or use open end for large amounts of debris). 2. Ventilate and oxygenate the patient as needed prior to the procedure. 3. Insert tip into oropharynx under direct vision, with sweeping motion. 4. Continue intermittent suction interspersed with active oxygenation by mask or cannula. Use positive pressure ventilation if needed. E. Catheter suction of endotracheal tube: IN 1. Hyperventilate patient prior to any suctioning attempts. 2. Put on sterile gloves. 3. When catheter tip has been gently advanced as far as possible, apply suction and withdraw catheter slowly. NOTE: Suctioning should only done with a sterile catheter. 4. Rinse catheter tip in sterile water or saline. 5. Administer oxygen appropriately following suctioning. F. Suction of the newborn: 1. Use neonatal suctioning device. 2. As soon as infant's head has delivered, insert suction tip into the mouth and back to oropharynx. 3. Apply suction while slowly withdrawing catheter from the mouth. 4. Insert catheter tip into each nostril and back to posterior pharynx. 5. Apply suction while slowly withdrawing catheter from each nostril. 6. As soon as infant has delivered, repeat process. IN G. Suction trachea under direct vision with laryngoscope if there is evidence of meconium aspiration. Complications A. Hypoxia due to excessive suctioning time without adequate ventilation between attempts. B. Persistent obstruction due to inadequate tubing size for removal of debris. C. Lung injury from aspiration of stomach contents due to inadequate suctioning. D. Asphyxia due to recurrent obstruction if airway is not monitored after initial suctioning. E. Conversion of partial to complete obstruction by attempts at airway clearance. F. Trauma to the posterior pharynx from forced use of equipment. Go to Table of Contents G. Vomiting and aspiration from stimulation of gag reflex. H. Induction of cardio-respiratory arrest from Vagal Nerve stimulation. Side Effects and Special Notes A. Complications may be caused both by inadequate and overly vigorous suctioning. Technique and choice of equipment are very important. Choose equipment with enough power to suction large amounts rapidly to allow time for ventilation. B. Proper airway clearance can make the difference between a patient who survives and one who dies. Airway obstruction is one of the most common treatable causes of prehospital death. Return to Table of Contents 1030 ASSISTING VENTILATION Indications A. Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory depression. B. To apply positive pressure ventilation in patients with pulmonary edema and severe fatigue. C. To ventilate patients in respiratory arrest. Precautions A. Two people are often required to obtain an adequate mask fit and also ventilate. B. Assisted ventilation will not hurt a patient, and should be used whenever the breathing pattern seems shallow, slow, or otherwise abnormal. Do not be afraid to be aggressive about assisting ventilation, even in patients who do not require or will not tolerate intubation. C. Early intubation may be of benefit for patients who continue to bleed or vomit. Technique A. Open the airway. Check for ventilation. B. Administer ventilations. If unsuccessful, go to Airway Obstruction protocol. C. Check pulse. If absent, go to Cardiac Arrest protocol. D. Attach oxygen to BVM. E. Position yourself above patient's head, continue to hold airway position, seat mask firmly on face, and begin assisted ventilation. F. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust mask fit as needed. G. If patient resumes spontaneous respirations, continue to administer supplemental oxygen. Intermittent assistance with ventilation may still be needed. H. Continuous monitoring of pulse oximetry is required. I. Use Capnography, if available. Complications A. Continued aspiration of blood, vomitus, and other upper airway debris B. Inadequate ventilations due to poor seal between patient's mouth and ventilatory device C. Gastric distention, possibly causing vomiting D. Trauma to the upper airway from forcible use of airways E. Pneumothorax Go to Table of Contents 1040 IN P OROTRACHEAL INTUBATION Indications A. In most cases orotracheal intubation provides definitive control of the airway. Its purposes include: 1. Actively ventilating the patient 2. Delivering high concentrations of oxygen 3. Suctioning secretions and maintaining airway patency 4. Preventing aspiration of gastric contents, upper airway secretions, or bleeding 5. Preventing gastric distention due to assisted ventilation 6. Administering positive pressure when extra fluid is present in alveoli 7. Allowing more effective CPR 8. Administering drugs during resuscitation for absorption through the lungs as a last resort. Precautions A. Do not use intubation as the initial method of managing the airway in an arrest. Oxygenation prior to intubation should be accomplished with pocket mask or BVM as needed. B. Appropriate intubation precautions should be taken in the trauma patient. Nasotracheal intubation is preferred in the breathing patient. Oral intubation with in-line cervical immobilization is the best alternative for a trauma patient requiring definitive airway control. C. Never lever the laryngoscope against the teeth. The jaw should be lifted with direct upward traction by the laryngoscope. D. Prepare suction beforehand. Vomiting is particularly common when the esophagus is intubated. E. Intubation should take no more than 20 seconds to complete: do not lose track of time. If visualization is difficult, stop and re-ventilate before trying again. F. Orotracheal intubation can be accomplished in trauma victims if an assistant maintains stabilization and keeps the neck in neutral position. Careful visualization with the laryngoscope is needed, and McGill forceps may be helpful in guiding the ET tube. G. If the patient presents with a difficult airway or difficulties are expected then use of OTHER AIRWAY DEVICES may be preferable to intubation. Technique A. Use BSI including gloves, mask, eye protection. Assemble the equipment while continuing ventilation: 1. Choose tube size (see table on next page). Use the largest tube available. 2. Introduce the stylette and be sure it stops ½" short of the tube's end. 3. Assemble laryngoscope and check light. 4. Connect and check suction. B. Position patient: neck flexed forward, head extended back. Back of head should be level with or higher than back of shoulders. C. Give a minimum of 4 good ventilations before starting procedure. D. Have an assistant apply gentle cricothyroid pressure to prevent aspiration and to assist in visualization of vocal cords. E. Gently insert laryngoscope to right of midline. Move it to midline, pushing tongue to left and out of view. Go to Table of Contents F. Lift straight up on blade (no levering) to expose posterior pharynx. G. Identify epiglottis: tip of curved blade should sit in vallecula (in front of epiglottis); straight blade should slip over epiglottis. H. With gentle further traction to straighten the airway, identify trachea from arytenoid cartilages and vocal cords. I. Insert tube from right side of mouth, along blade into trachea under direct vision. J. Advance tube so cuff is 1-1½" beyond cords. Inflate cuff with 5-10 ml of air, clamp if necessary to secure against leaks. K. Ventilate and watch for chest rise. Listen for breath sounds over stomach (should not be heard), lungs and axillae. L. Note proper tube position and secure tube with tape or ties. M. Re-auscultate over stomach and both sides of chest whenever patient is moved. N. End tidal CO2 colormetric devices can be used for initial tube confirmation however, IT IS REQUIRED TO CONFIRM TUBE PLACEMENT WITH CAPNOGRAPHY. See Protocol: Capnography O. Accurate documentation includes indications for intubation as well as measures taken for tube verification. P. If patient is in cardiac arrest for medical reasons then use of a ResQPod device is required. Complications A. Esophageal intubation: particularly common when tube not visualized as it passes through cords. The greatest danger is in not recognizing the error. Auscultation over stomach during trial ventilations should reveal air gurgling through gastric contents with esophageal placement. Also make sure patient's color improves as it should when ventilating. B. Intubation of right main stem bronchus: be sure to listen to chest bilaterally. C. Upper airway trauma due to excess force with laryngoscope or to traumatic tube placement D. Vomiting and aspiration during traumatic intubation or intubation of patient with intact gag reflex E. Hypoxia due to prolonged intubation attempt F. Cervical spine fracture in patients with arthritis and poor cervical mobility G. Cervical cord damage in trauma victims with unrecognized spine injury H. Ventricular arrhythmias or fibrillation in hypothermia patients from stimulation of airway I. Induction of pneumothorax, either from traumatic insertion, forceful bagging, or aggravation of underlying pneumothorax Return to Table of Contents OROTRACHEAL TUBE SIZE AGE ENDOTRACHEAL TUBE Preemie 2.5 - 3.0 uncuffed Newborn 3.0-3.5 uncuffed 6 mos. 3.5 uncuffed 18 mos. 4.0 uncuffed 3 yrs. 4.5 uncuffed 5 yrs. 5.0 uncuffed 8 yrs. 6.0 cuffed 15 yrs. 6.5-7.0 cuffed Adult 7.0-9.0 cuffed Note: The pediatric Broselow™ tape is the most accurate predictor of tube size. Return to Table of Contents 1050 P NASOTRACHEAL INTUBATION Indications A. Same function as orotracheal intubation in patients greater than 12 years of age B. Used in the breathing patient requiring intubation C. Asthma or pulmonary edema with respiratory failure, where intubation may need to be achieved in a sitting position Precautions A. Head must be exactly in midline for successful intubation. B. Have suction ready. Vomiting can occur, as with any stimulation of the airway. C. Often nares are asymmetrical and one side is much easier to intubate. Avoid inducing bilateral nasal hemorrhage by forcing a nasotracheal tube on multiple attempts. D. The use of nasotracheal intubation should be discouraged in patients with significant nasal or craniofacial trauma. E. Blind nasotracheal intubation is a very gentle technique. In the field, the secret of blind intubation is perfect positioning and patience. F. Only absolute contraindication is apnea G. Should not be attempted in children under 12 years of age Technique A. Choose correct ET tube size (usually 7 mm tube in adult). Limitation is nasal canal diameter. B. Position patient with head in midline, neutral position (cervical collar may be in place, or assistant may provide cervical stabilization in trauma patients). C. Administer Phenylephrine nasal drops, 1 – 2 gtts, in both nostrils. D. Assist ventilations prior to procedure if spontaneous respirations are inadequate. E. Lubricate ET tube with Xylocaine jelly or other water-soluble lubricant. F. With gentle steady pressure, advance the tube through the nose to the posterior pharynx. Use right or largest nostril. Abandon procedure if significant resistance is encountered. G. Keeping the curve of the tube exactly in midline, continue advancing slowly. H. There will be a slight resistance just before entering trachea. Wait for an inspiratory effort before final advance into trachea. Patient may also cough or buck just before breath. I. Continue advancing until air is exchanging through the tube. J. Advance about 1 inch further, then inflate cuff. K. Ventilate and auscultate chest and abdomen for proper tube placement. L. Note proper tube position and tape securely. M. Apply Capnography for continuous end tidal CO2 monitoring Complications A. Same as orotracheal intubation. In addition: 1. Further craniofacial injury particularly in patients presenting with facial trauma 2. Nasal bleeding caused by tube trauma. 3. Vomiting and aspiration in the patient with intact gag reflex. Go to Table of Contents 1060 END-TIDAL CO2 MONITORING IN P Indications A. All intubated patients require continuous end-tidal CO2 monitoring device and although end-tidal colorimetric devices can be used for initial confirmation, Capnography must still be used. Colorimetric devices are not standard of care for prolonged monitoring of intubated patients. B. Continuous end-tidal CO2 monitors are to be used to monitor patients requiring a mechanical ventilator during transportation. The monitor is used to determine if an endotracheal tube has become displaced or to detect the disruption of the ventilator circuit. See Protocol: Capnography Precautions A. Caution should be exercised to ensure that the clinical picture matches the colorimetric end-tidal CO2 detector reading. Technique - Colorimetric End-tidal CO2 Detectors A. The colorimetric end-tidal CO2 detector should be placed in-line between the endotracheal tube and the BVM immediately after the endotracheal tube is passed. B. Proper tube placement is confirmed by a color change in the colorimetric device, indicating the elevated concentrations of CO2 expected in the trachea. Elevated concentrations of CO2 are not expected in the esophagus. Complications A. Contamination with blood and secretions may render colorimetric end-tidal CO2 detectors ineffective. B. Device may be ineffective or inaccurate in patients without spontaneous circulation. Note A. Adhere to the expiration dates on these devices. B. Follow manufacturers instructions for appropriate ranges and color indications. Go to Table of Contents 1070 PERCUTANEOUS CRICOTHYROTOMY P Introduction A. Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be used only in extraordinary circumstances as defined below. The reason for performing this procedure must be documented and submitted for review to the physician advisor or designee within 24 hours. Percutaneous cricothyrotomy is to be performed only by paramedics trained in the procedure. Indications A. When a life threatening condition exists and advanced airway management is indicated, and you are unable to establish airway by other means. Precautions A. Bleeding is possible, even with correct technique. Straying from the midline is very dangerous and likely to cause hemorrhage from the carotid or jugular vessels, or their branches. Technique A. Using aseptic technique (Betadine/alcohol wipes) cleanse the area. B. Position the patient in a supine position, with in-line spinal immobilization if indicated. C. At this time the scalpel included with the kit may be used to make a ¼ inch vertical incision through the skin, over the cricothyroid membrane. D. Using the prepackaged set, insert the needle or over-the-needle-catheter through the cricothyroid membrane in a caudal direction at a 45-degree angle. E. If using an over-the-needle-catheter, remove the syringe and needle. Otherwise remove the syringe. F. Insert the guidewire through the catheter or needle. G. Remove the catheter or needle over the wire. H. Slide the dilator and tracheostomy tube onto the wire into the neck incision. I. Push the dilator through the cricothyroid membrane with a twisting motion, and insert the tracheostomy tube into the trachea. J. Remove the dilator and wire, leaving the tracheostomy tube in place. K. Ventilate with BVM and 100% oxygen. L. Confirm tube placement is successful. (Chest rise and fall, breath sounds, secondary confirmation device). Observe for subcutaneous air, indicating tracheal injury or improper placement. M. Secure tube with ties. N. Transport to appropriate facility. Go to Table of Contents 1080 OTHER AIRWAY DEVICES Introduction Dual lumen airway device(s) are to be used as a rescue when endotracheal intubation is not preferable, possible and/or BLS methods have proven unsuccessful. These devices have external insertion depth marks, an anatomically shaped proximal cuff to seal the nasopharynx and oropharynx, and a distal cuff to seal the esophagus and to help minimize the possibility of gastric insufflation. The second channel, or gastric access lumen, allows the ability to pass a French suction catheter (18 f for adults) into the stomach. Depending on the device, the airways may be sized or limited to patients between 4'8" and 6 ft in height. Indications 1. Cardiac arrest 2. Difficult airway cases where endotracheal intubation is not possible and BLS methods are unsatisfactory or unsuccessful. Contraindications/Precautions 1. Responsive patients with an intact gag reflex 2. Known esophageal disease 3. Known ingestion of caustic substances 4. Respiratory burns King LT-D 1. Choose correct size, based on patient height. 2. Test cuff and inflation system for leaks by injecting the maximum recommended volume of air into the cuffs. Remove all air from both cuffs prior to insertion. 3. Apply lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near the ventilatory openings. 4. Pre-oxygenate, if possible. 5. Position the head. The ideal head position is the "sniffing position". However, it may also be inserted with the head in a neutral position. 6. With the dominant hand holding the King device at the connector. With non- dominant hand, hold mouth open and apply chin lift. 7. With the device rotated laterally 45-90o such that the blue orientation line is touching the corner of the mouth, introduce tip into mouth and advance behind base of tongue. 8. As tube tip basses under tongue, rotate tube back to midline (blue orientation line faces chin). 9. Without exerting excessive force, advance tube until base of connector is aligned with teeth or gums. 10. Using syringe, inflate both cuffs, using the recommended amount of air for the device (size 3 = 50 ml, size 4 = 70 ml, size 5 = 80 ml). 11. Attach EtCO2 monitor to ventilation port. 12. While gently ventilating with a BVM, withdraw until ventilation is optimized. Go to Table of Contents 13. Attach ResQPod to ventilation port 14. Confirm proper position by auscultation, chest movement and verification of CO2 by EtCO2 monitor. a. Depth markings are provided at the proximal end of the King LT-D. These refer to the distance from the distal ventilatory opening. When properly placed, with the distal tip and cuff in the upper esophagus, and the ventilatory openings aligned with the opening to the larynx, the depth markings give an indication of the distance, in centimeters, from the vocal cords to the teeth. 15. Secure King device to patient using tape or other accepted means. A bite block can also be used, if desired. Complications and Special Notes Because of the relative lack of complications and the ability to place this airway without interruption of CPR, it should be considered a primary airway device in cardiac arrest. The King LT-D Airway is to be used in unconscious, apneic patients or those unconscious patients who are spontaneously breathing but without a gag reflex, If the patient regains consciousness or develops a gag reflex, prepare suction, immediately deflate all cuffs and remove the device. Patients that do not fall within the height ranges of the device will instead require intubation. DO NOT USE THIS DEVICE IF THE PATIENT IS NOT OF ADEQUATE HEIGHT. Return to Table of Contents 1081 ResQPod (Circulatory Enhancer) The ResQPOD circulatory Enhancer provides a small but important amount of resistance when breathing through the device. This resistance increases blood flow back to the heart, so that on the next chest compression, more blood is circulated out of the heart, through the coronary arteries and the rest of the body. This device can be used during assisted ventilation to improve circulation. Indications Assisted ventilations for patients with an advanced airway during cardiac arrest (ET tube or King Airway) Contraindications/Precautions Conscious patients Known dilated cardiomyopathy Known pulmonary hypertension and/or aortic stenosis Chest trauma Technique 1. Once the patient is endotracheally intubated, attach the EtCO2 device to the ET tube then attach the bottom of the ResQPOD directly to the top of the EtCO2 device. 2. Be sure all pieces fit as tightly together as possible, ensuring that the airway adjunct has not become dislodged. 3. Attach the BVM to the top of the ResQPOD and begin ventilating, using the EtCO2 values to direct your rate of ventilations. Complications and Special Notes The device has a timing assist light, that when switched to the "On" position may serve as a guide to administering ventilations at a rate of ten (10) per minute. The ResQPOD is for single patient use only. The ResQPOD may be used with other airway adjuncts, such as rescue airways (King LT-D). Return to Table of Contents 2000 CARDIAC ARREST GENERAL PRINCIPLES Specific Information Needed A. History of arrest: onset, preceding symptoms, bystander CPR, other treatment, duration of arrest B. Past history: medical/surgical history, medications, allergies C. Surroundings: environmental conditions, evidence of drug ingestion, trauma, other unusual presentations Document Specific Objective Findings A. Absence of consciousness B. Agonal or no respirations C. Absence of pulse D. Signs of trauma, blood loss E. Skin temperature General Treatment Guidelines A. Assure unobstructed airway B. Request ALS assistance if not already on scene or responding. C. Refer to appropriate protocol 1. Automated External Defibrillator (AED) – protocol 2010 2. Witnessed/Unwitnessed Adult Cardiac Arrest – protocol 2020 3. Trauma Arrest - protocol 5010 4. Pediatric Arrest - protocol 6020 Special Notes A. Survival from cardiac arrest is related to the time to BOTH BLS and ALS treatment. Don't forget CPR in the rush for advanced equipment. A call for back- up should be initiated promptly by any BLS unit. Likewise, standing order administration of the first steps in treatment is recommended to minimize time delays to ALS. B. Large peripheral veins (antecubital or external jugular) are preferred IV sites in cardiac arrest. IO access should be considered if first attempt peripheral access is unsuccessful. Additional lines can be started later in the arrest and IO access is preferred to ET drug administration. C. Quick-look paddles-or Combi-Pads are preferred for initial rhythm check. Be sure machine is set to record from whichever mode is in use. D. Be sure to recheck for pulselessness and unresponsiveness upon arrival, even if CPR is in progress. This will avoid needless and dangerous treatment of "collapsed" patients who are inaccurately diagnosed initially, or who have spontaneous return of cardiac function after an arrhythmia or vasovagal episode. E. After conversion to another rhythm, providers should switch to the appropriate protocol for continued and ongoing treatment. F. Good high quality CPR with minimal interruption is shown to improve survival more than any procedure or drug administration. Be sure it is being done correctly. Avoid hyperventilation. G. If appropriate, OTHER AIRWAY DEVICES like the King airway should be considered first line to avoid delay in securing the airway while minimizing interruptions to compressions. H. The ResQPod device should be used in arrest when appropriate. Go to Table of Contents 2010 AUTOMATED EXTERNAL DEFIBRILLATOR Indications A. Patient must be unconscious, pulseless and apneic. Precautions A. A patient who is talking is not pulseless. B. AEDs may be utilized for pediatric arrests if pediatric-sized defibrillator pads are available and compatible with the machine. C. Do not use on trauma patients. D. Dry the chest well if wet. E. Remove any transdermal patches to avoid igniting a Nitroglycerin patch. F. If an airway obstruction exists, clear the airway before using AED. G. Protect rescuers: "Clear" the patient, use only in safe and dry environment. H. May not be able to use in a moving vehicle. Technique A. Follow manufacturer directions for AED operation. In absence of specific operational instructions, the following technique is used. 1. Determine unresponsiveness. 2. Open airway, check for breathing, give a breath if no respirations. 3. Determine pulselessness. 4. Apply AED according to manufacturer's guidelines. 5. Turn the AED on and follow its instructions. 6. Assure all rescue personnel are "Clear" and not touching the patient or stretcher. 7. Whenever "no shock advised" or following a delivered shock, check patient's pulse. If no pulse, begin CPR and reanalyze every 2 minutes. 8. Use appropriate airway adjuncts to secure airway. If there is a pulse, check breathing and assist as needed. 9. Once the AED is applied, necessary steps should begin immediately to transport the patient to the hospital or rendezvous with an advanced life support ambulance. 10. Shocks may be continued during transport, as long as indicated. 11. After 2 minutes of CPR, check pulse again. If no pulse, repeat steps to analyze and defibrillate as long as shocks are indicated. Special Notes A. A rescuer may be shocked if one forgets to clear the area, or leans against metal stretcher or patient during procedure. B. Expired AED patches can cause arching of electricity or inadequate shock. C. Do not delay this procedure by performing other procedures first, such as airway adjuncts and IV access. D. In presumed hypothermic patients, institute hypothermia protocol and contact base. Go to Table of Contents 2020 VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA Unwitnessed * Witnessed Adult (>12) Cardiac Arrest 2 Minutes of Compressions (80- V-Fib or Pulseless V-Tach 100/min) No interruptions **IV, Epi, Airway Defibrillate 1x at Max Joules Asystole/PEA/NSA* V-Fib or Pulseless V-Tach ROSC ACLS/BCLS Algorithm Defibrillation x 1 Max joules ACLS/BCLS Algorithm Asystole/PEA/NSA* V-Fib or Pulseless V-Tach ROSC ACLS/BCLS Algorithm Compressions 2 minutes without ACLS/BCLS Algorithm pauses **IV, Epi, Airway Defibrillation x 1 Max joules Asystole/PEA/NSA* V-Fib or Pulseless V-Tach ROSC ACLS/BCLS Algorithm Compressions 2 minutes without ACLS/BCLS Algorithm pauses **IV, Epi, Airway Defibrillation x 1 Max joules Asystole/PEA/NSA* V-Fib or Pulseless V-Tach ROSC ACLS/BCLS Algorithm ACLS/BCLS V-Fib / Pulseless V- ACLS/BCLS Algorithm Tach Algorithm Must be medical, normothermic arrest Must be from primary respiratory mechanism NSA* - no shock advised on AED * Witnessed by provider with defibrillator immediately available ** If possible without interrupting compressions ** Ventilation rate should be 8-10 per minute Go to Table of Contents 2020 VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA (Continued from 2020 – Unwitnessed/Witnessed Adult Cardiac Arrest) 1. Administer Amiodarone 300 mg IV bolus for refractory VF/VT. 2. Defibrillate at maximum joule setting. (Pridemark: 360 Joules) 3. Consider Magnesium Sulfate, 2 gm IV bolus 4. Defibrillate at maximum joule setting. 5. Consider transport options. Special notes A. Per AHA guidelines CPR should be performed immediately after each defibrillation attempt for two minutes prior to performing rhythm checks. B. Torsade de pointes is a rare and special form of ventricular-tachycardia. Consider treating with Magnesium sulfate. C. The initiation of IV or airway treatments should not delay defibrillation. D. After conversion from VF/VT, consider Amiodarone 150 mg IV bolus infusion over 10 minutes. Return to Table of Contents 2030 ASYSTOLE IN A. Begin Basic Life Support measures, including CPR B. Establish airway. C. Establish IV/IO access D. Begin cardiac monitoring. Confirm asystole in at least two leads. E. Consider transcutaneous pacing. CB F. Administer epinephrine 1.0 mg, (1 ml of a 1:10,000 solution) IV bolus. If no IN change, repeat every 3-5 minutes. G. Administer atropine 1.0 mg, IV bolus. If no change, repeat every 3-5 minutes, not to exceed 3.0 mg. H. Administer sodium bicarbonate 1.0 mEq/kg, IV bolus. This should be considered only in prolonged cardiac arrest situations. I. Contact base for transport options. Special notes A. Patients who convert from a viable rhythm into asystole should have transcutaneous pacing initiated immediately. However, pacing should be withheld from those patients who present in asystole. B. The effectiveness of transcutaneous pacing is directly related to the speed with which this therapy is initiated. C. When asystole is diagnosed, check the integrity of the leads and electrode patches and confirm this interpretation in at least two leads. D. In pediatric patients, after ABCs have been initiated, ventilate, consider an IV fluid bolus of normal saline 20 ml/kg, reassess, consider epinephrine. Go to Table of Contents 2040 PULSELESS ELECTRICAL ACTIVITY (PEA) INITIATE SUPPORTIVE MEASURES: IN - ABCs - CPR - Endotracheal intubation - Establish venous access IN CB CONSIDER POSSIBLE CAUSES: TREATMENT: Hypovolemia IV fluid bolus (20 ml/kg normal saline) Tension pneumothorax Chest decompression (per protocol) Hypoxia Ensure airway patency Acidosis Ventilation Cardiac tamponade IV fluid bolus (20 ml/kg normal saline) Hypothermia see 4063 Hypothermia protocol Pulmonary embolism Myocardial infarction Drug overdose Hyperkalemia Sodium bicarbonate EPINEPHRINE (1:10,000) Pediatric doses: First dose: 0.01 mg/kg IV/IO/ET (0.1 ml/kg of 1:10,000 1.0 mg IV/IO push, repeat every 3 – 5 solution); Subsequent doses: 0.01 minutes mg/kg, IV/IO/ET (0.1 ml/kg of 1:10,000 solution ATROPINE for BRADYCARDIA 1.0 mg IV/IO push, repeat every 3-5 Pediatric dose: refer to Length Based minutes, not to exceed 3.0 mg Measurement tool INITIATE TRANSPORT Special notes A. Standing orders should expedite care - not prolong scene time. Rapid transport is still the goal. B. In pediatric patients, ventilate, consider fluid bolus, reassess, consider epinephrine. Go to Table of Contents 2050 IN ARRHYTHMIAS: GENERAL CONSIDERATIONS AND TREATMENT Specific Information Needed A. Present symptoms: sudden or gradual onset, palpitations B. Associated symptoms: chest pain, dizziness or fainting, trouble breathing, abdominal pain, fever C. Prior history: arrhythmias, cardiac disease, exercise level, pacemaker D. Current medications, particularly cardiac Specific Objective Findings A. Vital signs B. Signs of poor cardiac output: 1. Altered level of consciousness 2. Outward appearance of shock: cool/clammy skin, pallor, diaphoresis 3. Systolic blood pressure < 90 mmHg C. Signs of cardiac failure (increased back-up pressure): 1. Neck vein distention 2. Lung congestion, rales 3. Peripheral edema: sign of chronic failure, not acute D. Signs of hypoxia: marked respiratory distress, cyanosis, tachycardia Advanced treatment, general A. Administer oxygen, position of comfort. B. Establish venous access. C. Evaluate the patient. Is the patient perfusing adequately or are there signs of inadequate perfusion? D. Apply cardiac monitor and evaluate arrhythmia. 1. Is there a pulse corresponding to monitor rhythm? 2. Rate: tachycardia, bradycardia, normal? 3. Are the ventricular complexes wide or narrow? 4. What is the relation between atrial activity (P waves) and ventricular activity? 5. Is the arrhythmia potentially dangerous to the patient? E. Document the arrhythmia by rhythm strip and 12 lead EKG if available. F. Treat if needed according to pulse rate, perfusion status, risk of deterioration or as directed by base physician. G. Document results of treatment (or lack thereof) by checking pulse and recording change on paper tape. H. Transport patient. Monitor condition enroute. Go to Table of Contents Specific Precautions A. Treat the patient, not the arrhythmia! If the patient is perfusing adequately, he does not need emergency treatment. This is true of bradyarrhythmias as well as tachyarrhythmias. What is normal for one person may be fatal to another. B. Documentation of arrhythmias is extremely important. Field treatment of an arrhythmia may be life saving, but long-term treatment requires knowing what the problem was. C. Correct arrhythmia diagnosis based only on monitor strip recordings is difficult and often not possible. Treatment must be based on observable parameters: rate, patient condition and distance from the hospital. D. Dangerous rhythms are those which do not necessarily cause poor perfusion, but are likely to deteriorate. They require recognition and treatment to prevent degeneration to mechanically significant arrhythmias. Some of these dangerous rhythms include ventricular tachycardia and Mobitz II 2nd degree block. E. Cardiac arrest and life-threatening arrhythmias can be treated in the field, and show the benefits of "stabilization before transfer" in prehospital care. The patient is better off when the duration of arrest or poor perfusion is minimized. F. Drug dosages vary in the pediatric and elderly populations. Return to Table of Contents 2060 PREMATURE VENTRICULAR CONTRACTIONS (PVCs) IN A. The treatment of PVCs is rarely, if ever, indicated in the prehospital setting. B. Patients with PVCs and active chest pain should have their pain treated aggressively with oxygen, Aspirin, nitrates, and pain medications. C. Prophylactic use of Amiodarone is contraindicated. Go to Table of Contents 2070 IN BRADYCARDIA WITH PULSE Patients who are asymptomatic with normal blood pressure do not need treatment of bradycardia in the field, they require transport. Initiate Supportive Measures: • Airway management • Initiate oxygen therapy • Establish venous access Is the patient conscious, alert and without signs of poor perfusion? Yes No (Intermediates contact base) Initiate transport Atropine 0.5-1.0 mg IV bolus Evaluate response Systolic BP >90 Heart rate normal Persistent mmHg Systolic BP <90 mmHg hemodynamically unstable bradycardia Fluid bolus up to 250 cc Atropine Initiate transport maximum 0.5-1.0 mg IV push Evaluate response Initiate transport and contact base to consider dopamine Consider or epinephrine administration Transcutaneous pacing, if available Initiate transport and contact base to consider dopamine or epinephrine administration Special notes A. Do not delay Transcutaneous Pacing while awaiting IV access or for Atropine to take effect if the patient is showing signs of poor perfusion. Go to Table of Contents B. When pacing, verify mechanical capture and patient tolerance. Administer Midazolam or Diazepam per protocol, if conscious, after initial pacing. C. Differentiate premature ventricular beats from escape beats, which are wide complexes occurring late after preceding beat as a lower pacemaker cell takes over. Escape beats are beneficial to the patient and should be treated by increasing the underlying rate and conduction; not by suppressing the escape beats. D. In pediatric patients, bradycardia is most often a sign of hypoxia. After therapy for the ABCs has been initiated, hyperventilate, give fluid bolus, reassess, and consider epinephrine. Epinephrine should be the first medication utilized. Return to Table of Contents 2080 NARROW COMPLEX TACHYCARDIA WITH PULSE IN Initiate Supportive Measures: • Airway management • Initiate oxygen therapy • Establish venous access (If unable and patient is hemodynamically unstable, move to synchronized cardioversion) Is the patient conscious, alert and without signs of poor perfusion? Yes No (Intermediates contact base) Attempt Valsalva's maneuver Refer to Synchronized Cardioversion Protocol (paramedic only) Initiate Transport Initiate Transport Administer Adenosine 6 mg, rapid IV Contact Base bolus followed by 20 ml Normal Saline Flush If no change, administer Adenosine 12 mg, rapid IV bolus followed by 20 ml Normal Saline Flush Contact Base Special notes A. Valsalva's Maneuver 1. This is any action that causes the patient to bear down against the closed glottis. 2. Carotid sinus massage, orbital pressure or stimulation of mammalian diving reflex is Not Permitted. B. A narrow, QRS complex is less than 0.12 seconds in duration. C. Tachycardia is most likely a secondary problem when the pulse is less than 150 in an adult. Treat hypoxia, hypovolemia, pain, and other problems first. D. Adenosine is not effective in treating atrial fibrillation, which is an irregular rhythm. E. Adenosine must be administered over 1-3 seconds and followed by a rapid 20ml saline flush. A proximal vein and port are preferred. F. Pridemark specific: Consider Cardizem for A-Fib >150 Go to Table of Contents G. If the patient takes theophylline or xanthine derivatives, higher doses of adenosine may be needed. Return to Table of Contents 2081 IN WIDE COMPLEX TACHYCARDIA WITH PULSE Initiate Supportive Measures: • Airway management • Initiate oxygen therapy • Establish venous access (If unable and patient is hemodynamically unstable, move to synchronized cardioversion) Is the patient conscious, alert and without signs of poor perfusion? Yes No Initiate transport Refer to synchronized cardioversion protocol (paramedic only) Contact Base for consideration of one of Initiate transport the following medications: • Adenosine • Amiodarone • Magnesium (paramedics only) Special notes A. A wide QRS complex is defined as a complex with a width of 0.12 seconds or greater. B. A wide complex tachycardia is usually ventricular in origin but may, on occasion, be a supraventricular rhythm with aberrant conduction. C. Consider Midazolam or Diazepam for cardioversion in conscious patients. D. Immediate cardioversion is rarely needed for heart rates < 150. Go to Table of Contents 2090 CHEST PAIN Specific Information Needed A. Symptoms: Patient of either gender, more than 20 years old, with any of the following chief complaints: 1. Suspected Acute Coronary Syndrome a. Pressure, tightness, heaviness in chest b. Chest pain radiating into neck, jaw, shoulders, back, one or both arms c. Indigestion or heartburn, nausea and/or vomiting d. Persistent shortness of breath e. Weakness/dizziness/lightheadedness/loss of consciousness f. No pain or discomfort; however, patient may experience painless syncope, change in mental status, or dyspnea. g. Cocaine or other stimulant drug use 2. Respiratory a. Acute onset of shortness of breath b. Wheezing Document Specific Objective Findings A. Vital signs B. General appearance: color, apprehension, sweating C. Signs of heart failure: neck vein distention, peripheral edema, respiratory distress D. Lung exam by auscultation: rales, wheezes or decreased sounds E. Chest wall tenderness, abdominal tenderness Treatment A. Reassure and place patient at rest, position of comfort. B. Administer oxygen. C. If patient's history suggests a potential cardiac origin to the chest pain: 1. Administer 4 chewable aspirin tablets, 324mg total, if patient is able to swallow IV 2. Establish venous access. IN 3. Monitor cardiac rhythm and obtain 12 lead EKG if available. If patient has 1mm ST elevation in two or more contiguous leads, notify receiving hospital for CARDIAC ALERT. D. Administer nitroglycerin, 0.4mg SL if BP > 100 systolic. Repeat every 5 min until pain is relieved or systolic BP drops < 100. IN CB E. If pain persists after third nitroglycerin, administer morphine sulfate or Fentanyl for patients with no alteration of mental status and systolic BP > 100. F. Consider base contact for additional nitroglycerin and/or morphine sulfate or Fentanyl if pain persists. Go to Table of Contents Specific Precautions A. "All chest pain should be considered cardiac in origin until proven otherwise" but remember, there are many causes for chest pain. Consider pulmonary embolism, pneumonia, aortic aneurysm, pneumothorax. B. Consider Normal Saline fluid challenge or vasopressor if hypotensive. Beware of IV fluid overload in the potential cardiac patient. Document breath sounds. C. Patients taking medication for erectile dysfunction should not be given nitroglycerin. Return to Table of Contents 2095 CARDIAC ALERT Cardiac Alert: A. Cardiac alert is a program that is designed to mobilize cardiac catheterization staff and have them awaiting the arrival of EMS. This reduces the door to catheterization times and improves overall patient outcomes. By reducing time until reperfusion, less damage occurs in the myocardium and reduces mortality significantly. B. Most hospitals in the metro and Boulder County area recognize cardiac alert with the notable exceptions of Denver Health Medical Center and Boulder Foothills. Criteria 1. Pt presenting with active chest pain or discomfort consistent with acute coronary syndrome. 2. Pt is between the ages of 35 and 80 3. 1mm ST segment elevation in 2 or more anatomically contiguous leads See 12- Lead ECG Patterns protocol 4. Consider MD consultation if transport time is greater than 10 minutes. Exclusions 1. Paced Rhythm 2. Left Bundle Branch Block Procedure 1. Assess patient for all criteria listed above 2. Ensure that none of the exclusionary criteria exists 3. Contact dispatch IMMEDIATELY and inform them that you have a cardiac alert and where your intended transport destination is. 4. Transport emergently and notify the receiving hospital while transporting via normal means (Bio-phone) and inform them of patient condition and that the patient is a cardiac alert. 5. Attempt to include all of the following in your report i. Patient Age ii. Patient Sex iii. PMHx iv. Elevated Leads v. Cardiologist (if any) vi. ETA vii. Special Considerations 1. If a patient does not meet all cardiac alert criteria it does not mean that transport cannot be done emergently. 2. Cardiac Alert is a procedure and not a condition. Go to Table of Contents 2100 HYPERTENSION Specific Information Needed A. History of hypertension and current medications B. New symptoms: dizziness, nausea, confusion, visual impairment, paresthesia, weakness C. Drug use: phenylpropanolamine (found in a wide variety of over-the-counter weight-loss products), amphetamines, cocaine or other stimulant drug use D. Other symptoms: chest pain, breathing difficulty, abdominal/back pain, severe headache Specific Objective Findings A. Evidence of encephalopathy: confusion, seizures, coma, vomiting B. Presence of associated findings: pulmonary edema, neurologic signs, neck stiffness, unequal peripheral pulses Treatment A. Administer oxygen. B. Place patient in position of comfort. C. Monitor vital signs. D. Treat chest pain, pulmonary edema or seizure activity per protocol. E. Establish venous access. IN CB F. If diastolic blood pressure remains above 130 mmHg on repeated readings and patient has symptoms of encephalopathy without evidence of CVA or head injury, CONTACT BASE to consider: 1. Nitroglycerin, 0.4 mg SL. 2. Morphine sulfate, 4.0 mg slow IV bolus, with repeat boluses of 2.0 mg slow IV up to a maximum of 10 mg. G. Monitor cardiac rhythm. Obtain 12 lead ECG, if available. H. Monitor vital signs and mental status during transport. Specific Precautions A. Secondary hypertension (high BP in response to stress or pain) is commonly seen in the field. It does not require field treatment, and may not even mean the patient has chronic hypertension requiring ongoing treatment. B. Hypertensive encephalopathy is rare, but can be treated with nitroglycerin or morphine. Hypertension is more common in association with other problems (pulmonary edema, seizures, chest pain, coma, or altered mental states). It should be managed by treating the primary problem. C. Diastolic pressures and mean arterial pressures are much more important in determining danger of severe hypertension than is systolic pressure. These are poorly measured in the field. The diagnosis of "malignant" hypertension is not based on numerical levels, but rather on microscopic changes in blood vessels and damage to organs, which place this disease beyond the scope of prehospital care. Return to Table of Contents D. Hypertension is seen in severe head injury and intracranial bleeding, and is thought to be a protective response that increases perfusion to the brain. Treatment should be directed at the intracranial process, not the blood pressure. Return to Table of Contents 3010 RESPIRATORY DISTRESS Specific Information Needed A. History: acute change or injury, slow deterioration B. Past history: chronic lung or heart problems or known diagnosis, medications, home oxygen, past allergic reactions, recent surgery, tobacco abuse C. Associated symptoms: chest pain, cough, fever, hand or mouth paresthesia Document Specific Objective Findings A. Vital signs B. Oxygenation: level of consciousness, cyanosis C. Respiratory effort: accessory muscle use, forward position, pursed lips D. Neurologic signs: slurred speech, impaired consciousness, evidence of drug/alcohol ingestion E. Signs of upper airway obstruction: hoarseness, drooling, exaggerated chest wall movements, inspiratory stridor F. Signs of congestive failure: neck vein distention in upright position, rales, peripheral edema G. Breath sounds: clear, decreased, rales, wheezing, or rhonchi H. Hives, upper airway edema I. Evidence of trauma: crepitation of neck or chest, bruising, steering wheel damage, penetrating wounds Treatment A. Put patient in position of comfort, usually upright. B. Identify and treat upper airway obstruction if present (e.g. suctioning, NPA/OPA, CPAP, endotracheal intubation, etc.). C. Administer high flow oxygen. D. Prepare to assist ventilations if patient fatigues or develops altered mentation, or if respiratory arrest occurs. E. If diagnosis unclear, place patient in position of comfort, and administer oxygen, transport. F. Assess and consider treatment for other problems if respiratory distress is severe and patient does not respond to proper positioning and administration of oxygen. G. Establish venous access. H. Monitor cardiac rhythm. Specific Precautions A. Don't overdiagnose "psychogenic" in the field. Your patient could have a pulmonary embolus or other serious problem; give him/her the benefit of the doubt. Treatment with oxygen will not harm the "hyperventilator", and it will keep you from underestimating the problem. B. Wheezing in older persons may be due to pulmonary edema ("cardiac asthma"). Pulmonary embolus is an uncommon cause of wheezing Go to Table of Contents 3020 ASTHMA Specific Objective Findings A. Vital signs B. Oxygenation: level of consciousness, cyanosis C. Respiratory effort: accessory muscle use, forward position, pursed lips D. Breath sounds: clear, decreased, wheezing, or rhonchi Treatment A. Put patient in position of comfort, usually upright. B. Administer high flow oxygen. C. Use appropriate airway adjuncts as indicated. D. Assess and consider treatment for other problems if respiratory distress is severe and patient does not respond to proper positioning and administration of oxygen. E. If the patient is wheezing and has a metered dose inhaler (MDI), initiate MDI protocol. EMT's must contact base. IV F. Establish venous access. IN G. Monitor cardiac rhythm H. Administer Albuterol Sulfate. Consider adding Ipratropium. IN CB I. Use continuous nebulization of Albuterol Sulfate for respiratory distress. J. Consider Epinephrine, 0.3 mg SQ/IM (0.3 ml of 1:1,000 solution). K. Consider Methylprednisolone, 125 mg IV. P L. Consider Magnesium Sulfate, 2.0 gm, IV bolus, over 2 minutes Specific Precautions A. Prepare to assist ventilations if patient fatigues or develops altered mentation, or if respiratory arrest occurs. B. Wheezing in older persons may be due to pulmonary edema ("cardiac asthma"). Pulmonary embolus is an uncommon cause of wheezing. C. If available, utilize pulse oximetry and capnography. Go to Table of Contents 3030 CHRONIC OBSTRUCTIVE PULMONARY DISEASE Specific Objective Findings A. Vital signs B. Oxygenation: level of consciousness, cyanosis C. Respiratory effort: accessory muscle use, forward position, pursed lips D. Breaths sounds: clear, decreased, rales, wheezing, or rhonchi Treatment A. Place patient in position of comfort, usually upright B. Identify and treat upper airway obstruction of present (suctioning, nasopharyngeal airway, endotracheal intubation, etc.). C. Administer high flow oxygen. D. Use appropriate airway adjuncts as indicated. E. If the patient is wheezing and has a metered dose inhaler (MDI), initiate MDI protocol. EMT's must contact base. IN F. Monitor cardiac rhythm. Perform 12-lead, if available. G. Assess and consider treatment if respiratory distress is severe and patient does not respond to proper positioning and administration of oxygen. H. Administer Albuterol Sulfate. Consider adding Ipratropium. IN CB I. Use continuous nebulization of Albuterol Sulfate for respiratory distress. J. Consider Methylprednisolone, 125mg IV bolus. P K. CONTACT BASE for Magnesium Sulfate, 2 gms IV over 2 minutes. Specific Precautions A. Wheezing in older persons may be due to pulmonary edema ("cardiac asthma"). Pulmonary embolus is an uncommon cause of wheezing. B. Some COPD patients rely on a hypoxic drive for ventilatory support. Never withhold oxygen for fear of decreasing this hypoxic drive. C. If available, utilize pulse oximetry and capnography. Go to Table of Contents 3040 PULMONARY EMBOLISM Specific Information Needed A. History: diabetes, chronic lung disease, congestive heart failure (CHF). B. Past history: sedentary life style, surgery or recent fractures, pregnancy, oral contraceptives, atrial fibrillation. C. Associated symptoms: anxiety, dyspnea, chest pain, tachycardia, JVD Document Specific Objective Findings A. Vital signs B. Oxygenation: level of consciousness, anxiety C. Respiratory effort: dyspnea, tachypnea, shortness of breath D. Neurologic signs: impaired consciousness, syncope E. Objective findings: distended neck veins, chest splinting, hypotension, tachycardia. F. Breath sounds: clear, decreased, rales, wheezing, or rhonchi Treatment A. Put patient in position of comfort, usually upright. B. Identify and treat upper airway obstruction if present C. Administer high flow oxygen D. Assist ventilation if necessary E. If available, utilize pulse oximetry and capnography. Special Precautions A. Because prehospital care is primarily supportive and diagnosis difficult; understanding the contributing factors is paramount. B. A pulmonary embolism should be considered with any person who has an unexplained cardiorespiratory problem. Go to Table of Contents 3050 PULMONARY EDEMA Specific Objective Findings A. Vital signs B. Oxygenation: level of consciousness, cyanosis C. Respiratory effort: accessory muscle use, forward position, pursed lips D. Signs of congestive failure: Neck vein distention in the upright position, rales, peripheral edema. E. Breath sounds: clear, decreased, rales, wheezing, or rhonchi. Treatment A. Place patient in position of comfort, usually upright. 1. Sit patient up, legs dangling if possible. B. Administer high flow oxygen. C. Consider CPAP D. Assist ventilations with pocket mask or bag valve mask if necessary. E. Establish venous access. F. Monitor cardiac rhythm. Perform 12-lead, if available. IN CB G. Consider: 1. Nitroglycerin 0.4mg SL 2. Morphine Sulfate, initial dose up to 4mg, then 2mg increments up to a total dose of 10mg. P 3. Lasix, 20-80mg slow IV push. 4. If available, consider CPAP. Specific Precautions A. If diagnosis is unclear, place patient in position of comfort, administer oxygen, and transport. B. Wheezing in older persons may be due to pulmonary edema ("cardiac asthma"). Pulmonary embolus is an uncommon cause of wheezing. C. Prepare to assist ventilations if patient fatigues or develops altered mentation, or if respiratory arrest occurs. D. If available, utilize pulse oximetry and capnography. Go to Table of Contents 3060 HYPERVENTILATION Specific Information Needed A. History: anxiety provoking episode, acute change or injury B. Past history: panic attack, anxiety attack, chronic lung or heart problems or known diagnosis, medications, home oxygen, past allergic reactions, recent surgery, tobacco use, C. Associated symptoms: chest pain, cough, fever, hand or mouth paresthesia, carpal pedal spasm, cerebrovascular constriction resulting in headache, dizziness or euphoria. Document Specific Objective Findings A. Vital signs B. Oxygenation: level of consciousness, cyanosis C. Respiratory effort: accessory muscle use, forward position, pursed lips. D. Neurologic signs: slurred speech, impaired consciousness, evidence of drug/alcohol ingestion. E. Signs of upper airway obstruction: hoarseness, drooling, exaggerated chest wall movements, inspiratory stridor. F. Signs of congestive failure: neck vein distention in upright position, rales, peripheral edema. G. Breath sounds: clear, decreased, rales, wheezing, or rhonchi. H. Hives, upper airway edema I. Evidence of trauma: crepitation of neck or chest, bruising, steering wheel damage, penetrating wounds. Treatment A. Put patient in position of comfort, usually upright. B. Identify and treat upper airway obstruction if present. C. Administer high flow oxygen. D. Use appropriate airway adjuncts as indicated. E. Assess and consider treatment for the following problems 1. Coaching of breathing pattern and ventilations. 2. Calming of anxiety and stress inducing factors. 3. Suspicion that the symptoms are indicative of other illness, disorder or overdose, patient should be transported. Specific Precautions A. Don't over-diagnose "psychogenic" in the field. Your patient could have a pulmonary embolus or other serious problem; give him/her the benefit of the doubt. Treatment with oxygen will not harm the "hyperventilator", and it will keep you from underestimating the problem. B. Utilize pulse oximetry and Capnography, if available. Go to Table of Contents 3070 SPONTANEOUS PNEUMOTHORAX Specific Information Needed A. History: acute change or injury, slow deterioration B. Past history: chronic lung or heart problems, medications, home oxygen, past allergic reactions, recent surgery, tobacco use C. Associated symptoms: chest pain Document Specific Objective Findings A. Vitals signs B. Oxygenation: level of consciousness, cyanosis C. Respiratory effort: accessory muscle use, shortness of breath, tachypnea, decreased breath sounds on affected side D. Neurologic signs: impaired consciousness, evidence of drug/alcohol ingestion E. Signs of upper airway obstruction: exaggerated chest wall movements F. Breath sounds: clear, decreased, rales, wheezing, or rhonchi G. Assess for evidence of trauma: crepitation of neck or chest, bruising, steering wheel damage, penetrating wounds H. Other signs and symptoms: sudden onset of chest pain, diaphoresis, pallor, subcutaneous emphysema. Treatment A. Put patient in position of comfort, usually upright. B. Identify and treat upper airway obstruction if present C. Administer high flow oxygen. D. Use appropriate airway adjuncts as indicated. E. Assess and consider treatment for severe cases: airway, ventilatory and circulatory support. F. If a tension pneumothorax develops, follow "Tension Pneumothorax" protocol. Special Precautions A. May occur in apparently healthy persons; often men between 20 and 40 years of age, which are tall and thin. B. May occur in patients with COPD, patients with AIDS and pneumonia, history of Marfan's Syndrome, drug abusers. C. Utilize pulse oximetry and capnography if available. Go to Table of Contents 3080 PNEUMONIA Specific Information Needed A. History: acute change or injury, slow deterioration, general malaise. B. Past history: chronic lung or heart problems or known diagnosis, medications, home oxygen, past allergic reactions, recent surgery, tobacco abuse C. Associated symptoms: chest pain, productive cough, fever, sputum production. Treatment A. Place patient in position of comfort, usually upright. B. Identify and treat upper airway obstruction if present (suctioning, nasopharyngeal airway, endotracheal intubation, etc.). C. Administer high flow oxygen. D. Assist ventilation if necessary. E. Assess and consider treatment if respiratory distress is severe and patient does not respond to proper positioning and administration of oxygen. IN CB 1. Administer Albuterol Sulfate 2.5 mg nebulization. Special Precautions A. Pneumonia can be caused by bacterial, viral, or fungal infection; these diseases may spread by droplets or contact with infected persons. Utilize appropriate Body Substance Isolation (BSI) precautions. B. If diagnosis is unclear, place patient in position of comfort, administer oxygen, and transport. C. Prepare to assist ventilations if patient fatigues or develops altered mentation, or if respiratory arrest occurs. D. If available, consider pulse oximetry and capnography. Go to Table of Contents 4000 MEDICAL EMERGENCIES The following are protocols for various medical emergencies. Treatment for each may be unique but there are similar things to consider when treating all medical patients. A. Ensure the scene is safe and wear the appropriate protective equipment for proper body substance isolation. B. Obtain clues from the scene to help create a picture of the nature of the illness. C. Determine if your patient is physiologically stable or unstable. Certain assessment findings may help determine this, including: 1. Any airway obstruction that is limiting ventilation. 2. The patient is unable to maintain or protect their airway. 3. Not breathing or breathing inadequately. 4. Absent or diminished breath sounds. 5. Working hard to breathe and use of accessory chest muscles with retractions. 6. Absent or weak peripheral or central pulses. 7. H th8/chehat too fequason t, too sfol, oider1( thing out taregns of )( as. )]Tc -0.0009 Tc 0 TJ1.639 uout of thphere(Abseillnscle)5(s)se awhof (mo4(Arvedrwa)thpiohe 2. 3.3.evalue pthiof tbody systems affetre ses2.2. 2. reiesIe someoteeat(scsssclelly)5eslar (mentwitnass d ay )]TJ000009 Tc 0 TJ1.639 -1.153 Td 3. ahow lothii5hlasre ses. 3. eeth6oiderraionuma6(d (f thiconsure of tentmouth, lipsble )6(ay )]Tc 0 T 1. Repeat all previous assessments for any change. 2. Reassess vital signs. 3. Evaluate the effectiveness of any interventions. J. It is always appropriate to err on the side of caution. If you feel the patient is unstable, aggressively treat and transport rapidly to the appropriate facility. Return to Table of Contents 4010 NEUROLOGICAL EMERGENCIES Go to Table of Contents 4011 STROKE/CVA Indication A. For patients presenting with an acute episode of neurological deficits without any evidence of trauma as the causative agent. Specific Information Needed A. Symptoms: 1. Altered level of consciousness 2. Impaired speech 3. Unilateral weakness / hemiparesis 4. Facial asymmetry / facial droop 5. Headache 6. Poor coordination or balance 7. Vision changes 8. Seizure activity 9. Previous CVA / TIA 10. Chest Pain 11. Last time "without symptoms" Document Specific Objective Findings A. Vital signs and complete history including patient medications B. General appearance: color, apprehension, sweating C. Cincinnati Prehospital Stroke Scale (CPSS) 1. Face – facial droop present 2. Arm – upper extremity arm drift present (arms extended, palms up) 3. Speech – inability to speak a simple sentence 4. Time – time of onset of symptoms / last time without symptoms D. Complete Neurologic Exam IV E. Determine Blood Glucose level IN F. Monitor cardiac rhythm. Perform 12-lead EKG, if available. Treatment A. Reassure and place patient with head slightly elevated (<30 degrees) B. Administer oxygen. C. NPO D. Transport to appropriate facility E. Contact receiving facility early with symptoms and objective findings F. Establish venous access (proximal18 gauge or larger is preferred) G. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose reading <60 and if clinically indicated. Special Precautions A. Treatment of hypertension in the setting of CVA / TIA is not indicated in the prehospital setting. Go to Table of Contents 4012 COMA/ALTERED MENTAL STATUS/NEUROLOGIC DEFICIT Specific Information Needed A. Present history: duration of illness, onset and progression of present state illness; preceding symptoms such as headaches, seizures, confusion, or trauma. B. Past history: previous medical or psychiatric problems C. Medications: use, misuse, or abuse D. Surroundings: check for pill bottles or syringes and bring with patient. Note odor in house. Specific Objective Findings A. Safety of rescuer. Check for gases or other toxins. B. Vital signs C. Level of consciousness and neurological status D. Signs of trauma E. Breath odor F. Needle tracks G. Medical alert tag Treatment A. Use appropriate airway adjuncts as indicated B. Administer oxygen. C. If patient a known diabetic and can swallow administer one full tube of oral glucose per protocol. IV D. Establish venous access and fluid bolus as indicated. E. Draw appropriate blood tubes. Test blood glucose level F. Administer Dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose reading <60 and/or if clinically indicated. G. Administer Naloxone up to 2 mg IV, IN, IM or IO if clinically indicated. IN CB H. If venous access is unsuccessful and unable to administer dextrose, administer Glucagon 1 mg IM. I. Monitor cardiac rhythm. J. Transport in lateral recumbent position. (If trauma suspected, transport supine with cervical collar and backboard; logroll as necessary.) K. Monitor vitals during transport. Specific Precautions A. Be particularly attentive to airway. Difficulty with secretions, vomiting, and inadequate tidal volume are common. B. Hypoglycemia may present as a focal neurological deficit or coma (stroke like picture). C. Coma in the diabetic may be due to hypoglycemia or to hyperglycemia (diabetic ketoacidosis). Dextrose should be given IV Bolus to all unconscious diabetics, as well as patients with coma of unknown origin unless a blood glucose reading in the high range is obtained. The treatment may be life saving in hypoglycemic Go to Table of Contents patient, and will do no harm in the normal or hyperglycemic patient. Do not give oral sugar to an unconscious patient. D. Stroke patients may be alert but unable to respond (aphasic); therefore, communicate with the patient and explain what you are doing. Avoid inappropriate comments. E. Naloxone is useful in any potential narcotic overdose, but be sure the airway and the patient are controlled before giving naloxone to a known drug addict. The acute withdrawal precipitated in an addict may result in violent combativeness. Return to Table of Contents 4013 SEIZURES Specific Information Needed A. Seizure history: onset, time interval, previous seizures, type of seizure B. Medical history: especially head trauma, diabetes, headaches, drugs, alcohol, medications, compliance with anticonvulsants, pregnancy Document Specific Objective Findings A. Vital signs B. Description of seizure activity C. Level of consciousness D. Head and mouth trauma E. Incontinence F. Air temperature; patient temperature G. Skin color and moisture Treatment A. Ensure airway patency. Nasopharyngeal airways are useful. NOTE: Don't force anything between the teeth. B. Administer oxygen. C. Suction as needed. D. Protect patient from injury. E. Check pulse immediately after seizure stops. F. Keep patient on side. IV G. Establish venous access. H. Draw appropriate blood tube; test for blood glucose if available. I. Administer Dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose <60 and if clinically indicated. J. Administer Naloxone up to 2 mg IV or IN (may also be given IM or IO by EMT- Intermediate or paramedic) if clinically indicated. 1. If EMT-IV, contact base for consideration of administration of Naloxone as described above IN CB K. Administer Diazepam 1-10 mg slow IV push for status epilepticus. L. If venous access unsuccessful after two attempts, administer Midazolam 1-5 mg P IM or IN. IN CB M. If venous access is unsuccessful and unable to administer dextrose, administer Glucagon 1 mg, IM. N. Monitor cardiac rhythm. O. Keep in lateral recumbent position for transport. P. Monitor vitals. Specific Precautions Go to Table of Contents A. Move hazardous materials away from patient. Restrain the patient only if needed to prevent injury. Protect patient's head. B. Trauma to tongue is unlikely to cause serious problems, however, trauma to teeth may. Attempts to force an airway into the patient's mouth can completely obstruct airway. Do not use bite sticks or jaw screws. C. Seizure can be due to lack of glucose or oxygen to the brain, as well as to the irritable focus we associate with epilepsy. Hypoxia from transient arrhythmia or cardiac arrest (particularly in younger patients) may cause seizure and should be treated promptly. Don't forget to always check for pulse once a seizure terminates. D. Hypoxic seizures can also result when the tongue obstructs the airway in the supine position, or when overly helpful bystanders prop the patient up or improperly elevate the head. E. Alcohol related seizures are common, but cannot be differentiated from other causes of seizure in the field. Assessment in the intoxicated patient should still include consideration of hypoglycemia and all other potential causes. Field management is as for any seizure. F. Seizures may be due to arrhythmias or stroke. It is important to look for and recognize arrhythmias in the field since they may be the cause of the seizure. G. Medical personnel are often called to assist epileptics who seize in public. If patient clears completely, is taking his/her medications, has his/her own physician, and is experiencing his/her usual frequency of seizures, transport may be unnecessary. Consult your base physician. H. Diazepam has a tendency to decrease respiratory effort, therefore be prepared to assist ventilations. I. Seizures in pregnant patients (or even those who are postpartum) may be the presenting sign of eclampsia or toxemia of pregnancy. 1. Seizures in those patients will respond better to administration of magnesium P sulfate. Return to Table of Contents 4014 SYNCOPE Specific Information Needed A. History of the event: onset, duration, seizure activity, precipitating factors. Was the patient sitting, standing, or lying? Pregnant? B. Past history: medications, diseases, prior syncope C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache, palpitations Specific Objective Findings A. Vital signs B. Neurological status: level of consciousness, residual neurological deficit C. Signs of trauma to the head or mouth or incontinence D. Neck stiffness Treatment A. Place patient in position of comfort: do not sit patient up prematurely; supine or lateral positioning if not completely alert B. Monitor vital signs and level of consciousness closely for changes or recurrence. C. Establish venous access and administer Normal Saline if indicated. IV D. Consider hypoglycemia. If signs of hypoglycemia are present (clinical indications and blood glucose<60): 1. Establish venous access. 2. Draw appropriate blood tubes. 3. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus. IN 4. If venous access is unsuccessful and unable to administer dextrose, administer glucagon 1 mg IM. E. If vital signs unstable or age > 40 years: 1. Administer oxygen. 2. Keep patient supine, elevate legs 10-12 inches. IV 3. Establish venous access. IN 4. Monitor cardiac rhythm. Consider 12-lead EKG if available. Specific Precautions A. Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the patient is still unconscious, treat as coma. If the patient is confused, treat according to Coma/Altered Mental Status/Neurologic Deficit protocol. B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes. Recumbent position should be sufficient to restore vital signs and level of consciousness to normal. C. Syncope that occurs without warning or while in a recumbent position is potentially serious and often caused by an arrhythmia. Go to Table of Contents D. Patients with syncope, even though apparently normal, should be transported. In middle-aged or elderly patients, syncope can be due to a number of potentially serious problems. The most important of these to monitor and recognize are arrhythmias, occult GI bleeding, seizure, or ruptured abdominal aortic aneurysm. E. Any elderly patient with syncope and back pain should be considered to have a ruptured abdominal aortic aneurysm until proven otherwise. F. In children 1-4 years of age breath-holding spells associated with heightened emotional states can cause syncopal-like events. Children may be pallid or cyanotic and seizures can occur. No specific treatment is indicated for these events. Consult base station if questions. Return to Table of Contents 4020 ALLERGY/ANAPHYLAXIS Specific Information Needed A. History: current sequence of events, exposure to allergens (bee stings, drugs, nuts, seafood most common), prior allergic reactions. B. Current symptoms: itching, wheezing, respiratory distress, nausea, weakness, rash, anxiety, swelling. C. Medications, past medical history. Specific Objective Findings A. Vital signs, level of consciousness B. Respirations: wheezing, upper airway noise, effort C. Mouth: tongue and airway swelling D. Skin: hives, swelling, flushing Treatment A. Ensure airway patency. Early endotracheal intubation may be advisable before swelling becomes severe. Suction as needed. Prepare to assist ventilations. B. Position of comfort (upright if respiratory distress predominates; supine if shock prominent) C. Administer oxygen as indicated. D. Remove the mechanism of injection if still present (stinger, needle, etc). Do not squeeze venom sac; rather, scrape with straight edge. E. Remove any clothing or other items which may contain the allergen, for example if a person was horse back riding, clothing may still contain the allergen. F. If signs of severe generalized reaction present establish venous access. IV G. Consider Epi-Pen if available (EMT-B must contact base). IN H. Monitor cardiac rhythm. IN CB I. Administer diphenhydramine 50 mg IV or IM (IO if already established) as indicated. J. For objective findings of respiratory distress such as stridor, wheezing, hypoxia, tachypnea or angioedema, Epinephrine 0.3 mg of 1:1000 SQ/IM is indicated. K. For signs of shock (BP < 90) or altered mental status: 1. Fluid bolus of Normal Saline at 20 ml/kg 2. Administer epinephrine, 0.1 mg 1:10,000 IV followed by epinephrine 1.0 mg mixed in 250 ml Normal Saline infusion started at: 2mcg/min. Titrate to desired effects including signs of improved perfusion or a systolic blood pressure greater than 90 mmHg. Specific Precautions A. Allergic reactions can take multiple forms. Early consult with base physician is encouraged. B. Anxiety, tremor, palpitations, tachycardia, and headache are not uncommon with administration of epinephrine. These may be particularly severe with IV administration. In children, epinephrine may induce vomiting. Go to Table of Contents C. Angina, MI, or dysrhythmias may be precipitated. D. Use caution in the administration of epinephrine in cardiac patients or the elderly. E. Two forms of epinephrine are carried as part of paramedic equipment. The standard ampules of aqueous epinephrine contain a 1:1000 dilution appropriate for SQ or IM injection. IV epinephrine should be given in a 1:10,000 dilution. Use the 1:10,000 premix for IV dosing to avoid mistakes. Be sure you are giving the proper dilution to your patient, and give slowly. F. Before treating anaphylaxis, be sure your patient has objective signs as well as subjective symptoms and history. Hyperventilators will occasionally think they are having an allergic reaction. Epinephrine will just aggravate their anxiety. G. Lethal edema may be localized to the tongue, uvula, or other parts of the upper airway. Examine closely, and be prepared for early intubation before swelling precludes this intervention. Return to Table of Contents 4030 ABDOMINAL PAIN Specific Information Needed A. Pain: nature (crampy or constant), duration, location; radiation to back, groin, chest, shoulder B. Associated symptoms: nausea, vomiting (bloody or coffee ground), diarrhea, constipation, black or tarry stools, urinary difficulties, menstrual history, fever C. Past history: previous trauma, abnormal ingestions, medications, known diseases, surgery Document Specific Objective Findings A. Vital signs B. General appearance: restless, quiet, sweaty, pale C. Abdomen: tenderness, guarding, distention, rigidity, pulsatile mass D. Emesis, stool, or urine, describe, amount E. Check for equality of pulses. Treatment A. Place patient in position of comfort B. Give nothing by mouth C. If BP <90 mmHg systolic and signs of hypovolemic shock: 1. Administer oxygen. 2. Establish venous access with 2 large bore lines. Consider Normal Saline IV bolus of 20 ml/kg. 3. Consider transport to a trauma center based upon destination protocol. D. Establish venous access even if vital signs normal. E. Cardiac monitor and 12 lead EKG (if available) for upper abdomen pain. IN F. Consider pain medication for hemodynamically stable patients with transport IN CB times >10 minutes Fentanyl 1-2 mcg/kg IV bolus to a cumulative dose of less than 200 mcg. G. Monitor vitals during transport. H. For patients who are nauseated or vomiting consider antiemetic administration. Specific Precautions A. The most important diagnoses to consider are those associated with catastrophic internal bleeding: ruptured aneurysm, liver, spleen, ectopic pregnancy, etc. Since the bleeding is not apparent, you must think of the volume depletion and monitor patient closely to recognize shock. If a patient presents in shock, consider transport to a trauma center where appropriate surgical consultation is readily available. B. Elderly patients may have significant hypovolemic shock with systolic blood pressures above 90 mmHg. With signs of hypovolemia, treat with fluids. C. Upper abdomen and lower chest pain may reflect thoracic pathology such as myocardial infarction, etc. Massive fluid resuscitation may be contraindicated. Go to Table of Contents 4031 VOMITING Document Specific Objective Findings A. Frequency, duration of vomiting B. Presence of blood or bile in vomitus C. Associated symptoms: abdominal pain, weakness, confusion D. Medication ingestion E. Past medical history: diabetes, cardiac disease, abdominal problems, alcoholism F. Vital signs G. Color of vomitus: presence of blood H. Abdomen: tenderness, guarding, rigidity, distention I. Signs of dehydration: poor skin turgor, dry mucous membranes, confusion Treatment A. Position patient: left lateral recumbent if vomiting; otherwise, supine. B. Administer oxygen. C. Nothing by mouth IV D. If BP < 90 mmHg systolic and signs of hypovolemic shock or for signs of poor perfusion in pediatric patients: 1. Elevate legs 10-12 inches. 2. Establish venous access. 3. Normal Saline bolus of 20 ml/kg P E. For patients who are nauseated or vomiting consider antiemetic administration. a. Ondansetron (Zofran) 4mg IV/IM b. Promethazine (Phenergan) 12.5mg IV Specific Precautions A. Vomiting may be a symptom of a more serious problem. The most serious causes are GI bleed or other intra-abdominal catastrophe. A rare cardiac patient may also present with vomiting as the predominant symptom. B. Consider drug overdose; a patient who does not call the ambulance for medication ingestion may call later when GI symptoms become severe. C. The vast majority of persons with vomiting have become sick over days, not minutes. Treat appropriately. D. Dehydration may be particularly severe in children with simple vomiting. IVs may be very difficult to start, particularly with infants. Go to Table of Contents 4040 POISONS AND OVERDOSES Specific Information Needed A. Type of ingestion: What, when, and how much was ingested? Bring the poison, the container, description of emesis, all medications and everything questionable in the area with the patient to the Emergency Department. B. Reason for exposure: think of child neglect, depression, etc. C. Symptoms: respiratory distress, sleepiness, nausea, agitation or decreased level of consciousness D. Past history: medications, diseases, psychiatric E. Action taken by bystanders: induced emesis? "antidote" given? Document Specific Objective Findings A. Vital signs B. Airway: patency and adequacy of ventilation C. Level of consciousness and neurologic status: check frequently. D. Breath odor, increased salivation, oral burns E. Skin: sweating, cyanosis F. Systemic signs: vomitus, arrhythmias, lung sounds Treatment A. Use appropriate airway adjuncts as indicated. B. Administer oxygen. C. Support patient on side and protect airway. D. Establish venous access. IV E. Test for blood glucose level, if available. F. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose <60 and if clinically indicated. G. Administer naloxone up to 2 mg IV or IN (may also be administered IM or IO) in patients with decreased respiratory effort and observe patient for improved ventilations. CB H. If venous access is unsuccessful and unable to administer dextrose, administer IN glucagon 1 mg, IM. I. Monitor cardiac rhythm. J. Administration of sodium bicarbonate may be necessary with signs of a widened QRS or ventricular arrhythmias after excessive tricyclic antidepressant(s) ingestion. Administration of diazepam 1-10 mg slow IV bolus may be necessary in suspected stimulant use or abuse (cocaine, Ecstasy, etc.) Specific Precautions A. There are few specific "antidotes." Product labels and home kits can be misleading and dangerous. Watch the ABCs: these are important. B. Do not neutralize acids with alkalis. Do not neutralize alkalis with acids. These "treatments" cause heat releasing chemical reactions that can further injure the GI tract. C. Inhalation poisoning is particularly dangerous to rescuers. Recognize an environment with ongoing contamination and extricate rapidly. Go to Table of Contents D. Organophosphate exposure may require massive doses of atropine. E. For personal exposure to nerve agents refer to Mark I auto-injector protocol. Rocky Mountain Poison Center #: 303-739-1123 (local) or 1-800-332-3073 (statewide) Nationwide Poison Control Access#: 1-800-222-1222 Poison Control Phone for Hearing Impaired: 303-739-1127 CHEMTREC: 1-800-424-9300 Return to Table of Contents 4050 ENVIRONMENTAL EMERGENCIES Go to Table of Contents 4051 HIGH ALTITUDE ILLNESS Specific Information Needed A. Presenting symptoms generally fall into two categories: 1. Acute mountain sickness (AMS) - headache, sleeplessness, anorexia, nausea, fatigue. 2. High-altitude pulmonary edema (HAPE) - breathlessness, cough, headache, trouble breathing, confusion, fatigue, nausea 3. High-altitude Cerebral Edema (HACE) – ataxia, headache, confusion, stroke like picture with focal deficits, seizure and coma B. Current and highest altitude, time at this altitude, duration of ascent C. Medical problems, medications, previous experience at altitude Document Specific Objective Findings A. Vital signs B. Mental status: confusion, lack of coordination, coma C. Lungs: respiratory rate, distress, rales, sputum (bloody or frothy) Treatment A. Put patient at rest in position of comfort. B. Administer oxygen. C. Suction as needed. Assist ventilation if patient has cyanosis, confusion, and poor respiratory effort. D. For Pulmonary Edema consider Continuous Positive Airway Pressure (CPAP) and if the patient fails to respond consider intubation. IV E. Establish venous access if conditions permit Specific Precautions A. Recognition of the problem is the most critical part of treating high altitude illness. While in the mountains, recognize symptoms which are out of proportion to those being experienced by the rest of the party: fatigue, or trouble breathing (particularly at rest). B. The mainstay of treatment is descent from altitude. Even a loss of 1,000 - 1,500 feet makes enough difference in the oxygen content of air that symptoms may be relieved or stop progressing. Oxygen administration can also relieve symptoms and may allow more time for orderly evacuation. C. In addition to the more common pulmonary edema, cerebral edema may occur, with confusion and a stroke-like picture with focal deficits. Treatment is the same. D. Acute mountain sickness, the mild form of illness during altitude adaptation, consists of fatigue, headache, and poor sleeping, without severe CNS or respiratory symptoms. Treatment is rest. This increases the body's time to acclimatize. Descend if symptoms progress, or ataxia present. E. Commercial airlines pressurize cabins to a level equivalent to about 5,000 - 8,000 feet. F. Patients at risk for high altitude illness for whatever reason may be taking Diamox (acetazolamide). Diamox may be useful in preventing some altitude Go to Table of Contents illness because of direct effects on acid-base balance. Diuretics are not useful, however, in treating high altitude pulmonary edema, because the cause is excess capillary leakage of fluid, rather than increased venous pressure. Return to Table of Contents 4052 DROWNING/NEAR-DROWNING Specific Information Needed A. How long patient was submerged? B. Degree of contamination, water temperature? C. Diving accident? Water depth? Specific Objective Findings A. Vital signs B. Neurologic status: monitor on a continuing basis. C. Lung exam: rales or signs of pulmonary edema, respiratory distress Treatment A. Clear upper airway of vomitus or large debris. B. Start CPR if needed. C. Stabilize neck prior to removing patient from water if any suggestion of neck injury. D. Suction as needed. E. Administer oxygen. F. If patient not awake and alert: 1. Assist ventilation if necessary. IV 2. Establish venous access 3. Consider use of Continuous Positive Airway Pressure (CPAP) IN 4. Intubate when indicated and apply positive pressure ventilation. 5. Monitor cardiac rhythm during transport; treat arrhythmias per protocol. G. Transport patient, even if normal by initial assessment. Specific Precautions A. Be prepared for vomiting. Patients should be secured on spineboard when indicated for log-rolling to protect the neck and manage the airway. B. All near-drownings should be transported. Even if patients initially appear fine, they can deteriorate. Monitor closely. Pulmonary edema often occurs due to aspiration, hypoxia, and other factors. It may not be evident for several hours after near-drowning. C. Beware of neck injuries - they often go unrecognized. Collar and backboard straps can be applied in the water. D. If patient is hypothermic, defibrillation and pharmacologic therapy may be unsuccessful until the patient is rewarmed. Prolonged CPR may be needed. E. Under current ACLS standards, Heimlich maneuver is not indicated. Go to Table of Contents 4053 HYPOTHERMIA AND FROSTBITE Specific Information Needed A. Length of exposure B. Air temperature, water temperature, winds, patient wet? C. History and timing of changes in mental status D. Drugs: alcohol, tranquilizers, anticonvulsants, others E. Medical problems: diabetes, epilepsy, alcoholism, etc. F. With local injury: history of thawing/refreezing? Specific Objective Findings A. Vital signs, mental status, shivering. (Prolonged observation for 1-2 min. may be necessary to detect pulse, respirations.) B. Skin temperature (estimated); also note current temperature of environment C. Evidence of local injury: blanching, blistering, erythema of extremities, ears, nose D. Cardiac rhythm Treatment A. Generalized: 1. CPR, if no pulse 2. Administer oxygen. Assist with bag-valve-mask as needed. 3. Use appropriate airway adjunct only to protect airway or in absence of organized cardiac electrical activity. 4. Avoid unnecessary suctioning or airway manipulation. 5. Remove wet or constrictive clothes from patient. Wrap in blankets and protect from wind exposure. Increase ambient temperature in ambulance. 6. Attempt defibrillation, if appropriate, up to 3 shocks. 7. Establish venous access. Solution should be warmed if possible. Do not IV start IV until patient is moved to transport vehicle. IN 8. Monitor cardiac rhythm. 9. No more than one round of ACLS drugs should be administered to a IN CB hypothermic patient in the prehospital setting. B. Local (frostbite): 1. Remove wet or constricting clothing. Keep skin dry and protected from wind. 2. Do not allow the limb to thaw if there is a chance that limb may refreeze before evacuation is complete, or if patient must walk to transportation. 3. Rewarm minor "frostnip" areas by placing in axilla or against trunk under clothing. 4. Dress injured areas lightly in clean cloth to protect from pressure, trauma or friction. Do not rub. Do not break blisters. 5. Maintain core temperature by keeping patient warm with blankets, warm fluids, etc. 6. Transport with frostbitten areas supported and elevated if feasible. Go to Table of Contents Specific Precautions A. HYPOTHERMIA: 1. Shivering does not occur below 90˚ Fahrenheit. Below this the patient may not even feel cold, and occasionally will even undress and appear vasodilated. 2. The heart is most likely to fibrillate below 85-88˚ Fahrenheit. Defibrillation should be attempted with no more than 3 shocks. Prolonged CPR may be necessary until the temperature is above this level. 3. ALS drugs should be used sparingly, since peripheral vasoconstriction may prevent entry into central circulation until temperature is restored. At that time, a large bolus of unwanted drugs may be infused into the heart. 4. Bradycardias are normal and should not be treated. 5. If patient has organized monitor rhythm, CPR is currently felt to be unnecessary. In general, even very slow rates are probably sufficient for metabolic demands. CPR is indicated for asystole and ventricular fibrillation. 6. Patients who appear dead after prolonged exposure to cold air or water should not be pronounced "dead" until they have been rewarmed. Full recovery from hypothermia with undetectable vital signs, severe bradycardia, and even periods of cardiac arrest has been reported. 7. Rewarming should be accomplished with careful monitoring in a hospital setting, whenever possible. 8. Consider other reasons for altered mental status. B. FROSTBITE: 1. Thawing is extremely painful and should be done under controlled conditions, preferably in the hospital. Careful monitoring, pain medication, prolonged rewarming, and sterile handling are required. 2. It is clear that rewarming followed by refreezing is far more injurious to tissues than delay in rewarming or walking on a frozen extremity to reach help. Do not rewarm prematurely. Indications for field rewarming are almost nonexistent. 3. Warming with heaters or stoves, rubbing with snow, drinking alcohol and other methods of stimulating the circulation are dangerous and should not be used. Return to Table of Contents 4054 HYPERTHERMIA Specific Information Needed A. Patient age, activity level B. Medications: depressants, tranquilizers, alcohol, etc. C. Associated symptoms: cramps, headache, orthostatic symptoms, nausea, weakness Specific Objective Findings A. Vital signs: temperature; usually 104 degrees Fahrenheit or greater (if thermometer available) B. Mental status: confusion, coma, seizures, psychosis C. Skin flushed and warm to hot: with or without sweating D. Air temperature and humidity; patient dress Treatment A. Use appropriate airway adjuncts as indicated. B. Remove clothing. C. Administer oxygen. D. Cool with water-soaked sheets. IV E. Establish venous access: 1. TKO if vital signs stable 2. IV fluid bolus of 20 ml/kg if signs of hypovolemia. F. Treat seizures with diazepam 1-10 mg slow IV push. IN CB G. If unable to obtain venous access after two attempts administer midazolam 1-5 P mg IM. H. Monitor cardiac rhythm. . Specific Precautions A. Heat stroke is a medical emergency. It is distinguished by altered level of consciousness. Sweating may still be present, especially in exercise-induced heat stroke. The other persons at risk for heat stroke are the elderly and persons on medications which impair the body's ability to regulate heat. B. Differentiate heat stroke from heat exhaustion (hypovolemia of more gradual onset) and heat cramps (abdominal or leg cramps). Be aware that heat exhaustion can progress to heat stroke. C. Do not let cooling in the field delay your transport. Cool patient as possible while en route. D. Do not use ice water or cold water to cool patients, as these may induce vasoconstriction. Go to Table of Contents 4055 BITES AND STINGS Specific Information Needed A. Type of animal or insect. B. Time of exposure. C. Symptoms: 1. Local: pain, stinging 2. Generalized: dizziness, weakness, itching, trouble breathing, muscle cramps D. History of previous exposures, allergic reactions Specific Objective Findings A. Identification of spider, bee, marine animal if possible B. Local signs: erythema, swelling, heat in area of bite C. Systemic signs: hives, wheezing, respiratory distress, abnormal vital signs Treatment A. SNAKES: See Snake Bites. B. SPIDERS: 1. Ice for comfort 2. Bring in spider, if captured and contained or if dead, for accurate identification, if possible. 3. Transport for observation if systemic signs and symptoms present. C. BEES AND WASPS: 1. Remove sting mechanism. Do not squeeze venom sac if this remains on stinger, rather, scrape with straight edge. 2. Observe patient for signs of systemic allergic reaction. Treatment per the Allergy/Anaphylaxis protocol and transport rapidly if needed 3. Transport all patients with systemic symptoms or history of systemic symptoms from prior bites. Specific Precautions A. For all types of bites and stings, the goal of prehospital care is to prevent further inoculation and to treat allergic reactions. B. Allergy kits consist of injectable epinephrine and oral antihistamine, and are prescribed for persons with known systemic allergic reactions. Prehospital care personnel need not contact the resource hospital before assisting the patient with their own medication. C. About 60% of patients who have experienced a generalized reaction to a bite or sting in the past will have a similar or more severe reaction upon reinoculation. Thus, although it is not inevitable, this group of patients must be considered at high risk for anaphylaxis. In addition, a small group of patients will have anaphylaxis as a "first" reaction. D. Time since envenomation is important. Anaphylaxis rarely develops more than 60 minutes after inoculation. Go to Table of Contents 4056 SNAKE BITES Specific Information Needed A. Appearance of snake (e.g. rattle, color, banding) B. Time of bite C. Prior first-aid by patient or friends D. Symptoms: local pain and swelling, peculiar or metallic taste sensations. Severe envenomations may result in hypotension, coma, and bleeding. Specific Objective Findings A. Bite wound: location, configuration (1, 2, or 3 fang marks; entire jaw imprint, none) B. Snake identification: look for elliptical pupils, thermal pit and rattle C. Signs of envenomation: spreading numbness and tingling from the site, local edema and pain, ecchymosis, bleeding, hypotension. Mark time and extent of erythema and edema with pen. Treatment A. Remove patient and rescuers from area of snake to avoid further injury. B. Remove rings or other bands which may become tight with local swelling. C. Immobilize bitten part at heart level. D. Minimize venom absorption by keeping bite area still and patient quiet. E. Transport promptly for definitive observation and treatment. F. Do not use ice or refrigerants. G. For all suspected envenomations establish venous access and administer oxygen. H. Monitor vital signs, cardiac rhythm, and swelling. Specific Precautions A. The prairie rattlesnake is native to the Denver metro region. If the snake is dead, bring it in for examination. Do not jeopardize fellow rescuers by attempting to "round it up." Be careful: a dead snake may still reflexively bite and envenomate. Do not pick up with hands, even if dead. Use a shovel or stick. B. At least 25% of poisonous snake strikes do not result in envenomation. Conversely, the initial appearance of the bite may not reflect the severity of envenomation. C. Fang marks are characteristic of pit viper bites, such as from the rattlesnake, water moccasin, or copperhead, which are native to North America. Jaw prints (without fangs) are more characteristic of nonvenomous species. D. Ice can cause serious tissue damage. Never use! E. Exotic poisonous snakes, such as those found in zoos, have different signs and symptoms than those of pit vipers. Go to Table of Contents 4060 SHOCK: MEDICAL Specific Information Needed A. Onset: gradual or sudden; precipitating cause or event B. Associated symptoms: itching, peripheral or facial edema, thirst, weakness, respiratory distress, abdominal or chest pain, dizziness on standing C. History: allergies, medications, blood in vomitus or stools, significant medical diseases, history of recent trauma, last menstrual period, vaginal bleeding, fever Specific Objective Findings A. Vital signs: pulse > 120 (occasionally < 50); Systolic BP < 90 mmHg B. Mental status: apathy, confusion, restlessness, combativeness C. Skin: flushed, pale, sweaty, cool or warm, hives, or other rash D. Signs of trauma E. Signs of cardiogenic shock: jugular venous distention in upright position, rales, peripheral edema F. In children <8 years old, 2 or more of the following signs: tachycardic for age, diminished capillary refill, thready pulses, cool extremities, poor color, altered mental status, diminished respiratory effort Treatment A. Administer oxygen. B. Cover patient to avoid excess heat loss. Do not over bundle. C. Assess for cardiogenic cause: 1. If pulse is > 150 treat tachyarrhythmia according to protocol. IN 2. If pulse is < 60 treat bradyarrhythmia according to protocol. 3. If distended neck veins, chest pain, or other evidence of cardiac cause: a. Position of comfort b. Be prepared to assist ventilations or initiate CPR. c. Evaluate for possible tension pneumothorax IV d. Establish venous access. IN e. Monitor cardiac rhythm. P D. Consider dopamine. E. Transport rapidly for definitive diagnosis and treatment. F. If no evidence of cardiogenic cause, institute general treatment measures: 1. Place patient supine, elevate legs 10-12 inches. (If respiratory distress results, leave patient in position of comfort.) 2. Establish venous access. IV 3. Administer IV Fluid bolus of normal saline. G. Assess and treat for specific cause, such as anaphylaxis, if this can be determined. Go to Table of Contents H. Monitor vital signs, cardiac rhythm, and level of consciousness during transport. Specific Precautions A. Shock in a cardiac patient may be caused by hypovolemia; however, contact should be made with base prior to administering fluid boluses. B. Mixed forms of shock are treated as hypovolemia, but the other factors contributing to the low perfusion should be considered. Neurogenic shock is caused by relative hypovolemia as blood vessels lose tone, either from spinal cord trauma, drug overdose, or sepsis. Cardiac depressant factors can also be involved. Anaphylaxis is a mixed form of shock with hypovolemic, neurogenic, and cardiac depressant components. Epinephrine is used in addition to fluid load. C. Cardiogenic shock from various causes is difficult to treat even in a hospital setting. Rapid transport is recommended. SHOCK: MEDICAL Mechanism/Causes Differential/Symptoms HYPOVOLEMIA Dehydration suggestive illness Vomiting, diarrhea Diabetes with hyperglycemia Diabetes; acute illness, increased urine or blood loss, thirst, fever Ectopic pregnancy female, 12-50 years, abdominal pain GI bleed bloody vomitus, black or red stool Ruptured abdominal aneurysm severe back/abdomen pain, age, history of high blood pressure Vaginal bleeding suggestive history, miscarriage, abortion or delivery Intra-abdominal bleeding minor trauma; abdominal, back, or shoulder pain CARDIOGENIC Arrhythmia palpitations Pericardial tamponade chest area cancer, blunt or penetrating trauma Tension pneumothorax respiratory distress, COPD, trauma Myocardial failure chest pain, history of congestive failure Pulmonary embolus sudden respiratory distress, chest pain, SOB MIXED Sepsis symptoms fever, elderly, urinary symptoms Drug overdose suggestive history Anaphylaxis SOB, itching, mouth swelling, dizziness, exposure to allergen Return to Table of Contents 4070 PSYCHIATRIC/BEHAVIORAL Specific Information Needed A. Obtain history of current event, inquire about recent crisis, toxic exposure, drugs, alcohol, emotional trauma, suicidal or homicidal ideation B. Obtain past history; inquire about previous psychiatric and medical problems, medications. Specific Objective Findings A. Evaluate vital signs. B. Note medic alert tags, odor to breath. C. Determine ability to relate to reality. D. Note hallucinations and behavior. Treatment A. Attempt to establish rapport. B. Assure airway. C. Restrain if necessary. D. Chemical restraint if needed a. Midazolam (Versed) b. Diphenhydramine 50mg as a synergist (not stand alone treatment) OR c. Diazepam 1-10mg slow IVP d. DO NOT USE BOTH VERSED AND DIAZEPAM ON THE SAME PATIENT E. Monitor vital signs. F. If altered mental status or unstable vital signs: 1. Administer oxygen. 2. Establish venous access. IV 3. Draw appropriate blood tubes. 4. Administer dextrose 25 gm (50 ml of a 50% solution), IV bolus if blood glucose <60 and if clinically indicated. IN 5. Administer naloxone up to 2 mg IV or IN (may also be administered IM or IO) CB in patients with decreased respiratory effort and observe patient for improved ventilations. (EMT-IV can only give naloxone IV or IN) 6. If EMT-IV, contact base for consideration of administration of Naloxone as described above 7. If venous access is unsuccessful and unable to administer dextrose, administer Glucagon 1 mg, IM. 8. Consider Diazepam 1-10 mg slow IV bolus for stimulant use. Specific Precautions A. Psychiatric patients often have an organic basis for mental disturbances. P Beware of hypoglycemia, hypoxia, head injury, intoxication, or toxic ingestion. B. If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Try not to violate the patient's personal space. Go to Table of Contents C. If the situation appears threatening, consider a show of force involving police before attempting to restrain. D. Beware of weapons. These patients can become very violent. E. The paramedic may initiate a Mental Health Hold only with the permission and online contact with the BASE PHYSICIAN. Return to Table of Contents 4080 OBSTETRICS/GYNECOLICAL EMERGENCIES Specific Information Needed A. Symptoms: pain, cramping, passage of clots or tissue, dizziness, weakness; if pregnant, inquire about swelling of face and extremities, urge to push, contractions (regularity and timing), ruptured membranes, fever B. Obtain menstrual history: last normal menstrual period, duration of period, amount of flow, birth control method C. If pregnant, inquire about due date, prior problems with pregnancy. D. Past and present history of hypertension (preeclampsia/eclampsia) E. Past history: bleeding problems, pregnancies, medications, allergies Specific Objective Findings A. Vital signs and orthostatic changes B. Evidence of blood loss, clots or tissue fragments; bring tissue to the ED C. Signs of hypovolemic shock, altered mental status, hypotension, tachycardia, sweating, pallor D. Fever E. If pregnant, observe for contractions and relaxation of uterus. Where privacy is possible, examine perineum by observation only for: 1. Vaginal bleeding or fluid (note color) 2. Crowning (check during contraction) 3. Abnormal presentation (i.e. foot, arm, face, or cord) Treatment A. If patient is bleeding vaginally (moderate to heavy): 1. Administer oxygen. 2. If hypotensive and pregnant, position onto left side. 3. Establish venous access. IV 4. If hypotensive, give IV fluid bolus of normal saline, further fluids as directed and consider a second line. B. If patient is delivering: 1. Use clean or sterile technique. 2. Administer oxygen. 3. Guide and control but do not retard or hurry the delivery. 4. Suction the mouth (not throat) then nose with a bulb syringe. 5. Protect the infant from fall and temperature loss; wipe off amniotic fluid and wrap in a clean or sterile blanket, check vital signs, provide CPR as indicated. 6. Clamp the umbilical cord in two places approximately 8-10" from the infant. 7. Cut the cord between the clamps. IV 8. Establish venous access in mother and monitor vital signs. 9. Do not wait for or attempt delivery of placenta before transporting. If placenta delivers spontaneously bring it to the hospital. Go to Table of Contents C. If patient is bleeding in the postpartum period (within 24 hours of delivery): 1. Massage uterus and have mother nurse infant to aid in uterine contractions. 2. Administer oxygen. IV 3. Establish venous access. Specific Precautions A. If patient is in late pregnancy and there is crowning or other indication of imminent delivery, deliver or transport. Be prepared to stop ambulance for delivery while enroute. B. Amount of vaginal bleeding is difficult to estimate. Try to get an estimate of number of saturated pads in previous 6 hours. C. Transport immediately any pregnant patient with an abnormal presenting part or vaginal bleeding. D. A patient in shock from vaginal bleeding should be treated like any other patient with hypovolemic shock. E. If patient is pregnant, bring in any tissue that was passed. Laboratory analysis may be important in determining status of pregnancy. F. Always consider pregnancy as a cause of vaginal bleeding. The history may contain inaccuracies, denial, or wishful thinking. G. If the patient is pregnant, ask if she feels as though she is delivering. Particularly with prior deliveries, most mothers will know. H. The primary enemy of newborns is hypothermia, which can occur within minutes due to increased evaporative heat loss resulting from the infant's large body surface area and the presence of amniotic fluid. I. Record an APGAR score with vital signs, at one and five minutes. IN J. Consider early tracheal suctioning after delivery of the infant with evidence of meconium. APGAR Score Sign 0 1 2 Muscle tone (Activity) Limp Some flexion Active, good flexion Pulse Absent <100/min =100/min Reflex irritability* No response Some grimace or Cough, cry or sneeze (Grimace) avoidance Color (Appearance) Blue, pale Pink body, blue Pink hands/feet Respirations Absent Slow, irregular, Crying, rhythmic, effective ineffective *Nasal or oral suction catheter stimulus Return to Table of Contents 4090 EXCITED DELIRIUM Purpose Excited Delirium is a potentially lethal medical condition that often presents itself as a law enforcement issue. This protocol is to guide EMS interaction with persons who present with excited delirium. General Principles Excited Delirium seems to be a commonality in patients suffering cardiac arrest after struggling with law enforcement, EMS or hospital staff. Patients who seem to be prone to Excited Delirium generally fall into one of three categories. 1. Those suffering from psychiatric illness, eg., schizophrenia or bipolar disorder 2. Illicit substance users, especially stimulant drugs such as cocaine and methamphetamine, and chronic alcohol abusers 3. A combination of mental illness and substance abuse The patient presents with bizarre, violent behavior that usually leads them to be contacted by law enforcement. There are often acts of aggression against persons or property, with particular affinity to shiny, inanimate objects and may include breaking glass. They are further found to be paranoid, often shout incoherently; They don't seem to be able to effectively communicate. They appear to be impervious to pain. As a result, traditional methods of gaining compliance using pain are often ineffective. Often they demonstrate superhuman strength and can battle multiple people for long periods of time. They are almost always hyperthermic. These patients tend to disrobe and are often found fully unclothed. Patients seem to follow a pattern that culminates in full cardiac arrest preceded by a period of calm, listlessness that may be mistaken as compliance. When patients progress to full arrest, they are most times refractory to treatment. Procedure 1. Be aware of the signs and symptoms of Excited Delirium 2. Be prepared for the patient to have a full cardiac arrest, particularly if they suddenly become calm. 3. Consider Midazolam (Versed) or Diazepam (Valium) for chemical restraint. 4. If at all possible, keep the patient supine while attempting to control them 5. Keep in mind that these patients will not respond to pain 6. As soon as it is feasible, begin continuous monitoring of vital signs, EKG, SpO2, and ETCO2 7. There is conjecture that hypoventilation is ultimately what causes the cardiac arrest so be prepared to assist in ventilations in patients who suddenly become calm even though they have a patent airway. Special Notes 1. While these patients will generally declare themselves, it is imperative that they are transported by Advanced Life Support. 2. Law enforcement may request that the patient go to jail but responders must reinforce that this is a significant medical problem that requires ALS transport. 3. It is not uncommon for these patients to have been exposed to a Conducted Energy Weapon such as a Taser, multiple times. 4. Current reports are showing possible links that Taser use in conjunction with excited delirium increases mortality. See Protocol: Taser Go to Table of Contents 5000 MULTIPLE TRAUMA OVERVIEW Specific Information Needed A. Mechanism of injury: 1. Cause, precipitating factors, weapons used 2. Trajectories and forces involved 3. For vehicular trauma: a. Specific description of mechanism such as auto vs. pole, rollover, broadside, high speed b. Condition of vehicle including windshield, steering wheel, compartment intrusion, condition of dashboard/firewall/pedals, type and use of seatbelts, supplemental restraint system (e.g. airbag) deployment 4. Helmet use; motorcycle, bicycle, skiing, snowboarding, skateboarding, rollerblading B. Patient complaints. C. Initial position and level of consciousness of patient. D. Patient movement, treatment since injury E. Other factors such as drugs, alcohol, medications, diseases, pregnancy Specific Objective Findings A. Scene evaluation: 1. Note potential hazard to rescuers and patient. 2. Identify number of patients; organize triage operations if appropriate 3. Observe position of patient, surroundings, probable mechanism, and vehicle condition. B. Patient evaluation: see treatment below Treatment A. Initial assessment in multiple trauma is performed at the same time as treatment. B. Airway with spinal precautions and immobilization C. Breathing D. Circulation, with control of major bleeding E. Transport decision 1. If patient unstable, transport immediately. Treat enroute. 2. If patient stable, assess for potentially life-threatening injuries and treat accordingly. F. Monitor vital signs, neurologic status and cardiac rhythm enroute. G. CONTACT BASE. Specific Precautions A. Assessment and management of trauma in the field has changed considerably in the past 5 years. There are patients who cannot tolerate a full assessment before life saving intervention is needed. Likewise, splinting, bandaging, and, often, the focused history and physical examination are procedures that may need to be bypassed in the critical patient. Time and the treatment available in a trauma center are critical elements in resuscitation. Therefore, with severely injured patients, it is most appropriate to rapidly transport ("load and go") the patient Return to Table of Contents rather than using extended stabilization or the old "grab and run," with no trauma stabilization or care rendered. B. Critical injuries involve: 1. Difficulty with respiration. 2. Difficulty with circulation (hypoperfusion a.k.a. shock). 3. Decreased level of consciousness. 4. Any trauma patient with one or more of these above conditions is a "load and go," with treatment occurring enroute. C. Even in the noncritical patient with significant injury, "stabilization in the field" does not occur. With major injuries, the very most you can do is to buy time. If the initial bolus of fluids results in improved vitals, do not become complacent. This patient frequently needs blood and an operating room to truly "stabilize" the traumatic process. Rapid transport is still the highest priority. D. Serial vital signs and observations of respiratory, circulatory and neurologic status prior to arrival are critical. E. The trauma patient is the greatest risk to the rescuer for exposure to "bodily fluids." Use all appropriate body substance isolation precautions. Return to Table of Contents 5010 TRAUMA ARREST Specific Information Needed A. Time of arrest B. Mechanism: blunt vs. penetrating C. Signs of irreversible death (decapitation, dependent lividity, etc.) Specific Objective Findings A. Vital signs B. Evidence of massive external blood loss C. Evidence of massive blunt head, thorax or abdominal trauma Treatment A. Blunt trauma arrest: 1. Initiate basic life support 2. Use appropriate airway adjuncts as indicated. Administer oxygen. 3. If no vital signs or other signs of life present after above treatments, consider field pronouncement. 4. If pulse returns with above treatment, treat per protocol and transport rapidly to a Level I or II trauma center. 5. CONTACT BASE. B. Penetrating trauma arrest: 6. Initiate basic life support 1. Use appropriate airway adjuncts as indicated. Administer oxygen 2. Begin rapid transport. 3. CONTACT BASE to report patient status. 4. Establish venous access, administer IV fluid bolus of normal saline. IV 5. If cardiac activity returns with above treatment, treat arrhythmias per protocols. 6. Consider field pronouncement (See Resuscitation and Field Pronouncement) Guidelines for the following: a. Signs of irreversible death b. ALS has been unavailable for at least 20 minutes from the time EMS personnel initiate on-scene assessment and there is no return of vital signs or signs of life Specific Precautions A. Victims of blunt trauma arrest without vital signs at the scene after initiation of ALS have a mortality rate of nearly 100%. B. Trauma arrests secondary to penetrating truncal injuries can be resuscitated and saved. There is a higher rate of survival in victims of low velocity penetrating injuries versus victims of high velocity injuries. Go to Table of Contents 5020 AMPUTATIONS Specific Information Needed History: time and mechanism of amputation; care for severed part prior to rescuer arrival Past history: medications, bleeding disorders, medical problems Specific Objective Findings A. Vital signs B. Other injuries C. Blood loss at scene D. Structural attachments in partial amputations if identifiable Treatment A. Manage airway and breathing B. Resuscitate and treat other more urgent injuries. C. Control hemorrhage with direct pressure, elevation. D. If hypotension or signs of shock: 1. Establish venous access. IV 2. Fluid bolus: normal saline 3. CONTACT BASE. E. Patient: gently cover stump with sterile dressing. Saturate with sterile saline. Cover with dry dressing. Elevate. F. Severed part: wrap in sterile gauze, preserving all amputated material. Moisten with sterile saline. Place in watertight container (specimen cup, plastic bag, etc). Place container in cooler with ice (do not freeze). G. CONTACT BASE for optimal transport destination. Specific Precautions A. Partial amputations should be dressed and splinted in alignment with extremity to ensure optimum blood flow. Avoid torsion in handling and splinting. B. Do not use dry ice to preserve severed part. C. Control all bleeding by direct pressure only to preserve tissues. The most profuse bleeding may occur in partial amputations, where cut vessel ends cannot retract to stop bleeding. Never clamp bleeding vessels. D. Many factors enter into the decision to attempt replantation (age, location, condition of tissues, other options). A decision regarding treatment cannot be made until the patient and part have been examined by a physician and may not be made at the primary care hospital. Try to help the family and patient understand this, and don't falsely elevate hopes. Go to Table of Contents 5030 HEAD TRAUMA Specific Information Needed A. History: mechanism of injury, estimate of force involved; helmet use. B. History since injury: loss of consciousness (duration), change in level of consciousness, memory loss for events before and after trauma, movement (spontaneous or moved by bystanders), seizure activity C. Past history: medications (esp. insulin), medical problems, seizure history, alcohol or drug use Specific Objective Findings A. Vital signs (note respiratory pattern and rate) B. Neurologic assessment: Glasgow Coma Score C. External evidence of trauma: contusions, abrasions, lacerations, drainage from nose, ears Treatment A. Assess airway and breathing; treat life threatening conditions. Use assistant to provide in-line cervical immobilization when indicated, while managing respiratory difficulty. B. Administer oxygen. C. Control hemorrhage. Stop scalp bleeding with direct pressure. Continued pressure may be needed. D. TRANSPORT RAPIDLY if patient has multiple injuries, or unstable neurologic, respiratory or circulatory status. E. Obtain initial vital signs, neurologic assessment. F. If unconscious: 1. Assist ventilations. 2. Consider airway adjuncts 3. Ventilate at 10 breaths per minute for adults (15 breaths for children, 20 breaths for infants). 4. If signs of cerebral herniation are present, hyperventilate at 20 bpm for adults (30 bpm for children, 35 bpm for infants). 5. CONTACT BASE. G. Immobilize cervical, thoracic and lumbosacral spine when indicated. H. If signs of hypovolemic shock are present, initiate treatment en route: 1. Establish venous access. IV 2. Fluid bolus of normal saline. 3. Look carefully for possible sources of bleeding (abdomen, pelvis, chest). 4. CONTACT BASE. I. If patient stable: IV 1. Establish venous access. 2. Complete detailed assessment. 3. Splint fractures and dress wounds if time permits. Go to Table of Contents J. Monitor and record airway, vital signs, and level of consciousness repeatedly at scene and during transport. Status changes are important. Specific Precautions A. When head injury patients deteriorate, check first for airway, oxygenation and blood pressure. These are the most common causes of "neurologic" deterioration. If the patient has tachycardia or hypotension, evaluate for hypovolemia from associated injuries. B. Secondary brain injury and adverse outcomes can occur in brain-injured patients who exhibit hypotension and/or hypoxia. Early aggressive treatment of hypotension and administration of high flow oxygen may prevent further injury. C. The most important information you provide for the base physician is level of consciousness and its changes. Is the patient stable, deteriorating or improving? D. Restlessness can be a sign of hypoxia. Cerebral anoxia is the most frequent cause of death in head injury. E. Hypoventilation aggravates cerebral edema. F. Scalp lacerations can cause profuse bleeding, and are difficult to define and control in the field. If direct local pressure is insufficient to control the bleeding, evacuate any large clots from flaps and large lacerations with sterile gauze, and use direct hand pressure to provide hemostasis. If the underlying skull is unstable, pressure should be applied to the periphery of the laceration over intact bone. G. Routine prophylactic hyperventilation should be avoided. It has been shown to be detrimental to cerebral blood flow and patient outcome. Hyperventilation in the field for head trauma is indicated only when signs of cerebral herniation such as extensor posturing or pupillary abnormalities (asymmetric or bilaterally fixed and dilated pupils) are present after correcting hypotension and/or hypoxemia. Return to Table of Contents 5040 FACE AND NECK TRAUMA Specific Information Needed A. Mechanism of injury: impact to steering wheel, windshield, or other objects; clothesline type injury to face or neck; blunt object to head, face, or neck B. Management before arrival by bystanders, first responders C. Patient complaints: areas of pain; trouble with vision, hearing; neck pain; dental occlusion, tooth loss; short of breath D. Past medical history: medications, medical illnesses Specific Objective Findings A. Vital signs B. Airway: jaw or tongue instability, loose teeth, vomitus or blood in airway, other evidence of impairment or obstruction C. Neck: tenderness, crepitation, hoarseness, bruising, swelling, stridor D. Blood or drainage from ears, nose E. Level of consciousness, evidence of head trauma F. Injury to eye: lid laceration, blood anterior to pupil, abnormal pupil, abnormal globe position Treatment A. Control airway with cervical spine immobilization if indicated: 1. Open airway using jaw thrust, keeping neck in alignment with in-line cervical immobilization. 2. Use finger sweep to remove oral foreign bodies. 3. Suction blood and other debris. 4. Stabilize tongue and mandible with chin lift. Manual traction of the tongue may be necessary to keep posterior pharynx open as needed. 5. Note evidence of laryngeal injury and transport immediately if signs present. 6. If bleeding is severe, attempt to manage with suctioning, oral airway, and bag-valve-mask. 7. Support breathing as needed. 8. Use appropriate airway adjuncts as indicated. IN 9. If intubation cannot be performed due to severe facial injury, attempt to manage with suctioning and bag-valve-mask. P 10. If necessary, consider percutaneous cricothyrotomy B. Administer oxygen. C. Control hemorrhage, check pulse and circulation. D. Establish venous access: IV 1. TKO if stable 2. With signs of hypovolemia: a. Fluid bolus of normal saline; CONTACT BASE. Go to Table of Contents E. Cover injured eyes with protective shield or cup; avoid pressure or direct contact to eye. F. Do not attempt to stop free drainage from ears, nose. Cover lightly with dressing to avoid contamination. G. Bring avulsed teeth with you. Keep moist in saline soaked gauze. H. Monitor airway closely during transport for development of obstruction or respiratory distress. Suction and treat as needed. Specific Precautions A. Fracture of the larynx should be suspected in patients with respiratory distress, abnormal voice, and history of direct blow to neck from steering wheel, rope, fence wire, etc. Both intubation and percutaneous cricothyrotomy may be unsuccessful in the patient with a fractured larynx, and attempts may result in increased injury. Transport rapidly for definitive treatment if you suspect this potentially lethal injury. Do not attempt intubation or percutaneous cricothyrotomy unless the patient is in severe respiratory distress. Bag-valve- mask ventilation is preferred. B. Airway obstruction is the primary cause of death in persons sustaining head and face trauma. Meticulous attention to suctioning and basic airway maneuvers may be the most important treatment rendered. C. Remember that the apex of the lung extends into the lower neck and may be injured in penetrating injuries of the lower neck, resulting in pneumothorax or hemothorax. D. Do not be concerned with contact lens removal in the field. E. When midface fractures are suspected, nasotracheal intubation is contraindicated. F. No nasotracheal intubation under age 12. Return to Table of Contents 5050 SPINAL TRAUMA Specific Information Needed A. Mechanism of injury and forces involved: be suspicious with falls, decelerations, diving accidents and motor vehicle accidents. B. Past medical problems and medications Specific Objective Findings A. Vital signs, including neurological assessment B. Level of sensory and motor deficit; presence of any evidence of neurological function below level of injury C. Physical exam, with careful attention to organs or limbs which may not have sensation Treatment A. Assess airway and breathing; treat life threatening difficulties. Use controlled ventilation for high cervical cord injury associated with abdominal breathing. Use assistant to provide in-line cervical immobilization while managing ABCs. B. Administer oxygen. C. Control hemorrhage. D. Immobilize cervical, thoracic and lumbosacral spine as indicated. E. Obtain and record vital signs and neurologic assessment before and after immobilization. IV F. Establish venous access. If signs of hypovolemia: fluid bolus of Normal Saline, CONTACT BASE G. Monitor airway, vitals, and neurologic status frequently at scene and during transport. Specific Precautions A. Be prepared to turn entire board on side if patient vomits (patient must be secured to spine board or scoop stretcher). B. Neurogenic shock is likely with significant spinal cord injury. If present, elevate legs 10-12 inches. Ensure adequate respirations. C. If hypotension is unresponsive to simple measures, it is likely due to other injuries. Neurological deficits make other injuries hard to evaluate. Cord injury above the level of T-8 makes the abdominal examination unreliable. D. Spinal immobilization in patients with penetrating trauma should be accomplished only when neurological deficit or impaled foreign body is present. E. It is important from a clinical and medical legal perspective to record neurological assessment before and after spinal immobilization. Go to Table of Contents 5055 SELECTIVE SPINAL IMMOBILIZATION The purpose of this protocol is to minimize unnecessary application of spinal precautions in trauma or potential trauma patients. Selective Spinal Immobilization may only be performed by EMTs or Paramedics trained in this procedure, and approved by their medical director. 1. Patients who meet the following criteria may be excluded from spinal precautions. All other patients must be placed in spinal immobilization 2. This protocol is for the patient over the age of 12 and under the age of 60 Assessment - Mental Status, Speech and History 1. There is no complaint of neck or back tenderness or pain elicited either while obtaining a history or from the physical exam. 2. The patient is reliable 3. There is no significant language barrier 4. There is no history or appearance of drug or alcohol ingestion. 5. The patient is alert and oriented to person, place, time and event. 6. The history and exam exclude mental retardation, senility, Alzheimer's disease, stroke, significant closed head injury, anoxia or hypovolemia. 7. There is no distracting social or emotional situation in which the patient cannot focus on his/her physical condition. 8. There is no potentially distracting injury such as a painful extremity or abdominal injury. Assessment - Physical If at any time, pain or discomfort occurs as a result of the exam, stop the assessment and immobilize the patient. 1. Palpate down the spinal cord including the occipital notch at the top and the sacrum at the bottom. 2. Have the patient shrug their shoulders against resistance. 3. Have the patient turn their head against resistance. 4. Test for motor strength, weakness, numbness, tingling, focal deficits or other paresthesias or discomfort by having the patient move each joint against resistance and compare to the opposite side. Be methodical. 1. Have the patient spread their fingers against your resistance 2. Have the patient squeeze your hands 3. Have the patient flex wrist against your resistance 4. Have the patient extend wrist against your resistance 1. Have the patient flex their elbow against your resistance 2. Have the patient extend their elbow against your resistance 3. Have the patient flex their hip 4. Have the patient extend their knee 5. Have the patient flex their knee 6. Have the patient dorsiflex their ankle 7. Have the patient plantar flex their ankle Go to Table of Contents If there is notable weakness, determine if the weakness if unilateral or bilateral. Special Considerations Do not use in the elderly over the age of 60. Arthritic spinal rigidity and osteoporosis can result in increased risk of injury even with minor mechanism such as a ground level fall. There is a high degree of peripheral neuropathy in the elderly, therefore complaints of pain are unreliable. Being ambulatory does not exclude spinal immobilization. If the patient does not meet these criteria for exclusion, spinal immobilization should be applied. It is inappropriate to walk a patient to the ambulance and have them lie down on a board. Immobilization devices, once applied, may require re-adjustment while maintaining alignment, but shall not be removed. Once applied, immobilization devices shall only be removed by the receiving facility physician. A patient may refuse any treatment being rendered at any time. If a patient is refusing spinal precautions, the risks involved must be relayed and the proper documentation of the patients condition and associated risks must be documented on a patient care report or refusal form that the patient signs. Patients immobilized on devices are prone to losing body heat. Keep the patient warm. Return to Table of Contents 5060 CHEST INJURY Specific Information Needed A. Patient complaints: chest pain type (pleuritic, positional, location sharp, dull, etc.) respiratory distress, neck pain, other areas of injury. B. Mechanism: amount of force involved (particularly deceleration), speed of impact, seatbelt use/type, airbag. C. Penetrating trauma: size of object, caliber of bullet, trajectory, distance from patient. D. Past medical history: medications, prior medical problems. Specific Objective Findings A. Observe: wounds, air leaks, chest wall movement, neck veins B. Palpate: tenderness, crepitation, tracheal position, tenderness on sternal compression, pulse pressure C. Auscultate: breath sounds, heart sounds (quality) D. Surroundings: vehicle, steering wheel condition, dashboard. Treatment A. Clear and open airway. Immobilize cervical spine, if indicated. B. Use appropriate airway adjuncts as indicated. C. Assist breathing if patient is apneic or respirations depressed. D. Administer oxygen. E. If penetrating injury present, transport rapidly with further stabilization en route. F. For open chest wound with air leak, use Vaseline type gauze or occlusive dressing taped on three sides only, to allow air to escape but not enter the chest. G. Observe chest for paradoxical movements. H. Obtain baseline vital signs, neurologic assessment. 1. If the patient is in shock transport rapidly to a trauma center and CONTACT BASE. IV 2. If neck veins flat and patient in shock, transport rapidly and treat hypovolemia en route: a. Establish venous access. b. Fluid bolus: normal saline IN c. Monitor cardiac rhythm. 3. If patient in shock with neck veins distended, also transport rapidly, and consider: a. Tension pneumothorax if respiratory status markedly deteriorating with clinical findings of pneumothorax: i. Release occlusive dressings on open chest wounds. P ii. Needle decompression; CONTACT BASE for orders b. Pericardial tamponade, if suggested by clinical findings (distant heart sounds, narrow pulse pressure): Return to Table of Contents i. Establish venous access. IV ii. Fluid bolus: normal saline c. Cardiac contusion with typical ischemic chest pain or severe chest IN wall contusion: i. Monitor cardiac rhythm. 4. If patient stable without signs or symptoms of shock: a. Complete focused assessment. b. If significant injury suspected: IV i. Establish venous access. IN ii. Monitor cardiac rhythm en route. I. Immobilize impaled objects in place with dressings to prevent movement. Large objects may require manual stabilization during transport. J. Monitor and record vital signs, and level of consciousness every five minutes with significant injury. Specific Precautions A. Chest trauma is treated with difficulty in the field and prolonged treatment before transport is not indicated if significant injury is suspected. If patient is critical, transport rapidly and avoid treatment of nonemergent problems at the scene. Penetrating injury particularly should receive immediate transport with minimal intervention in the field. B. Consider medical causes of respiratory distress such as asthma, pulmonary edema or COPD that have either caused trauma or been aggravated by it. C. Chest injuries sufficient to cause respiratory distress are commonly associated with significant blood loss. Consider hypovolemia. D. Myocardial contusion can occur, particularly with sudden deceleration injury, as from a steering wheel. Pain is similar to myocardial infarct pain. Monitor the patient and treat arrhythmias as in a medical patient, but think first of hypoxia and hypovolemia as potential causes of arrhythmias. E. Check the back for injuries, especially the patient in shock, where a cause is not evident (check the back, axillary region and base of neck). F. Significant intrathoracic injuries can exist without external signs of injury. Return to Table of Contents 5070 ABDOMINAL TRAUMA Specific Information Needed A. Patient complaints B. For penetrating trauma: weapon, trajectory C. For auto: condition of steering wheel, dash, vehicle; speed, patient trajectory; seatbelts in use, airbag deployment D. Past history: medical problems, medications, pregnancy, drugs, alcohol Specific Objective Findings A. Observe: distention, bruising, entrance/exit wounds B. Palpate: areas of tenderness, guarding; pelvis stability to lateral and suprapubic compression Treatment A. Stabilize life threatening airway and circulatory problems first. B. Administer oxygen. C. Observe carefully for signs of blood loss. If signs of shock: 1. Rapid transport 2. Establish venous access. Consider second IV using large bore catheter. IV 3. Administer fluid bolus of normal saline if clinically indicated; further fluids as directed. 4. CONTACT BASE. D. For penetrating injuries: cover wounds and eviscerations with moist saline gauze to prevent further contamination and drying. Do not attempt to replace. E. Monitor vital signs during transport. Special precautions A. The extent of abdominal injury is difficult to assess in the field. Be very suspicious; with significant blunt trauma, injuries to multiple organs are the rule. B. Patients with spinal cord injury, altered sensorium due to drugs or alcohol, head injury or significant distracting injuries (i.e. long bone fractures) may not complain of tenderness and may lack guarding in the face of significant intra abdominal injury. C. Seatbelts, steering wheels, and other blunt objects may cause occult intra abdominal injury that is not apparent until several hours after the trauma. You must consider forces involved to properly assess and treat a trauma victim. D. In children, significant intra-abdominal injury, which may lead to shock, may be present without any external signs of injury, such as abrasions or hematomas. E. The pregnant patient deserves special attention during transport. Transport the patient on her side or angle backboard to prevent Supine Hypotension Syndrome from uterine compression of the inferior vena cava. Go to Table of Contents 5080 EXTREMITY INJURIES Specific Information Needed A. Mechanism of injury: direction of forces, if known B. Areas of pain, swelling or limited movement C. Treatment prior to arrival: realignment of open or closed fracture, or dislocations, movement of patient D. Past medical history: medications, medical illnesses Specific Objective Findings A. Vital signs B. Observe: localized swelling, discoloration, angulation, lacerations, exposed bone fragments, loss of function, guarding C. Palpate: tenderness, crepitation, instability, quality of distal pulses, sensation D. Note estimated blood loss at scene. Treatment A. Treat airway, breathing, and circulation as first priorities. B. Immobilize cervical spine when appropriate. C. Examine for additional injuries to head, face, chest, and abdomen; treat those problems with higher priority first. D. If patient unstable, transport rapidly, treating life threatening problems en route. Splint patient to minimize fracture movement by securing to long board. E. If patient stable, or isolated extremity injury exists: 1. Check and record distal pulses and sensation prior to immobilization of injured extremity. 2. Apply sterile dressing to open fractures. Note carefully wounds that appear to communicate with bone. 3. Splint areas of tenderness or deformity: apply gentle traction throughout treatment and try to immobilize the joint above and below the injury in the splint. 4. Realign angulated fractures by applying gentle axial traction if indicated: 5. To restore circulation distally 6. To immobilize adequately, i.e., realign femur fracture 7. Check and record distal pulses and sensation after reduction and splinting. 8. Elevate simple extremity injuries. Apply ice pack if time and extent of injuries allow. 9. Monitor circulation (pulse and skin temperature), sensation, and motor function distal to site of injury during transport. IV 10. Establish venous access. 11. Consider Morphine Sulfate 2-10 mg, IV bolus for pain control IN CB OR Consider Fentanyl, 1-2 mcg/kg, slow IV bolus for pain control. Go to Table of Contents Special precautions A. Patients with multiple injuries have a limited capacity to recognize areas which have been injured. A patient with a femur fracture may be unable to recognize that he has other areas of pain. Be particularly aware of missing injuries proximal to the obvious ones (e.g., a hip dislocation with a femur fracture, or a humerus fracture with a forearm fracture). B. Do not use ice or cold packs directly on skin or under air splints. Pad with towels or leave cooling for hospital setting. C. Do not attempt to realign angulated fractures in the field unless circulation is compromised. Splint in the position of comfort. D. Injuries around joints may become more painful and circulation may be lost with attempted realignment. If this occurs, stabilize the limb in the position of most comfort with the best distal circulation. Return to Table of Contents 5090 BURNS Specific Information Needed A. History of injury: time elapsed since burn. Was patient in a closed space with steam or smoke? Electrical contact? Loss of consciousness? Accompanying explosion, toxic fumes, other possible trauma? B. Past history: prior cardiac or pulmonary disease, medications? Specific Objective Findings A. Vital signs B. Extent of burns: description or diagram of areas involved C. Depth of burns: superficial - erythema only; partial or full thickness - blistered or charred areas. Estimate size of burn. Use Rule of Nines or area of one patient palm = 1% burn. D. Evidence of carbon monoxide poisoning or other toxic inhalation: altered mental state, headache, vomiting, seizure, coma E. Evidence of inhalation burns: respiratory distress, cough, hoarseness, singed nasal or facial hair, soot erythema of mouth, carbonaceous sputum F. Entrance and exit wounds for electrical burns G. Associated trauma Treatment A. THERMAL BURNS: 1. Remove clothing which is smoldering or which is non-adherent to the patient. 2. Administer oxygen if indications from history or physical of respiratory burns, toxic inhalation, or significant flame or smoke exposure. 3. Assess and treat for associated trauma (blast or fall). 4. Consider cervical spine injury. 5. Remove rings, bracelets, and other constricting items. 6. If burn is moderate-to-severe (over 15% of body surface area), cover wounds with dry clean dressings to avoid hypothermia. Preheat ambulance to maximum temperature to prevent hypothermia during transport. 7. Use cool, wet dressings in smaller burns (less than 15%) for patient comfort. IV 8. Establish venous access in non-burned extremity when possible. IN CB 9. Consider morphine sulfate 2-10 mg, IV bolus for pain relief. 10. If IV access is delayed consider Nebulized or IN (MAD device) Fentanyl 11. Transport, monitoring vital signs. 12. Observe for airway distress IN a. Be prepared to intubate. NOTE: Patients older than 12 years of age, with isolated second degree or third degree burns greater than 20% body surface area, consider direct transport to the University Hospital Emergency Department. Go to Table of Contents Patients 12 years of age and younger, with isolated second degree or third degree burns greater than 20% body surface area, consider direct transport to the Children's Hospital Emergency Department. Patients in immediate need of airway management should be transported to the nearest Emergency Department. B. INHALATION INJURY: 1. Administer 100% oxygen during transport. IN 2. Be prepared to intubate or assist if respirations inadequate. 3. Monitor cardiac rhythm. C. CHEMICAL BURNS: 1. Protect rescuer from contamination. Wear appropriate gloves and clothing. 2. Remove all clothing and any solid chemical that might provide continuing contamination. 3. Assess and treat for associated injuries. 4. Decontaminate patient using running water for 15 min. prior to transport if patient stable. 5. Check eyes for exposure and rinse with free-flowing water for 15 min. 6. Evaluate for systemic symptoms that might be caused by chemical contamination. CONTACT BASE for possible treatment. 7. Remove rings, bracelets, constricting bands. 8. Wrap burned area in clean, dry cloths for transport. Keep patient as warm as possible after decontamination. D. ELECTRICAL INJURY: 1. Protect rescuers from continued live electric wires. 2. Separate victim from electrical source when area safe for rescuers. 3. Initiate CPR as needed, monitor cardiac rhythm and treat arrhythmias per protocols. 4. Prolonged respiratory support may be needed. 5. Immobilize cervical spine when appropriate, assess for other injuries. IV 6. Establish venous access. Specific Precautions A. Leave blisters intact when possible. B. Suspect airway burns in any facial burns or burns received in closed places. Edema may become severe, but not be immediately apparent. Avoid unnecessary trauma to the airway. Humidified oxygen is preferred if available. C. Assume carbon monoxide poisoning in all closed space burns. Treatment is 100% oxygen continued for several hours. In addition, other toxic products of combustion are more commonly encountered than realized. D. CONTACT BASE for special instructions if other toxic inhalations are suspected. Consider suicide attempt as cause of burn, and child abuse in pediatric burns. E. Lightning injuries can cause ventricular asystole and prolonged respiratory arrest. Prompt, continuous respiratory assistance (sometimes for hours to days) can result in full recovery. Return to Table of Contents F. Field decontamination of chemical exposures has been shown to significantly reduce extent of burn. Gross decontamination should occur prior to transport. Notify hospital immediately to mobilize internal resources. G. EMS personnel should not participate in decontamination unless trained and equipped to do so. H. In patients with severe burns, their ability to prevent heat loss is significantly compromised. The time of transport may be enough to cause hypothermia. Keep the ambulance as warm as possible during transport despite discomfort to EMS personnel. I. Isolated carbon monoxide poisoning should be taken to a hyperbaric oxygen chamber. Multiple trauma patients with suspected carbon monoxide poisoning should be taken to the appropriate trauma center. Return to Table of Contents 5100 TASER PROTOCOL I. Purpose To provide guidelines in handling patient who has been subjected to a Taser General Principles The Taser is a popular conducted electronic control weapon primarily used by law enforcement as a less-than-lethal device A Taser can be used as a contact device (touch-Taser) but is primarily used as a distance weapon where it can fire probes up to 25 feet and engage an assailant A controlled, pulsed electrical current is delivered that cause muscles in between the probes to spasm uncontrollably This is quite painful, and incapacitating Special Considerations 1. Think safety—subjects who have been Tasered can still remain a threat 2. A thorough history and physical exam should be completed 3. All patients for whom a Taser has been utilized on shall be transported. 4. Patients with suspected stimulant use that have been tasered should have continuous cardiac monitoring. Procedure Taser Probe Removal 1. Taser probes imbedded anywhere above the clavicles, or in the nipple or genitalia If found in this area, leave in place and transport 2. On most Taser probes there is a groove that runs along the side that has the barb on it. Gently place counter pressure on each side of the probe downward and perpendicular to the groove with one hand, then firmly tug on the probe straight back. 3. Law enforcement may keep the probes as evidence. Otherwise treat the probe as any other contaminated sharp and dispose of appropriately. 4. Document the contact appropriately See Protocol: Excited Delirium Go to Table of Contents 5200 Boulder Specific Trauma Activation Guidelines Full Trauma Activation 1. GCS < 10 with trauma 2. Systolic BP < 90 and/or Pulse > 120 3. Respirations <10 or >29 or requiring intubation 4. Pediatric Criteria a. Tachycardia with 2 or more signs of poor perfusion b. BP lower limits for age (70 + 2 x age) 5. Flail chest 6. Multiple system traumatic blunt injury associated with suspected pelvic or long bone fractures or altered mental status 7. Burns > 15% in adults and 10% in children AND associated trauma or hemodynamically unstable or with inhalation injury 8. Suspected spinal injuries with neuro deficits 9. Amputation proximal to wrist or ankle 10. Penetrating trauma to Head, Neck, Chest, Abdomen, or Groin 11. Deterioration from Stable 12. Field Request for Activation Limited Activation 1. Hemodynamically stable patient without respiratory distress, but potential for deterioration 2. High energy transfer situations a. Intrusion into passenger compartment > 12 inches b. Auto vs. pedestrian, auto vs. bike, struck > 20 mph or thrown > 15 ft or run over c. MCC or ATV crash with separation of rider from vehicle d. Death in same vehicle OR Ejection from vehicle e. Unrestrained in rollover OR Extrication > 20 minutes f. Blast injury OR Crush injury g. Extrication > 20 minutes 3. Stable electrical injury including lightning strikes 4. Fall greater than 15 feet. Pediatric 2x height 5. Pregnancy greater than 20 weeks, with mechanism 6. Field Request for Activation Special Considerations: 1. Extremes of age < 5 and > 55 y/o 2. Medical illness (COPD, CHF, renal failure, diabetes, HTN, etc.) 3. Presence of intoxicants Special Notes: 1. The hospital shall be notified as soon as possible of a Trauma Activation. 2. A Trauma activation request will include: age, brief physiologic data and MOI. 3. Full Trauma Activation is based on physiological criteria while Limited Trauma Activation is based on mechanism of injury. 4. A Full Trauma Activation will activate a surgeon who will evaluate the patient. 5. A Limited Trauma Activation will be met by the Emergency Physician who will then evaluate the patient. Return to Table of Contents 6000 GENERAL GUIDELINES FOR PEDIATRICS Pediatric patients, for the purpose of the protocols, defined as age < 12 years, have unique anatomy, physiology, and developmental needs that affect prehospital care as well as hospital care. Because children make up a small percentage of total calls and few pediatric calls are critically ill or injured, it is important to stay attuned to these differences to provide good care. Therefore, CONTACT BASE early for guidance when treating pediatric patients with significant complaints, including abnormalities of vital signs. Pediatric emergencies are usually not preceded by chronic disease. If recognition of compromise occurs early, and intervention is swift and effective, the child will often be restored to full health. The following should be kept in mind during the care of children in the prehospital setting: A. Airways are smaller, softer, and easier to obstruct or collapse. B. Respiratory reserves are small. A minor insult like improper position, vomiting, or airway narrowing can result in major deficits in ventilation and oxygenation. C. Circulatory reserves are also small. The loss of as little as one unit of blood can produce severe shock in an infant. Conversely, it is difficult to fluid overload children. You can be confident that good hands-on circulation assessment will accurately determine fluid needs. D. Assessment of the pediatric patient can be accurately done using your knowledge of the anatomy and physiology specific to infants and children. E. Listen to the parents' assessment of the patient's problem. They often can detect small changes in their child's condition. This is particularly true if the patient has chronic disease. F. The proper equipment is very important when dealing with the pediatric patient. A complete selection of pediatric airway management equipment, IV catheters, cervical collars, and drugs has been mandated by the state. This equipment should be stored separately to minimize confusion. G. When following these protocols, the age groups used are: 1. INFANTS: birth to one year 2. TODDLERS: one through five years 3. SCHOOL AGE: six through fourteen years NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP AGE PULSE RESPIRATIONS BLOOD PRESSURE Average/minute breaths/minute systolic in mm Hg Newborn 150 40-60 60-80 6 mo 140 25-40 65-105 1 yr 135 20-30 70-110 3 yr 110 20-30 76-116 5 yr 100 20-30 80-120 8 yr 90 12-25 86-126 12 yr 80 12-25 95-120 Return to Table of Contents 6010 INFANT AND CHILD RESUSCITATION Specific Information Needed A. Time since the child was last in good health B. History of any recent illness or injury C. Past medical history Specific physical findings A. General appearance: LOC, muscle tone, color B. Airway: obstruction, stridor, drooling, cough C. Breathing: respiratory rate, skin color (cyanosis late sign), chest wall symmetry and depth of movement, work of breathing (grunting, nasal flaring, retractions), wheezing. D. Circulation: heart rate, peripheral pulses, capillary filling time, skin color, extremity skin temperature. E. Level of consciousness, pupil size and reaction to light. F. Physical assessment. G. Respiratory distress is a critical situation that can be made worse with prolonged scene times. H. Any child with or suspected apnea episode should be transported. Treatment A. Airway/Breathing: 1. Manage airway. Effective airway management is by far the most critical aspect of treatment. Bag-mask ventilation may be as good as and in some cases superior to endotracheal intubation for EMS treatment. 2. Administer oxygen via blow-by, non-rebreather mask, or bag-mask ventilation. 3. If apneic, ventilate with a BVM, intubate as indicated, ventilation rate per AHA BLS protocols. Ensure adequate chest rise and fall (tidal volumes), and air entry. 4. Note the drugs that are appropriate for endotracheal administration IN (naloxone, epinephrine, atropine). (mnemonic: N.E.A. – naloxone, epinephrine, atropine). Endotracheal administration of any medication should be considered LAST RESORT. B. Circulation: 1. Initiate CPR if indicated. IN 2. Monitor cardiac rhythm. 3. Establish peripheral venous access. 4. If unable to establish a peripheral IV after 1 attempt, establish an intraosseous infusion. If unable to see good peripheral vein, go straight to IO infusion. 5. If any signs of poor perfusion, infuse a 20 cc/kg of normal saline fluid bolus. CONTACT BASE if you feel perfusion is compromised on reassessment. C. Medications: Go to Table of Contents 1. Stabilizing the airway and supporting respiration are the mainstays of treatment. Specific treatment should be focused on the etiology of the arrest. 2. Arrhythmias are treated as noted in Arrhythmia Algorithms. 3. Hypoglycemia is common in younger children. If the child has altered mental status, either administer dextrose (1-8 years should receive 2 ml/kg of a 25% solution IV; <1 year should receive 5 ml/kg of 10% solution) or rule out hypoglycemia with a bedside blood sugar check. Hypoglycemia in pediatrics is commonly defined as a blood sugar <40. Specific Precautions A. The most successful pediatric resuscitations occur before a full cardiopulmonary arrest. Assess pediatric patients carefully and assist with airway, breathing, and circulatory problems before the arrest occurs, to improve the outcome in pediatric patients. B. Pediatric arrests are most likely to be primary respiratory events. The rescuer's primary attention must be directed to securing the airway and providing good ventilation before specific treatment of cardiac rhythm. Any cardiac rhythm can spontaneously convert to sinus rhythm in a well-ventilated child. C. Oxygen and epinephrine are the mainstays of pediatric resuscitations. Atropine and sodium bicarbonate are not first line drugs in pediatrics. D. Cardiopulmonary arrest from trauma is treated with airway management, rapid transport, CPR and fluid administration en route. E. Recommendations for obstructed airway are abdominal thrusts over the age of one year. Infants less than one year old should be treated with back blows and chest thrusts. Early laryngoscopy should be used in an attempt to visualize and remove upper airway obstructions. F. If a child 1 year of age or older is in cardiac arrest, an AED may be used, preferably one with pediatric capabilities. G. Use of a length-based emergency tape (LBET) such as the Broselow™ tape is highly accurate and allows for rapid drug and fluid doses and correct equipment size and use. LBET use should be routine for any pediatric emergency. Return to Table of Contents 6020 POSSIBLE SUDDEN INFANT DEATH SYNDROME (SIDS) Specific Information Needed A. History: position in which the child was found, condition of the bed, last time the child was seen well, seizure activity, trauma, possibility of ingestion B. Associated symptoms: history of fever, respiratory symptoms, infection, vomiting, diarrhea, other signs of infections C. Past medical history: prematurity, chronic illness Specific physical findings A. ABCs B. Neurologic: level of consciousness, responsiveness, muscle activity and tone C. Skin: signs of trauma D. Dependent lividity or early rigor mortis. E. Body temperature. Treatment A. Initiate or continue resuscitation based on field pronouncement protocol. B. Use appropriate airway adjuncts as indicated. C. Ventilate with 100% oxygen; suction as needed. D. Support cardiac output as indicated by: 1. CPR 2. External chest compressions 3. Establish venous access. 4. Pediatric ALS as indicated IN 5. Monitor cardiac rhythm E. CONTACT BASE for field pronouncement if appropriate. F. Support the parents and siblings. Special Considerations A. Activate appropriate support for the family if the patient is pronounced dead in the field. Police, County Social Services, and the SIDS support line should be contacted. B. Automatic External Defibrillator (AED) should be used in patients >1 year old. C. Avoid premature assessments. D. The cause of SIDS is unknown. Cases occur between one month and one year of age. All cases are mandatory coroner cases. E. Consider possible NAT (non-accidental trauma, child abuse) and pass on any concerns to receiving facility personnel. F. For family support and community education, family members may welcome the following contact information: The Colorado SIDS Program, 6825 East Tennessee Ave., Suite 300, Denver, CO 80224 Local#: 303-320-7771 or toll-free#: 1-888-285-7437; Web: http://www.coloradosids.org Go to Table of Contents 6030 PEDIATRIC DEHYDRATION Specific Information Needed A. History: onset and progression of symptoms, frequency of vomiting and diarrhea, urine output, oral intake, recent trauma, possible drug ingestion B. Past medical history Document Specific physical findings A. General appearance: LOC, muscle tone, color B. ABCs and vital signs C. Skin: warmth of distal extremities, color, skin turgor, capillary fill time (should be less than 2 seconds), pulses D. Mucous membranes: wetness of mouth, presence of tears E. Musculoskeletal: evaluate for trauma F. The signs of dehydration are: 1. EARLY - tachycardia and tachypnea for age, decreased LOC, capillary filling time longer than two seconds, cool skin, mucous membranes dry, sunken eyes and fontanelle; 2. LATE - loss of skin turgor, diminished pulses, and shock Treatment A. Use appropriate airway adjuncts as indicated. B. Administer oxygen C. Breathing: ventilation as indicated D. Circulation: 1. Establish pulse rate and capillary refill time IV 2. Establish peripheral venous access. 3. Consider fluid bolus of normal saline 20cc/kg. 4. Do not delay transport for IV attempts. 5. The patient with simple dehydration is not a candidate for intraosseous infusion, CONTACT BASE for approval of IO if shock is present. Specific Precautions A. Assessment of dehydration is primarily by physical exam. Vital signs may be abnormal, but they are nonspecific. B. Determination of tachycardia or hypotension is based on age. C. Monitor carefully for signs of decreased tissue perfusion (shock). Early (compensated) shock is present if capillary fill time is greater than 2 seconds, and there are poor pulses, muscle tone and color, and/or are normotensive. Decompensated shock is present if systolic BP is <normal for age, have a decreased mental status and/or have weak or absent central pulses. Go to Table of Contents 6040 PEDIATRIC RESPIRATORY DISTRESS Specific Information Needed A. History: sudden or gradual onset of symptoms, cough, fever, sore throat, hoarseness B. History of potential foreign body aspiration or trauma C. Past medical history D. Current medication use Specific Objective Findings A. Airway: look for respiratory distress during inspiration, listen for abnormal breathing sounds such as stridor, cough (croup-like?), and wheezing, feel for air movement, crepitation, and tracheal deviation (late finding). B. Breathing: respiratory rate and effort, chest wall movement/adequacy of tidal volume, color, use of accessory muscles, retractions, nasal flaring, head bobbing, or grunting C. Respiratory sounds by auscultation of chest: wheezing, rales, decreased (unilateral?), prolonged inspiratory (croup) or expiratory (wheezing) phases. D. Mental status: AVPU E. General appearance: leaning forward or drooling (suggests upper airway obstruction), skin color and temperature, muscle tone. Treatment A. Administer high-flow oxygen by blow-by or non-rebreather mask. B. As long as the child is adequately ventilating and has adequate mentation, avoid agitating the patient. Keep the patient in his position of comfort. C. If the child is not ventilating adequately, assist with a BVM. D. If the patient is wheezing and has a metered dose inhaler (MDI), initiate MDI protocol. EMT's must contact base. E. In the rare case that the child cannot be ventilated with a BVM device: IN 1. Reposition airway. Consider oral airway if patient unconscious. 2. If still unable to ventilate, visualize the airway with a laryngoscope. Remove any foreign object with Magill forceps. 3. If nothing is seen, orally intubate the patient. F. Consider intubation only if unable to provide ventilatory support with a BVM and oral airway. G. Assess and consider treatment for the following problems if respiratory distress is severe and the patient does not respond to proper positioning and administration of high flow oxygen. IN CB 1. Croup or Epiglottitis: a. Allow patient to remain in position of comfort if alert. b. Consider administering nebulized racemic epinephrine 0.5 ml or L- epinephrine, 5 mg (5.0 ml of a 1:1000 solution) (under 10 kg use 0.5 ml/kg of a 1:1000 solution) via nebulizer if croup is likely and there is respiratory distress. 2. Asthma: Go to Table of Contents a. Administer albuterol sulfate, one unit dose bottle by nebulizer. Consider adding Ipratropium (0.5 mg/2.5ml) for patients over 2 years of age. b. Use continuous nebulization of Albuterol sulfate for respiratory distress. c. Consider Epinephrine 0.01 mg/kg (0.01 ml/kg of a 1:1000 solution), SQ/IM. H. If diagnosis is unclear, transport patient with 100% oxygen, reassess frequently and be prepared to manage the patient's airway. Specific Precautions A. Children with croup, epiglottitis, or laryngeal edema usually have respiratory arrest due to exhaustion. Most children can still be ventilated with a BVM. B. Children with severe asthma may not exhibit wheezing. The patients will have prolonged expiratory phases and may appear listless, agitated, or unresponsive. C. Respiratory distress is a critical situation that can be made worse with prolonged scene times. D. Cyanosis is a late sign in pediatric hypoxia. Provide 100% oxygen for any child in distress. E. Consider the differential assessment for each finding: 1. Stridor: foreign body, croup, epiglottitis or other bacterial upper airway infection, larynx trauma, etc 2. Wheezing: foreign body, asthma, bronchiolitis, hydrocarbon exposure, etc 3. Respiratory distress: pneumothorax, foreign body, pneumonia, shock, CHF, etc IN F. Any child with a witnessed or suspected apnea episode should be transported. G. Intubation of the infant is most easily accomplished with an infant-sized straight laryngoscope blade. H. Do not intubate unless you can visualize the ETT going through the cords. If you are unable to intubate the trachea quickly, withdraw, re-oxygenate with BVM, and try again. No harm will result to the child if you keep the patient well oxygenated and don't traumatize the airway with intubation attempts. Transporting while using BVM only is acceptable and may be preferable in many circumstances. Return to Table of Contents 6050 PEDIATRIC SEIZURES Specific Information Needed A. History: preceding activity level, onset and duration of seizure, description of seizure activity, fever, color change, recent illness, head trauma, possibility of ingestion, cardiac symptoms. B. Past history: previous seizures, current medications, chronic illness Specific Objective Findings A. Airway: look for respiratory distress, listen for abnormal breathing sounds, feel for air movement, crepitus. B. Breathing: respiratory rate and effort, chest wall movement (adequacy of tidal volume), use of accessory muscles, retractions. C. Circulation: heart rate, pulse, capillary filling time, skin color, blood pressure D. Neurologic: mental status, muscle tone, focal findings, post-ictal period, incontinence. Note improvement or deterioration in mental status with time. E. Musculoskeletal: note any associated injuries. Treatment A. Airway: Maintain patent airway by BLS maneuvers. Suction as needed. Administer high concentration oxygen. B. Breathing: Assist ventilation as needed. (rarely necessary) C. If child is in status epilepticus: IN CB 1. Attempt peripheral venous access x1. If successful, administer diazepam 0.3 mg/kg, IV/IO bolus, slowly, over 2 minutes OR 0.5 mg/kg rectally up to a maximum of 10 mg OR administer diazepam, 0.5 mg/kg rectally, not to exceed 10 mg. 2. If unable to start peripheral IV: a. for ages 8 and under, administer diazepam, 0.5 mg/kg rectally, not to exceed 10 mg. P b. for ages 9 and above, administer midazolam 0.1 mg/kg IM, not to exceed 10 mg. 2. Determine blood glucose level and draw appropriate blood tubes if possible. 3. If hypoglycemic, give dextrose (1-8 years should receive 2 ml/kg of a 25% IV solution IV; <1 year should receive 5 ml/kg of 10% solution). 4. If seizures continue, CONTACT BASE. D. If the child has stopped seizing and is postictal, transport while continuing to monitor vital signs and neurological condition. Continue to provide supplemental oxygen. IN E. If child is febrile initiate passive cooling measures. Go to Table of Contents Specific Precautions A. Febrile seizures occur in normal children between 6 months and 6 years. Such seizures are usually short, lasting less than 5 minutes, generalized, and usually do not require anti-seizure drug therapy. B. Do not force anything between the teeth. C. Consider hypoglycemia as a cause for non-traumatic seizure. D. Breath-holding spells in toddlers can resemble seizures, but are not a true seizure. E. Most airways of seizing children can be managed with BLS measures. Intubation is only necessary if there is prolonged apnea from diazepam or from the seizure activity itself. Return to Table of Contents 7010 STANDARD DRUG ADMINISTRATION PROTOCOL A. The following protocol should be followed with the administration of any pre- hospital medication. 1. Perform initial patient assessment. 2. Administer supplemental oxygen. 3. Obtain vital signs. 4. Assess the need for medication. 5. Ensure medication to be delivered is prescribed to the patient. 6. Contact on-line medical control for an order to administer medication. 7. Administer the medication. 8. Reassess the vital signs and patient condition after 1-2 minutes. 9. If the patient's condition persists or worsens, re-contact the base station for additional guidance. 10. Complete your patient care record with full documentation of the patient's symptoms, the patient assessment, the patient vital signs, the time and the amount of the drug given, and the effect the medication had on the patient's condition. B. The above steps should be performed while initiating patient transportation. The administration of field medication should not delay patient transportation. C. ALL PATIENTS RECEIVING PATIENT ASSISTED DRUG ADMINISTRATION SHOULD BE TRANSPORTED TO THE HOSPITAL. Go to Table of Contents 7020 MEDICATION ADMINISTRATION (PARENTERAL) Indications A. Illness or injury which requires medication to improve or maintain the patient's condition Precautions A. Use BSI. B. Certain medications can be administered via one route only, others via several. If you are uncertain about the drug you are giving - check with base. C. Make certain that the medication you want to give is the one in your hand. Always double check medication and dose before administration. D. IM and SQ routes are unpredictable: medications are absorbed erratically via these routes and may not be absorbed at all if the patient is seriously ill and severely vasoconstricted. The IV route should be used almost exclusively in the field. If an IV cannot be started, the endotracheal route is the best alternative. Technique A. Use syringe just large enough to hold appropriate quantity of medication (or use prefilled syringe). B. Attach large gauge needle to syringe. C. Break ampule (use filtered needle, when available) or cleanse multi-dose vial with alcohol (the latter is less desirable for field use). D. Using sterile technique, draw medication into syringe. E. Change needles to small gauge for IM or SQ. Endotracheal Technique (LAST RESORT) A. Prepare medication to be given, and set next to patient being ventilated. B. Ventilate fully and rapidly 4-5 times prior to disconnecting the bag from the endotracheal tube. C. Check medication in hand. Confirm medication, dose, amount, and expiration date. D. Higher doses are required when administering drugs endotracheally E. Dilute medication with 10 ml of normal saline, unless using prefilled syringes. F. Administer medication. G. Connect the bag and ventilate rapidly an additional 4-5 times. H. Disconnect the bag and administer the remaining half of medication into the endotracheal tube. I. Again connect the self-inflating bag and ventilate rapidly 4-5 times before resuming the recommended ventilation rate according to the age and condition of patient. J. Record medication given, dose, amount, and time. Intraosseous Technique A. Prepare medication to be administered. B. Check medication in hand. Confirm medication, dose, amount, and expiration date. C. Wipe port site with alcohol. D. Inject into port on intraosseous line, or E. Remove needle from syringe and inject directly into intraosseous needle. Go to Table of Contents F. Record medication given, dose, amount, and time. Intramuscular Technique (for ages 8 or greater only) A. Prepare medication to be administered. B. Check medication in hand. Confirm medication, dose, amount, and expiration date. C. Prep area of skin with alcohol or Betadine wipe. D. Inject 22 g/1½" needle into desired muscular site (deltoid, gluteus, or vastus lateralis) at 90˚ angle. Aspirate to ensure needle is not in blood vessel. E. Inject medication slowly into muscular site. F. Withdraw needle and observe for any bleeding or swelling. Apply sterile dressing to injection site. G. Record medication given, dose, amount, and time. Intravenous Push (IVP) Technique A. Use needle appropriate for viscosity of fluid injected. B. Wipe IV tubing injection site with alcohol. C. Check medication in hand. Confirm medication, dose, amount, and expiration date. D. Eject air from syringe. E. Insert needle into injection site. F. Pinch IV tubing closed between bag and needle. G. Inject at a rate appropriate for medication. H. Withdraw needle and release tubing to restore flow. I. Record medication given, dose, amount, and time. J. Give 20 cc saline fluid flush after giving any drugs. Nebulization Technique A. Use hand-held nebulizer with mouthpiece (or mask for patient unable to hold mouthpiece). B. Check medication in hand. Confirm medication, dose, amount, and expiration date. C. Draw up dose of medication in syringe or dropper; inject into nebulizer. D. Attach to oxygen tubing and set at 6-8 L/min (sufficient to produce good vaporization). E. Administer for approximately 5 minutes, until solution is gone from chamber. F. Record medication given, dose, amount, and time. Rectal Technique A. Technique One 1. Use a tuberculin syringe (without needle) lubricated with a water-soluble, lubricating jelly. 2. Check medication in hand. Confirm medication, dose, and expiration date. 3. Insert needleless syringe into rectum completely to end of syringe (4-5cm). 4. Inject the medication and withdraw the syringe. No flushing is necessary. B. Technique Two 1. Lubricate with a water-soluble lubricating jelly and insert a feeding tube 4-5 cm into the rectum. 2. Attach a syringe containing the appropriate dose of the medication to be given and instill. Return to Table of Contents 3. Remove the syringe from the tube, draw up 1 cc of air, reattach the syringe to the tube, and instill the air to clear the tube of medication. Then withdraw the feeding tube from the rectum. Subcutaneous Injection Technique A. Use 25 g needle, 5/8" length for most subcutaneous injections. B. Check medication in hand. Confirm medication, dose, amount, and expiration date. C. Select injection site (usually jrm misctr todeltoid)(. )]TJEMC /P <</MCID119 >>BDC 0.001 Tc -0.0001 time. This may include the dilution of a medication to facilitate a slow administration. Return to Table of Contents ADENOSINE (ADENOCARD) Description Adenosine is primarily formed from the breakdown product of adenosine triphosphate (ATP). Both compounds are found in every cell of the human body and have a wide range of metabolic roles. Adenosine slows tachycardias associated with the AV node via modulation of the autonomic nervous system without causing negative inotropic effects. It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic and dromotropic activity. Adenosine is the drug of choice for paroxysmal supraventricular tachycardia (PSVT). Onset & Duration Onset: almost immediate Duration: 10 sec Indications Conversion of PSVT to sinus rhythm Contraindications Second- or third-degree AV block Sick sinus syndrome Hypersensitivity to adenosine Adverse Reactions Facial flushing Lightheadedness Paresthesia Headache Diaphoresis Palpitations Chest pain Hypotension Nausea Metallic taste Shortness of breath Drug Interactions Methylxanthines (for example, caffeine and theophylline) antagonize the action of adenosine. Dipyridamole potentiates the effect of adenosine; reduction of adenosine dose may be required. Carbamazepine may potentiate the AV-nodal blocking effect of adenosine. Dosage and Administration Adult: 6.0 mg IV bolus, rapidly, followed by a Normal Saline flush. Observe EKG monitor for 1-2 minutes for evidence of cardioversion. If there is no evidence of cardioversion, administer Adenosine 12 mg, IV bolus, rapidly, followed by a Normal Saline flush. Observe EKG monitor for 1-2 minutes for evidence of cardioversion. Contact medical control for further considerations NOTE: Total maximum dose should not exceed 18 mg. Go to Table of Contents Pediatric: 0.1 mg/kg, IV or IO bolus, rapidly, followed by Normal Saline flush. If SVT persists, a second dose may be given using 0.2 mg/kg IV or IO bolus, followed by Normal Saline flush If this fails to convert the dysrhythmia, Adenosine may be repeated at 0.2 mg/kg, IV or IO bolus, rapidly, followed by Normal Saline flush. Protocol Narrow Complex Tachycardia Special Considerations May produce bronchoconstriction in patients with asthma or bronchopulmonary disease. At the time of conversion asystole or new rhythms may result. These generally last a few seconds without intervention Adenosine is not effective in atrial flutter or fibrillation Adenosine is safe in patients with a history of Wolff-Parkinson-White syndrome. Concomitant use of dipyridamole (Persantine) enhances the effects of adenosine. Smaller doses may be required. Caffeine and theophylline antagonize adenosine's effects. Larger doses may be required. A 12-lead EKG should be performed and documented, when available. Return to Table of Contents ALBUTEROL SULFATE (PROVENTIL, VENTOLIN) Description Albuterol is a sympathomimetic that is selective for beta-2 adrenergic receptors. It relaxes smooth muscles of the bronchial tree and peripheral vasculature by stimulating adrenergic receptors of the sympathetic nervous system. Onset & Duration Onset: 5-15 min. after inhalation Duration: 3-4 hr after inhalation Indications Relief of bronchospasm in patients with reversible obstructive airway disease Prevention of exercise-induced bronchospasm Contraindications Prior hypersensitivity reaction to albuterol Cardiac dysrhythmias associated with tachycardia Tachycardia caused by digitalis intoxication Adverse Reactions Tachycardia Restlessness Anxiety Headache Dizziness Nausea Palpitations Hypertension Dysrhythmias Drug Interactions Sympathomimetics may exacerbate adverse cardiovascular effects. Antidepressants may potentiate the effects on the vasculature. Beta blockers may antagonize albuterol. Albuterol may potentiate diuretic-induced hypokalemia. How Supplied MDI: 90 mcg/metered spray (17-g canister with 200 inhalations) Prediluted nebulized solution: 2.5 mg in 3 ml NS (0.083%) Dosage and Administration Bronchial asthma Adult: Albuterol sulfate solution 0.083% 2.5mg (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5 to 15 minutes. Pediatric: Albuterol sulfate 0.083% 2.5mg (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5-15 minutes. Protocol Asthma Go to Table of Contents Chronic Obstructive Pulmonary Disease Pneumonia Pediatric Respiratory Distress Special Considerations May precipitate angina pectoris and dysrhythmias Should be used with caution in patients with diabetes mellitus, hyperthyroidism, prostatic hypertrophy, or seizure disorder Return to Table of Contents AMIODARONE (CORDARONE) Description Amiodarone has multiple effects showing Class I, II, III and IV actions with a quick onset. The dominant effect is prolongation of the action potential duration and the refractory period. Indications Ventricular Fibrillation Ventricular Tachycardia without a pulse Wide complex tachycardia refractory to cardioversion Precautions Wide complex irregular tachycardia Sympathomimetic toxidromes, i.e. cocaine or amphetamine overdose NOT to be used to treat ventricular escape beats or accelerated idioventricular rhythms Contraindications Wolff-Parkinson-White Syndrome (relative contraindication) Pulmonary congestion Cardiogenic shock Adverse Reactions Severe hypotension Profound bradycardia Dosage and Administration Adult: Cardiac Arrest 300 mg IV bolus. Repeat once 150 mg IV bolus in 3-5 minutes. CONTACT BASE for additional doses. After successful defibrillation, 150 mg IV bolus infusion over 10 minutes Wide Complex tachycardia 150 mg IV bolus infusion over 10 minutes. Pediatric: Cardiac Arrest 5mg/kg IV over 3-5 minutes. CONTACT BASE for additional doses. Protocol Ventricular Fibrillation/Ventricular Tachycardia without a pulse Wide complex tachycardia refractory to cardioversion Special Considerations A 12-lead EKG should be performed and documented, when available. Go to Table of Contents ASPIRIN (ASA) Description In low doses, aspirin inhibits blood clotting, specifically the formation of thromboxane A2, a platelet aggregating, vasoconstricting prostaglandin. Platelet aggregation has been implicated in the pathogenesis of atherosclerosis contributing to the acute episodes of transient ischemic attacks, unstable angina, and acute myocardial infarction. This has been linked to anginal episodes. Unstable angina is precipitated by a sudden fall in coronary blood flow. Aspirin has been shown to be beneficial in decreasing sudden cardiac death and myocardial infarction in patients with unstable angina. It has also been shown to be of added benefit in maintaining vessel patency after thrombolytic therapy Indications Patients with chest pain that may be related to cardiac origin. Contraindications Patients with an active gastrointestinal bleed Patients with an allergy to aspirin Adverse Reactions Wheezing, Tinnitus, GI Upset, GI bleeding How Supplied Chewable tablets 81mg Dosage and Administration Aspirin should be given to conscious patients who can voluntary chew and swallow. Dose is four (4) 81 mg tablets for a total of 324mg. Protocol Premature Ventricular Contractions (PVCs) Chest Pain Special Considerations Aspirin should not be given for analgesia, i.e. head or body aches. Patients on coumadin may be given aspirin Go to Table of Contents ATROPINE SULFATE Description Atropine is a parasympathetic or cholinergic blocking agent. As such, it has the following effects: • Increases heart rate (by blocking vagal influences) • Increases conduction through A V node • Reduces motility and tone of GI tract • Reduces action and tone of urinary bladder (may cause urinary retention) • Dilates pupils Note: This drug blocks cholinergic (vagal) influences already present. If there is little cholinergic stimulation present, effects will be minimal. Indications Asystole and idoventricular cardiac arrests Hemodynamically unstable bradycardias To improve conduction in 2nd and 3rd degree heart block or in pacemaker failure Organophosphate poisoning Precautions Should not be used without medical control direction for stable bradycardias Closed angle glaucoma Adverse Reactions Headache Dry mouth Nausea Dizziness Tachycardia Palpitations Dosage and Administration Cardiac Arrest Adult: 1.0 mg IV/IO rapid bolus. Repeat every 3-5 minutes, not to exceed 3.0 mg. Pediatric: Refer to Length Based Measurement tool. Hemodynamically Unstable Bradycardia Adult: 0.5 – 1.0 mg IV/IO rapid bolus. Repeat if needed at 3-5 minute intervals to a dose of 3 mg. (Stop at ventricular rate which provides adequate mentation and B/P.) Pediatric: 0.02 mg/kg, IV/IO bolus. Minimum dose is 0.1 mg. Acute Organophosphate Exposure Adult: 2mg IV/IO every 5 min. until secretions dry Pediatric: 0.05 to 0.2mg/kg every 5 min. until secretions dry Protocol Go to Table of Contents Asystole Bradycardia with a pulse Poisoning/Overdose Infant and Child Resuscitation Special Considerations • Atropine causes pupil dilation, even in cardiac arrest settings. • Endotracheal administration should be used only as a last resort. • If given ET, dosing is x2 normal dosing with a max ET dose of 6mg. Return to Table of Contents Diltiazem (Cardizem) Description Diltiazem is an Antiarrhythmic / Calcium Channel Blocker. As such it has the following effects: • Slows conduction through the AV node. • Vasodilation • Decreases rate of ventricular response • Decreases myocardial oxygen demand Indications To control rapid ventricular rates (>150 bpm) associated with atrial fibrillation and atrial flutter. Rapid narrow complex PSVT, unresponsive to adenosine. Contraindications Known hypersensitivity to diltiazem Hypotension Pulmonary congestion Wide-complex tachycardia Conduction disturbances: WPW, sick sinus syndrome, AV block Precautions Concurrent use with Midazolam may require decreased dose Use with caution in patients on oral / IV beta-blockers Adverse Reactions Nausea and vomiting, hypotension, and dizziness Dosage and Administration 1. Initial dose: Bolus 0.25 mg / kg (typically 20 mg) IV over 2 minutes 2. Second dose in 15 minutes if inadequate response to initial dose: 3. Bolus 0.35 mg / kg (typically 25 mg) IV over 2 minutes 4. All dosing in the physiologically elderly pt. should be reduced 50%. Protocol Narrow complex tachycardia Special Considerations • Patients with rapid atrial fibrillation who are unstable (BP < 80 and altered mental status or signs of ischemia) should be cardioverted. If cardioversion is unsuccessful then diltiazem can be considered. • Patients with chronic atrial fibrillation run the risk of embolization with sudden cessation of the rhythm by cardioversion. Therefore, in the semi-unstable patient with chronic atrial fibrillation and now with a rapid ventricular response, slowing of the rate with diltiazem is preferred so that cardioversion can be done after the patient is anticoagulated. Go to Table of Contents • The use of calcium channel blockers in patients with rapid atrial fibrillation secondary to accessory conduction pathways (WPW) can potentially accelerate conduction through the accessory pathway causing a fatal dysrhythmia. This effect is primary found with verapamil and not diltiazem. • Stable patients with rapid atrial fibrillation and short transport times should be transported to the ED, where calcium channel blocker therapy can be initiated. Return to Table of Contents DEXTROSE 50% Description Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop in blood sugar level will result in disturbances of normal metabolism, manifested clinically as a decrease in mental status, sweating and tachycardia. Further decreases in blood sugar may result in coma, seizures, and cardiac arrhythmias. Serum glucose is regulated by insulin, which stimulates storage of excess glucose from the blood stream, and glucagon, which mobilizes stored glucose into the blood stream. Indications • Hypoglycemic states (i.e., insulin shock in the diabetic) • The unconscious patient with an unknown history. Any patient with focal or partial neurologic deficit or altered state of consciousness, which may be due to hypoglycemia • Non-traumatic seizure patients who show no improvement in post-ictal state • Patients in status epilepticus not responsive to Valium • Blood glucose test < 60 if clinically indicated • Poisons and Overdoses protocol • In children with alcohol exposure, suspected sepsis, hypoperfusion or altered mental status Precautions Patients presenting with signs of CVA, unless presenting with a significantly low blood glucose. Dextrose can exacerbate Wernicke's encephalopathy and Korsakoff''s Psychosis found primarily in the chronic ETOH abuse patient. Dosage and Administration Adult: 25 gm (50 ml of a 50% solution), IV bolus or Rectal. Pediatric: 1-8 years: 2-4 ml/kg of a 25% solution IV or Rectal. <1 year: 2-4 ml/kg of a 10% solution IV or Rectal. NOTE: Oral glucose can be used for conscious patients able to swallow. Protocol Altered Mental Status Seizures Syncope Poisoning/Overdose Psychiatric/Behavioral Infant and Child Resuscitation Pediatric Seizures Special Considerations Draw blood sample before administration if possible. Return to Table of Contents Use glucometer before administration. Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to ensure route patency. Dextrose should be diluted 1:1 with normal saline (to create D25W) for patient 8 years and younger Return to Table of Contents DIAZEPAM (VALIUM) Description Diazepam acts as a tranquilizer, anticonvulsant, and skeletal muscle relaxant through effects on the central nervous system Indications Status epilepticus Drug-induced hyperadrenergic states manifested by tachycardia and hypertension (i.e., cocaine, amphetamine overdose) Combative patients from head injury or from suspected stimulant abuse (i.e.: cocaine, PCP, ecstasy, amphetamines) Severe musculoskeletal back spasms Precautions Patients under the influence of alcohol Adverse Reactions Drowsiness Dizziness Respiratory depression Fatigue Ataxia Paradoxical excitement or stimulation may occur Dosage and Administration A. Adult 1. Status Seizures a. Initial dose: 1-10 mg IV or IM b. Repeat dose: 1-10 mg IV or IM 2. Hyperadrenergic States/ Severe Musculoskeletal Spasm/ Combative Patients/Sedation a. Initial dose 1-10 mg IV or IM b. Repeat dose 1-5 mg IV or IM 3. Combination Analgesia a. 1-5 mg IV over 2 minutes for spasm and/or anxiety. b. Repeat Dose 1-2 mg IV over 2 minutes. B. PEDIATRIC DOSAGES Status Seizures a. Initial dose 0.2 mg/kg IV/IM OR 0.50 mg/kg rectal b. Repeat dose 0.2 mg/kg IV/IM OR 0.50 mg/kg rectal Protocol Seizures Combination Analgesia Poisoning/Overdose Hyperthermia Psychiatric/Behavioral Pediatric Seizures Go to Table of Contents Head trauma Special Considerations Since diazepam can cause respiratory depression and/or hypotension, the patient should be monitored closely (vitals signs, cardiac monitor, pulse oximeter). Very rarely, cardiac arrest can occur. Patients receiving diazepam should be placed on oxygen. Do not give unless the patient is actively seizing. Diazepam should be used with caution in any patient under the influence of alcohol. Return to Table of Contents DIPHENHYDRAMINE (BENADRYL) Description Diphenhydramine blocks action of histamine released from cells during an allergic reaction. Direct CNS effects, which may be stimulant or, more commonly, depressant, depending on individual variation. Also has anticholinergic, antiparkinsonian effects, which is used to treat acute dystonic reactions to antipsychotic drugs (Haldol, Thorazine, Compazine, etc.) These reactions include oculogyric crisis, acute torticollis, and facial grimacing. Indications Moderate allergic reactions Second line for anaphylaxis and severe allergic reactions Control extrapyramidal effects Synergist to other medications in Combative Patient Precautions Lower respiratory diseases such as asthma or COPD Narrow-angle glaucoma Bladder obstruction Side effects Dose-related drowsiness Dilated pupils Dry mouth and throat Flushing May potentiate with alcohol usage Drug Interactions CNS depressants and alcohol may have additive effects. MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines. Dosage and Administration Adults: 25-50 mg, IV bolus, or IM if vascular access has not been obtained <8 years: 1-2 mg/kg slow IV bolus/IM (not to exceed 50 mg) Protocol Restraint Allergic Reaction Go to Table of Contents DOPAMINE (INTROPIN) Description Dopamine is chemically related to epinephrine and norepinephrine. It acts primarily on alpha-1 and beta-1 adrenergic receptors, increasing systemic vascular resistance and exerting a positive inotropic effect on the heart. In addition, the actions of this drug on dopaminergic receptors dilate renal and splanchnic vasculature, maintaining blood flow. Dopamine is commonly used to treat hypotension associated with cardiogenic shock. Indications Symptomatic hypotension from causes other than hypovolemia Contraindications Patients with hypovolemia Cardiogenic Shock secondary to Arrhythmia prior to treatment of the arrhythmia Adverse Reactions Dose-related tachydysrhythmias Hypertension Increased myocardial oxygen demand Dosage and Administration Mix: 400 mg in 250 ml NS or 800 mg in 500 ml NS to produce concentration of 1600 mcg/ml. Actions of dopamine are dose dependent: 1. <5 mcg/kg/min Dilates renal/mesenteric vessels with no effect on heart rate or blood pressure 2. 5-10 mcg/kg/min Mild effect on cardiac output and peripheral vasoconstriction leading to slight increase in blood pressure 3. 10-20 mcg/kg/min Increased heart rate, cardiac output, and peripheral vasoconstriction leading to increased blood pressure 4. >20 mcg/kg/min Diffuse vasoconstriction leading to increased blood pressure, however, major decrease in renal and mesenteric blood flow Adults: 5-20 mcg/kg/min Pediatrics: 5-20 mcg/kg/min CONTACT BASE EXCEPT IN CASES OF CARDIAC ARREST Protocol Shock: Medical Special Considerations • Dopamine is better administered using an infusion pump to ensure accurate dosing • May become ineffective is added to solutions containing alkaloids • At low doses, decreased blood pressure may occur due to peripheral vasodilatation. Increasing infusion rate will correct this. Go to Table of Contents • Tissue extravasation at the IV site can cause skin sloughing due to vasoconstriction. Be sure to make Emergency Department personnel aware if there has been any extravasation of dopamine-containing solutions, so that proper treatment can be instituted. • Can cause hypertensive crisis in susceptible individuals • Certain antidepressants potentiate the effects of this drug. INTRAVENOUS DRIP RATES FOR DOPAMINE Concentration: 1600 mcg/ml Dose (mcg/kg/min) Weight 5 10 15 20 microdrips/min 50 10 20 30 40 60 10 25 35 45 70 15 25 40 50 80 15 30 45 60 90 15 35 50 70 100 20 35 55 75 110 20 40 60 85 Return to Table of Contents EPINEPHRINE (ADRENALIN) Description Epinephrine stimulates alpha, beta-1, and beta-2 adrenergic receptors in dose-related fashion. Indications Bronchial asthma Acute allergic reaction Bradycardia Cardiac arrest Airway obstruction secondary to croup or epiglottitis Adverse Reactions Headache Nausea Vomiting Anxiety Tremors Palpitations May precipitate angina Drug Interactions May be deactivated by alkaline solutions (sodium bicarbonate, furosemide). Dosage and Administration Adult: Cardiac Arrest 1.0 mg (10 ml of a 1:10,000 solution), IV/IO bolus. Repeat every 3-5 minutes. Bradycardia refractory to other interventions: 1.0 mg in 250 ml of Normal Saline. Infuse at 2 mcg/min until desired BP of 90 mmHg systolic. Asthma: 0.3 mg (0.3 ml of a 1:1,000 solution), SQ/IM. Moderate to Severe Allergic Reaction: 0.3 mg (0.3 ml of a 1:1,000 solution), SQ/IM. Anaphylactic Reaction: 0.1 mg (1 ml of a 1:10,000 solution), IV followed by 1.0 mg in 250 ml of Normal Saline infused at 2 mcg/min until desired BP of 90 mmHg systolic Pediatric: Cardiac arrest: First dose: 0.01 mg/kg IV/IO/ET (0.1 ml/kg of 1:10,000 solution) Subsequent doses: 0.01 mg/kg, IV/IO/ET (0.1 ml/kg of 1:10,000 solution) Bradycardia 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO Moderate to Severe Allergic Reactions 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM/SQ Anaphylaxis 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV/IO Asthma 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM/SQ Go to Table of Contents Life threatening airway obstruction suspected secondary to croup or epiglottitis In the absence of racemic epinephrine, plain L-epinephrine can be used. The dose is 5 mg (5.0 ml of 1:1000 solution of L-epinephrine, undiluted, nebulized). In smaller infants, weighing <10 kg, the recommended dose is 0.5 ml/kg of 1:1000 L- epinephrine. Protocol Asystole Bradycardia with a pulse Asthma Allergy/Anaphylaxis Infant and Child Resuscitation Pediatric Respiratory Distress Pediatric Anaphylactic Reaction Special Considerations Syncope has occurred after epinephrine administration to asthmatic children. May increase myocardial oxygen demand. IV doses may be given through ET tube at 2 times the IV dose. Endotracheal administration is a LAST RESORT. Return to Table of Contents EPINEPHRINE AUTO-INJECTOR (Adrenaline, Epi-Pen and Epi-Pen Jr.) Pharmacology and Actions Cardiovascular 1. Increased heart rate 2. Increased blood pressure 3. Arterial vasoconstriction 4. Increased myocardial contractile force 5. Increased myocardial oxygen consumption 6. Increased myocardial automaticity and irritability Pulmonary 1. Potent bronchodilator Indications 1. The patient has a history consistent with allergic reaction and exhibits any one of the following: a. Respiratory distress/airway compromise with tongue swelling or stridor. b. Signs and symptoms of hypoperfusion (shock) 2. Patient has his/her own physician prescribed Epinephrine Auto-Injector. Precautions 1. Increased myocardial oxygen consumption can precipitate angina or myocardial infarction in patients with coronary artery disease. 2. Use with caution in patients with hypertension or known coronary artery disease. Administration 1. The initial dosage for adult: one Epinephrine Auto-Injector (0.3 mg.) 2. The initial dosage for pediatric: one pediatric Epinephrine Auto-Injector (0.15 mg.) 3. Follow the standard drug administration protocol. 4. Contact on-line medical control for an order to administer if EMT-I or Basic 5. Standing order for Paramedics 6. Administer a single dose of Epinephrine Auto-Injector. 7. In a patient with hypoperfusion, early venous access should be anticipated. 8. Dispose of Auto-Injector in a biohazard container. 9. Reassess patient's vital signs and condition 1-2 minutes after administration. Side Effects and Special Notes 1. Experienced side effects include increased heart rate, pallor, dizziness, chest pain, nausea, vomiting, excitabilty, anxiousness, headache, hypertension. 2. Only a single auto-injector should be utilized. Should the patient's condition persist or worsen, contact the base station for additional orders. Go to Table of Contents FENTANYL Description Used as an analgesic and sedative. Does not cause histamine release. Onset & Duration Onset: Within 5 minutes, with a peak effect within 30 minutes Duration: 90 minutes Indications Pain management of extremity injuries; to be given only in the absence of any evidence of head, chest or abdominal injuries Management of pain secondary to selected medical problems (abdominal pain, back pain, Chest Pain, kidney stones) Burns Contraindications Hypersensitivity to opiates Hypotension Side Effects Can cause significant respiratory depression and hypotension especially when used in combination with other sedatives such as alcohol or benzodiazepines. Can increase intracranial pressure Chest wall rigidity has been reported with rapid administration that is unaffected by narcan administration. Pediatric patients may develop apnea without manifesting significant mental status changes Dosage and Administration Adult: The initial adult dose is 1-2 mcg / kg, SLOW IV bolus. Pediatric (<12 years): Initial dose is 1-2mcg / kg, SLOW IV bolus. Contact base for any single or cumulative dose > 3 mcg/kg (not to exceed 100 mcg) Combination Analgesia: 0.5 – 1.0 mcg/kg IV over two minutes Repeat dose at 0.5 -1.0 mcg/kg over two minutes Initial pain management : In certain circumstances it is appropriate to give fentanyl via MAD device or nebulizer to initiate pain control. In the hospice patient where no IV access is required, fentanyl may be Nebulized. In the pediatric population it may be beneficial to initiate pain control so IV access can be obtained more readily. In the pediatric population MAD device administration should be the preferred route but nebulization is acceptable. Once administered, every reasonable attempt should be made to gain IV access Go to Table of Contents Special Notes:.Fentanyl should be given SLOWLY (over 2 min.) to prevent a sudden onset of chest wall rigidity. This can be accomplished by diluting it in a syringe or 50 ml bag and running it in over time. Use with caution in patients with headache. If the headache is associated with a clinical picture of CVA extra precaution should taken or the drug withheld. NOTE: Continuous pulse oximetry is necessary. Frequent evaluation of the patient's vital signs is also necessary. Emergency resuscitative equipment must be immediately available Protocol Abdominal Pain Combination Analgesia Extremity Injuries Return to Table of Contents FUROSEMIDE (LASIX) Description Rapid acting, potent diuretic; inhibits re-absorption of Sodium Chloride. It is also a venous dilator that decreases preload Indications Cardiogenic Pulmonary Edema Contraindications Pregnancy Known hypersensitivity Dehydration or shock Side Effects Hypotension Headache Dizziness Hypovolemia Nausea Vomiting Adverse Reactions Rapid administration may cause auditory problems including tinnitus and hearing loss Special Notes Digitalis toxicity may be potentiated by the potassium depletion that can result from furosemide administration. Drug may be deactivated by exposure to light Dosage and Administration 20-80 mg, IV bolus. Patients not on Lasix should receive 20 mg. Patients compliant with Lasix should receive higher doses in the 40-80 mg range Protocol Pulmonary Edema Go to Table of Contents GLUCAGON Description Increases blood sugar concentration by converting liver glycogen to glucose. Glucagon also causes relaxation of smooth muscle of the stomach, duodenum, small bowel, and colon. Onset & Duration Onset: Within 1 min. Duration: 3-6 min. Indications Altered level of consciousness where hypoglycemia is suspected and IV access is unavailable. May be used for beta-blocker overdose. Contraindications Hypersensitivity Use with caution in patients with a history of cardiovascular disease, renal disease, pheochromocytoma or insulinoma Side Effects Tachycardia Headache Nausea and vomiting Dosage and Administration Adult: Hypoglycemia 1.0 mg, IM Beta Blocker/Calcium Channel overdose 2.0 – 5.0mg IV bolus Pediatric: Hypoglycemia 0.1 mg/kg IM. Maximum dose 1.0 mg Beta Blocker/Calcium Channel overdose 2.0 mg IV bolus Protocol Altered Mental Status Seizures Syncope Poisoning/Overdose Psychiatric/Behavioral Go to Table of Contents HALOPERIDOL (HALDOL) Description Haloperidol is a butyrophenone in the therapeutic class of antipsychotic medications. Haloperidol produces a dopaminergic blockade, a mild alpha-adrenergic blockade, and causes peripheral vasodilation. Its major actions are sedation and tranquilization. Onset & Duration Onset: Within 10 minutes after IM administration. Peak effect within 30 minutes Duration: 2-4 hours (may be longer in some individuals) Indications Acts as a chemical restraint in patients that require transport and are behaving in a manner that poses a threat to their own well-being or others. Contraindications Suspected myocardial infarction Systolic BP of less than 100 mmHg or the absence of a radial pulse Signs of sedation, respiratory or CNS depression Known Parkinson's Disease Known pregnancy History of severe liver or cardiac disease Under 8 years of age Precautions A. Haldol may cause hypotension, tachycardia, and prolongation of the QT interval. B. When administering this IM medication, paramedic must put patient on cardiac monitor and establish an IV as soon as possible. C. Due to the vasodilatory effect, haloperidol can cause a transient hypotension that is usually self-limiting and can be treated effectively with position and fluids. Haloperidol has also been known to cause tachycardia, which usually does not require pharmacologic intervention. D. Should profound hypotension occur that is unresponsive to positioning and fluid therapy and vasopressors are required, epinephrine should not be used since haloperidol may block its vasopressor activity and paradoxically further lower the blood pressure. Haldol may also decrease the effectiveness of dopamine. E. Some patients may experience unpleasant sensations manifested as restlessness, hyperactivity, or anxiety following haloperidol administration. F. Extra-pyramidal reactions have been noted hours to days after treatment, usually presenting as spasm of the muscles of the tongue, face, neck, and back. This may be treated with diphenhydramine. G. Rare instances of neuroleptic malignant syndrome (very high fever, muscular rigidity) have been known to occur after the use of haloperidol. Dosage and Administration Standing order: 5 - 10 mg, IM May be followed with Diphenhydramine 25 – 50 mg, IV or IM Base contact must be made for additional doses (consider if no effects within 10 minutes) Go to Table of Contents Special Considerations A. Although extra-pyramidal reactions are infrequent and usually present after the prehospital phase, be prepared to administer 50 mg diphenhydramine IVP/IM. B. Hypotension and tachycardia secondary to haloperidol are usually self-limiting and hypotension is correctable through recumbent positioning and fluid administration. Be aware of other causes of these conditions, especially in relation to a patient that is the victim of trauma. C. The action of haloperidol potentiates the effect of sedative/tranquilizer type medications and is relatively contraindicated in the presence of these types of medications. In this setting, be prepared for respiratory depression, apnea, muscular rigidity, and hypotension. D. Patients 65 and older will respond more readily to haloperidol, and a reduced IPRATROPIUM BROMIDE (ATROVENT) Description Used as a bronchodilator that dries respiratory tract secretions. Onset & Duration Onset: 5-15 min. after inhalation Duration: 6-8 hr after inhalation Indications Bronchospasm related to asthma, chronic bronchitis, or emphysema Contraindications Hypersensitivity reaction to this drug or atropine or soy or peanuts Adverse Reactions Palpitations Dizziness Anxiety Tremors Headache Nervousness Dry mouth Precautions Should not be used as the primary agent for treatment of bronchospasm. Use with caution in patients with coronary artery disease. Vital signs, and EKG must be monitored How Supplied Premixed Container: 0.5 mg in 2.5ml NS Dosage and Administration Bronchial asthma Adult and Pediatrics over 2 years of age: A. Mild / Moderate Bronchospasm: 1. Ipratropium may be used in combination with albuterol as described below if patient is unresponsive to initial albuterol nebulization treatment. B. Severe Bronchospasm: 1. Place one premixed vial of ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer and administer via oxygen-powered nebulizer to create a fine mist. If patient requires further treatment, continuous nebulization of plain albuterol should be utilized Protocol Asthma Chronic Obstructive Pulmonary Disease Pediatric Respiratory Distress Special Considerations Can cause paradoxical bronchospasm. Discontinue treatment if this occurs. Go to Table of Contents IV SOLUTIONS Pharmacology and Actions Initiation of all IVs in the field in these protocols utilizes normal saline (NS). The standard IV drip rate will be TKO unless a fluid bolus or fluid challenge is required. TKO FLUID RATE Indications Prophylactic IV Drug administration Administration TKO = 5-10 drops/min. or saline lock. FLUID REPLACEMENT/BOLUS Indications Hemorrhagic shock, volume depletion (dehydration, burns, severe vomiting) Shock caused by increased vascular space (neurogenic shock) Precautions A. In hemorrhagic shock, volume expansion with blood is the treatment of choice. Normal saline will temporarily expand intravascular volume and "buy time," but does decrease oxygen-carrying capacity, and is insufficient in severe shock. Because of this, rapid transport is still necessary to treat severely hypovolemic patients who need blood and possibly surgical intervention. B. Volume overload is a constant danger, particularly in cardiac patients. Keep a close eye on your IV rate during transport. For this reason, a fluid challenge (see below) is more appropriate in cardiac patients. Administration 20 ml/kg NS through large bore cannula, as rapidly as possible. FLUID CHALLENGE Indications Hypotension felt to be secondary to cardiac cause (i.e. acute MI, pericardial tamponade, cardiogenic shock) Administration 250-500 ml rapidly through a large bore cannula, then reassess the patient. Side Effects and Special Notes A. Flow rate through a 14g cannula is twice the rate through an 18g cannula, and volume administration in trauma patients can be accomplished more rapidly. If the patient has poor veins, a smaller bore is better than no IV at all, in some instances. B. IVs in an unstable trauma patient should be placed enroute, and may be left to the hospital setting for short transports. Do not delay transport in critical patients for IV attempts. C. If you are unable to start in two attempts, another qualified attendant may try, or you may leave the IVs for the hospital. Go to Table of Contents D. If IV access is required but volume expansion is not, consider starting a saline lock. E. 1 ml/min = 60 microdrops/min = 15 regular drops/min. Return to Table of Contents LIDOCAINE 2% SOLUTION Description Used as a local anesthetic to reduce somatic pain during intraosseous fluid administration. Indications Given following intraosseous insertion to patients over 8 years of age Contraindications Allergy to lidocaine or novacaine Side Effects Seizures Drowsiness Tachycardia Bradycardia Confusion Hypotension Precautions Lidocaine is metabolized in the liver; elderly patients and those with liver disease or poor liver perfusion secondary to shock or congestive heart failure are more likely to experience side effect Dosage and Administration 0.5 mg/kg IO bolus, slowly, maximum dose is 50 mg Protocol Intraosseous Administration Special Notes Diazepam should be available if seizures manifest NOT to be used for treatment of cardiac events Go to Table of Contents Lidocaine (Xylocaine) Gel Description Used as a local anesthetic and lubricant to minimize discomfort and trauma during airway insertion. Indications Prior to nasal pharangeal airway placement Prior to nasal intubation Contraindications Allergy to lidocaine, xylocaine, or novacaine Side Effects When administered to nares side effects are uncommon and minimal Precautions and Special Notes Use with caution in patients with a heart rate <50 on in the presence of high degree AV block. In Atrial fibrillation patients it may cause ventricular acceleration. Should not be used to treat cardiac events. Dosage and Administration Administration can be accomplished in two ways: 1. Apply gel directly to airway 2. Insert gel directly in nare prior to airway insertion As the medication is used to facilitate a procedure, the dose should be the amount required to adequately lubricate the airway device. In nearly all cases this will not exceed one container. Protocol Nasotracheal Intubation Go to Table of Contents MAGNESIUM SULFATE Description Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. In cardiac patients, it stabilizes the potassium pump, correcting repolarization. It also shortens the Q-T interval in the presence of ventricular arrhythmias due to drug toxicity or electrolyte imbalance. In respiratory patients, it may act as a bronchodilator in acute bronchospasm due to asthma or other bronchospastic diseases. For best results, it should be used after normal field inhalation therapy has been attempted. For obstetric cases, it controls seizures by blocking neuromuscular transmission. Also lowers blood pressure and decreases cerebral vasospasm Indications A. Cardiac: Refractory VF and pulseless VT (after amiodarone) Cardiac arrest from suspected torsade de pointes Wide complex tachycardia with pulse and without poor perfusion B. Respiratory: Acute bronchospasm unresponsive to continuous inhaled beta- agonists, ipratropium, and epinephrine. C. Obstetrics: Pregnancy > 20 weeks with signs and symptoms of pre-eclampsia, defined as: 1. Blood pressure > 180 mmHg systolic or > 120 mmHg diastolic with altered mental status or 2. Seizures (eclampsia) Precautions Heart block Decrease in respiratory or cardiac functions Use with caution in patients on digitalis Adverse Reactions Reduced heart rate Circulatory collapse Respiratory depression Dosage and Administration Cardiac Arrest (refractory VF/VT; Torsades de Pointes) 2 gm, IV bolus. Wide complex tachycardia with a pulse and poor perfusion 2.0 gm, IV bolus, over 2 minutes Acute bronchospasm 2.0 gm, IV bolus, over 2 minutes Seizure activity associated with pregnancy: Mix 6.0 gm, IV drip, diluted in 50 ml of Normal Saline (0.9 NS), over 15-30 minutes. If no IV access can be obtained, IM injection of 4g in each buttock (8g total) Protocol Ventricular Fibrillation/Pulseless Ventricular Tachycardia Asthma Chronic Obstructive Pulmonary Disease Obstetric Complications Return to Table of Contents Special Considerations Principal side effect is respiratory depression NOT to be used in pediatric patients Return to Table of Contents MARK I NERVE AGENT ANTIDOTE KIT Description Nerve agents can enter the body by inhalation, ingestion, and through skin. These agents are absorbed rapidly and can produce injury or death within minutes. The Mark I Nerve Agent Antidote Kit consists of two auto-injectors for self and/or buddy administration. One injector contains atropine and another which contains pralidoxime chloride (2-PAM) Indications Suspected nerve agent exposure accompanied with signs and symptoms of nerve agent poisoning Injection Sites Outer thigh – mid-lateral thigh (preferred site) Buttocks – upper lateral quadrant of buttock (gluteal) in thin individuals Procedure A. Utilize appropriate safety precautions including BSI B. Remove atropine injector (smaller of the two). Once removed, it is now active. Use caution not to self-inject. C. Hold securely in one hand and place against injection site on patient. D. Firmly apply constant pressure against site for at least 10 seconds. E. Repeat using the 2-PAM injector. F. Contact receiving hospital to set up appropriate decontamination facilities. Dosage and Administration Atropine injector contains 2 mg 2-PAM injector contains 600 mg No more than three (3) sets of antidote should be administered. Protocol WMD exposure Special Considerations Within 5-10 minutes after administration, tachycardia and dry mouth may occur. This indicates the antidote is working and that you should not need another injection Usage Instructions Go to Table of Contents 1. Hold the set of auto-injectors with the non-dominant hand and by the plastic clip. 2. Grasp the atropine injector 3. Remove the atropine injector with the thumb and first two fingers. 4. Repeat using the 2-PAM injector Return to Table of Contents METERED DOSE INHALER Medication Name Generic: albuterol, isoetharine, metaproternol Trade: Proventil, Ventolin, Bronchosol, Alupent, Metaprel Pharmacology and Actions A. These medications are all bronchodilators. These medications have a rapid onset of action and duration between 2 and 4 hours. All of these agents will have cardiovascular side effects, including increasing heart rate and increasing blood pressure. Indications A. Wheezing due to bronchial asthma, COPD, or bronchospasm related to an allergic reaction. B. Patient has chief complaint of shortness of breath and has a history of bronchial asthma or COPD. C. Patient has a physician prescribed bronchial inhaler. Note: The bronchodilator must be prescribed for this patient. If in doubt, contact medical control. No over-the–counter medications should be administered. Precautions A. If the patient is not breathing adequately on his/her own, the treatment of choice is ventilation. B. The patient in need of a metered dose inhaler for wheezing should also be on supplemental oxygen. Administration A. Follow the steps in the standard drug administration protocol. B. Administer supplemental oxygen. C. Confirm prescription identification. D. Ascertain how many times the patient has used the inhaler. E. Contact on-line medical control for an order to administer. F. Shake the inhaler vigorously. G. Have the patient place the actuator two finger breadths away from his/her mouth.(If the patient has a spacer, use it.) The patient should begin to inhale deeply as he/she can. H. Depress the canister shortly after inhalation has begun. Have the patient hold his/her breath as long as comfortably possible, then exhale. This should be repeated to accomplish the two puffs. I. In the event of a prolonged transport and the patient is not getting better, contact base station for additional orders. Side Effects and Special Notes Some common side effects which may be experienced include, hypertension, chest pain, increased heart rate, nervousness, tremors, nausea, vomiting and sore throat. Go to Table of Contents METHYLPREDNISOLONE (SOLU-MEDROL) Description Methylprednisolone is a synthetic steroid that suppresses acute and chronic inflammation and may alter the immune response. In addition, it potentiates vascular smooth muscle relaxation by beta-adrenergic agonists and may alter airway hyperactivity. An additional newer use is for reduction of posttraumatic spinal cord edema. Indications Anaphylaxis Severe asthma COPD Contraindications Hypersensitivity Adverse Reactions Gastrointestinal bleeding Hypertension Dosage and Administration Adult: 125 mg, IV bolus, slowly, over 2 minutes Pediatric: 2 mg/kg, IV bolus, slowly, over 2 minutes Protocol Asthma Chronic Obstructive Pulmonary Disease Special Considerations • Must be reconstituted and used immediately • Be aware that the effect of methylprednisolone is generally delayed for several hours. Although it is worthwhile to administer methylprednisolone early in the treatment of a patient with severe respiratory distress or anaphylaxis you may not see any effect from the drug for several hours. • Methylprednisolone is not considered a first line drug. Initial effects can be seen at about 20 minutes but the medication effect will not peak for about 2 hours. Be sure to attend to the patient's primary treatment priorities (i.e. airway, ventilation, beta-agonist neublization) first. If primary treatment priorities have been completed and there is time while in route to the hospital, then methylprednisolone can be administered. Do not delay transport to administer this drug • Use in Pregnancy: Since adequate human reproduction studies have not been done with this medication, the use of this drug in pregnancy or with nursing mothers requires that the possible benefits of the drug be weighed against the potential hazards to the mother and the embryo or fetus. Go to Table of Contents MIDAZOLAM (VERSED) Description Midazolam HCl is a water-soluble benzodiazepine that may be administered for sedation to relieve apprehension or impair memory. It is also used as an anti-convulsant. Indications Sedation for cardioversion or transcutaneous pacing (TCP) Status Epilepticus in adults; as an IM benzodiazepine when two IV attempts have been unsuccessful. If an IV is obtained, then diazepam should be used. combination analgesia, combative patients, and severe anxiety states. Contraindications Hypersensitivity to benzodiazepines Acute narrow angle glaucoma Adverse Reactions Significant hypotension Significant respiratory depression Apnea Amnesia Drug Interactions Sedative effect of midazolam may be heightened by associated use of barbiturates, alcohol, CNS depressants, or narcotics. Dosage and Administration C. ADULT DOSAGES 1. Combination Analgesia 1-2 mg IV after Fentanyl or Morphine administration 2. Status Epilepticus 2.5 mg IV/ 5 mg IM or IN (MAD Device) 3. Combative Patient 2.5 mg IV / 5 mg IM 4. Severe Anxiety State 0.5 - 1 mg IV/IM Special Considerations Midazolam should be given slowly. This may be accomplished in different ways. 1. The appropriate dose my be diluted in a 10cc syringe with normal saline and pushed slowly over 2 minutes. 2. The appropriate dose may be placed in a 50cc bag of normal saline and administered over 2 minutes via a microdrip administration set. 3. The appropriate dose may be administered Intra Nasally via the MAD device in Status Seizure Go to Table of Contents D. PEDIATRIC DOSAGES 1. Combination Analgesia a. 0.05 mg/kg IV b. Maximum dose 2 mg 2. Status Epilepticus a. 0.10 mg/kg IV/IM/IO/IN b. Maximum dose 2 mg Protocol Bradycardia with a pulse Combination Analgesia Wide Complex Tachycardia Seizures Hyperthermia Pediatric Seizures Combination Analgesia Special Considerations Provide continuous monitoring of respiratory and cardiac function. Have resuscitation equipment and medication readily at hand. Consider lower doses for elderly patients MORPHINE SULFATE Description Morphine sulfate is a natural opium alkaloid that increases peripheral venous capacitance and decreases venous return. It promotes analgesia, euphoria, and respiratory and physical depression. Morphine sulfate is a schedule II drug. Onset & Duration Onset: Immediate Duration: 2-7 hr Indications Chest pain of a likely cardiac origin Severe burns Cardiogenic pulmonary edema Isolated extremity injuries Pain management Contraindications Hypersensitivity Hypovolemia Hypotension (relative) Head injury or undiagnosed abdominal pain Side effects Hypotension Nausea and/or vomiting Vasodilation (Tachycardia or bradycardia) Respiratory depression Dosage and Administration Adult: Cardiac Chest Pain Initial dose 1 – 4 mg. Repeat doses of 2.0 mg, up to 10 mg. IV only Injuries / Burns Initial dose 0.1 mg/kg slow IV/IM/IN, up to 10 mg. Pediatric: 0.1-0.2 mg/kg, IV/IM SLOWLY. Maximum single dose is 5.0 mg. Protocol Chest pain Hypertension Pulmonary Edema Abdominal Pain Extremity Injuries Burns Special Considerations Go to Table of Contents IV is the preferred route for all indications. IM or IN should only be used for pain if an IV cannot be obtained and should NOT be used for cardiac indications. Vital signs, including pulse oximetry and EKG when available, should be monitored regularly Naloxone and resuscitation equipment should be readily available Return to Table of Contents NALOXONE (NARCAN) Seizures Poisoning/Overdose Psychiatric/Behavioral Infant and Child Resuscitation Pediatric Altered Mental Status Special Considerations Patients receiving Naloxone must be transported to a hospital If dose is given endotracheally, double the dose. This should be an absolute last resort. Give with extreme caution prior to administering endotracheally as the patient may awake violently and the endotracheal tube placement may be displaced. Return to Table of Contents NITROGLYCERINE (NITROSTAT, NITROQUICK, etc) Description It was originally believed that nitrates and nitrites dilated coronary blood vessels, thereby increasing blood flow to the heart. It is now believed that atherosclerosis limits coronary dilation and that the benefits of nitrates and nitrites result from dilation of arterioles and veins in the periphery. The resulting reduction in preload and to a lesser extent in afterload decreases the work load of the heart and lowers myocardial oxygen demand. Nitroglycerin is very lipid soluble and is thought to enter the body from the Gl tract through the lymphatics rather than the portal blood. Onset & Duration Onset: 1-3 min. Duration: 20-30 min. Indications Angina Chest, arm, or neck pain caused by coronary ischemia Patients with 12-lead evidence of acute MI, with or without chest pain Control of hypertension in angina, acute MI, or hypertensive encephalopathy without evidence of CVA Cardiogenic pulmonary edema: to increase venous pooling, lowering cardiac preload and afterload Contraindications Blood Pressure under 90 mmHg Precautions Hypersensitivity Use with caution in patients with EKG evidence of right ventricular infarction Hypotension Patients taking erectile dysfunction drugs should not receive nitroglycerine in any form Adverse Reactions Transient headache Postural syncope Hypotension Nausea and vomiting Flushing Dizziness Burning under the tongue Dosage and Administration • 0.4 mg (1/150 gr) sublingually or spray, every 5 minutes. Vital signs must be re- assessed after each administration. • Nitropaste 1 inch (if available) Protocol Premature Ventricular Contractions (PVCs) Chest Pain Hypertension Go to Table of Contents Pulmonary Edema Special Considerations Susceptibility to hypotension in older adults increases. Nitroglycerin loses potency when exposed to light or heat. Must be kept in airtight, dark containers. Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective in relieving chest pain caused by esophageal spasm Return to Table of Contents ODANSETRON (ZOFRAN) Description Odansetron is a selective 5-HT3 receptor agonist. Mechanism of action has not been fully characterized. It is not certain whether odansetron's antiemetic action is mediated centrally, peripherally, or in both sites. Indications Nausea with concern for potential vomiting Vomiting Contraindications Patients with a known hypersensitivity to odansetron. Precautions Odansetron is listed as a category B with regard to use in pregnancy. Dosage and Administration Adult: 4 mg undiluted SLOW IV push over 2 to 5 minutes or IM. Repeat dose 4mg. CONTACT BASE for cumulative dose above 8mg. Pediatric (1 to 12 years of age): under 40 kg: 0.1 mg/kg SLOW IV push over 2 to 5 minutes or IM or SL** over 40 kg: 4 mg SLOW IV push over 2 to 5 minutes or IM or SL** **(For SL administration, the IV solution may be used, simply remove the needle and administer under the tongue) Protocol Antiemetic situations Go to Table of Contents ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE) Description Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop in blood sugar level will result in disturbance of normal metabolism, manifested clinically as decrease in mental status, sweating, and tachycardia. Further decreases in blood sugar may result in coma, seizures, and cardiac arrhythmia. Serum glucose is regulated by insulin, which stimulates storage of excess glucose from the body's blood stream, and glucagon, which mobilizes stored glucose into the blood stream. The oral glucose paste is rapidly absorbed into the oral mucosa, thus elevating the body's blood glucose level. Indications Hypoglycemia Altered Mental Status with a history of (hypoglycemia) diabetes Contraindications Inability to swallow Patient who may experience an airway obstruction from administration Administration The dosage of oral glucose is one full tube. Follow the standard drug administration protocol. Squeeze a small portion of the tube (approximately 1/3) into the patient's mouth between the cheek and gum. Or, utilizing a tongue depressor, deposit a small portion of the tube (approximately 1/3) onto the tongue depressor and slide it into the patient's mouth between the cheek and gum. Repeat the procedure until one full tube of glucose has been administered. Reassess the vital signs and the patient's condition Protocol Altered Mental Status Special Notes There are few, if any, side effects with this medication. Be aware of possible airway obstruction. Have suction available. Go to Table of Contents OXYGEN Description Oxygen added to the inspired air increases the amount of oxygen in the blood, and thereby increases the amount delivered to the tissue. Tissue hypoxia causes cell damage and death. Breathing, in most people, is regulated by small changes in the acid-base balance and CO2 levels. It takes relatively large decreases in oxygen concentration to stimulate respiration. Indications Suspected hypoxemia or respiratory distress from any cause Acute chest or abdominal pain Hypotensive states from any cause Trauma All acutely ill patients Any suspected carbon monoxide poisoning Pregnant females Precautions • If the patient is not breathing adequately, the treatment of choice is assisted ventilation, not just oxygen. • A small percentage of patients with chronic lung disease breathe because they are hypoxic. Administration of oxygen will inhibit their respiratory drive. Do not withhold oxygen because of this possibility. Be prepared to assist ventilations if needed. • When pulse oximetry is available, titrate Sa O2 to 90% or greater. This may take some time. Be patient within reason. • In the COPD patient: increase oxygen in increments of 2 liters/minute every 2 3 minutes until improvement is noted (color improvement or increase in mental status). Administration Flow LPM dosage Indications Low Flow 1-2 LPM Minor medical / trauma Moderate Flow 3-9 LPM Moderate medical / trauma High Flow 10-15 LPM Severe medical / trauma Special Notes Restlessness may be an ominous sign of hypoxia. Some people become more agitated when a nasal cannula is applied, particularly when it is not needed. Acquiesce to your patient if it is reasonable. Nasal prongs work equally well on nose and mouth breathers, except babies. Non humidified oxygen is drying and irritating to mucous membranes. Oxygen toxicity is not a hazard of short term use. Do not use permanently mounted humidifiers. If the patient warrants humidified oxygen, use a single patient use device. During long transports for high altitude illness, reduce oxygen flow from high to low, to conserve oxygen. Go to Table of Contents OXYGEN FLOW RATES METHOD FLOW RATE OXYGEN INSPIRED AIR (approximate) Room Air 21% Nasal Cannula 1 LPM 24% 2 LPM 28% 6 LPM 44% Simple Face Mask 8 - 10 LPM 40-60% Non-rebreather Mask 10 LPM 90% Mouth to Mask 10 LPM 80% 15 LPM 50% Bag/Valve/Mask (BVM) Room Air 21% 12 LPM 40% Bag/Valve/Mask with Reservoir 10-15 LPM 90-100% OXYGEN -powered breathing hand-regulated 100% device NOTE: Most hypoxic patients will feel more comfortable with an increase of inspired oxygen from 21% to 24%. Return to Table of Contents PHENYLEPHRINE (INTRANASAL) Description Used for topical nasal administration, phenylephrine primarily exhibits alpha adrenergic stimulation. This stimulation can produce moderate to marked vasoconstriction and subsequent nasal decongestion. Indications Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa Pain related to middle ear congestion or infection Epistaxis without hypertension Contraindications Known Hypersensitivity Precautions Avoid administration into the eyes, as it will cause dilation of the pupils Dosage and Administration Instill two drops of 1% solution in the nostril prior to attempting nasotracheal intubation In epistaxis moisten gauze and place in affected nare Side Effects Headache, dizziness, insomnia, sedation, hypertension, mydriasis Protocol Nasotracheal Intubation Go to Table of Contents PROMETHAZINE (PHENERGAN) Description Promethazine is a first-generation H1 receptor antagonist antihistamine and antiemetic medication which acts centrally and has sedative properties. It is related to the phenothiazine family and may cause extrapyramidal and anticholinergic symptoms. Indications Nausea with concern for potential vomiting Vomiting Contraindications Patients in a comatose state CNS depression from alcohol or drug usage Pediatric patients 2 years old or younger Precautions Promethazine does not eliminate the need to monitor the airway. Respiratory depression may occur if the patient has used alcohol or drugs. Extrapyramidal effects are more likely to manifest in pediatric patients with acute illness or dehydration Side Effects Hypotension if administered too quickly. Give Normal Saline to reverse the hypotension. Extrapyramidal effects. Give Benadryl 25 mg to reverse these effects. Dry mouth Dilated pupils Incontinence/Constipation Dosage and Administration Adult: 12.5 mg, IV bolus slowly over 1-2 minutes. Consider 6.25mg dosing for patients that have: 1. Consumed alcohol 2. Been given narcotic analgesics 3. Present with signs/symptoms of CHI Pediatric (3-8 years of age): 0.25 mg/kg IV bolus slowly or IM. Geridatric: 6.25mg Slow IVP FOR REPEAT DOSES consider use of Ondansetron (Zofran) or a repeat dose of 6.25mg after 15 min. Protocol Nausea/Vomiting Return to Table of Contents RACEMIC EPINEPHRINE (VAPONEPHRINE) Description Racemic epinephrine is an epinephrine preparation in a 1:1000 dilution for use by oral inhalation only. Effects are those of epinephrine. Inhalation causes local effects on the upper airway as well as systemic effects from absorption. Vasoconstriction may reduce swelling in the upper airway, and beta effects on bronchial smooth muscle may relieve bronchospasm. Onset & Duration Onset: 1-5 minutes Duration: 1-3 hours Indications Life threatening airway obstruction suspected secondary to croup or epiglottitis Laryingeal Edema Side Effects Tachycardia Anxiety Palpitations Dosage and Administration Do NOT delay transport to begin administration 0.5 ml racemic epinephrine (acceptable dose for all ages) mixed in 2 ml saline, via nebulizer at 6-8 LPM to create a fine mist If racemic epinephrine is not available plain L-epinephrine may be used: Place 5 mg (5.0 ml of a 1:1,000 solution) undiluted in a nebulizer at 6-8 LPM to create a fine mist For infants <10 kg, the recommended dose is 0.5 mg/kg undiluted (0.5 ml/kg of 1:1,000 solution) of L-epinephrine. Protocol Pediatric Respiratory Distress Special Considerations Always try to utilize the parents help as the mask may frighten children Is heat and photo-sensitive and needs to be protected from heat and light sources Do not confuse the side effects with respiratory failure or imminent respiratory arrest. If respiratory arrest occurs, it is usually due to patient fatigue or laryngeal spasm. Complete obstruction is not usually present. Ventilate the patient, administer oxygen, and transport rapidly. If you can ventilate and oxygenate the patient adequately with mouth-to-mask, pocket mask, or BVM, intubation is best left to a specialist in a controlled setting Try to differentiate croup from epiglottitis by history. Cough is usually present in croup. Do not use a tongue blade to examine the back of the throat. The diagnosis is frequently difficult in the field, but a critical patient deserves a trial of racemic epinephrine during transport. Although used as specific therapy for croup, it may also buy some time in patients with epiglottitis Go to Table of Contents SODIUM BICARBONATE Description Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. Acids are increased when body tissues become hypoxic due to cardiac or respiratory arrest. Indications Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures Consider in patients with prolonged cardiac arrest. Consider in dialysis patients with cardiac arrest (presumed secondary to hyperkalemia) Contraindications Metabolic and respiratory alkalosis Hypocalcemia Hypokalemia Adverse Reactions Metabolic alkalosis Hyperosmolarity may occur, causing cerebral impairment Drug Interactions May precipitate in calcium solutions. Alkalinization of urine may increase half-lives of certain drugs. Vasopressors may be deactivated. Dosage and Administration A. STANDING ORDER in cardiac arrest B. CONTACT BASE for all other indications. C. Solutions: 1. Adult / Pediatric: 8.4% = 1.0 mEq/ml 2. Neonatal: 4.2% = 0.5 mEq/ml a. (Either prepackaged or adult solution diluted 1:1 with sterile NS or water) D. For cardiac arrest / Tricyclic Overdose: 1. Adult: 1 mEq/kg (1 ml/kg) 2. Pediatric: 1 mEq/kg (1 ml/kg) 3. Neonatal: 1 mEq/kg (2 ml/kg) Protocol Asystole Poisoning/Overdose Special Considerations • Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a paradoxical intracellular acidosis. • Each ampule of sodium bicarbonate contains 44-50 mEq of sodium. This increases intravascular volume, which increases the workload of the heartSodium bicarbonate's lack of proven efficacy and its numerous adverse effects have lead to the reconsideration of its role in cardiac resuscitation. Effective ventilation and circulation of blood during CPR are the most effective treatments for acidemia associated with cardiac arrest Go to Table of Contents • Administration of sodium bicarbonate has not been proven to facilitate ventricular defibrillation or to increase survival in cardiac arrest. Metabolic acidosis lowers the threshold for the induction of ventricular fibrillation, but has no effect on defibrillation threshold. • The inhibition effect of metabolic acidosis on the actions of catecholamines has not been demonstrated at the pH levels encountered during cardiac arrest. • Metabolic acidosis from medical causes (e.g. diabetes) develops slowly, and field treatment is rarely indicated. • Sodium bicarbonate may be considered for the dialysis patient in cardiac arrest due to suspected hyperkalemia. Return to Table of Contents TOPICAL OPHTHALMIC ANESTHETICS (TETRACAINE) Description Used for topical administration as a pain reliever for eye irritation. Only proparacaine and tetracaine are approved for use. Indications Used to provide topical ophthalmic anesthesia during transport of patients with actual or potential serious eye injuries that present with a "foreign body sensation" Contraindications Known allergy to local anesthetics (Novacaine, Lidocaine, Xylocaine, etc.) Eyelid lacerations Global lacerations or rupture Discoloration of medication Precautions Occasional burning/stinging can occur when initially applied, although this is usually transient Dosage and Administration Instill two drops into affected eye. Repeat only with Base Contact and physician consult Protocol Eye injury Special Considerations This is single patient use. Unused portions are to be discarded and only new bottles are to be used. Do not administer until patient consents to transport and transport has begun Topical ophthalmic anesthetics should never be given to a patient for self-administration Go to Table of Contents Inter-Facility Drug Protocol Antibiotics Description Due to the vast number of antibiotics available, it is not practical to develop a written protocol for every antibiotic. Therefore, this protocol shall serve as a general guide to the inter-facility maintenance of antibiotic drips. Indications Treatment and prevention of Bacterial Infections Contra-Indications: Hypersensitivity Precautions: Adverse Reactions Allergic or Anaphylactic reactions Dosage and Administration • The Paramedic shall consult drug reference guide for proper dosage and administration information. Protocol 1. For inter-facility transport only when initiated by a sending facility. 2. Must be maintained on an IV pump 3. Paramedic must familiarize him/herself with proper dosage and administration information utilizing appropriate drug guide or manufacturer information as well as general information regarding the particular antibiotic. 4. The Paramedic shall consult with Nursing staff or Medical control to obtain any specific instructions for transport. 5. Signs and Symptoms of anaphylaxis should be watched for at all times. 6. Treatment of allergic or anaphlaxtic reactions shall be per normal ALS protocol. 7. In the event of allergic or anaphlaxtic reaction the antibiotic shall be stopped and disconnected from the patient, and medical control should be advised. Return to Table of Contents Reference Material: Antibiotics[6] Generic Name Brand Names Common Uses Possible Side Effects Aminoglycosides Amikacin Amikin Infections caused by Gram-negative bacteria, such as Gentamicin Garamycin Escherichia coli and Kanamycin Kantrex Hearing loss Klebsiella particularly Neomycin Pseudomonas Vertigo aeruginosa. Effective Netilmicin Netromycin against Aerobic Kidney damage Streptomycin bacteria (not obligate/facultative Tobramycin Nebcin anaerobes). Paromomycin Humatin Ansamycins Geldanamycin Experimental, as Herbimycin antitumor antibiotics Carbacephem Loracarbef Lorabid Carbapenems Ertapenem Invanz Bactericidal for both Gram-positive and Gastrointestinal Doripenem Finibax Gram-negative upset and diarrhea Imipenem/Cilastatin Primaxin organisms via inhibition of cell wall Nausea synthesis and therefore useful for Seizures empiric broad- Headache Meropenem Merrem spectrum antibacterial coverage. (Note Rash and Allergic MRSA resistance to reactions this class.) Cephalosporins (First generation) Cefadroxil Duricef Gastrointestinal Cefazolin Ancef upset and diarrhea Cefalotin or Cefalothin Keflin Cefalexin Keflex Nausea (if alcohol Return to Table of Contents taken concurrently) Allergic reactions Cephalosporins (Second generation) Cefaclor Ceclor Gastrointestinal Cefamandole Mandole upset and diarrhea Cefoxitin Mefoxin Nausea (if alcohol Cefprozil Cefzil taken concurrently) Cefuroxime Ceftin, Zinnat Allergic reactions Cephalosporins (Third generation) Cefixime Suprax Cefdinir Omnicef Cefditoren Spectracef Cefoperazone Cefobid Gastrointestinal Cefotaxime Claforan upset and diarrhea Cefpodoxime Nausea (if alcohol Ceftazidime Fortaz taken concurrently) Ceftibuten Cedax Allergic reactions Ceftizoxime Ceftriaxone Rocephin Cefdinir Cephalosporins (Fourth generation) Gastrointestinal upset and diarrhea Cefepime Maxipime Nausea (if alcohol taken concurrently) Allergic reactions Glycopeptides Teicoplanin Vancomycin Vancocin Macrolides Zithromax, Streptococcal Azithromycin Sumamed, infections, syphilis, Nausea, vomiting, Zitrocin respiratory infections, and diarrhea (especially mycoplasmal Clarithromycin Biaxin at higher doses) infections, Lyme Dirithromycin disease Jaundice Erythromycin Return to Table of Contents Roxithromycin Troleandomycin Visual Disturbance, LIVER TOXICITY. This medication's approval in the U.S. was controversial, and one doctor went to jail in followup attempts to ascertain its safety because she falsified Telithromycin Ketek Pneumonia the results of her part of the testing precisely because it seemed to cause liver problems, including liver failure, to a greater extent than would be expected of a common-use antibiotic.[7] Antimetabolite, Spectinomycin Anticancer Monobactams Aztreonam Penicillins Amoxicillin Novamox Ampicillin Azlocillin Carbenicillin Gastrointestinal Cloxacillin Wide range of upset and diarrhea Dicloxacillin infections; penicillin Allergy with serious used for streptococcal Flucloxacillin infections, syphilis, anaphylactic reactions Mezlocillin and Lyme disease Brain and kidney Nafcillin damage (rare) Penicillin Piperacillin Ticarcillin Polypeptides Bacitracin Eye, ear or bladder infections; usually Colistin applied directly to the Kidney and nerve damage eye or inhaled into (when given by injection) Polymyxin B the lungs; rarely given by injection Quinolones Ciproxin, Urinary tract Nausea (rare), tendinosis Ciprofloxacin CiploxESTECINA infections, bacterial (rare) prostatitis, Enoxacin Return to Table of Contents Gatifloxacin Tequin community-acquired pneumonia, bacterial Levofloxacin Levaquin diarrhea, Lomefloxacin mycoplasmal Moxifloxacin Avelox infections, gonorrhea Norfloxacin NOROXIN Ofloxacin Ocuflox Trovafloxacin Trovan Sulfonamides Mafenide Nausea, vomiting, Prontosil (archaic) Sulfacetamide and diarrhea Sulfamethizole Allergy (including Urinary tract Sulfanilimide (archaic) infections (except skin rashes) sulfacetamide and Sulfasalazine mafenide); mafenide Crystals in urine Sulfisoxazole is used topically for Kidney failure burns Trimethoprim Decrease in white Trimethoprim- Sulfamethoxazole (Co- blood cell count Bactrim trimoxazole) (TMP- Sensitivity to sunlight SMX) Tetracyclines Demeclocycline Gastrointestinal Doxycycline Vibramycin upset Minocycline Minocin Syphilis, chlamydial Sensitivity to sunlight Oxytetracycline Terracin infections, Lyme disease, Staining of teeth mycoplasmal infections, acne (especially in children) rickettsial infections Potential toxicity to Tetracycline Sumycin mother and fetus during pregnancy Others Spirochaetal Arsphenamine Salvarsan infections (obsolete) Chloramphenicol Chloromycetin acne infections, Clindamycin Cleocin prophylaxis before surgery acne infections, Lincomycin prophylaxis before surgery Return to Table of Contents Ethambutol Antituberculosis Fosfomycin Fusidic acid Fucidin Furazolidone Isoniazid Antituberculosis Linezolid Zyvox Metronidazole Flagyl Giardia Mupirocin Bactroban Macrodantin, Nitrofurantoin Macrobid Platensimycin Pyrazinamide Antituberculosis Quinupristin/Dalfopristin Syncercid Binds to the β subunit of "RNA polymerase" to inhibit transcription Reddish-orange sweat, tears, Rifampin or Rifampicin of mostly "Gram- and urine positive" and "mycobacteria" Tinidazole Return to Table of Contents Heparin Inter-Facility Drug Protocol Description Heparin is an anticoagulant (blood thinner) Indications Treatment and prevention of blood clots often associated in treatment of: • Acute Coronary Syndrome • Pulmonary Embolus • Pre-Operatively • A-Fib • DVT Contraindications • Known Hypersensitivity • Active Bleeding Disorder Precaution for Patients with: • Liver Disease • Menstrual period • Hypertension • GI Problems • Endocarditis Side Effects • Bleeding • Bruising • Allergic Reaction Dosage and Administration • The following is provided for information and reference purposes only. • Traditional regimen calls for Bolus dose followed by maintenance infusion. • Normal Bolus 50-100 units/kg (70units/Kg average) • Normal Infusion 15-25 units/kg/hr (Typically around 20ml/hr) Protocol 1. For inter-facility transport only when initiated by a sending facility. 2. Heparin infusions must be maintained on an IV pump at all times during transport at facility initiated maintenance dosage. 3. Heparin dosage may not be titrated in the interfacility environment. 4. Heparin Bolus may not be given. 5. Heparin infusion should be stopped if life threatening bleeding develops. (CVA, GI Bleed, etc.) 6. If infusion is stopped, medical control or the receiving facility should be consulted for further instructions and consultation. Return to Table of Contents Inter-Facility Drug Protocol Nitroglycerin Drip Description It was originally believed that nitrates and nitrites dilated coronary blood vessels, thereby increasing blood flow to the heart. It is now believed that atherosclerosis limits coronary dilation and that the benefits of nitrates and nitrites result from dilation of arterioles and veins in the periphery. The resulting reduction in preload and to a lesser extent in afterload decreases the work load of the heart and lowers myocardial oxygen demand. Nitroglycerin is very lipid soluble and is thought to enter the body from the Gl tract through the lymphatics rather than the portal blood. Indications Angina Chest, arm, or neck pain caused by coronary ischemia Patients with 12-lead evidence of acute MI, with or without chest pain Control of hypertension in angina, acute MI, or hypertensive encephalopathy without evidence of CVA Cardiogenic pulmonary edema: to increase venous pooling, lowering cardiac preload and afterload Contra-Indications: Hypersensitivity Hypotension Patients taking erectile dysfunction drugs should not receive nitroglycerine in any form Precautions: Use caution in patients with Right Ventricular Infarct patterns. Adverse Reactions Transient headache Postural syncope Hypotension Nausea and vomiting Flushing Dizziness Burning under the tongue Dosage and Administration • Continue Nitroglycerin drip at the rate begun at the transferring hospital • Refer to dosing chart below based on 25mg or 50mg Nitro in 250ml solution. • Be advised that varying concentrations for Ntiroglycerin exist, please refer to facility specific concentration guidelines • Typical dosing starts a 5-10mcg/min (typically 3-6ml/hr) • Typical titration increases or decreases in 5-10mcg increments q 5-10 minutes titrated to cessation of pain and Systolic BP >90 Return to Table of Contents Protocol 1. For inter-facility transport only when initiated by a sending facility. 2. Nitro infusions must be maintained on an IV pump at all times during transport. 3. Blood Pressure Monitoring must be maintained on q 5-10 minute intervals depending on stability of patient. (q 5 when titrating, q 10 if stable) 4. Maintain continuous EKG and Pulse Oximetry monitoring 5. Nitro Dosage may be titrated downward in 5mcg increments at 5-10 minute intervals to maintain systolic BP >90 or according to facility specific transfer orders. 6. If systolic BP drops below 90 a 250ml fluid challenge of NS should be given in addition to lowering titration. 7. If systolic remains below 90 after 250ml fluid challenge and decreasing titration, Nitro drip should be stopped and medical control contacted for further instructions. 8. Maximum drip rate should not exceed 200mcg/min 9. Nitroglycerin requires non-polyvinyl tubing and glass or maxide IV bag as Nitro bonds to certain plastics which can alter dosing accuracy. Nitro Concentration Ml per Hour Nitro Concentration ML per Hour 25mg/250ml 50mg/250ml 5mcg 3ml 5mcg 1.5ml 10mcg 6ml 10mcg 3ml 15mcg 9ml 15mcg 4.5ml 20mcg 12ml 20mcg 6ml 25mcg 15ml 25mcg 7.5ml 30mcg 18ml 30mcg 9ml 35mcg 21ml 35mcg 10.5ml 40mcg 24ml 40mcg 12ml 45mcg 27ml 45mcg 13.5ml 50mcg 30ml 50mcg 15ml 55mcg 33ml 55mcg 16.5ml Return to Table of Contents BANDAGING Indications A. To stop external bleeding by application of direct and continuous pressure to wound site B. To protect patient from contamination to lacerations, abrasions, burns Precautions A. Although external skin wounds may be dramatic, they are rarely a high management priority in the trauma victim. B. Do not use circumferential dressings around neck. Continued swelling may block airway. Technique A. Use BSI. B. Control hemorrhage with direct pressure, using sterile dressing. C. Assess patient fully and treat all injuries by priority once assessment is complete. D. Remove gross dirt and contamination from wound: clothing (if easily removable), dirt, gasoline, acids, or alkalis. Use copious irrigating saline or tap water for chemical contamination. E. Evaluate wound for depth, presence of fracture in wound, foreign body, or evidence of injury to deep structures. Note distal motor, sensory, and circulatory function prior to applying dressings. F. Apply sterile dressing to wound surface. Touch outer side of dressing only. G. Wrap dressing with clean gauze or cloth bandages applied just tightly enough to hold dressing securely (if no splint applied). H. Assess wound for evidence of continued bleeding. I. Check distal pulses, color, capillary refill, and sensation after bandage applied. J. Continue to apply direct hand pressure over dressing, or use air splint if bleeding not controlled with bandage alone. K. For deep or gaping muscle wounds in which bleeding cannot be controlled with direct pressure, pack the wound with sterile gauze than reapply a sterile dressing with pressure. Complications A. Loss of distal circulation from bandage applied too tightly around extremity; for this reason, do not use elastic bandages or apply bandages too tightly. B. Airway obstruction due to tight neck bandages. C. Restriction of breathing from circumferential chest wound splinting D. Continued bleeding no longer visible under dressings. (This is particularly common with scalp wounds that continue to lose large amounts of unnoticed blood.) E. Inadequate hemostasis: some wounds require continuous direct manual pressure to stop bleeding. Go to Table of Contents AIRWAY MANAGEMENT CAPNOGRAPHY E. Indications 1. All intubated patients REQUIRE continuous end-tidal CO2 monitoring to assess: a. Proper initial placement of the endotracheal tube and continued airway patency. b. Inadvertent displacement of the endotracheal tube. c. Effectiveness of cardiopulmonary resuscitation d. Patients requiring mechanical ventilation during transportation. The monitor is used to determine if the endotracheal tube has become displaced or to detect the disruption of the ventilator circuit 2. Patients receiving procedural sedation and analgesia (PSA) require continuous monitoring for hypoventilation. 3. Patients with evidence of hypoventilation for any reason (pain management, ingestion, seizure, CNS disorders, etc) should receive continuous end-tidal CO2 monitoring. 4. Patients with bronchospasm or CHF should receive continuous end-tidal CO2 monitoring. F. Precautions 1. Caution should be exercised to ensure that the clinical picture matches the end- tidal CO2 reading. 2. Determination of patient status should always involve a combination of end-tidal CO2 readings, pulse oximetry readings and clinical signs. G. Technique - End-tidal CO2 Monitor – Lifepak 12 1. Attach the CO2 sensor in- line between the endotracheal tube and the BVM or mechanical ventilator. 2. Open the CO2 tubing connector door and connect the Microstream CO2 FilterLine tubing by turning the tubing clockwise. 3. Press ON 4. Verify EtCO2 monitor display is on. 5. Display CO2 waveform on channel 2 or 3. 6. (Typically displayed on channel 3, although shown here on channel 2) 7. Pridemark preselected lead group #2 is II, III, CO2 Go to Table of Contents H. Evaluate the capnograph waveform and numerical value. 1. It is important to evaluate both the numerical value (capnometry) and the waveform (capnography). Evaluating the numerical value alone may lead to erroneous interpretations. There are multiple sita etations i whichg the numerical value isnor waveform isabnormca,e sgnifytinganh ore ormcaity. . Cardiac Output EtCO2 (L) (mmHg) 2 20 3 28 4 32 5 36 Return to Table of Contents By monitoring the EtCO2 value during cardiopulmonary resuscitation, efficacy of CPR in relation to cardiac output can be indirectly determined. EtCO2 can be used as a feedback mechanism to optimize chest compressions during CPR. f. If the shape of the capnogram appears abnormal it indicates an underlying physiologic abnormal suggestive of different clinical pictures. The following quick-reference with example waveforms can be used to help identify underlying clinical disorders: Bronchospasm Bronchospasm with hypoventilation Return to Table of Contents CARDIOVERSION ALGORITHM (Patient is not in cardiac arrest) Tachycardia: With serious signs and symptoms related to the tachycardia If ventricular rate is > 150 beats/min., prepare for IMMEDIATE CARDIOVERSION. May give brief trial of medications based on specific arrhythmia algorithms. Immediate cardioversion is generally not needed for rates < 150 beats/min. Check ● Ensure adequate oxygenation ● Section Device ● IV Line ● Intubation equipment Premedicate with midazolam whenever possible Synchronized Cardioversion VT Adult Dose Pediatric Dose PSVT 100j, 200j .05j/kg, 1.0j/kg Atrial fibrillation 300j, 360j 1.5j/kg, 2.0j/kg Atrial flutter Precautions A. Precautions for defibrillation apply. Protect rescuers! B. A patient who is talking to you is probably perfusing adequately. C. If the defibrillator does not discharge on "synch" with tachycardia, turn off "synch" button and refire. The waves may not have enough amplitude to trigger the "synch" mechanism. D. If sinus rhythm is achieved, even transiently, with cardioversion, subsequent cardioversion at a higher energy setting will be of no additional value. Leave the setting the same; consider correction of hypoxia, acidosis, etc. to hold the conversion. E. If the patient is pulseless, begin CPR and treat as cardiac arrest, even if the electrical rhythm appears organized. F. People with chronic atrial fibrillation are very difficult to convert, and their atrial fibrillation is not usually the cause of their decompensation. If you get a history of "irregular heartbeat," look elsewhere for the problem. G. Sinus tachycardia rarely exceeds 150 beats/min. in adults (220 beats/min. in children < 8 years old), and does not require cardioversion. Treat the underlying cause. Return to Table of Contents H. Do not be overly concerned about the dysrhythmias that normally occur in the few minutes following successful cardioversion. These usually respond to time and adequate oxygenation, and should only be treated if they persist. I. Biphasic monitors require different energy doses. Return to Table of Contents Combination Analgesia A. Introduction 1. The appropriate management of anxiety, spasm and pain is an important component of comprehensive emergency medical care. 2. The American College of Emergency Physicians state that proactively addressing pain and anxiety will improve quality of care and patient satisfaction by minimizing patient suffering. 3. Frequently it is necessary to combine a narcotic (analgesic) and a benzodiazepine (anxiolytic) to provide adequate control of pain in combination with anxiety and/or spasm. 4. Since combining a benzodiazepine and narcotic in the field is typically used for treatment of pain in combination with anxiety and/or spasm and not to facilitate a procedure the term Combination Analgesia will be used. 5. This protocol will address the use of combination narcotic and benzodiazepine for combination analgesia. See Pain Management protocol for issues related to patients who receive analgesia for pain management without sedatives. Additionally, see Diazepam and Midazolam guidelines for treatment of anxiety and spasm in the absence of pain. 6. Combination Analgesia describes a level of sedation that reduces the degree of anxiety, spasm, pain or awareness a patient may experience during a pain illness or injury. The patient retains their ability to maintain a patent airway independently and continuously. They maintain their protective reflexes and their ability to respond appropriately to physical stimulation and/or verbal command and are easily aroused. 7. Combination Analgesia can only be performed by ALS providers who have met the following requirements: a. Completed training in the procedure and have met competency requirements leading to certification. b. Remain current through continuing education and semiannual skills check- offs. c. Only paramedics certified in combination analgesia can perform this procedure. B. Indication Combination Analgesia is indicated for conditions that require pain management in combination with anxiety and/or spasm management (i.e. shoulder / hip dislocations, severe back spasms, etc). I. Precautions 1. Patients with cardiopulmonary disorders, multiple trauma, head trauma, or who have ingested a central nervous system depressant such as alcohol are at increased risk of complications from this procedure and require a high level of vigilance. 2. Elderly patients (>65) tend to be more sensitive and therefore should always receive the low end of the dose range. Administration should be slow and titration with additional doses should be given with extreme care. J. Technique 1. Equipment: Go to Table of Contents a. Cardiac monitor / defibrillator b. Pulse oximeter c. Capnography d. Oxygen e. Advanced airway management equipment f. Suction equipment g. IV Equipment h. Reversal agent: Naloxone K. Preparation: a. Place the patient on a cardiac monitor. b. Place the patient on oxygen c. Place the patient on a pulse oximeter d. Place the patient on capnography e. Insert an intravenous line. f. Make sure airway equipment, suction and reversal agent are available and ready. L. Pre-procedure assessment: a. Complete an appropriate history and physical examination: i. Focused exam of heart, lungs and airway evaluation ii. Vital signs including oxygen saturation iii. Level of consciousness / Mental status exam iv. Pain Scale Evaluation v. Determine patient's NPO status: (a) If patient has not been NPO for 6-8 hours for solids and 2-3 hours for liquids, the risk of the procedure and necessary or anticipated benefit of the procedure must be weighed. vi. Obtain Consent: (a) Inform the patient of the risks and benefits of using combination analgesia. (b) If the patient is able to give informed consent after being advised of the risks and benefits document said consent in narrative. M. Combination Analgesia Procedure: The following parameters will be continuously monitored during Combination Analgesia. a. Responsiveness to commands b. Capnography c. Oxygen saturation d. Heart rate e. Respiratory rate f. Blood pressure g. Heart rhythm h. Pain Scale Evaluation N. Drug administration 1. A key to minimizing complications in Combination Analgesia is the slow titration of drugs to the desired effect. 2. The combined use of opioids and benzodiazepines increases the risk of respiratory depression Return to Table of Contents 3. When both a benzodiazepine and an opioid are used, the opioid, which possesses the greatest risk for respiratory depression, should be given first and the benzodiazepine dose titrated. 4. Administer Fentanyl 0.5 – 1.0 mcg/kg IV over two minutes 5. Then administer Midazolam 1-2 mg IV over 2 minutes for anxiety or administer Valium 1-5 mg IV over 2 minutes for spasm and/or anxiety. 6. Titrate additional drugs to desired effect: 7. If the patient needs additional sedation, use repeat doses of 1 mg IV Midazolam or 1-2mg IV Valium. 8. If the patient needs additional pain control, use repeat doses of 0.5 – 1 mcg/kg IV Fentanyl 9. Fentanyl, Midazolam & Diazepam should be given slowly. This may be accomplished in several ways. (1) The appropriate dose may be diluted in a 10cc syringe with normal saline and then push slowly over 2 minutes. (2) The appropriate dose may be placed in a 50cc bag of normal saline and administered over 2 minutes via a microdrip administration set. 10. Carry-out procedure and/or transport with continuous monitoring 11. If patient has significant respiratory depression or hemodynamic instability, consider reversal agent. a. Reversal agents vii. Naloxone - An agent used for reversal of narcotics (opioids). Duration of action is approximately 30 minutes, which may be shorter than the clinical effect of the agonist agent it is reversing. Use with caution. May precipitate withdrawal in patients dependent on narcotic agents viii. Dose: Administer 2 mg IV, Repeat as needed O. Documentation 1. The procedure shall be documented in the patient care report 2. The opiod should be documented as administered for pain management 3. The benzodiazepine should be documented as administered for anxiety and/or spasm management. 4. Each of these medications is given to treat a separate condition, the fact that they are being used in combination only add's to the risk of the the combination therapy. Therefore, it is important to document the administration of these medications for the individual purpose for which they were administered. 5. The following information should be documented in the PCR a. Equipment Checklist b. Pre-Procedure Assessment c. History and Physical Examination d. Reason for the use of combination analgesia e. Vital Signs and Mental Status (before, during, and post administration) f. Informed Consent g. Medications used h. Response to medications (Pain Scale Evaluation) i. Any complications or side effects noted during combination analgesia j. Patient condition when turned over to the receiving facility P. Quality Management 1. An audit will be performed on any case in which the patient receives Combination Analgesia 2. Any case where there is a complication from the procedure will be referred to the Medical Director within 24 hours. Return to Table of Contents 3. Any case that is noted to be out-of-protocol will be referred to the Medical Director within 24 hours. Q. Complications 1. Altered consciousness, sedation, dizziness and euphoria 2. Respiratory depression 3. Hypotension, bradycardia 4. Nausea and vomiting 5. Allergic reactions and anaphylaxis 6. Bronchospasm Return to Table of Contents Continuous Positive Airway Pressure (CPAP) Indications A. For consideration in moderate to severe respiratory distress secondary to asthma/reactive airway disease, near drowning, COPD, CHF, acute pulmonary edema or pneumonia who present with any of the following: 1. Pulse oximetry < 88% not improving with standard therapy. 2. ETCO2 > 50mmHg 3. Accessory muscle use / retractions 4. Respiratory rate > 25 5. Wheezes, rales, rhonchi 6. Signs of fatigue Contraindications A. Age <12 B. Cardiac or respiratory arrest C. Agonal respirations D. Inability to maintain patent airway E. Hypotensive, systolic BP (< 90mmHg) F. Major trauma (face, neck, chest/abdomen, pneumothorax) G. Nausea/vomiting H. Inability to sit upright I. Upper GI bleeding J. Suspected pneumothorax K. Unresponsive to speech, and/or unable to follow commands Procedure A. Treat patients underlying condition according to appropriate protocol B. Ensure full monitoring in place (EKG, SpO2 ) (ETCO2 if available) C. Document breath sounds, ensure no signs or symptoms of pneumothorax D. Document adequate BP (>90mmHg) E. Have patient sitting up F. Carefully explain procedure to patient G. Place head strap over occipitoparietal area H. Gently hold the delivery device to the patient's mouth and nose I. Attach the straps, loosely at first, gradually tightening as the patient tolerates. Proceed with tightening the straps until air leaks are eliminated. J. Progressively increase the pressure to a max of 10 cmH2O (see attached chart for reference). There is better tolerance with gradual progression of pressure. K. Repeat and record vital signs every 5min Considerations and Special Notes A. Success is highly dependent upon patient tolerance, and EMT-P ability to coach 1. Instruct patient to breath in through nose and exhale through mouth as long as possible B. Deterioration on CPAP ⇒ mechanical ventilation/intubation 1. Deterioration of mental status 2. Increase of the EtCO2 3. Decline of SpO2 Return to Table of Contents 4. Progressive fatigue C. Monitor closely for development of pneumothorax and or hypotension D. Patients should be closely monitored with SpO2, EKG, BP (ETCO2 if available) E. Monitor patients closely for vomiting and or gastric distention F. Inline nebulization may be used with CPAP and is required if the procedure is being done to treat bronchospasm. G. Chemical and physical restraints should never be used to facilitate this procedure The following charts are for reference and represent flow rates and information pertaining to the Boussignac CPAP System. They are guidelines only and other devices necessitate following manufacturer and Medical Director guidelines. The chart below gives the approximate CPAP/ PEEP in cmH2O based on the flow of O2. Flow (LPM) CPAP / PEEP (cmH2O) 10 2.5 - 3.0 15 4.5 - 5.0 20 7.0 - 8.0 25 8.5 - 10.0 > 25 > 10 Minutes of Oxygen by Cylinder Size All based on full 2200 PSI Cylinders Flow D Cylinder E Cylinder M Cylinder (LPM) EMS Portable EMS Portable EMS Ambulances 5 70 123 703 6 58 102 598 8 44 77 498 10 35 61 374 12 29 51 299 15 23 41 199 20 16 29 175 25 14 23 140 Return to Table of Contents FIELD DRAWN BLOOD SAMPLES Indications A. Patients receiving an IV in the field and who, in the judgment of the field providers, will need blood tests in the emergency department B. Patients receiving IV dextrose in the field C. Patients that may have been exposed to carbon monoxide Precautions A. Use BSI. B. Proper identification of the patient and the specimen(s) is mandatory. C. Improper technique in obtaining the specimen will result in inaccurate or invalid test results. This wastes critical time and defeats the purpose of drawing specimens in the field. Technique A. 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.) B. Fill all the desired blood tubes in appropriate order per system requirements. C. Tubes containing anticoagulant should be inverted gently back and forth at least ten times to insure adequate mixing of blood with the substance in the tube. Do not shake the tube as this could cause hemolysis, which could interfere with test results. D. The tubes should be placed in a small biohazard bag. The bag should be labeled with the patient's name and time of draw, and taped to the patient's IV bag. The tubes may also be handed directly to the nurse attending the patient. Side Effects and Special Notes A. Any discrepancy in identification must be reported immediately to the emergency department charge nurse. B. Pediatrics receiving an IV should have at least a speckled 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. C. The blue top tube must be filled exactly, according to the vacuum. D. Blood samples should be drawn prior to the administration of IV fluid, in order to provide a better and less dilute sample for potential "donor" patients. Go to Table of Contents IV BLOOD DRAW FOR LAW ENFORCEMENT Purpose A. To meet all requirements of the Board of Health rules relating to chemical tests for alcohol determination Indications A. Request of the law enforcement officer, and B. Agency authorization Precautions A. Blood samples shall be collected only in an appropriate clinical or public safety facility and in the presence of the officer. B. In no event shall the collection of blood samples interfere with the provision of essential medical care. C. Do not use alcohol or phenolic solutions as a skin antiseptic. Technique A. Assure the patient's consent to the procedure. B. Utilize blood draw supplies provided by the law enforcement agency. C. Use BSI. D. Apply tourniquet proximal to the proposed site. E. Scrub the insertion site with non-alcohol prep provided in blood draw kit. F. Put on disposable medical gloves prior to venipuncture. G. Hold vein in place by applying gentle traction on the vein distal to the point of entry. H. Puncture the skin and the vein with the bevel of the needle upward. I. Once in the vein, collect the sample directly into the sterile blood tubes provided by the officer. J. Remove tourniquet. K. Remove the needle from the vein and hold pressure to stop any bleeding. L. Give the blood sample to the officer. M. Sign any paper work required by the officer. N. Ensure all seals and samples are labeled accurately and completely as failure to do so can result in case dismissal and other legal complications O. Obtain Officer's name, Patient name, and if possible SSN and DOB and document on the patient care report. P. Dispose of contaminated needles appropriately. Go to Table of Contents P PERCUTANEOUS CRICOTHYROTOMY Introduction A. Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be used only in extraordinary circumstances as defined below. The reason for performing this procedure must be documented and submitted for review to the physician advisor or designee within 24 hours. Percutaneous cricothyrotomy is to be performed only by paramedics trained in the procedure. Indications A. When a life threatening condition exists and advanced airway management is indicated, and you are unable to establish airway by other means. Precautions A. Bleeding is possible, even with correct technique. Straying from the midline is very dangerous and likely to cause hemorrhage from the carotid or jugular vessels, or their branches. Technique A. Using aseptic technique (Betadine/alcohol wipes) cleanse the area. B. Position the patient in a supine position, with in-line spinal immobilization if indicated. C. At this time the scalpel included with the kit may be used to make a ¼ inch vertical incision through the skin, over the cricothyroid membrane. D. Using the prepackaged set, insert the needle or over-the-needle-catheter through the cricothyroid membrane in a caudal direction at a 45-degree angle. E. If using an over-the-needle-catheter, remove the syringe and needle. Otherwise remove the syringe. F. Insert the guidewire through the catheter or needle. G. Remove the catheter or needle over the wire. H. Slide the dilator and tracheostomy tube onto the wire into the neck incision. I. Push the dilator through the cricothyroid membrane with a twisting motion, and insert the tracheostomy tube into the trachea. J. Remove the dilator and wire, leaving the tracheostomy tube in place. K. Ventilate with BVM and 100% oxygen. L. Confirm tube placement is successful. (Chest rise and fall, breath sounds, secondary confirmation device). Observe for subcutaneous air, indicating tracheal injury or improper placement. M. Secure tube with ties. N. Transport to appropriate facility. Go to Table of Contents PNEUMATIC ANTI SHOCK GARMENT (PASG-formerly MAST) Indications The Denver Metropolitan EMS Medical Directors Group does not recommend the use of this device in the field for the management of shock. Go to Table of Contents RESTRAINTS Indications A. Use of physical restraint on patients is permissible if the patient poses a danger to himself or to others. Only reasonable force is allowable, i.e., the minimum amount of force necessary to control the patient and prevent harm to the patient or others. CONTACT BASE for physician direction if there is uncertainty as to whether or not the use of restraints is warranted to transport the unwilling or uncooperative patient. B. Restraints are to be applied to patients only in limited circumstances: 1. A patient whose medical or mental condition warrants immediate ambulance transport and who is exhibiting behavior that the prehospital provider feels may or will endanger the patient or others 2. The prehospital provider reasonably believes the patient's life or health is in danger and that delay in treatment and transport would further endanger the patient's life or health, and there is no reasonable opportunity to obtain the necessary consent to provide treatment or obtain informed refusal. 3. The patient is being transported under the direction of a mental health hold, security hold, or police custody. Precautions A. Restraints shall be used only when necessary to prevent a patient from seriously injuring themselves or others (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be done without restraints. They may not be used as punishment, or for the convenience of the crew. B. Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts to restrain a patient should only be done with adequate assistance present. C. Be sure to evaluate the patient adequately to determine the medical condition, mental status and decisional capacity of the patient. The hostile, angry, unwilling patient with decision-making capacity may refuse treatment. D. Be sure that restraints are in good condition (will not break and will not injure the patient). E. Do not use "hobble" restraints and do not restrain patient in the prone position. F. Ensure that patient has been searched for weapons. Technique A. Determine that the patient's medical or mental condition warrants ambulance transport to the hospital and that the patient lacks decision-making capacity, or there is basis for police custody or a mental health hold to be instituted. B. Treat the patient with respect. Attempts to verbally calm the patient should be done prior to the use of restraints. To the extent possible, explain what is being done and why. C. Have all equipment and personnel ready (restraints, suction, a means to promptly remove restraints, and adequate number of personnel). D. Use assistance such that, if possible, one rescuer handles each limb and one manages the head or supervises the application of restraints. E. Consider the patient's strength and range of motion in the need for and method of applying restraints. Go to Table of Contents F. Apply restraints to the extent necessary to subdue the patient. Do not use restraints to punish the patient. G. After application of restraints, check all limbs for circulation. During the time that a patient is in restraints, an assessment of the patient's condition including assessment of the patients airway, circulation and vital signs shall be made at least every fifteen minutes, but more frequently if conditions warrant. H. During transport and pending the arrival at the hospital, the patient shall be kept under constant supervision. I. The run report shall include: attempts at verbal persuasion to calm patient; description of the facts justifying use of restraints; the type of restraints; a description of the steps taken to assure that the patient's needs, comfort and safety were properly cared for; the condition of the patient during restraint, including reevaluations during transport; and the condition of the patient on arrival at the hospital. J. Removal of restraints should be done with sufficient manpower and caution for protection of the patient and healthcare providers. K. Utilize police assistance if necessary and if possible. L. Handcuffs or other "hard restraints" are not to be applied by prehospital providers. If police apply handcuffs, the officer should be requested to stay with the patient and ride in the ambulance during transport. M. The use of chemical restraints is limited to the use of Haloperidol, Versed and Benadryl. If used, cardiac monitoring and intravenous access should be performed as soon as possible. Complications A. Aspiration can occur, particularly if the patient is supine. It is the responsibility of the attendant to continually monitor the patient's airway. B. Nerve injury can result from hard restraints. C. Do not overlook the medical causes for combativeness, such as hypoxia, hypoglycemia, stroke, hyperthermia, hypothermia, or drug ingestion. P D. Contraindications, precautions, and Special Considerations regarding the use of chemical restraints are found in the appropriate drug protocol, i.e. Haloperidol. Versed, and Benadryl Return to Table of Contents SPLINTING: AXIAL Indications A. Pain, swelling, or deformity of spine which may be due to fracture, dislocation, or ligamentous instability. B. Neurologic deficit that might be due to spine injury. C. Prevention of neurologic deficit or further deficit in patients with suspected spine injury or instability. D. In all trauma victims who are unconscious or with impaired consciousness due to head injury or drug ingestion, to protect against damage or further damage in patients where injury to the spine cannot be ruled out by accurate exam or history. Precautions A. All patients with significant head trauma should be immobilized because of the potential for unrecognized coexistent neck trauma. B. Perform and document complete neurologic exam prior to moving the patient. Reassess and document finding after splinting is completed and after each set of vital signs (i.e. – every 5 minutes for a critical patient and every 15 minutes for a non-emergent patient). Cervical Splinting Technique A. Perform cervical splinting immediately following initial assessment (if indicated). If necessary, use assistant to maintain cervical stabilization while completing initial assessment. B. Use two people to apply splint if at all possible. C. Do not use excessive force to straighten. Gently restore normal alignment. D. Advise patient of procedure and purpose before and during application. E. Immobilize the cervical spine with a semi-rigid collar of appropriate size for age. F. Pad behind head in adults to maintain an anatomically neutral position. G. Use long/short spine board or orthopedic scoop to support patient as situation dictates. H. Use tape and/or straps to secure patient effectively and allow turning as a unit for airway control. I. Continue to monitor airway and effectiveness of immobilization. J. Board with an appropriate size collar is preferred to KED in pediatric patients. Spine Immobilization Technique A. Splint cervical spine concurrent with the initial assessment. Document neurologic findings. B. Complete detailed assessment and splint fractures prior to movement of patient when possible. C. Document neurologic findings. D. In a sitting patient, use short board or Kendrick Extrication Device (KED) may be beneficial for extrication: 1. Slide short board or KED behind patient. 2. Apply thigh straps snugly as close to groin as possible. 3. Apply shoulder or chest straps. 4. Use padding as needed to keep neck (in cervical collar) in a neutral position. Go to Table of Contents a. For pediatrics, use padding as needed to prevent misalignment. 5. Secure head to board. E. Use long backboard or full body vacuum splint for supine patients. 1. For sitting patients, after short board or KED is applied: a. Logroll or lift patient as a unit to board. Apply continuous cervical stabilization during movement. One person should protect neck in collar. Do not use force to straighten spine. b. Release leg straps if short board or KED was used. c. Use padding as needed behind knees to support a neutral axis under small of back, neck and knees. d. Use towel rolls or commercially available cervical immobilization device and tape to secure neck immobilization. e. Apply straps or tape to secure chest, thighs, and lower legs to allow turning as a unit in case of vomiting or airway difficulty. F. Reassess patient status, particularly airway and neurologic findings frequently. Complications A. Vomiting is common in head/spine-injured patients. Your splinting must be good enough to allow turning of the patient for airway protection but must not impede breathing efforts. B. It is easy to miss injuries below the level of a neurological deficit. Look carefully for abdominal and chest injuries, pelvic fractures, and extremity injuries without symptoms. With loss of sensation below T-8, there will be no guarding, rebound pain, or tenderness to alert you to internal abdominal injuries. C. Pelvis fractures are difficult to diagnose in the field. Suspected pelvis injury can be immobilized by use of the long board during spine immobilization with a circumferential "pelvic wrap" or by use of a full body vacuum splint. Side Effects and Special Notes A. Patients with helmets and shoulder pads (Football, Lacrosse, Hockey) 1. When immobilization is indicated for football players with shoulder pads and helmets, it should be accomplished with the helmet and pads in place. 2. The only indications for removal of a football helmet during immobilization are: a. Airway management cannot be accomplished without removal. b. Bleeding cannot be controlled without removal. c. The helmet does not provide adequate control of the head. 3. If the helmet is removed, the provider(s) should ensure adequate padding is in place behind the head to allow for neutral alignment. 4. If the patient is immobilized with helmet and pads in place, the facemask/shield must be removed prior to transport. 5. Lacrosse and hockey shoulder pads may not provide enough padding to prevent hyperflexion. The helmet may need to be removed and head padded or padding may be placed under the shoulders to accomplish neutral alignment. 6. EMS responders should utilize the tools and expertise that the athletic trainers at the scene can provide. 7. A "flat lift" with the backboard introduced from the patients feet is preferred to a standard roll when the patient has shoulder pads. 8. It is recommended that EMS practice these procedures and become familiar with athletic training staff tools and policies frequently. Return to Table of Contents 9. As always, neurologic exam must be done and documented reflecting status before and after the procedure. B. Patient with motorcycle, ATV, racing helmets 1. Patients with these types of helmets should usually have them removed early in the assessment to allow immediate access to the airway, face and posterior skull. 2. Two providers are required to perform this procedure. One to control the head and maintain in-line stabilization and one to manipulate and remove the helmet. 3. As always, neurologic exam must be done and documented reflecting status before and after the procedure. C. Axial immobilization should be initiated any time it is indicated. However, the procedure is not without complications. Research indicates that axial immobilization may cause back pain, muscle spasm, pressure sores, claustrophobia or restricted breathing efforts. As such, routine prophylactic axial immobilization may not be indicated in a patient who meets all the following criteria: 1. Is conscious, awake, and oriented to person, place and time (Glasgow Coma Score = 15) and has no pre-existing mental impairment which might hinder cognitive function (i.e. psychological disorder or mental retardation) and does not complain of neck pain. 2. No language barrier exists which might hinder the assessment process. 3. Did not experience a loss of consciousness (either documented or suspected). 4. The mechanism of injury does not warrant activation of a trauma team. 5. Upon physical exam, there is no evidence of tenderness, deformity, or spasm in the neck, back or paraspinal region. 6. There is no evidence of peripheral sensory or motor deficit or impairment (i.e. paresthesia, "peripheral tingling", or decreased motor function following incident). 7. There are no complaints or evidence of visual disturbances such as diplopia or blurred vision. 8. There is no evidence of an unstable or staggered gait. 9. There is no evidence that suggests the use of prescribed CNS depressants, analgesics, ETOH, or other mind-altering substances. 10. The patient has no pre-existing neck, back or neurologic injury. 11. There are no distracting injuries present which might mask an underlying neurologic or spinal injury. 12. Once a patient has been immobilized by a first responder, the patient may not have a cervical collar or other immobilization device removed by subsequent responders. Patient must be transported to a healthcare facility. CONTACT BASE if questions and/or clearance is desired. See Also Protocol: Selective C-spine Immobilization Return to Table of Contents SPLINTING: EXTREMITY Indications A. Pain, tenderness, swelling, or deformity in extremity which may be due to fracture or dislocation B. In an unstable extremity injury: to reduce pain; limit bleeding at the site of injury; and prevent further injury to soft tissues, blood vessels or nerves Precautions A. Critically injured trauma victims should not be delayed in transport by lengthy evaluation of possible non-critical extremity injuries. Prevention of further damage may be accomplished by securing the patient to a spine board when other injuries demand prompt hospital treatment. B. The patient with altered level of consciousness from head injury or drug/alcohol influences should be carefully examined and conservatively treated, because his ability to recognize pain and injury is impaired. C. Make sure the obvious injury is also the only one. It is particularly easy to miss fractures proximal to the most visible one. D. In a stable patient where no environmental hazard exists, splinting should be done prior to moving the patient. Extremity Splinting Technique A. Check pulse and sensation distally prior to movement or splinting. B. Remove bracelets, watches, or other constricting bands prior to splint application. C. Identify and dress open wounds. Note wounds that contain exposed bone or are near fracture sites and may communicate with a fracture. D. To minimize pain and soft tissue damage, avoid sudden or unnecessary movement of fracture site. E. Choose splint to immobilize joint above and below injury. Pad rigid splints to prevent pressure injury to extremity. F. Apply gentle continuous traction to extremity and support to fracture site during splinting operation. G. Reduce angulated fractures (if no pulses), including open fractures, with gentle axial traction as needed to immobilize properly. H. Check distal pulses and sensation after reduction splinting. Realign gently if adequate circulation and sensation is lost. Traction Splinting Technique (for suspected femur fractures): A. Use two persons for splint application procedure. B. Remove sock and shoe and check for distal pulse and sensation (unless you cannot protect exposed foot from weather; then just ask patient about sensation and observe movement). C. Identify and dress open wounds, and note exposed bone or wounds overlying fractures and potential communicating wounds. D. Measure splint length prior to application. E. Apply gentle axial traction with support to calf and fracture site, reducing angulation of open fractures as necessary for secure traction. Go to Table of Contents F. Position ischial pad under buttocks, up against bony prominence (ischial tuberosity). Empty pockets if necessary for patient comfort and appropriate splinting. G. Secure groin strap carefully. H. Maintain continuous traction and support to fracture site throughout procedure. I. Adjust support straps to appropriate positions under leg. J. Apply ankle hitch and tighten traction until patient experiences improved comfort. (Movement at the fracture site will cause some pain, but if traction continues to cause increased pain, do not proceed. Splint and support leg in position of most comfort.) K. Secure support straps after traction properly adjusted. L. Recheck distal pulses and sensation. Complications A. Circulatory compromise from excessive constriction of limb B. Continued bleeding not visible under splint C. Pressure damage to skin and nerves from inadequate padding D. Delayed treatment of life-threatening injuries due to prolonged splinting procedures Side Effects and Special Notes A. Traction splints should only be used if the leg can be straightened easily and patient is comfortable with the traction device on. Particularly with injuries about the hip and knee, forced application of traction device can cause increased pain and damage. If this occurs, do not use traction device, but support in position of most comfort and best neurovascular status. B. When in doubt and the patient is stable, splint. Do not be deceived by absence of deformity or disability. Fractured limbs often retain some ability to function. C. Splinting body parts together can be a very effective way of immobilizing: arm-to- trunk or leg-to-leg. Padding will increase comfort. This method can be very useful in children when traction devices and pre-made splints do not fit. IN D. Consider pain management prior to splinting as needed. Return to Table of Contents P TENSION PNEUMOTHORAX DECOMPRESSION Indications A. Tension pneumothorax is rare, but when present may rapidly lead to death and must be treated promptly. B. Nontension pneumothorax is relatively common, is not immediately life threatening, and should not be treated in the field. C. Treatment of tension pneumothorax is not difficult, although complications of the procedure can be severe, but diagnosis must be accurate and is not always easy. D. The following signs are significant. Signs of pneumothorax as well as signs of tension must be present before treatment is undertaken: 1. Simple Pneumothorax: a. Respiratory distress - mild to severe b. Chest pain c. Decreased or absent breath sounds on affected side to auscultation of chest d. Subcutaneous crepitation, and 2. Signs of Tension: a. Progressive respiratory distress (severe) b. Tympanitic percussion note on affected side c. Hyperexpanded chest on affected side d. Tracheal shift away from affected side e. Distended neck veins f. Shock – low BP g. If patient is intubated, increasing difficulty in bagging Precautions A. Accurate diagnosis is paramount. Note that simple pneumothorax has one set of signs and tension pneumothorax has an additional set of signs. B. Tension pneumothorax is a rare condition, but can occur both with trauma and spontaneously. It can also occur as a complication of CPR. Technique A. Decompress using one of the following techniques: 1. Needle: a. Expose entire chest. Clean chest vigorously with alcohol, Betadine, or soap. b. Insert an angiocath (14g or larger in adult; 18g in children) with syringe attached, in the 4th or 5th intercostal space, midaxillary line (horizontal "nipple line" in children). Alternatively, the angiocath may be inserted between the 2nd and 3rd intercostal space, midclavicular line. c. Hit the rib, then slide above it. d. If air is under tension, barrel will pull easily and "pop" out the back. Remove syringe, advance catheter and remove needle. e. Only one attempt to be done per side. Complications A. Complications include: Go to Table of Contents 1. Creation of pneumothorax if none existed previously 2. Laceration of lung 3. Laceration of blood vessels: slide above rib (intercostal vessels run in grove under each rib) 4. Severe pain: if you're doing this in the field, patient should be sick enough not to require anesthesia, but they'll let you know when you go through pleura. Don't let that deter you - move briskly on. 5. Infection: clean rapidly but vigorously. Use sterile gloves, if possible. Side Effects and Special Notes A. Sudden onset of chest pain and shortness of breath in a normal individual may also be caused by a pneumothorax (particularly in patients with COPD or asthma). These can also progress to a "tension" state. B. Tension pneumothorax can be precipitated by occlusion of an open chest wound with a dressing. If, after dressing an open chest wound, the patient deteriorates, remove the dressing. Return to Table of Contents P TRANSCUTANEOUS CARDIAC PACING Indications A. Use cardiac pacing only when there is insufficient cardiac rate to maintain adequate perfusion, and rate is unaffected by atropine and adequate oxygen and ventilation. B. Symptomatic bradyarrhythmias (includes A-V block) C. P.E.A. (Pulseless Electrical Activity) with bradycardia D. Patients who convert from a viable rhythm into asystole Precautions A. Capture can be difficult in some patients. B. Patient may experience discomfort; consider midazolam. C. Use the same precautions as with defibrillation. D. Patients in atrial fibrillation may require higher energy settings for capture than others. Technique A. Apply electrodes as per manufacturer specifications: (-) left anterior, (+) left posterior. B. Turn pacer unit on. C. Select pacing rate at 80 beats per minute (BPM) D. If the patient is awake, consider the use of sedation E. Start pacing unit. F. Confirm that pacer senses intrinsic cardiac activity by adjusting ECG size. If not, pacer may discharge on an existing complex. G. Set initial current to 40 mAmps. H. Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps (usually captures around 100 mAmps). I. If there is capture, check for pulses. J. If there are no pulses with capture, consider a fluid challenge or dopamine. K. If no capture occurs with maximum output, discontinue pacing and resume ACLS. Complications A. Ventricular fibrillation and ventricular tachycardia are rare complications, but follow appropriate protocols if either occur. B. Pacing is rarely indicated in patients under the age of 12 years. C. Muscle tremors may complicate evaluation of pulses. D. Pacing may cause diaphragmatic stimulation. E. CPR is safe during pacing. A mild shock may be felt if direct active electrode contact is made. Go to Table of Contents TRANSPORT OF THE HANDCUFFED PATIENT Indications The patient is being transported under police custody and has already been placed in handcuffs by a police officer. Precautions Any attempt to restrain a patient involves risks to the patient and the prehospital provider. Efforts to restrain a patient should only be done with adequate assistance present. At no time should the patient be placed in a prone position for a prolonged time at the scene or during transport to the hospital. Ensure that patient has been searched for weapons. Technique A. For the patient who does not require spinal immobilization or transport in a supine position: 1. Maintain restraint via the handcuffs. 2. Escort the patient to the bench seat inside the ambulance. 3. Secure the patient in a sitting position with the seat belt. 4. Treatment and transport should be done with the patient remaining in the handcuffs. 5. Request that the officer stay with the patient and ride in the ambulance during transport. Ultimately, we are not responsible for the hold on this patient. B. For the patient who requires transport with spinal immobilization or in a supine position and is found in standing or sitting position: 1. Ensure that you have adequate assistance available to maintain restraint of the patient. 2. Secure the patient's cervical spine with a cervical collar if indicated. 3. Assign one individual to support the patient's head. 4. Bring the stretcher, with backboard or scoop if indicated, to the patient. 5. Have the patient sit down on the stretcher and secure each arm with Kerlix before having the officer remove the handcuffs. 6. Lie the patient down on the stretcher in a supine position. 7. Secure one arm of the patient to the scoop or backboard with the handcuffs. If further restraint is required, use Kerlix or Velcro cuffs to restrain other extremities. C. For the patient who requires transport with spinal immobilization or in a supine position and is found in a prone position: 1. Ensure that you have adequate assistance available to maintain restraint of the patient. 2. Secure the patient's cervical spine with a cervical collar if indicated. 3. Assign one individual to support the patient's head. 4. Secure each arm and both legs with Kerlix prior to having the officer remove the handcuffs. 5. Roll the patient onto a backboard or scoop. 6. Place the stretcher next to the patient and lift the patient onto the stretcher. Go to Table of Contents 7. Secure one arm of the patient to the scoop or backboard with handcuffs. If further restraint is required, use Kerlix or Velcro cuffs to restrain other extremities. Note: If the patient remains combative after physical restraints, consider the use of chemical restraint. Return to Table of Contents P VASCULAR ACCESS DEVICES Specific Information Needed: A. Obtain pertinent medical history if possible. B. Obtain any information possible regarding the type of Vascular Access Device (VAD), number of lumens, purpose of the VAD, etc. Indications A. To obtain rapid venous access for the critical patient when peripheral access cannot be obtained. Precautions A. Obtain information and assistance from family members or home health professionals who are familiar with the device. B. Discontinue any intermittent or continuous infusion pumps. C. Assure placement and patency of the VAD prior to infusing any fluids or medications. D. Flush the catheter completely with sterile normal saline. E. Use aseptic technique. Central Venous Catheters or PICC Lines A. Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of VAD. B. Identify the location and type of VAD (i.e. central venous catheter, peripheral inserted central catheter). C. Utilize knowledgeable family members, significant others or home visiting nurse if available. D. Discontinue and/or disconnect any pumps or medications. E. Clamp the VAD closed to prevent air embolus. F. If multiple lumen, identify the lumen to be used. G. Utilize aseptic technique. H. Briskly wipe the injection cap with an alcohol and/or povidone-iodine pad. I. Insert the needle (attached to syringe) into the cap. Aspirate slowly for a positive blood return. Obtain blood samples if necessary. Then flush the line with solution. J. Insert the needle (attached to a medication syringe or IV tubing) and infuse medications or fluids. K. Secure the IV tubing. L. Reassess the infusion site. M. Reassess patient condition. Implanted Ports A. Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of the VAD. B. Identify the location and type of VAD (e.g. implanted port). C. Utilize knowledgeable family members, significant others or home visiting nurse if available. D. Discontinue and/or disconnect any pumps or medications. E. Carefully palpate the location of the implanted port. Go to Table of Contents F. If multiple ports, identify the port to be used. G. Using sterile technique, prep the site with alcohol and/or povidone-iodine pad. Wipe from the center outward three times in a circular motion. H. Using a sterile gloved hand, press the skin firmly around the edges of the port. I. Using a syringe filled with solution, insert the needle perpendicular to the skin. J. Aspirate slowly for blood return, then flush the port prior to infusion. When aspirating blood from a VAD, use a syringe that is 10cc or less to avoid complications. K. Secure the IV tubing. L. Reassess the infusion site. M. Reassess the patient. Complications A. Patients with VADs are very susceptible to site infection or sepsis. Use sterile techniques at all times. B. Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is suspected, do not utilize the lumen. C. Rarely, a catheter will migrate. The symptoms may include the following: 1. burning with infusion 2. site bleeding 3. shortness of breath 4. chest pain 5. tachycardia 6. hypotension D. If a catheter migration is suspected, do not use the VAD and treat the patient according to symptoms. E. Catheters are durable but may leak or be torn. Extravasation of fluids or medications occurs and may cause burning and tissue damage. Clamp the catheter and do not use. F. Air embolism may occur if the VAD is not clamped in between infusions. Avoid this by properly clamping the catheter and preventing air from entering the system. Return to Table of Contents IV VENOUS ACCESS TECHNIQUE - GENERAL PRINCIPLES Indications A. Administer fluids for volume expansion B. Administer drugs Precautions A. Do not start IVs distal to a fracture site or through skin damage with more than erythema or superficial abrasion. B. Due to the uncontrolled environment in which prehospital IVs are started, take extra care to use sterile technique. C. Due to the high complication rate associated with prehospital IV therapy, use good judgment when deciding which patients should receive an IV. Technique A. Connect tubing to IV solution bag. B. Fill drip chamber one-half full by squeezing. C. Tear sufficient tape to anchor IV in place. D. Use BSI. E. For pediatric patients consider applying an arm board or splint prior to venipuncture. F. Scrub insertion site with alcohol or iodine pads. G. Don't palpate, unless necessary, after prep. H. Perform venipuncture or enter bone marrow as described in the specific techniques described in this protocol. I. After the catheter is in place, remove the needle or stylette, draw bloods when possible and connect tubing. J. Open full to check flow and placement, then slow to TKO rate unless otherwise indicated or ordered. K. Secure tubing with tape, making sure of at least one 180-degree turn in the tubing when taping to be sure any traction on the tubing is not transmitted to the cannula itself. L. Anchor with arm board or splint as needed to minimize chance of losing line with movement. M. Recheck to be sure IV rate is as desired. Complications A. Pyrogenic reactions due to contaminated fluids become evident in about 30 min after starting the IV. Patient will develop fever, chills, nausea, vomiting, headache, backache, or general malaise. If observed, stop and remove IV immediately. Save the solution so it may be cultured. B. Local: hematoma formation, infection, thrombosis, phlebitis. Note: the incidence of phlebitis is particularly high in the leg. Avoid use of lower extremity if possible. C. Systemic: sepsis, pulmonary embolus, catheter fragment embolus, fiber embolus from solution in IV Go to Table of Contents Side Effects and Special Notes A. Antecubital veins are useful access sites for patients in shock, but if possible, avoid areas near joints (or splint well!). B. The point between the junction of two veins is more stable and often easier to use. C. Start distally, and if successive attempts are necessary, you will be able to make more proximal attempts on the same vein without extravasating IV fluid. D. Venipuncture has little morbidity; however, the excess fluids inadvertently run in when nobody is watching can be fatal! E. The most difficult problem associated with IV insertion is knowing when to try and when to stop trying. Valuable time is often wasted attempting IVs when a critical patient requires blood. IV solutions may "buy time," but they frequently lose time instead. In critical patients do not delay transport while attempting IV insertion at the scene. IVs may be placed en route. F. For the purpose of this protocol, peripheral IV will be defined as extremity or external jugular vein. Return to Table of Contents IV VENOUS ACCESS TECHNIQUE - SALINE LOCK (Buff Cap) Indications A. Prophylactic IV access B. Drug administration Precautions A. Consider the patient, and whether a running IV or a buff cap is needed. B. For any buff cap established in the prehospital setting, the attendant is responsible for showing the buff cap to the receiving nurse. Technique A. Assemble the necessary equipment. B. Prefill the saline lock with sodium chloride. C. Proceed with the technique for extremity IVs. D. Remove the needle from the catheter and insert the saline lock. E. Flush the saline lock with 2-5 ml of sodium chloride. Contraindications A. Any catheter placed in the external jugular vein B. Any patient who is in need of fluid or is hypotensive C. The cardiac arrest patient Go to Table of Contents IN P VENOUS ACCESS TECHNIQUE - EXTERNAL JUGULAR VEIN Indications A. Inability to secure extremity IV access Technique A. Position the patient: supine, head down (this may not be necessary or desirable if congestive heart failure or respiratory distress present). Turn patient's head opposite side of procedure. B. Align the cannula in the direction of the vein, with the point aimed toward the ipsilateral shoulder (on the same side). C. "Tourniquet" the vein lightly with one finger above the clavicle and apply traction to the skin above the angle of the jaw. D. Make puncture midway between the angle of the jaw and the midclavicular line, "tourniqueting" the vein lightly with one finger above the clavicle. E. Puncture the skin with the bevel of the needle upward; enter the vein either from the side or from above. F. Note blood return and advance the catheter over the needle and remove tourniquet. Go to Table of Contents IV VENOUS ACCESS TECHNIQUE - EXTREMITY Technique A. Apply tourniquet proximal to proposed site to venous return only. B. Hold vein in place by applying gentle traction on vein distal to point of entry. C. Puncture the skin (with the bevel of the needle upward) about 0.5 to 1 cm from the vein and enter the vein either from the side or from above. D. Note blood return and advance the catheter over the needle and remove tourniquet. Go to Table of Contents IN VENOUS ACCESS TECHNIQUE - INTRAOSSEOUS INFUSION Indications (Must meet all criteria) A. Rescue or primary vascular access device when peripheral IV access not obtainable (see vascular access protocol) B. Patient with critical illness. Critical illness is defined as: 1. Cardiopulmonary arrest 2. Impending arrest 3. Profound shock with hypotension (SBP<80) and poor perfusion 4. Utilization of IO access for all other patients requires base station contact C. Adults IOs can be used in children age > 8 years old or weight > 40 kg D. May be considered prior to peripheral IV attempts in patients without identifiable peripheral vein Technique A. Site of choice – tibial plateau - one finger breadth below the tuberosity on the anteromedial surface B. Clean skin with povidone-iodine. C. Place intraosseous needle perpendicular to the bone. D. Follow manufacturer's guidelines specific to the device being used for insertion. E. Entrance into the bone marrow is indicated by a sudden loss of resistance. F. Even if properly placed, the needle will not be secure. The needle must be secured and the IV tubing taped. The IO needle should be stabilized at all times. A person should be assigned to monitor the IV at the scene and en route to the hospital. G. Only one intraosseous attempt is to be done in each tibia. H. Puncture site should be covered with a dressing and notify hospital staff of all insertion sites/attempts. Complications A. Bone fracture (pushing too hard while not twisting the needle enough) B. Infection Contraindications A. Fractures B. Cellulitis C. Osteogenesis imperfecta D. Total knee replacement Side Effects and Special Notes A. Some authorities recommend aspiration of marrow fluid or tissue to confirm needle location. This is not recommended for field procedures, as it increases the risk of plugging the needle. B. Expect flow rates to be slower than peripheral IV's. Pressure bags may be needed. Any drug or IV fluid may be infused. C. Prior to IO insertion, consider rectal administration of benzodiazepines in patients 8 and under with status epilepticus. Consider IM midazolam for ages 9 and above for patients in status epilepticus. Go to Table of Contents D. Some manufacturers recommend the use of lidocaine for the treatment of pain associated with fluid administration. Check with your manufacturer and Medical Director for further guidance. Return to Table of Contents PREHOSPITAL PATIENT ASSESSMENT PATIENT ASSESSMENT ALGORITHM Scene Size-Up BSI Safe Scene Unsafe Scene Control Scene Move Patient Correct Hazard Initial Assessment TRAUMA PATIENT MEDICAL PATIENT Focused History and Focused History and Physical Exam Physical Exam Evaluate Mechanism of Injury (MOI) Responsive Unresponsive Significant MOI No Significant MOI SAMPLE History Rapid Medical Assessment Focused Trauma Rapid Trauma Assessment for Specific Assessment Injury Focused Medical Assessment for specific Baseline Vital Signs complaint Baseline Vital Signs Baseline Vital Signs Baseline Vital Signs SAMPLE History SAMPLE History SAMPLE History Transport Transport Transport Transport Detailed Physical Exam Components of Detailed Detailed Physical Exam Components of Detailed Exam Physical Exam Ongoing Assessment Communication Documentation Go to Table of Contents SCENE SIZE UP A. Recognize environmental hazards to rescuers, and secure area for treatment. Implement body substance isolation (BSI). B. Make sure you and your partner are safe. Also make sure the patient and bystanders are safe. Move the patients and bystanders to safe area if needed. C. Recognize hazard for patient, and protect from further injury. D. Identify number of patients. Initiate a triage system if appropriate. E. Observe position of patient, mechanism of injury, surroundings. F. Identify self. G. Initiate communications if hospital resources require mobilization; call for backup if needed. Go to Table of Contents INITIAL ASSESSMENT A. Form a general impression of the patient (sick/not sick; hurt/not hurt) B. Determine the chief complaint/apparent life threats C. Assess mental status (AVPU) • A----Alert • V----Responsive to verbal stimulus • P----Responsive to painful stimulus • U----Unresponsive D. Briefly note body position and extremity movement. E. Airway: 1. Observe the mouth and upper airway for air movement. 2. Open airway if needed: use head tilt chin lift in medical patients; chin lift (without head tilt) or jaw thrust in trauma victims. 3. Protect cervical spine from movement in appropriate trauma victims. Use assistant to provide continuous manual stabilization. 4. Look for evidence of upper airway problems, such as vomitus, bleeding, facial trauma. 5. Clear upper airway of mechanical obstruction with finger sweep or suction, as needed. F. Breathing: 1. Expose chest and observe chest wall movement. 2. Note respiratory rate (qualitative), noise, and effort. 3. Auscultate for breath sounds. 4. Treat respiratory arrest with: a. Pocket mask or bag-valve-mask for initial ventilatory control. b. Check pulse and begin CPR if no pulse. IN c. Intubate after initial ventilation if necessary. 5. Assess for partial or complete obstruction. 6. If respiratory rate < 12/min or breathing appears inadequate: a. Assist respirations with pocket mask or BVM; administer supplemental oxygen. IN b. Consider tracheal intubation to secure airway if necessary. c. Transport rapidly. 7. Observe skin color, mentation for signs of hypoxia. 8. Administer oxygen if signs of hypoxia 9. Look for life threatening respiratory problems and briefly stabilize: a. Open or sucking chest wound: seal. b. Large flail segment: stabilize. c. Tension pneumothorax: transport rapidly and decompress chest. G. Circulation: 1. Pulse a. Palpate for pulse: radial pulse presence implies BP>80 systolic; carotid or femoral pulse presence implies BP>60-70. If the patient is pulseless and apneic, begin CPR Go to Table of Contents b. Note pulse quality (strong, weak) and general rate (slow, fast, moderate). c. Check capillary refill time in fingertips: 2 sec. is normal. Pediatric patients only. 2. Major Bleeding a. Control hemorrhage by direct pressure with clean dressing to wound. (If needed, use elevation, pressure points; tourniquet if appropriate) H. Identify Priority of Patients 1. If evidence of medical shock or severe hypovolemia, obtain baseline vital signs immediately and begin treatment according to protocols: medical and trauma. Special notes A. Initial assessment may take 30 seconds or less in a medical patient or victim of minor trauma. In the severely traumatized patient, however, assessment and treatment of life threatening injuries evaluated in the initial assessment may require rapid intervention, with treatment and further assessment en route to the hospital. B. In the awake patient, the initial assessment may be completed by your initial greeting to the patient. This may make it clear that the ABCs are stable and emergency intervention is not required before completing assessment. C. Neck should be immobilized and secured during airway assessment or immediately following initial assessment if indicated. D. Vital signs should be obtained during the focused and detailed assessment. If immediate intervention for profound shock or hypoventilation is required, this may need to be initiated before numerical vital signs are taken. Return to Table of Contents FOCUSED ASSESSMENT MEDICAL A focused medical assessment is done on all conscious medical patients. In awake patients, this may consist only of identifying yourself and noting the patient's responsiveness and general appearance. The formal detailed assessment may not need to be done on patients with a specific complaint, such as "chest pain". Assessment must be no less thorough, but it may be limited to the body systems that are pertinent to the presenting problem. Based on the information obtained from the initial assessment, perform either a rapid or focused medical assessment, and a detailed exam. Focused-Responsive A. Assess history of present illness • O---Onset (When it first began?) • P---Provocation (What brings it on or makes it better or worse?) • Q---Quality (On scale of 1-10, rate the pain) • R---Radiation (Does pain go anywhere & where is the pain?) • S---Severity (Compare pain to before, is it worse or same?) • T---Time (How long does the pain last, how long did it last before, what helped before for relief?) B. Obtain SAMPLE Information: • S---Signs and Symptoms, chief complaint • A--- Allergies • M---Medications • P--- Pertinent Medical History • L--- Last oral intake, Last menstrual period • E--- Events leading to illness C. Perform a focused Medical Assessment 1. Chief Compliant 2. Signs 3. Symptoms D. Obtain baseline vital signs: blood pressure, pulse, respirations, skin temperature and color. E. Based on the exam findings, initiate proper intervention. F. Make transport decision. G. Perform detailed physical exam H. Transport as soon as possible. I. Perform Ongoing Assessment Go to Table of Contents History History of Present Illness (HPI) An essential part of history taking. A proper history can give the provider all the essential information necessary to diagnose the problem. Chief Complaint - This is what the patient tells you, in his/her own words, is wrong. O-P-Q-R-S-T (need to know) Onset Provocation Quality Radiation Severity Time R-O-A-D-Q-A-L (nice to know, helpful in chest pains) Radiation Onset Aggravating/Alleviating Factors Duration Quality Associated problems Location Types of Pain Focal - Pain that is located in one area and does not travel or move. Radiating - Pain that originates in one spot and travels away from the focal point. Diffuse - Pain that can be localized. S-A-M-P-L-E History Signs and symptoms Allergies Medications Past history Last meal eaten Events leading to incident Vital Signs There are four vital signs that are recorded in the field. They are: Pulse (Heart Rate) Respiratory Rate Blood Pressure Skin Condition Go to Table of Contents TRAUMA A. Focused-No Significant 1. The Focused Assessment is performed on the Specific Injury Site. 2. As you inspect and palpate specific injury, look and feel for the following examples of injuries or signs of injury: • D---Deformity • C---Contusions/Crepitation • A---Abrasions • P---Punctures/Penetrations/Paradoxical Movement • B---Burns • T---Tenderness • L---Lacerations • S---Swelling 3. Assess baseline vital signs: blood pressure, pulse, respirations, skin temperature, and color 4. Assess SAMPLE history: • S--- Signs and Symptoms, chief complaint • A--- Allergies. • M--- Medications • P--- Pertinent past medical history • L--- Last oral intake, last menstrual period • E--- Events leading to injury, illness 5. Based on the exam findings, initiate proper intervention 6. Transport as soon as possible. 7. Perform Detailed Assessment 8. Perform Ongoing Assessment Go to Table of Contents RAPID ASSESSMENT MEDICAL-Unresponsive A. Perform a rapid assessment of the specific area of complaint 1. Position the patient to protect the airway 2. Assess the head 3. Assess the neck 4. Assess the chest 5. Assess the abdomen 6. Assess the pelvis 7. Assess the extremities 8. Assess the posterior body B. Obtain baseline vital signs: blood pressure, pulse, respirations, skin temperature and color C. Obtain SAMPLE Information: • S---Signs and Symptoms, chief complaint • A---Allergies • M---Medications • P---Pertinent medical history • L---Last oral intake, Last menstrual period • E---Events leading to illness D. Based on the exam findings, initiate proper interventions E. Transport as soon as possible F. Perform Detailed Assessment G. Perform ongoing assessment Go to Table of Contents TRAUMA A. Perform a rapid trauma assessment on patients with significant mechanism of injury (MOI) to determine life-threatening injuries. The rapid trauma assessment should be performed on responsive and unresponsive patients alike. An integral part of this assessment is evaluation using the simple mnemonic "DCAP-BTLS". For each area of the body, you should quickly look for Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling. In the responsive patient, symptoms should be sought before and during the trauma assessment. 1. Continue spinal immobilization. 2. Reconsider transport decision. 3. Assess mental status: • A----Alert • V----Verbal • P----Painful • U----Unresponsive B. As you inspect and palpate, look and feel for the following examples of injuries or signs of injury: • D----Deformity • C----Contusions/Crepitation • A----Abrasions • P----Punctures/Penetrations/Paradoxical Movement • B----Burns • T----Tenderness • L----Lacerations • S----Swelling C. Assess the Head; inspect and palpate for injuries of signs of injury (DCAP BTLS) D. Assess the Neck; inspect and palpate for injuries of signs of injury (DCAP BTLS) E. Assess the Chest; inspect and palpate for inures of signs of injury (DCAP BTLS) F. Assess the Abdomen; inspect and palpate for injuries of signs of injury (DCAP BTLS) G. Assess the Pelvis; inspect and palpate for injuries of signs of injury (DCAP BTLS) H. Assess the Extremities; inspect and palpate for injuries of signs of injury (DCAP BTLS) I. Roll patient with spinal precautions and assess posterior body; inspect and palpate for injuries or signs of injury (DCAP BTLS) J. Assess baseline vital signs: Blood pressure, Pulse, Respirations, Skin Temperature, and Color K. Assess SAMPLE history: • S---Signs and Symptoms, chief complaint • A---Allergies • M---Medications • P---Pertinent Medical History • L---Last oral intake, LMP • E---Events leading to illness L. Based on the exam findings, initiate proper intervention M. Transport as soon as possible N. Perform ongoing assessment Go to Table of Contents ALGORITHM: TRAUMA PEDIATRIC PATIENT ASSESSMENT Children can be examined easily from head to toe, but lack of understanding by the patient, poor cooperation, and fright often limit the ability to assess completely in the field. Children often cannot verbalize what is bothering them, so it is important to do a systematic survey which covers areas that the patient may not be able to tell you about. Any observations about spontaneous movements of the patient and areas that the child protects are very important. In the patient with a medical problem, the more limited set of observations listed below should pick up potentially serious problems. A. General 1. Level of alertness, eye contact, attention to surroundings. 2. Muscle tone: normal or increased, weak or flaccid. 3. Responsiveness to parents, caregivers; Is patient playful or irritable? B. Head 1. Signs of Trauma 2. Fontanelle, if open: abnormal depression or bulging C. Face 1. Pupils: size, symmetry, reaction to light. 2. Hydration: brightness of eyes; Is child making tears? Is mouth moist? D. Neck: note stiffness E. Chest 1. Note presence of stridor, retractions (depressions between ribs on inspiration) or increased respiratory effort. 2. Ausculate the chest: a. Breath sounds: symmetrical, rales or wheezing? b. Heart: rate, rhythm F. Abdomen: distension, rigidity, bruising, tenderness. G. Extremities a. Brachial Pulse b. Signs of Trauma c. Muscle tone: symmetry of movement d. Skin temperature and color, capillary refill e. Areas of tenderness, guarding or limited movement H. Neurologic Exam Go to Table of Contents SPECIAL ASSESSMENT NOTES A. Do not let the gathering of information distract from management of life- threatening problems. B. Appropriate questioning can provide valuable information while establishing authority, competence, and rapport with patient. Questions should be objective and should not "lead" the patient. C. Two types of information are used to assess medical or trauma conditions. Subjective information is related by the patient in taking a history, and describes symptoms. The physical exam provides signs or objective information that may or may not correlate with the patient's symptoms. D. In medical situations, history is commonly obtained before or during physical assessment. In trauma cases, it may be simultaneous or following the detailed assessment. An assistant is often used for gathering information from family or bystanders. E. In trauma cases, carefully examine all areas where the patient complains of pain, but realize that the patient's capacity to feel pain is usually limited to one or two areas- even if more areas are injured! That is why a systematic survey is important even in an awake patient. F. Use bystanders to confirm information obtained from the patient and to provide facts when the patient cannot. History from the scene is invaluable. G. Over-the-counter medications including aspirin, homeopathic remedies, and herbal supplements are frequently overlooked by patient and rescuer, but may be important to emergency problems. Birth control pills are also frequently overlooked so be sure to ask. H. Confidentiality is mandatory. Patients are in need and vulnerable, they deserve respect, kindness and discretion. I. Complete legible documentation is critical to convey the information above. J. Be systematic. If you jump from one obvious injury to another, the subtle injury that is most dangerous to the patient is easily missed. K. If the patient has any significant airway or circulatory deterioration, these problems must be addressed immediately. Otherwise, complete the assessment before you begin to address the problems that have been identified. L. Obtain and record two or more sets of vital signs and neurologic observations. A patient cannot be called "stable" without at least two sets of vital signs giving similar normal readings. Serial vital signs are an important parameter of the patient's physiologic status. Vital signs should be repeated frequently, at least every 15 minutes in stable patients and at least every 5 minutes in unstable patients. Return to Table of Contents DETAILED ASSESSMENT Detailed assessment is the systematic assessment of the entire patient. It should be performed after: a) Initial assessment b) Stabilization and initial treatment of life threatening airway, breathing, or circulatory difficulties c) Cervical immobilization as needed The purpose of the detailed assessment is to uncover problems which are not life- threatening, but which could be injurious or could become life threatening to the patient. A. Initial vital signs B. Head and Face: 1. Observe for deformities, asymmetry, bleeding. 2. Palpate for deformities, tenderness, crepitation. 3. Recheck airway for potential obstruction: dentures, bleeding, loose or avulsed teeth, vomitus, abnormal tooth position from mandible fracture, absent gag reflex. 4. Eyes: pupils (equal or unequal, responsiveness to light), foreign bodies, contact lenses 5. Nose: deformity, bleeding, discharge. 6. Ears: bleeding, discharge, bruising behind ears C. Neck: 1. Recheck for deformity or tenderness if not already immobilized. 2. Observe for wounds, neck vein distention, use of neck muscles for respiration, altered voice, and medical alert tags. 3. Palpate for crepitation, tracheal shift. D. Chest: 1. Observe for wounds, chest wall movement, and accessory muscle use. 2. Palpate for tenderness, wounds, fractures, crepitation, unequal rise of chest. 3. Have patient take deep breath: observe for pain, symmetry, air leak from wounds. 4. Auscultate chest for rales, wheezes, rhonchi, or decreased breath sounds. E. Abdomen 1. Observe for wounds, bruising, distention. 2. Palpate all 4 quadrants for tenderness, rigidity. 3. Consider orthostatic vital signs for volume status. F. Pelvis 1. Palpate and compress lateral pelvic rims, symphysis pubis, for tenderness or instability. G. Shoulders/Upper Extremities 1. Observe for angulation, protruding bone ends, symmetry. 2. Palpate for tenderness, crepitation. 3. Note distal pulses, color, medical alert tags. 4. Check sensation. 5. Test for weakness if no obvious fracture present (have patient squeeze your hands). 6. If no obvious fracture, gently move arms to check overall function. H. Lower Extremities Go to Table of Contents 1. Observe for angulation, protruding bone ends, symmetry. 2. Palpate for tenderness, crepitation. 3. Note distal pulses, color. 4. Check sensation. 5. Test for weakness if no obvious fracture present (have patient push feet against your hands and pull back against your hands). 6. If no obvious fracture, gently move legs to check overall function. I. Back 1. Immobilize if any suspicion of back injury. To the extent immobilization allows, palpate for wounds, fractures, tenderness. 2. Recheck motor and sensory function as appropriate. Return to Table of Contents ONGOING ASSESSMENT A. Repeat initial assessment for a stable patient, repeat and record every 15 minutes. For an unstable patient, repeat and record at a minimum every 5 minutes. 1. Reassess mental status. 2. Maintain an open airway. 3. Monitor breathing for rate and quality. 4. Reassess pulse for rate and quality. 5. Monitor skin color and temperature. 6. Reassess and record vital signs. B. Repeat focused assessment regarding patient complaint or injuries. C. Check interventions: 1. Assure adequacy of oxygen delivery/artificial ventilation. 2. Assure management of bleeding. 3. Assure adequacy of other interventions. Go to Table of Contents NEUROLOGIC ASSESSMENT Management of patients with head injury or neurologic illness depends on careful assessment of neurologic function. Changes are particularly important. The first observations of neurologic status in the field provide the basis for monitoring sequential changes. Therefore, it is important that the first responder accurately observes and records neurologic assessment, using measures which will be followed throughout the patient's hospital course. A. Vital Signs: observe particularly for adequacy of ventilations; depth, frequency, and regularity of respirations. B. Level of consciousness: Glasgow Coma Score Eye opening: None 1 To pain 2 To speech 3 Spontaneously 4 Best verbal None 1 response: Garbled sounds 2 Inappropriate words 3 Disoriented sentences 4 Oriented 5 Best motor None 1 response: Abnormal extension 2 Abnormal flexion 3 Withdrawal to pain 4 Localizes pain 5 Obeys commands 6 Score = Sum of scores in 3 categories: (15 points possible) C. Eyes: 1. Direction of gaze, extraocular movement. 2. Size and reactivity of pupils. D. Movement: observe whether all four extremities move equally well. E. Sensation (if patient awake): observe for absent, abnormal, or normal sensation at different levels if cord injury is suspected. Special Notes A. The Glasgow Coma Scale (GCS) used above has gained acceptance as one method of scoring and monitoring patients with head injury. It is readily learned, has little observer to observer variability, and accurately reflects cerebral function. Always record specific responses rather than just the score (sum of observations). In areas where numerical assignment of scores is not a formal procedure, the observations of the GCS still provide an excellent basis for field neurologic assessment. Note also that the other parameters listed must be observed to assess fully the neurologically impaired patient. B. Use your written report to follow and document changes in neurologic findings. C. At a minimum, gross motor function must be documented before and after moving a patient with suspected spinal injury. Go to Table of Contents D. Sensory deficit levels should be marked gently on the patient's skin with a pen to help identify any changes. E. Note what stimulus is being used when recording responses. Applied noxious stimuli must be adequate to the task but not excessive. Initial mild stimuli can include light pinch, dull pinprick, or light sternal rub. If these are unsuccessful at eliciting a pain response, pressure with a dull object to base of nailbed, stronger pinch (particularly in axilla), or sternal rub will be necessary to demonstrate the patient's best motor response. F. When responses are not symmetrical, use motor response of the best side for scoring GCS and note asymmetry as part of neurologic evaluation. G. Use of restraints or intubation of patient will make some observations less accurate. Be sure to note on chart if circumstances do not permit full verbal or motor evaluation. H. Remember that a patient who is totally without response will have a score of 3, not 0. I. In small children, the GCS may be difficult or impossible to evaluate. Use an age- appropriate neurological assessment for small children. Children who are alert and appropriate should focus their eyes and follow your actions, respond to parents or caregivers, and use language and behavior appropriate to their age level. In addition, they should have normal muscle tone and a normal cry. Several observers should attempt to elicit a "best verbal response," to avoid over or underestimation of level of consciousness. Return to Table of Contents PATIENT ASSESSMENT GUIDELINES APPROACH TO DIFFICULT ASSESSMENTS A. Background and Philosophy 1. Common difficulties that the care provider encounters are communication barriers. The care provider frequently depends on effective communications in dealing with patient evaluations and treatment. 2. Communication means more than the simple spoken word. Communication is the collaboration of ideas between individuals based on body position, affect, gestures, sounds, and sensory input. Communication occurs when the care provider palpates the fractured extremity and the patient moans in response to pain. Communication occurs when the care provider enters the patient's residence and the patient's body language suggests hostility. Communication also occurs when the care provider asks a question that evokes fear in the patient, creating a response of denial. 3. The Approach to Difficult Assessments Protocol separates the communication barrier into five main categories, with suggestions to assist the care provider in overcoming communication difficulties specific to each category. Suggestions have been separated into "Reactive" strategies, which may be used by a care provider when confronted with a current communication barrier, and "Proactive" strategies, which the care provider may utilize to prepare for future potential communication barriers. The five communication barrier categories are as follows: a. Category 1: The patient's language is foreign to the care provider (sign language, foreign nationality, etc.): Reactive troubleshooting techniques: Quickly attempt to locate an interpreter. Bilingual family members are ideal. Almost without exclusion, children can be very effective as interpreters. Situations where there are no immediate family members or bystanders are more challenging and require creativity on the part of the care provider. Look for pictures of family members in the immediate vicinity, point to the picture, and make a gesture of talking on the phone. Pay close attention to gestures, sounds, and body language. Try to use gestures similar to those of the patient in order to clarify meaning. The care provider can generally obtain an idea of the nature of the complaint. Consider using a pocket handbook for foreign language medical questions (not highly recommended as the patient usually responds in a language that you do not understand, causing further frustration). However, the care provider can show patients a list of symptoms that are translated into their primary language and have them point out their complaints. This method may allow the care provider to develop a general impression of the patient's condition. Proactive troubleshooting techniques: Return to Table of Contents Consider enrolling in language classes if there is a predominate language in your response area that you know little about. Attempt to discover different personnel in the company who know different languages and utilize them as translational and educational resources. There are telephone hotlines available in several areas that assist medical personnel in interpretation of foreign languages. Care providers should research their area for number listings of this type of hotline. b. Category 2: The patient has experienced an acute impairment in his/her ability to communicate or the patient has a chronic sensory deficit that hinders communication (acute visual disturbances, acute hearing impairment, inability to speak, etc.): Reactive troubleshooting techniques: Attempt to establish an alternative means of communication. For example, the patient with Broca's aphasia may not be able to speak to you, but can understand what you are saying. Establish a hand-squeeze or an eye- blinking system of communication. Be patient. Impairment to the patient's normal means of communication can be incredibly frustrating to the patient. Assuming that the patient cannot understand what you say because they cannot respond is a false assumption in many cases. Proactive troubleshooting techniques: The care provider should practice establishing alternative means of communication with their fellow employee, family members, etc. Research pathology that causes impairment of communication. For example, understanding different types of aphasia may help in developing alternative means of communication. c. Category 3: There is a cognitive barrier between the patient and the care provider that hinders communication (the patient does not understand your terminology, etc.): Reactive troubleshooting techniques: Physically position yourself at a level equal to the patient. Your body position alone can help you to communicate more effectively. Attempt to use phrases that the patient will understand. For example, when assessing the pediatric patient for mental status, the patient may understand "Pokemon," but may not understand "visual disturbance." The care provider should consider the use of props or objects that the patient can understand. Proactive troubleshooting techniques: Return to Table of Contents The care provider can prepare for interaction with patients by taking classes on communication. The care provider can expand on their skills in breaking down cognitive barriers by teaching different topics to people with different levels of understanding of, or experience with, the subject matter. d. Category 4: There is an affective barrier between the patient and the care provider that hinders communication (the patient is angry, upset, or frustrated about your intrusion into his/her life, is distancing himself/herself from the care provider, etc.): Reactive Troubleshooting Techniques: For the patient with a high need for control and/or authority: Avoid the creation of conflict. Validate your patients' input by repeating their statements back to them. Validate your patients' complaints—repeating back their complaints establishes that you are listening to their concerns and allows your patients to clarify any misinterpretation, adding to their trust in you as their care provider. Utilize your partner's input during conflict. Attempt to get the patient's family member/s to agree with you, they can assist in convincing the patient of the need for treatment. Attempt to identify and address the anxiety-causing agent. For the patient that does not want to participate in assessment and/or treatment: Positively reinforce participatory behavior that the patient exhibits (your body language and dialog should reflect your appreciation of the patient assisting you or cooperating with assessment and treatment). Reassure the patient of your intentions. Attempt to find common ground for initiating dialog (this should segue into dialog about the patient's condition). Do not perform procedures on patients without telling them first—even if the procedure is necessary, the patient has the right to refuse treatment. For the patient with an adversarial attitude toward the care provider: Attempt to find common ground with the patient. Identify and point out the similar intentions that you share with the patient. This technique should be performed in a discerning fashion because it can be perceived as condescending. For example, if the patient tells you that he/she wishes to harm him/herself and you tell the patient, "I understand that you are hurting and I want to get you help as well," the patient may assume your response is condescending. Be careful to avoid adding your own interpretation to the patient's statements. By repeating patients' words back to them, you allow them to reflect and help to establish trust. As a last resort, attempt to resolve the conflict by taking authority of the situation (for example, with the hostile or violent patient). e. Category 5: The patient is a poor historian, does not have a clearly defined complaint, and/or continually sidetracks the dialog. Troubleshooting techniques: Return to Table of Contents Establish a basic approach for every conscious patient. Consider the following questions: "Why were emergency services activated? Why were we called?" If there is no clear reason given, consider "What is bothering you? What is bothering you the most?" If no clear reason is given, consider "What is different about right now compared to what is normal?" If the care provider is still unable to establish a clearly defined complaint, consider questioning the patient on a linear body systems approach. Start with the head and make your way down through the rest of the body systems until a complaint is established. Once a clearly defined complaint is established, consider using that as a chief complaint until an additional complaint arises. The care provider needs to discern a careful balance between pressing the patient for specific critical information and listening to the patient's version of their complaints and concerns. The patients that continually sidetrack the dialog need to be given direction in the dialog. As the patient gives you the information that you need, validate the patient by repeating that information and carefully move the direction of the dialog to the next question. If the care provider too quickly or forcefully directs the conversation, trust may be broken and the sidetracking behavior may increase. B. Special Considerations 1. Although the Approach to Difficult Assessments Protocol is based on experience and research, it should only be used as a guideline, not as a rule. There are many different approaches to dealing with difficult assessment situations and there are many different situations that are not practical to include in this protocol. Inevitably, the care provider will have to incorporate the assessment tools that are most effective for him/herself when approaching difficult patient assessments. 2. The fundamental key to mastering difficult patient assessment is awareness and effectiveness in communication skills. Return to Table of Contents PATIENT CARE REPORT REQUIREMENTS General Principles A. The prehospital report is an integral component of patient care, quality improvement and professional responsibility. B. The prehospital report must be legible. C. Vital information should also be immediately communicated to the Emergency Department (ED) staff for efficient and safe transfer of care. D. A legible copy of the prehospital report should be given to the ED staff at the time of transport to the ED. If this is not possible, the report or a facsimile copy must be received in the ED within 24 hours from the time of transport. Procedure A. All prehospital run reports must include the information noted in the EMS Division policy statement. B. Additional considerations and information to be included to the extent pertinent. 1. The physical examination should include assessment findings: a. Head, Ears, Eyes, Nose and Throat (HEENT), including mentation, skin color and condition, and trauma b. Neck c. Chest d. Abdomen e. Pelvis f. Back g. Extremities h. Neurologic status i. Cardiovascular status j. Respiratory status 2. Treatment rendered should be detailed, including: a. The reason or assessment findings that were the basis of the treatment, procedure or medication b. The effects (including lack of effect) c. Treatment rendered prior to your arrival or by others d. Medication administration should include time(s) and dose(s). 3. Facility contact information: a. Name of physician and facility b. Orders requested or denied c. Time of contact 4. Additional documentation should be included, where pertinent to particular protocols; for example: a. Resuscitations in the field should document time and effects of all procedures and medications, and time of pronouncement or termination of resuscitation. b. Refusals of transport should include documentation of mental status, decision-making capacity, warnings given and condition of patient at termination of contact. c. Copies of EKG tracings should be affixed to copies of run reports left with the hospital. d. The mechanism of injury in trauma should be descriptive, not general. Go to Table of Contents 5. The prehospital provider who authors the report must include his/her name and signature on the report. Return to Table of Contents Pridemark Paramedic Services Patient Care Report Requirement A. Purpose In addition to the specific requirements of the Denver Metro Protocols, Pridemark Paramedic Services has a higher expectation of PCR (Patient Care Report) requirements. These requirement are designed to assure smooth continuity of care. This Process shall outline Pridemark specific requirements. B. Process 1. A paper PCR shall be left at the receiving hospital facility for all patients transported prior to departure from the unit. If utilizing electronic documentation, this may be accomplished by syncing the completed PCR thus faxing it to the unit. 2. In the event you are unable to leave a complete PCR either by electronic or written means you shall complete and leave a PPCR (Preliminary Patient Care Report) as approved by the Foothills RETAC or Draft Patient Care Report from the TPCR Toughbook. 3. If you choose to leave a Draft PCR from the Toughbook, it must contain at a minimum the same information the PPCR requires. 4. If leaving a PPCR or Draft be sure to keep a copy of that record for utilization later when you complete your full report. C. General Principles 1. The final and complete patient care report shall serve as the complete medical record. 2. Draft or Preliminary reports are done to facilitate smooth continuity of care and as a courtesy to the receiving facility. They may contain partial or incomplete data. 3. These are provided at the request of the Foothills RETAC and participating hospital facilities with the full knowledge that these are preliminary or draft documents. Go to Table of Contents REQUIRED RECORDS ON TREATMENT AND TRANSPORTATION Policy Statement of the Colorado Dept. of Health EMS Division: REQUIRED RECORDS ON TREATMENT AND TRANSPORTATION OF PATIENTS FOR PREHOSPITAL CARE EMS ORGANIZATIONS Section 9.2 of the EMS Rules specifies that each ambulance service shall maintain records of the treatment and transportation of all patients cared for. Such records shall include all information determined by the Department of Health to be essential for the maintenance of adequate minimum records on a patient's condition and medical care provided. In addition, these records shall be preserved by the ambulance service for a period of three (3) years. In compliance with Section 9.2, the Emergency Medical Services Division of the Department of Health has established the foregoing policy that specifies the essential information to be recorded and preserved for each patient cared for by an ambulance service. The Emergency Medical Services Division of the Colorado Department of Health hereby determines that the following information shall be recorded and preserved by each Prehospital care EMS service in the State on each patient cared for: A. Patient name, if known, as complete as possible and ideally including full first and last name. B. Patient residential address, if known, as complete as possible (to allow medical or public health follow up, if needed). C. Patient sex (both for purposes of identification and to facilitate diagnosis and treatment). D. Patient age, as accurate as possible (both for purposes of identification and to facilitate diagnosis and treatment). E. Patient location at time of response and apparent cause of the injury or nature of illness (to assist in subsequent diagnosis and treatment). F. Patient condition at time of response, including a preliminary assessment of the patient based on vital signs, apparent symptoms, and known medical history. G. Patient vital signs at time emergency medical care is begun, to include respiratory rate, pulse rate, blood pressure, level of consciousness, and pupil size and reaction to light. Subsequent vital signs shall be recorded at least every 15 minutes when either treatment or transport time exceed 15 minutes. H. Known patient history related to the apparent illness or injury, including allergies and medications. If it is determined that the patient is on medication of any kind, the prescribing physician should be identified, if possible, so he/she may be contacted for confirmation, consultation, or actual care of the patient. I. Treatment rendered to the patient at the scene and during transport, in sufficient detail to permit the receiving facility (i.e., hospital, clinic, etc.), physician advisor, and any other reviewing physician or nurse to determine the nature and extent of treatment rendered. J. Patient's apparent condition upon delivery to the receiving facility, and any pertinent comments regarding changes in the patient's condition during transport (to assist the receiving physician in diagnosis and treatment). Return to Table of Contents K. Identity and location of the receiving facility and signature or other indication of the physician or nurse receiving the patient and assuming responsibility for the care of the patient. L. Full name and level of training and certification or licensure of each member of the EMS crew caring for the patient. M. Times of dispatch and departure to the emergency scene, time of arrival at the scene, time of departure from the scene, and time of arrival at the receiving facility. N. Indication of whether emergency lights and siren were used enroute to the scene and/or during transport. In all cases, a copy of the patient care report should be delivered to the receiving facility along with the patient. Return to Table of Contents COMMONLY ACCEPTED ABBREVIATIONS FOR FIELD USE a before AAA abdominal aortic aneurysm A&O x alert and oriented times abd abdomen AB abortion ABC airway, breathing, circulation ACLS Advanced Cardiac Life Support adm admission ALS Advanced Life Support am morning AMA against medical advice AMS altered mental status amp(s) ampule(s) ant anterior asa aspirin ASCVD arteriosclerotic cardiovascular disease ASHD arteriosclerotic heart disease asys asystole ATLS Advanced Trauma Life Support A&P anterior and posterior a&p auscultation and percussion ≈ approximately @ at BBB Bundle Branch Block BCLS Basic Cardiac Life Support BLS Basic Life Support bil bilateral BM bowel movement BP blood pressure BS breath sounds BVM bag, valve, mask c with C Centigrade Ca cancer Ca++ calcium CABG coronary artery bypass graft(s) CAD coronary artery disease cath catheter, catheterization CBC complete blood count cc cubic centimeter CC chief complaint CCU coronary care unit CHF congestive heart failure CHI closed head injury circ circulation Go to Table of Contents cm centimeter CMS circulation, movement, sensation CNS central nervous system CO carbon monoxide c/o complaining of/complaint of CO2 carbon dioxide change COPD chronic obstructive pulmonary disease COR-0 cardiopulmonary arrest C-spine cervical spine C-section cesarean section CSF cerebrospinal fluid CSM carotid sinus massage CVA cerebral vascular accident CVP central venous pressure CPR cardiopulmonary resuscitation d/c discharge/discontinue D&C dilatation and curettage detox detoxification D5W dextrose 5% in water D50W dextrose 50% in water DOA dead on arrival DOB date of birth DOE dyspnea on exertion DOS dead on-scene Dr. doctor drsg/dsg dressing DT delirium tremens Dx diagnosis ↓ decrease ea each ED emergency department ECG/EKG electrocardiogram EENT eye, ear, nose, throat EMS emergency medical services ENT ear, nose, throat EOA esophageal obturator airway EOM extraocular movement et and ET endotracheal ETT endotracheal tube ETA estimated time of arrival etc and so forth ETOH alcohol (ethyl) exam examination = equal F Fahrenheit Return to Table of Contents FB foreign body FD fire department fl fluid Fx fracture ♀ female 1o first degree/primary GB gallbladder GC gonorrhea or gonococcus GCS Glasgow coma scale GI gastrointestinal g gram GPA gravida, para, abort gr grain GSW gunshot wound gtt(s) drop(s) GU genitourinary GYN gynecology → going to/leading to > greater than h/hr hour HA headache HACE high-altitude cerebral edema HAPE high-altitude pulmonary edema HAZMAT hazardous materials (incident) HB heart block HBV hepatitis B virus Hct hematocrit HEENT head, eyes, ears, nose, throat Hg mercury Hgb hemoglobin HIV human immunodeficiency virus H&P history and physical HR heart rate ht height Hx history hypo- low H2O water ICS intercostal space ICU intensive care unit I&D incision and drainage IM intramuscular inf inferior int internal IV intravenous ↑ increase J Joule(s) JVD jugular venous distention Return to Table of Contents K+ potassium KVO/ TKO keep vein open / to keep open L/l liter L left lac laceration lat lateral LBBB left bundle branch block lb pound lg large LLL left lower lobe LLQ left lower quadrant LMP last menstrual period LOC loss of consciousness L-spine lumbar spine LUL left upper lobe LUQ left upper quadrant < less than O /\ lying ♂ Male MAE moves all extremities MAST medical antishock trousers, military antishock trousers mcg microgram MCL midclavicular line, modified chest lead med(s) medication(s) mEq milliequivalent Mg magnesium mg/mgm milligram MI myocardial infarction misc miscellaneous ml milliliter mm millimeter MOE x movement of extremities times MS/MSO4 morphine sulfate MVA motor vehicle accident male N/A not applicable NaCl/NS normal saline NaHCO3 sodium bicarbonate NC nasal cannula neg negative NKA no known allergies noc/noct night NPO nothing by mouth NSR normal sinus rhythm NTG nitroglycerin N/V/D nausea and vomiting and diarrhea Return to Table of Contents ∅ none O2 oxygen OB obstetrics occ occasional O.D. right eye (oculus dexter) OD overdose OJ orange juice ophth ophthalmology OPP organophosphate poisoning OR operating room Ortho orthopedics O.S. left eye (oculus sinister) O.U. both eyes (oculus uterque) oz ounce P after PAC premature atrial contraction PASG pneumatic antishock garment PAT paroxysmal atrial tachycardia path pathology PD police department PE physical examination/pulmonary edema/pulmonary embolus peds pediatrics per by or through PERL pupils equal and react to light PERLA pupils equal and react to light and accommodation PID pelvic inflammatory disease PND paroxysmal nocturnal dyspnea po by mouth pos/ö/+ positive post posterior POV privately owned vehicle PSVT paroxysmal supraventricular tachycardia psych psychiatric pt patient PTA prior to arrival PVC premature ventricular contractions Ψ psychiatric q every ® right RBBB right bundle branch block RBC red blood cell resp respirations RHD rheumatic heart disease/right hand dominant RLQ right lower quadrant R/O rule out ROM range of motion Return to Table of Contents ROS review of systems RUQ right upper quadrant Rx take, treatment s without SAB spontaneous abortion SC/sub q subcutaneous SL sublingual SOB shortness of breath sol solution sm small stat at once sup superior Sx sign/symptom surg surgery SVT supraventricular tachycardia synch synchronous 2o second degree/secondary TAB therapeutic abortion TB tuberculosis tbsp tablespoon temp temperature TIA transient ischemic attack tid three times a day TKO to keep open TLC tender loving care, total lung capacity TM tympanic membranes tol tolerated tsp teaspoon Tx treatment ∴ therefore 3o third degree, tertiary U/A upon arrival uncons unconscious unk unknown URI upper respiratory infection uro urology UTI urinary tract infection ≠ not equal/unequal vag vaginal VD venereal disease VF ventricular fibrillation via by way of vol volume V/S vital signs VT ventricular tachycardia WAP wandering atrial pacemaker WBC white blood cell Return to Table of Contents wc wheelchair WNL within normal limits WPW Wolff-Parkinson-White Syndrome wt weight x times y/o year(s) old yr year(s) Return to Table of Contents COMBINED ADVANCE DIRECTIVES AND CPR DIRECTIVE ADVANCE MEDICAL DIRECTIVES A. There are several types of advance medical directives (documents in which a patient identified the treatment to be withheld in the event the patient is unable to communicate or participate in medical treatment decisions). 1. Do not resuscitate (DNR) orders are generally intended to be written by a physician for a patient whose medical condition is such that commencement of resuscitation efforts would be futile. 2. A Colorado living will ("Declaration as to Medical or Surgical Treatment") requires a patient to have a terminal condition, as certified in the patient's hospital chart by two physicians. For the document to become operative, the patient must be unresponsive because of a terminal condition for a period of seven days. In most cases, these do not impact prehospital care, but become effective in the in hospital setting. 3. "Durable Medical Power of Attorney" or "Health Care Proxy" are documents which can be very complex and require careful review and verification of validity, and application to the patient's existing circumstances. Therefore, the consensus is that resuscitation should be initiated until a physician can review the document or field personnel can discuss the patient's situation with the base physician. 4. The Colorado CPR Directive is a specific situation under Colorado law that provides for CPR to be withheld or withdrawn. B. Resuscitation may be withheld from or terminated for a patient who has a valid, written do not resuscitate order or other advanced medical directive only if: 1. The documentation is clear, unequivocally to the prehospital provider that CPR, intubation and defibrillation are refused by the patient or by the patient's attending physician who has signed the document, and 2. Base physician has approved of withholding or ceasing resuscitative efforts, and 3. There is no apparent indication of suicidal gesture or intent by the patient. 4. If there is disagreement at the scene about what should be done, the base should be contacted immediately for guidance. 5. Prehospital providers presented with equivocal DNR orders or advance medical directives should proceed with resuscitation and establish base contact for guidance on treatment and transport. a. If the directive document is long and detailed, then it is probably more reasonable for resuscitation to be initiated and the patient to be transported so that the base physician can review the document and possibly contact the patient's attending physician. b. The duration of the resuscitation should be guided by the same factors of any medical cardiac arrest. C. Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family or an attending physician directs resuscitation be ceased, the prehospital provider should immediately CONTACT BASE. The prehospital provider should accept verbal orders to cease resuscitation only from the base physician. D. There may be times in which the prehospital provider feels compelled to perform or continue resuscitation, such as hostile scene environment, family members adamant that "everything be done", or other highly emotional or volatile Go to Table of Contents situations. In such circumstances, the prehospital provider should attempt to confer with the base for direction and if this is not possible, the prehospital provider must use his or her best judgment in deciding what is reasonable and appropriate, including transport, based on the clinical and environmental conditions, and established base contact as soon as possible. Documentation of these events must be explicit. CPR DIRECTIVE PROTOCOL General Principles A. This protocol is for the prehospital management of the statutory "CPR Directive," which refers to a specifically identifiable, numbered form that is printed on security paper. The form must be signed by the patient or the patient's authorized agent. The form must also be signed by the patient's attending physician. B. In addition to the written CPR Directive form, the patient or authorized agent may obtain a CPR Directive necklace or bracelet to be worn by the patient. This bracelet or necklace will have imprinted on it the same number as the form. C. CPR shall be withheld or terminated if the original CPR Directive form is readily accessible with an original signature, or if the necklace or bracelet is worn by the patient. D. A CPR Directive may be implemented for a minor only after a physician issues a "Do Not Resuscitate" order and the parents of the minor (if married and living together), custodial parent, or legal guardian execute(s) a CPR Directive for the minor. E. A CPR Directive does not only apply to patients in full cardiac arrest, but should also be honored by withholding resuscitation in patients who are seriously ill or near arrest. Procedure A. Upon finding a patient with a CPR Directive (form, bracelet, or necklace): 1. Perform initial patient assessment. 2. Verify that the CPR Directive form is one of the original copies (it should be light blue color below the title portion of document) and is unaltered (not defaced or altered physically in some way). 3. Verify that the information on the form or, if present, on the back of necklace or bracelet, appears to be appropriate for the patient (look at race, sex, date of birth, eye and hair color). If possible, try to verify identity of patient by an additional source (e.g., family member, driver's license or other readily available sources). 4. Upon verification of the CPR Directive, withhold CPR. If CPR has been started, it should be stopped. 5. If there is any question of the validity of the document or the identity of the patient, initiate full resuscitation measures and contact the base for guidance. Be sure to inform the base of the CPR Directive form, bracelet, or necklace, and the condition and history of the patient. 6. Complete documentation, including attaching a copy of monitor strips on each copy of the run report (EMT-P or EMT-I). Additional required documentation is listed in section K below. 7. Provide appropriate emotional support to family if possible. Return to Table of Contents 8. If the death occurs outside of a health care facility or if tissue donation has been declared, then the coroner is to be immediately contacted. If the declarant has indicated on the CPR Directives form a desire to donate any tissues, appropriate authorities should be notified. 9. The following resuscitation measures are to be withdrawn or withheld from a person who has a valid CPR Directive: 10. CPR and chest compressions 11. Endotracheal intubation or other advanced airway management 12. Artificial ventilation 13. Defibrillation 14. Cardiac resuscitation measures and medications. B. The following interventions may be administered or provided: 1. Assist in maintenance of airway (non-advanced airway management, such as positioning) 2. Suctioning 3. Oxygen 4. Pain medication 5. Control bleeding C. In addition to the standard documentation, the following information should be documented when possible by the prehospital provider on the run report: 1. Patient's status (e.g. condition found, medical history obtained) 2. Type of "CPR Directive" found (document, bracelet or necklace) 3. CPR Directive number 4. Name of attending physician, if known 5. Special circumstances which justify initiating resuscitation if this was done despite the presence of the CPR Directive 6. Monitor strips in at least two leads (EMT-P and EMT-I) Additional Considerations A. The patient may revoke the CPR Directive at any time by oral expression of revocation or by destruction of the CPR Directive form, bracelet or necklace. If a guardian, agent or proxy decision-maker executed the CPR Directive, then the guardian, agent or proxy decision-maker may revoke the CPR Directive. B. CPR is to be initiated if the original CPR Directive form, necklace or bracelet is not readily available, (i.e., being worn by or physically present with the patient). The bracelet or necklace is only available to the patient after the form has been properly executed. Removal of the bracelet or necklace may be construed as revocation. Therefore, if the bracelet or necklace is readily accessible but not on the patient, any question as to whether or not the Directive has been revoked should result in resuscitation until the situation is clarified. Consult with base if you have questions about terminating CPR and transport. If not in full arrest, patients with CPR Directives may still be transported to provide comfort measures. C. In the absence of the existence of a CPR Directive, a person's consent to CPR shall be presumed. The statutorily authorized CPR Directive is only one manner for a patient to document resuscitation preferences. Other "Do Not Resuscitate" forms and advance directives may be honored but base contact is required. D. Under Colorado Law, refraining from performing CPR, when there is a CPR Directive, does not constitute assisting a suicide, and caregivers who honor a CPR Directive by withholding CPR are protected from legal liability. Return to Table of Contents COMMUNICATION A. The purpose of contacting the receiving hospital is to provide enough data to allow the Emergency Department staff to decide what preparations they will need to make for the patient. In addition, a base physician may direct appropriate treatment to be administered en route. B. Radio contact should only include essential, relevant information. Remember, the Emergency Department staff may be busy and radio time is valuable. C. First, always identify agency, unit, person, and the reason for contact such as a treatment orders/requests, notification, and/or consultation. Procedure for Notification to Receiving Facility A. Report the following, to the extent pertinent, to the receiving facility: 1. Transport status or code 2. Chief complaint 3. Age and gender of patient 4. General status and course of events, stable, improving, deteriorating 5. Past medical history, only if pertinent 6. State of consciousness 7. Vital signs 8. Pertinent localized findings 9. Treatment in progress 10. Estimated time of arrival Procedure for Requests for Treatment Orders A. Only a physician may provide authorization to a paramedic to perform a procedure or administer a medication pursuant to these protocols. The paramedic should be clear and concise in requesting that a physician be available for consultation or orders. B. Request to talk to a physician to obtain an order. C. Identify yourself to the physician and state the order you are requesting. D. Provide pertinent information that is the basis of the request, such as: 1. Enroute (emergent or non-emergent, estimated time to destination hospital) or on scene 2. Chief complaint 3. Course of events, stable, improving, deteriorating 4. Past medical history, only if pertinent 5. General status 6. State of consciousness 7. Vital signs 8. Pertinent localized findings 9. Treatment in progress 10. Order requested, stating dosage and route to be given 11. All allergies the patient has E. In the event a request is for a field pronouncement, the report should include information about the responses to resuscitation efforts, mechanism, and duration of resuscitation efforts. If the pronouncement is made, state the time. F. Communication with a physician at the base is appropriate if you are not sure whether or not a treatment, procedure or destination is appropriate for a patient. Go to Table of Contents BASE CONTACT should be considered as a consultation, not just as a source of authorization for medications and procedures. G. Requests for orders should be made to a hospital's recorded line whenever possible. Return to Table of Contents DESTINATION POLICY Purpose A. To provide a set of guidelines to help ensure proper disposition of the various patients encountered in the field. Philosophy A. Critical patients with a special medical need should be taken to the nearest facility that can best provide for that need. B. Critical patients without a special need (i.e., cardiopulmonary arrest) should be taken to the closest emergency department. C. All other patients should have their request accommodated, consistent with the ability of that system to meet that request. Special Needs A. Burns 1. Patients older than 12 years of age, with second degree or third degree burns greater than 20% body surface area, should be transported directly to the University Hospital emergency department. Patients 12 years of age and younger, with second degree or third degree burns greater than 20% body surface area, should be transported directly to The Children's Hospital emergency department. 2. Special Considerations. Complications of airway compromise or cardiovascular instability, require transport to the nearest appropriate emergency department. Burns associated with multi-system trauma should be transported according to the State of Colorado Trauma Triage Algorithm and RETAC rules. B. Trauma 1. The destination of trauma patients should always be in accordance with the Colorado Department of Health approved Rules and Regulations and RETAC rules. C. Psychiatric patients 1. Patients placed on a Mental Health Hold (MHH) by the Denver Police Department or Mental Health Corporation of Denver shall be transported to DHMC. 2. Patients placed on a MHH by other police departments or other state licensed providers shall be taken to the nearest emergency department. 3. Patients with psychiatric problems not on an MHH shall be taken to the closest hospital. 4. Patients with psychiatric problems who have an acute medical or traumatic concern shall be treated according to the appropriate medical or trauma protocol. 5. MHH may be placed by a state-certified EMT-P under the auspices of the receiving physician. D. Obstetric/Gynecologic 1. For patients in uncomplicated labor: a. Delivery not imminent: i. If the patient has a private obstetrician or gynecologist, then follow the patient's request for destination, when possible. Go to Table of Contents b. If the patient has no private physician, then follow the patient's request for destination (if expressed), or transport to the closest hospital. 2. Imminent delivery a. If the patient has a private obstetrician/care giver, then follow the patient's request for destination, when appropriate. If the requested facility does not meet these time constraints and the patient still requests the facility, CONSULT BASE physician. b. If the patient has no private physician, then transport to the closest appropriate hospital. Return to Table of Contents DIVERT POLICY (modified with permission from document created by Art Kanowitz, Pridemark Paramedic Services) Purpose A. To provide a standard approach to ambulance diversion that is practical for field use. B. To facilitate unobstructed access to hospital emergency departments for ambulance patients C. To allow for optimal destination policies in keeping with general EMS principles and Colorado State Trauma System Rules and Regulations. General Principles A. EMSystem, an internet-based tracking system, is used to manage diverts in the Denver Metro region. B. The State Trauma Triage Algorithms should be followed. C. The only time an ambulance can be diverted from a hospital is when that hospital is posted on EMSystem as being on official divert (RED) status. As of December 15, 2001, Emergency Department divert is the only category recognized in the Denver Metro region. D. Overriding factors: the following are appropriate reasons for a paramedic to override ED divert and, therefore, deliver a patient to an emergency department that is on ED divert: 1. Cardiopulmonary arrest 2. Imminent cardiopulmonary arrest 3. Unmanageable airway emergencies 4. Unstable "Level I" trauma patients for Level I and Level II trauma centers E. Prehospital personnel should honor advisory categories, when possible, considering patient's condition, travel time, and weather. Patients with specific problems that fall under an advisory category should be transported to a hospital not on that specific advisory when feasible. F. There are several categories that are considered advisory (yellow) alert categories. These categories are informational only and should alert field personnel that a hospital listed as being on an advisory alert may not be able to optimally care for a patient that falls under that advisory category. G. The following are advisory (yellow) categories: 1. ICU (Intensive Care Unit) 2. OB (Obstetrics) 3. Psych (Psychiatric) 4. Trauma (Trauma Services) 5. Operating Room (OR) H. Zone saturation is when all hospitals in that zone are on ED Divert. I. A Zone Master is a hospital contact that is responsible for determining hospital destinations when the zone is saturated. J. When an ambulance is transporting a patient that the paramedic feels cannot go outside the zone due to patient acuity or other concerns, the paramedic should contact the Zone Master and request a destination assignment. K. In general, patients contacted within a zone should be transported to an appropriate facility within the zone. Patients may be transported out of the Go to Table of Contents primary zone at the paramedic's discretion, if it is in the patient's best interest or if the transport to an appropriate facility is shorter. L. The zones, hospitals in each zone, Zone Masters, and the Zone Master contact phone numbers listed in the following table. ZONE HOSPITALS ZONE MASTER ZONE MASTER PHONE NUMBER Zone 1 North Suburban St. Anthony's Central 303-595-6135 St. Anthony's North NORTH/ St. Anthony's Central NORTHWEST Lutheran Zone 2 Swedish Swedish 303-788-6911 SOUTH Porter Littleton Sky Ridge Zone 3 University Aurora AND University* EAST Rose 303-695-2946 - Aurora Aurora ALTERNATE every Parker QUARTER: 720-848-5120 - 1st and 3rd quarter – University Aurora 2nd and 4th quarter - University (*Zonemaster date rollover occurs at midnight on the first day of each quarter.) Zone 4 Denver Health Denver Health 303-436-8100 MIDTOWN St. Joseph/Kaiser Presbyterian-St. Luke's Return to Table of Contents ATAC ADULT PREHOSPITAL TRAUMA TRIAGE ALGORITHM COLORADO STATEWIDE TRAUMA SYSTEM AREA TRAUMA ADVISORY COUNCILS ADULT PREHOSPITAL TRAUMA TRIAGE ALGORITHM The Denver Metro EMS Medical Directors now recommends the use of local RETAC rules for this protocol. Go to Table of Contents COLORADO STATEWIDE TRAUMA SYSTEM PEDIATRIC PREHOSPITAL TRAUMA TRIAGE ALGORITHM Triage and transport requirements for pediatric (< 12 years old*) trauma patients The Denver Metro EMS Medical Directors now recommends the use of local RETAC rules for this protocol. See also: Boulder Specific Trauma Activation Protocol Go to Table of Contents HAZARDOUS MATERIALS (HAZMAT) Indications A. Responding to reported and/or known hazardous materials incident B. Vapor clouds, fire, smoke, leaking substances, frost lines on cylinders, sick personnel, dead or distressed animals and noxious odors are present on or near scene. Precautions A. Senses are one of the best ways to detect chemicals, particularly the sense of smell. If you smell something you are too close. B. A safe approach to the scene is the first element of any EMS response. Unless you arrive safely at the site, you will not be able to perform your duties. C. Observe the site from a distance using binoculars, if possible, before you get too close. Look for danger signs such as vapor clouds, fire and smoke, placards, shape of vehicle or container, leaking substances, frost lines on cylinders, injured personnel, and dead or distressed animals. These are key clues to warn you not to get too close. Remember that you want to be part of the solution, not part of the problem. D. If the fire department is already on the scene, report in to the incident commander. If you are first on the scene and a hazardous material is suspected, request a hazardous materials team response. Keep yourself and your unit at a safe distance. This usually requires your unit to leave the scene, leaving patients and bystanders in a hazardous situation. Your safety comes first. Seek a location uphill and upwind from the incident. E. EMS personnel should not be participating in patient decontamination unless trained and equipped to do so in a safe manner. Procedure A. Your safety is the highest priority. EMS operations should be established in the cold zone. You should report to the incident commander. B. Position your vehicle to make a hasty retreat. This may require you to leave the scene to seek safety. C. The hazardous materials team should perform the initial assessment, treatment, and decontamination. Decontaminated patients should then be brought to the EMS unit. D. Once the situation has been assessed, notify the receiving hospital of the following information: 1. Location of the incident 2. Name of chemicals/products involved 3. Number of injured and contaminated 4. Extent of the injuries/contamination 5. Extent that the patients will be decontaminated in the field 6. Your estimated time of arrival 7. Other pertinent information that is available E. Patient treatment is usually based on signs and symptoms. Specific patient treatment should be based on information obtained from BASE CONTACT. Go to Table of Contents HELICOPTER TRANSPORT A. Air transport is a useful adjunct to the EMS System. The risks and benefits of the helicopter transport should be carefully weighed, especially when flying into a less than optimal landing zone. Benefits of helicopter transport should be considered when: 1. Rapid transport is desired. An obvious beneficiary of air transport is the rural trauma victim requiring rapid transport to the trauma center. 2. Multiple victims require multiple unit response/transport. 3. Extrication is complicated by difficult access requiring prolonged scene time. 4. Advanced life support is not available by ground within a reasonable time period. B. In order to effect the most expedient use of ground and air ambulance resources, the following guidelines should be considered: 1. The helicopter should be placed on standby when responding to a scene which may include any of the elements listed in section A. 2. The helicopter should be dispatched when it is the most appropriate means of transport. 3. In order to save time, the helicopter should be contacted through your own dispatched. 4. Please note that an accurate ETA will not be available until the helicopter is actually airborne. Consider alternative flight services or ground transport if the helicopter is not immediately available. 5. Generally speaking, the helicopter will stand-down only when so requested by the agency initiating the original response. Do not forget to stand down or cancel the helicopter if it is not required. 6. Public safety officers should be informed of the impending arrival of the helicopter. 7. Patient care in the field is a team response. State statutes dictate that ultimate responsibility rests with highest trained medical person on the scene. In this regard, the flight nurse assumes responsibility only for the patients turned over to him/her by the attending EMS personnel, unless the flight nurse is the first EMS person on the scene. Go to Table of Contents INFECTIOUS and COMMUNICABLE DISEASES A. Field personnel occasionally come into contact with infectious and communicable diseases. It is important that a protocol is followed so that the appropriate persons are notified. Not all diseases require immediate treatment; however, early awareness will assist those involved to take any necessary precautions and actions. B. Contamination by infectious and communicable diseases may be minor or serious. Field personnel should take precautions to avoid unnecessary exposure. When dealing with a suspected contagious patient, attempt to avoid direct contact with the patient's blood, sputum, emesis, urine, feces, or respiratory and lesion secretions. The provider should wear disposable latex or vinyl gloves and any other appropriate BSI. Routine practice of good hand washing and equipment cleaning may help decrease the incidence of contamination. C. The following guidelines have been provided for reference. Follow your individual agency infectious and communicable disease exposure policy and procedure. 1. All healthcare personnel should always practice good hygiene before, during and after delivering patient care. Each patient contact should be considered to be a potential source of infection. 2. Persons with significant exposure must report the incident to the designated Infection Control Officer of his/her agency. All personnel should be advised to consult with their private physician as well. 3. Agency policy, developed in conjunction with the Physician Advisor, will dictate procedure with regard to screening, follow-up testing, prophylaxis and/or treatment. 4. Exposed prehospital care personnel may be counseled and treated according to established guidelines. 5. Refer to the following website resource for information on diseases, means and methods of exposure, exposure risks, and recommended precautions, actions, and treatment: www.cdc.gov Go to Table of Contents INTERHOSPITAL TRANSFER A. Interhospital patient transfers are commonly initiated when definitive diagnostic or therapeutic needs of a patient are beyond the capacity of transferring hospital. In these cases the patient may be unstable, and medical treatment must be continued and possibly even initiated en route. Likewise, patients being transferred for diagnostic or therapeutic purposes may be stable but on continuous pharmacological or ventilatory therapy. It is imperative that such therapies be continued or interruptions in care planned to minimize risk to the patient. These guidelines encourage orderly transfer of patients with appropriate continuity of care. B. All patients should be stabilized, if possible, before transfer. C. Attending EMT or paramedic should receive a summary of the patient's condition, current treatment, possible complications and other pertinent medical information. D. Treatment orders should be given to the attending EMT or paramedic. These orders should be either in writing or by direct verbal order from the doctor who is initiating the transfer. E. Any unstable or potentially unstable patients must have at least one IV in place. Orders for IV fluid and rate should be provided. F. Transfer papers (summary, lab work, x-rays, etc.) should be given to the attending EMT or paramedic, rather than the family or friends. G. The attending EMT or paramedic should confirm that the receiving hospital and physician have been notified prior to initiation of transfer. H. The personnel used to transfer a patient should be appropriate to the treatment needed or anticipated during transfer. EMT-Bs who are not IV approved should not attend patients who have or may require IV therapy. Paramedics should be utilized if any advanced resuscitation or treatment is anticipated. In specialized fields not ordinarily handled by paramedics (i.e. high risk obstetrics, high risk newborns) an appropriately trained person should accompany the patient. I. The equipment used to transfer a patient should be appropriate to the treatment being provided. Example: IV medications being delivered by an IV pump should be either maintained on an IV pump during the transfer, discontinued, or the IV tubing be appropriate to the manual control. In order to maintain these standards, it may be appropriate for the receiving hospital to send an ambulance with more specifically trained personnel to transfer the patient. This is particularly true in the case of newborns, but has also been shown to be effective in the treatment of other critically ill or injured patients Go to Table of Contents MENTAL HEALTH HOLDS (MHH) Indications A. Any person who appears to be: 1. mentally ill and 2. an imminent danger to others or to him/herself or 3. gravely disabled Procedure A. Restrain if necessary. B. Call receiving facility for the physician to place MHH. C. Transport to Emergency Department. D. Provide appropriate documentation of events so 72-hour MHH can be filled out by the physician at the receiving facility. General Principles A. The paramedic may initiate an MHH only with the permission and online contact with the receiving physician. B. The law allows only physicians, trained nurses, and peace officers to place MHH. C. Paramedics may act as the field representative of the physician when the above protocol is followed. Go to Table of Contents NON-TRANSPORT OF PATIENTS General Principles A. A patient who has decision-making capacity may refuse treatment, examination or transport. B. A person has decision-making capacity sufficient to refuse treatment/transport if he/she: 1. Understands the nature of the illness/injury or risk of injury/illness; and 2. Understands the possible consequences of refusing treatment/refusing transport; and 3. Given the risks and options, the patient voluntarily refuses treatment/transport. C. The prehospital provider is responsible for deciding if the patient's refusal is informed and voluntary. The prehospital provider should consider the nature of the incident, potential mechanism, obvious actions of the patient, as well as the verbal statements of the patient. The prehospital provider is responsible for a reasonable assessment of the patient to determine if there is an injury/illness or reason for transport or treatment. Only then is a patient's refusal an informed refusal. Do not attempt to diagnose, do assess carefully. D. Remember: it is your assessment and advice to the patient, and proper documentation of it, that are most important in the non-transport. Procedure for Non-Transports (See Non-Transport/Refusal of Care Algorithm following) A. If the patient is 18 years of age or older, has no demonstrable illness or injury, has no mechanism of injury, demonstrates competency (as defined in the "Consent" portion of this section), and did not initiate the call for help, then base contact is not required. B. For the patient who has only an isolated soft tissue injury and has decision- making capacity, treatment and transport should be offered. If the patient refuses, then warn the patient of the risks of non-transport and delay in treatment. Agency policy determines base contact requirement. C. Patients with medical conditions/injuries that may recur or deteriorate, or may render the patient unable to seek medical care, should be carefully evaluated and warned to not delay in obtaining medical treatment. High-risk areas in EMS are head injury, chest pain, abdominal pain, "flu" like symptoms, alcohol-related illnesses, or injuries. D. For the patient refusing transport/treatment: 1. Assess patient to the extent possible. Look for objective causes of injuries/illnesses that may impair decision-making. Evaluate mechanism/history, scene and potential for unseen injuries/illnesses. Do not diagnose. 2. Inform patient of findings, possible injuries or illnesses that warrant treatment and transport, and of the risks of non-transport, delaying treatment, and non- physician examination. 3. If the patient still refuses treatment/transport, then determine the patient's ability to understand the immediate medical situation and need for treatment. Questions asked might include: a. Why don't you want to go to the hospital? b. What other means of transport do you have? Go to Table of Contents c. What will you do if you get sick again? d. What are the risks I just explained to you about delaying treatment? E. If the patient still refuses transport, CONTACT BASE. F. The base physician may: 1. Agree or determine that the patient's decision-making capacity is impaired and instruct transport of the patient. a. The patient may be transported under the basis of a medical emergency (i.e., patient is incapacitated and unable to consent.) b. The patient may be transported under the basis of a mental health emergency. Police should be requested to place the patient under a Mental Health Hold. Appropriate paperwork, such as the Mental Health Hold, must accompany the patient. 2. Agree or determine that the patient has decision-making capacity, in which case: a. The patient may refuse treatment and transport but must be advised of the risks of non-transport (informed refusal). b. The prehospital provider must warn the patient that non-transport is against medical advice (AMA). c. The patient should be urged to seek medical attention and transport. G. For the patient who refuses treatment and transport (against medical advice), providing the patient with clear instructions and warnings is imperative. Use of an Information Sheet is recommended. H. Minors: CONTACT BASE any time a minor under the age of 18 is not left in the custody of the parents. I. The following must be documented for every patient examined, offered and refused treatment/transport (in addition to EMS Division guidelines): 1. All assessment findings 2. Description of mechanism or scene factors (damage, environment, etc.) 3. Description of mental status and decision-making capacity 4. Vital signs, unless the patient refused 5. Patient's response to warning about risks of non-transport/non-treatment 6. Base physician's advice 7. Patient's condition at termination of patient contact, such as "ambulatory", "with family" J. The "AMA" (refusal) patient should be provided with an Information Sheet. Obtaining a patient's signature on a run report or release form is encouraged because signing may be evidence of the patient's decisional capacity and physical stability. However, do not have a patient sign a release or waiver that you do not understand, and do not expect that a signature relieves you of responsibility for a reasonable assessment or treatment of the patient. K. The role of base contact is to assist in determining or verifying the patient's ability or inability to make medical treatment decisions and assist when transport should be done. It is imperative that an accurate, concise report be given for the physician to give good advice. L. Have all AMA forms co-signed by a witness. The witness should not be an employee of the responding agency. Return to Table of Contents NON-TRANSPORT/REFUSAL OF CARE ALGORITHM (See Non-Transport of Patients protocol) Determine mental status and extent and history of injury, mechanism or illness Pt is alert, oriented and has decision- Injury or illness or has impaired decision- making capacity making capacity • No apparent Limited injury Pt refuses consent or offer of treatment injury/illness consistent with and transport • No complaints mechanism • No significant history Contact Base • No MOI Offer treatment and transport Base physician Base physician determines pt does determines pt does have decision- not have decision making capacity making capacity. Pt still refuses (Treatment/transpo 18 years or older rt may be and did not call for authorized under Warn pt of risks of help MHH, ATH or non- treatment/transport implied consent if a against medical medical advice emergency exists Pt does not want Refer to agency help policy Document Transport: request appropriately MHH or police if necessary for assistance Advise pt and Base contact document Document appropriately appropriately Return to Table of Contents TRIAGE: MULTIPLE PATIENT ASSESSMENT REFER TO: THE COLORADO STATE UNIFIED DISASTER TAG AND TRIAGE SYSTEM - A GUIDE TO MCI (multiple/mass causality incident) Definition A. MCI: The combination of numbers and types of injuries that goes beyond the capability of an entity's normal response. B. Triage: From French - means to sort, sift, or pick out; specifically, the sorting of and allocation of treatment to patients. Indications A. Medical emergency involving more than one patient, interaction between different agencies, and the need to make choices regarding treatment. Procedure A. Park vehicle in safe location. B. Contact appropriate command personnel and follow instructions. C. If assigned to triage, do initial assessment of scene; proceed only when safe to rescuer. D. Rapidly estimate number of victims and severity of injuries. Do not provide extensive treatment. E. Establish communications and request necessary assistance as per department or agency procedure; this may include contacting the appropriate hospital and providing initial estimate of number and types of injuries. F. Designate or ensure designation of: 1. The Incident Command System (ICS) depending on the size of the event and the number of agencies involved (see Diagram A - Incident Command System) 2. Medical command: follow departmental and jurisdictional procedures. 3. Medical Triage Team: a. Categorize patients after brief assessment using the Simple Triage and Rapid Treatment START) system (see Diagram B - START Algorithm). b. Update categorizations and provide transport to stabilization area as able. c. Initiate medical stabilization to patients awaiting transport after triage duties completed. 4. Transport Team (if necessary): a. Transport patients in order of priority from field to stabilization area. b. Establish venous access or perform other stabilization procedures as needed in support of triage team. c. If ongoing assessment, categorization, and transport are to be required, organize the area into an appropriate Triage/MCI format (see Appendix Section F, Triage/MCI Templates; diagrams C-1, C-2, and C-3) Precautions A. Identification of medical charge personnel is extremely important and often overlooked. Use vests, hats, or other labeled equipment consistent with departmental or agency procedures. B. Location of stabilization area is very important. It should fulfill the following criteria as much as possible: Go to Table of Contents 1. Away from objective dangers of scene 2. Close enough for access from scene for stretchers 3. Accessible by multiple rescue vehicles, both in and out 4. Near communications and other command personnel for coordination of evacuation C. If triage tags are part of departmental or agency procedures, attach triage tags to patient, not clothing. D. Triage assessment and management differs from single patient assessment. Certain problems recur in major disasters, and should be avoided: 1. Do not use up ambulance space initially transporting class III (green) patients before more serious injuries have been transported (red and yellow). 2. Do not delay transport to treat patients at the scene. 3. Reassess patients when able and communicate any changes to the medical command and transport officers. 4. Disaster scenes require discipline within the team. Be sure that the leadership and individual roles are well identified. It is important that individuals fulfill their roles as members of the team and in turn give up those roles appropriately as personnel and officers arrive to the MCI scene. Special notes A. The Incident Command Structure developed and disseminated by the National Interagency Incident Management System (NIIMS) and Federal Emergency Management Agency (FEMA) provides an excellent overall approach to disaster management. The structure is designed to allow flexibility and local differences, as well as incorporation of different training levels (physician, nurse, paramedic, EMT-B) within Medical Control at the scene. It is important that individuals are aware of the command structure and follow instructions. (see ICS Flow chart below). B. Multiple trauma patients with no vital signs upon arrival of rescue personnel have a very poor chance of survival even if they are the only victim. If there are additional victims with any signs of life, attention will be better spent with the living. Return to Table of Contents INCIDENT COMMAND SYSTEM * Command system with group and branch divisions based on functions Incident Commander Operations Branch Medical Branch (i.e. fire) Branch (i.e. law enforcement) Triage Officer Treatment Transport Logistics Officer Officer Officer Deputy Transport Triage Group Area Leaders Officer Clerk Leader Leader Leader Leader Group 0 Group I Group II Group III (Black tags) (Red tags) (Yellow tags) (Green Tags) Area Staff Area Staff Area Staff Area Staff Go to Table of Contents START TRIAGE FLOWCHART Respirations No Yes Reposition >30 / minute <30 / minute Airway No Yes Immediate Assess Red Tag Perfusion Non- Immediate Salvageable Red Tag Black Tag Capillary refill >2 Capillary refill <2 seconds OR seconds OR No palpable radial palpable radial pulse pulse Immediate Assess Mental Red Tag Status Fails to follow simple Able to follow simple commands commands Immediate Delayed Red Tag Yellow Tag Remember – Patients that can initially ambulate with or without assistance are GREEN tags. Constant reassessment is necessary and there should be no hesitation in up- triaging when necessary. Go to Table of Contents CRITICAL CARE TRANSPORT UTILIZATION GUIDELINES Revised: January 22, 2008 Purpose A. To effectively triage and process any request for service in which Critical Care Transport (CCT) may be utilized. Policy A. The Communications Center employees will utilize the standard operating procedures to process CCT requests and appropriate utilization of CCTs and ALS resources to manage acute patients. A request of services within the scope of an Advanced Life Support paramedic-staffed ambulance will be scheduled as a non-CCT transport unless specifically requested by the transferring physician. This policy is included as a reference for clarity and support in decision making for Denver Metro paramedics and other non-CCT staff. Definition A. CCT: Transport of a patient whose clinical needs in transport exceed those procedures and medications included in the acts allowed for paramedics, and for whom additional care providers are required (RN, RT, etc.). Procedure Mandatory Critical Care Utilization The following situations will result in utilization of a Critical Care Transport: Patient Origin/Destination A. Intensive care unit (ICU) to ICU or Cardiac Care unit (CCU) unless the following criteria are met: 1. Patient on a psychiatric hold in an ICU, with medical clearance completed (versus mental health clearance) 2. Patients in ICU because of non-ICU overflow or telemetry bed overflow status at the referring or receiving facility B. CCU or ICU to Cardiac Cath Lab unless the following criteria are met: 1. Patients with acute myocardial infarctions 36 hours out or greater from admission who have no ongoing chest pain, malignant arrhythmias, or cardiovascular instability (non-emergent cath only). 2. Patients with Acute Coronary Syndrome who have been ruled out for myocardial infarction after 12 hours or more. They should have no ongoing chest pain, malignant arrhythmias, or cardiovascular instability (non-emergent cath only). Monitoring/Equipment/Medication Needs A. Transports requiring intra-aortic balloon pump B. Transports requiring invasive treatment modalities including: 1. Non-standard airway management, requiring conscious sedation and/or anesthetic agents Go to Table of Contents 2. Intensive care monitoring (condition in which clinical presentation in or is at risk of being unstable, including: intracranial monitoring devices, arterial lines, Swan-Ganz catheters, etc). C. Patients requiring medications and infusions not approved by the Denver Metro Protocols. D. Patients on vasoactive infusions initiated or adjusted within two hours of transport. ("2-hour rule") E. Patients requiring fetal monitoring/high risk OB patients Instability A. Multi-Systems trauma patient < 24 hours post-injury with a potential for hemodynamic instability as determined by the transferring physician B. Patients with known cardio-thoracic compromise (e.g., AAA, dissecting aneurysms) C. Hemodynamically unstable patient. D. Any other patient whom the sending facility indicates is clinically unstable (a physician or registered nurse must authorize the use of the CCT) Exceptions A. Patients may be sent by paramedic ambulance if, in the opinion of the transferring physician, time consideration outweighs the need for RN presence if the following criteria are met: 1. Critical Care Transport Services are not available in a reasonable response time. 2. There is no nurse available from the sending facility to accompany the transport. 3. The transport requirements are not outside of the acts allowed for paramedics, or the medications specified by the Denver Metro Protocols. 4. The sending facility will provide additional resources when possible including other staff, IV pumps, etc. Medications A. The following is a complete list of medications that the Pridemark Protocols authorize Colorado State Paramedics to administer and maintain pursuant to the scope of practice under Rule 500 Acts Allowed for the State of Colorado. B. Denver Metro Protocol Pharmacy List: 1. Adenosine (Adenocard) 2. Albuterol Sulfate 3. Antibiotics 4. Amiodarone 5. Aspirin (ASA) 6. Atropine 7. Dextrose 50% 8. Diazepam (Valium) 9. Diphenhydramine (Benadryl) 10. Dopamine (Intropin) 11. Epinephrine 12. Fentanyl 13. Furosemide (Lasix) Return to Table of Contents 14. Glucagon 15. Haloperidol (Haldol) 16. Heparin 17. Ipratropium Bromide (Atrovent) 18. IV Solutions 19. Magnesium Sulfate 20. Methylprednisolone (Solu-Medrol) 21. Metoclopramide (Reglan) 22. Midazolam (Versed) 23. Morphine Sulfate 24. Naloxone (Narcan) 25. Nitroglycerin 26. Ondansetron (Zofran) 27. Oral Glucose (Glutose, Insta-Glucose) 28. Oxygen 29. Phenylephrine (Intranasal) 30. Promethazine (Phenergan) 31. Racemic Epinephrine (Vaponephrine) 32. Sodium Bicarbonate 33. Topical Ophthalmic Anesthetics C. Maintenance IV Infusions D. IV Solutions 1. 0.9% Normal Saline 2. Lactated Ringers 3. D5W 4. Any combination of the above solutions E. Vasoactive Drips 1. Dopamine (2-hour rule) 2. Epinephrine (2-hour rule) Medications or infusions not included in this section will most likely require CCT transfer or, at a minimum, an EMS physician consult and approval. The Communications Specialist should use the CCT vs ALS Transport Algorithm to assist in the determination of the Level of Care: Return to Table of Contents CCT vs ALS Transport Algorithm Has the PHYSCIAN REQUESTED that the patient yes [ ] CCT be transported by CCT. No [ ] Intensive Care Setting to antoher Intensive Setting yes [ ] CCT ICU to ICU, PICU to NICU, SICU to CICU, etc. No [ ] Is the patient being transport from an ICU to a procedure yes [ ] CCT and then returning to the ICU? No [ ] Will the patient have any medication drips running yes [ ] List Medications: __________________________________________ during transport? _________________________________________________________ _________________________________________________________ _________________________________________________________ No [ ] _________________________________________________________ Will the patient have any special equipment needs? ___ Intra-aortic balloon pump ___ Chest tube to drainage yes [ ] yes [ ] Are any of these medications outside CCT ___ Arterial Line of the (BME / Metro Protocols defined) ___ Invasive Pressure Monitoring (Arterial, ICP, CVP) paramedic scope of practice? (See Back) No [ ] If any question whether CCT Vs ALS Date: Time: Call Director of Clinical Medicien 720-641-4093 Patient Name: No [ ] Run Number: Ordering MD: ALS Ambulance Assigned Unit: Receiving MD: All patients requiring CCT transport should be referred to Flight for Life of Colorado unless another service is specifically requested by the caller. Return to Table of Contents Appendix F TRIAGE/MCI TEMPLATES Simple Triage Template OMCI Triage Area Green Black Yellow Red Landing Zone Ingress / Egress Go to Table of Contents Moderate Triage Template OMCI Green Black Triage Area Yellow Red Supply Landing Zone Ingress / Egress Staging Go to Table of Contents Complex Triage Template OMCI Bus Coroner Green Black Triage Area Yellow Red Supply Landing Zone Egress Ingress Egress Staging Staging Go to Table of Contents PEDIATRIC PATIENT ASSESSMENT Children can be examined easily from head to toe, but lack of understanding by the patient, poor cooperation, and fright often limit the ability to assess completely in the field. Children often cannot verbalize what is bothering them, so it is important to do a systematic survey which covers areas that the patient may not be able to tell you about. Any observations about spontaneous movements of the patient and areas that the child protects are very important. In the patient with a medical problem, the more limited set of observations listed below should pick up potentially serious problems. A. General: 1. Level of alertness, eye contact, attention to surroundings 2. Muscle tone: normal, increased, or weak and flaccid 3. Responsiveness to parents, caregivers; is the patient playful or irritable? B. Head: 1. Signs of trauma 2. Fontanelle, if open: abnormal depression or bulging C. Face: 1. Pupils: size, symmetry, reaction to light 2. Hydration: brightness of eyes; is child making tears? Is the mouth moist? D. Neck: note stiffness. E. Chest: 1. Note presence of stridor, retractions (depressions between ribs on inspiration) or increased respiratory effort. 2. Auscultate the chest: 3. Breath sounds: symmetrical, rales, wheezing? 4. Heart: rate, rhythm F. Abdomen: distention, rigidity, bruising, tenderness G. Extremities: 1. Brachial pulse 2. Signs of trauma 3. Muscle tone, symmetry of movement 4. Skin temperature and color, capillary refill 5. Areas of tenderness, guarding or limited movement H. Neurologic exam NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP AGE PULSE RESPIRATIONS BLOOD PRESSURE avg./min. breaths/min. Premature 140 40-60 40-60 Newborn 150 40-60 60-80 6 mo 140 25-40 65-105 1 yr 135 20-30 70-110 3 yr 110 20-30 80-110 5 yr 100 20-30 80-110 8 yr 90 12-25 90-115 Go to Table of Contents LAB VALUES HEMATOLOGY - Red Blood Cells RBC (Male) 4.2 - 5.6 M/µL RBC (Female) 3.8 - 5.1 M/µL RBC (Child) 3.5 - 5.0 M/µL HEMATOLOGY - White Blood Cells WBC (Male) 3.8 - 11.0 K / mm3 WBC (Female) 3.8 - 11.0 K / mm3 WBC (Child) 5.0 - 10.0 K / mm3 HEMOGLOBIN Hgb (Male) 14 - 18 g/dL Hgb (Female) 11 - 16 g/dL Hgb (Child) 10 - 14 g/dL Hgb (Newborn) 15 - 25 g/dL HEMATOCRIT Hct (Male) 39 - 54% Hct (Female) 34 - 47% Hct (Child) 30 - 42% MCV 78 - 98 fL MCH 27 - 35 pg MCHC 31 - 37% neutrophils 50 - 81% bands 1 - 5% lymphocytes 14 - 44% monocytes 2 - 6% eosinophils 1 - 5% basophils 0 - 1% CARDIAC MARKERS troponin I 0 - 0.1 ng/ml (onset: 4-6 hrs, peak: 12-24 hrs, return to normal: 4-7 days) troponin T 0 - 0.2 ng/ml (onset: 3-4 hrs, peak: 10-24 hrs, return to normal: 10-14 days) myoglobin (Male) 10 - 95 ng/ml (onset: 1-3 hrs, peak: 6-10 hrs, return to normal: 12-24 hrs) myoglobin (Female) 10 - 65 ng/ml (onset: 1-3 hrs, peak: 6-10 hrs, return to normal: 12-24 hrs) GENERAL CHEMISTRY acetone 0.3 - 2.0 mg% albumin 3.5 - 5.0 gm/dL alkaline phosphatase 32 - 110 U/L anion gap 5 - 16 mEq/L ammonia 11 - 35 µmol/L amylase 50 - 150 U/dL AST,SGOT (Male) 7 - 21 U/L AST,SGOT (Female) 6 - 18 U/L Go to Table of Contents bilirubin, direct 0.0 - 0.4 mg/dL bilirubin, indirect total minus direct bilirubin, total 0.2 - 1.4 mg/dL BUN 6 - 23 mg/dL calcium (total) 8 - 11 mg/dL carbon dioxide 21 - 34 mEq/L carbon monoxide symptoms at greater than or equal to 10% saturation chloride 96 - 112 mEq/L creatine (Male) 0.2 - 0.6 mg/dL creatine (Female) 0.6 - 1.0 mg/dL creatinine 0.6 - 1.5 mg/dL ethanol 0 mg%; Coma: greater than or equal to 400 - 500 mg% folic acid 2.0 - 21 ng/mL glucose 65 - 99 mg/dL (diuresis greater than or equal to 180 mg/dL) HDL (Male) 25 - 65 mg/dL HDL (Female) 38 - 94 mg/dL iron 52 - 169 µg/dL iron binding capacity 246 - 455 µg/dL lactic acid 0.4 - 2.3 mEq/L lactate 0.3 - 2.3 mEq/L lipase 10 - 140 U/L magnesium 1.5 - 2.5 mg/dL osmolarity 276 - 295 mOsm/kg parathyroid hormone 12 - 68 pg/mL phosphorus 2.2 - 4.8 mg/dL potassium 3.5 - 5.5 mEq/L SGPT 8 - 32 U/L sodium 135 - 148 mEq/L T3 0.8 - 1.1 µg/dL thyroglobulin less than 55 ng/mL thyroxine (T4) (total) 5 - 13 µg/dL total protein 5 - 9 gm/dL TSH Less than 9 µU/mL urea nitrogen 8 - 25 mg/dL uric acid (Male) 3.5 - 7.7 mg/dL uric acid (Female) 2.5 - 6.6 mg/dL LIPID PANEL (Adult) cholesterol (total) Less than 200 mg/dL desirable cholesterol (HDL) 30 - 75 mg/dL cholesterol (LDL) Less than 130 mg/dL desirable triglycerides (Male) Greater than 40 - 170 mg/dL triglycerides (Female) Greater than 35 - 135 mg/dL URINE color Straw specific gravity 1.003 - 1.040 pH 4.6 - 8.0 Return to Table of Contents Na 10 - 40 mEq/L K Less than 8 mEq/L C1 Less than 8 mEq/L protein 1 - 15 mg/dL osmolality 80 - 1300 mOsm/L 24 HOUR URINE amylase 250 - 1100 IU / 24 hr calcium 100 - 250 mg / 24 hr chloride 110 - 250 mEq / 24 hr creatinine 1 - 2 g / 24 hr creatine clearance (Male) 100 - 140 mL / min creatine clearance (Male) 16 - 26 mg / kg / 24 hr creatine clearance (Female) 80 - 130 mL / min creatine clearance (Female) 10 - 20 mg / kg / 24 hr magnesium 6 - 9 mEq / 24 hr osmolality 450 - 900 mOsm / kg phosphorus 0.9 - 1.3 g / 24 hr potassium 35 - 85 mEq / 24 hr protein 0 - 150 mg / 24 hr sodium 30 - 280 mEq / 24 hr urea nitrogen 10 - 22 gm / 24 hr uric acid 240 - 755 mg / 24 hr COAGULATION ACT 90 - 130 seconds APTT 21 - 35 seconds platelets 140,000 - 450,000 /ml plasminogen 62 - 130% PT 10 - 14 seconds PTT 32 - 45 seconds FSP Less than 10 µg/dL fibrinogen 160 - 450 mg/dL bleeding time 3 - 7 minutes thrombin time 11 - 15 seconds CEREBRAL SPINAL FLUID appearance clear glucose 40 - 85 mg/dL osmolality 290 - 298 mOsm/L pressure 70 - 180 mm/H2O protein 15 - 45 mg/dL total cell count 0 - 5 cells WBCs 0 - 6 / µL HEMODYNAMIC PARAMETERS cardiac index 2.5 - 4.2 L / min / m2 cardiac output 4 - 8 LPM left ventricular stroke work index 40 - 70 g / m2 / beat right ventricular stroke work index 7 - 12 g / m2 / beat mean arterial pressure 70 - 105 mm Hg Return to Table of Contents pulmonary vascular resistance 155 - 255 dynes / sec / cm to the negative 5 pulmonary vascular resistance index 255 - 285 dynes / sec / cm to the negative 5 stroke volume 60 - 100 mL / beat stroke volume index 40 - 85 mL / m2 / beat systemic vascular resistance 900 - 1600 dynes / sec / cm to the negative 5 systemic vascular resistance index 1970 - 2390 dynes / sec / cm to the negative 5 systolic arterial pressure 90 - 140 mm Hg diastolic arterial pressure 60 - 90 mm Hg central venous pressure 2 - 6 mm Hg; 2.5 - 12 cm H2O ejection fraction 60 - 75% left arterial pressure 4 - 12 mm Hg right atrial pressure 4 - 6 mm Hg pulmonary artery systolic 15 - 30 mm Hg pulmonary artery diastolic 5 - 15 mm Hg pulmonary artery pressure 10 - 20 mm Hg pulmonary artery wedge pressure 4 - 12 mm Hg pulmonary artery end diastolic pressure 8 - 10 mm Hg right ventricular end diastolic pressure 0 - 8 mm Hg NEUROLOGICAL VALUES cerebral perfusion pressure 70 - 90 mm Hg intracranial pressure 5 - 15 mm Hg or 5 - 10 cm H2O ARTERIAL VALUES pH 7.35 - 7.45 PaCO2 35 - 45 mm Hg HCO3 22 - 26 mEq/L O2 saturation 96 - 100% PaO2 85 - 100 mm Hg BE -2 to +2 mmol/L VENOUS VALUES pH 7.31 - 7.41 PaCO2 41 - 51 mm Hg HCO3 22 - 29 mEq/L O2 saturation 60 - 85% PaO2 30 - 40 mm Hg BE 0 to +4 mmol/L Return to Table of Contents 12 LEAD EKG LANDMARKS & INFARCT PATTERNS RA = Right Arm V1 - 4th ICS, R sternal border LA = Left Arm V2 - 4th ICS, L sternal border RL = Right Leg V3 - Midway between V2 and V4 LL = Left Leg V4 - 5th ICS, Left MCL V5 - Follow V4 in a straight line to the anterior axillary line. V6 - Follow V4 and V5 to mid- axillary line. Locations of Infarcts Inferior wall II, III, aVF Anterior wall V1, V2, V3, V4, V5, V6 Anteroseptal V1, V2, V3, V4 Anterolateral V3, V4, V5, V6 Lateral wall I, aVL, V5, V6 Return to Table of Contents Clinical Division Standard Operating Procedure Effective Date: February 01, 2008 Approval: DOCM_______HR_______ Policy: BLS Transport Utilization Objective: To provide clear standards for the proper utilization of BLS ambulances to transport patients in the 911 system. Scope: Clinical Director, Clinical Manager, Team Leaders, Field Instructors, Paramedics, EMT-Basics Procedure: 1. A Pridemark paramedic will respond to all 911 calls as the primary responder and perform a full ALS examination to determine the type of care that is required. Certain vital signs will be disqualifiers for BLS transport. a. Blood Pressure below 100 systolic b. A heart rate in excess of 108/min. c. A respiratory rate in excess of 30 d. Altered mental status of unknown etiology i. AMS due to dementia is acceptable as long as it is not below patient baseline ii. AMS due to alcohol is acceptable as long as the patient is not obtunded or in need of airway support. A good benchmark would be the ability to ambulate with minimal assistance. iii. Co-ingestion of drugs and alcohol is a disqualifier for BLS e. Poor skin signs 2. If the patient is determined to need ALS monitoring, ALS procedures, or has the potential for deterioration, a Paramedic will attend during transport to the hospital. If ALS treatment is initiated by the Paramedic, then transport will be continued by ALS. 3. ALS transport of patients that have been excluded from BLS care can be handled in one of two ways: a. If the responding Paramedic is a member of an ALS ambulance, they will continue to take the patient in their ambulance and initiate transport. b. If the responding Paramedic responded on a supervisor vehicle, the paramedic can assume the attendant role in the BLS ambulance which is possible because all vehicles are equipped as standard ALS units. 4. All attendants from BLS units that can be utilized in the 911 system will have successfully completed a field instruction program. This will ensure that they will be able to provide care at the same level as an EMT working on a standard Pridemark ALS unit. Return to Table of Contents 5. If during transport the patient deteriorates and develops vital signs that exceed the initial transport criteria, Base Contact will be initiated and ALS will be called in to complete transport if appropriate. 6. Use of the BLS transport model will be restricted to urban areas within 15 minutes or less transport time to a hospital and per individual contract requirements. Return to Table of Contents Clinical Division Standard Operating Procedure Effective Date: January 31, 2008 Approval: DOCM_______HR_______ Policy: Controlled Substances Objective: To clearly identify the process and responsibilities for storage, administration, and restocking of controlled substances as required by state and federal law Scope: Clinical Director, Clinical Manager, Team Leaders, Field Instructors, EMT-Paramedics Procedure: General Principles Controlled substances, drugs that come under the jurisdiction of the Federal Controlled Substances Act of 1970, are drugs that have a high risk for misuse or abuse by patients, professionals, and the public. The Drug Enforcement Administration (DEA) administers The Federal Controlled Substances Act. Because of the high potential for abuse, controlled substances have special requirements for ordering, receiving, storing, and administering. Very strict security and record-keeping is mandatory. The Clinical Director is responsible for overseeing the entire process and ensuring that security remains high. Anytime there is a suspected breech in security, the Director of Clinical Medicine must be notified immediately. A thorough investigation is mandatory. If criminal activity is suspected, law enforcement officials and the DEA must be notified immediately. Pridemark Paramedic Services/Medical Director must maintain a current DEA license. The DEA license is registered under Pridemark Paramedic Services with the Medical Director also listed on the license and shall be held by the Director of Clinical Medicine. Procedure Ordering Controlled Substances Schedule II Controlled Substances Include Fentanyl and Morphine Schedule II Substances must be ordered on an Official US DEA Order Form (DEA-222). The order must be entered on the DEA-222 Tracking Record and a copy of the DEA-222 form must be kept on file and tracked. Include on the tracking record the Form 222 #, the order form #, the item ordered, quantity ordered, date ordered, date received, and quantity received. Schedule IV Controlled Substances Include Valium (Diazepam), and Versed (Midazolam) Schedule IV Substances may be ordered directly from the supplier without an Official US DEA Order Form. Invoices must be kept on file and tracked. Storing Controlled Substances All controlled substances must be handled with the highest security. All controlled substances will be placed in the Clinical Director's safe immediately upon receipt. Return to Table of Contents All controlled substances coming into or going out of the Clinical Director's safe must be logged on the Clinical Director's Narcotic Log. The safe count must be reconciled with every transaction. The flow of controlled substances shall be as follows: The Clinical Director will initially secure all controlled substances. a) Controlled substances will then be distributed to the appropriate divisions as needed to replace used stock. Controlled substances shall be kept in the Team Leaders' safe. All controlled substances coming into or going out of the Team Leaders' safe must be logged. The safe count must be reconciled with every transaction. iv. Using Controlled Substances during the shift: a. At the beginning of the shift, the paramedic or RN shall access the controlled substances cabinet and sign out an intact box. b. At the end of the shift, or during the shift if call volume requires, the box is returned to the cabinet with the appropriate documentation if substances have been used and the box appropriately handled. A witness must verify the procedure. c. Should a narcotic box be used or unsealed, it shall be placed in the lower locker cabinet with proper documentation rubber banded around box. v. The sealed controlled substances boxes must be kept in a locked cabinet in each ambulance. Each ALS provider shall be issued a combination lock which can be custom coded for this purpose. This code shall not be shared with others. e. Tamper controls i. The controlled substance box should remain in the heat-sealed plastic until use, and the plastic unique lock should remain attached to the box. ii. Each individual controlled substance container, vial or pre-load, also has a tamper seal. As soon as the tamper has been broken, the entire contents of the container should be drawn up and prepared for use. a) Should no controlled substance be given, the medication should be wasted and properly documented with a witness signature. Said witness may be EMT partner. b) Should a container be discovered with the tamper seal missing, the Team Leader shall be notified as soon as possible and the container not used. i) An IR regarding the circumstances surrounding the missing tamper shall be filed. Administration of Controlled Substances Controlled substances must be administered according to Pridemark Protocols, Policies, and Procedures. The only time that a controlled substance may be administered out of compliance with the protocols is when a direct order is given from a base hospital physician (see Operational Guidelines—Base Physician Consultation). Any time a paramedic administers a controlled substance, the paramedic must complete a Patient Care Record and a "Controlled Substance Storage and Administration Record." Documentation of Controlled Substance Usage All controlled substance usage shall be documented in the PCR. The controlled substance may be documented using either the generic or trade name. Initials or abbreviations should not be used. A Controlled Substance Storage and Administration Record (SAR) shall also be filled out for every usage or waste. Return to Table of Contents The original SAR should be attached to the narc box with a rubber band and placed with the box in the lower locked cabinet for Team Leader restock. Exchange of Controlled Substances After any usage or waste, the box and documentation shall either be turned in directly to the Team Leader, or returned to the controlled substances cabinet. The Team Leader will restock used controlled substances by turning over all Patient Care Records/Administration Record Forms to the Director of Clinical Medicine once per month. The Director of Clinical Medicine will also keep records of all controlled substances used and related information to include: Date Replaced Substance Trip Number Patient Name Patient Date of Birth Dosage Administered Dosage Wasted Administered By Employee Number Serial Number Return to Table of Contents EMT Field Instruction Program Purpose: To outline the field orientation process in an effort to create an effective and consistent training program for new Pridemark EMT's. Scope: Team Leaders, Field Instructors, & EMT's Description: The EMT Field Instruction program shall consist of five stages. The following is merely a guide and may at the discretion of the Clinical Manager or Administration be custom tailored to meet individual employee or operational needs. Phase I: Classroom Orientation Phase II: Third Rides Phase III: Para-transit Phase IV: Operations Phase V: Medical Details: Phase I: Phase I shall consist of general classroom orientation to Pridemark. This includes but is not limited to Human Resource policies, benefits, and mandatory new employee training. It shall also include system specific training in mapping, radios, and paperwork. Phase I will be managed and administered by the Human Resources Staff, in coordination with the Directors of Operations, Risk, Customer Service, and Clinical Managers. Phase II: Phase II shall consist of 3rd rides with Pridemark Paramedic EMT's. This phase in intended to introduce the new employee to Pridemark Para-transit operations and prepare them for Phase III where they will operate as the sole crew member on Para-transit. During Phase II, the new employee shall be oriented on radio operations, mechanical wheel chair lift usage, securing patients, mapping, and general Para-transit operations and expectations. The Return to Table of Contents new EMT should also be oriented on all patient care equipment and van inventory. Phase III: While working independently on Para-transit, the new EMT should focus on mastering general operational aspects of working at Pridemark to prepare them for future BLS and eventually ALS roles. Specifically, the new EMT should learn the system specific street rotations, mapping, hospital and SNF locations around the district, radio etiquette, and general operational expectations such as proper care of vehicles and equipment. Questions and help during this phase should be solicited from peers, Team Leaders, Field Instructors, and management as needed. It is expectation that time on Para-transit will allow the new EMT to learn partially thru the example of others, and partially thru self study. Some self initiative and motivation are required during this phase to be successful. Historically, the best EMT's and Medics in the company have started in Para-transit. Most all will tell you that it was a valuable learning opportunity. At regular intervals thru out the year, which shall be available by going to the education calendar on line at www.Pridemark.net Pridemark shall offer EMT FI testing. This testing process shall serve to rank EMT's for entry into the BLS and ALS systems and further Field Instruction. The testing will be based on much of what is expected during Phase III. A prerequisite to this testing shall also be the completion of an approved IV therapy course. Basic EKG class is also strongly recommended. It is the goal that people transition from Para-transit to BLS only after going thru Field Instruction with an EMT FI. However, at times, operational needs may necessitate moving people sooner. In such cases every attempt will be made to FI EMT's as soon as possible. It may at times also be necessary to place people in FI out of ranking order, as may be necessary to facilitate scheduling or operational needs of the company or individual employees who may not be able to participate in FI due to schedule conflicts, etc. Phase IV: Once selected and placed into Field Instruction with an EMT or Paramedic Field Instructor you will be given one week to complete phase IV. Phase IV shall introduce the aspects of scene management and operations. Additional time may be granted at the discretion of the Clinical Manager and Operations. During this phase emphasis shall be placed on the following: • Customer Service & Communication (Pt's, Fire, Hospital, everyone we meet) • Scene Management & Safety • Driving & Vehicle operations • Radio Operation & Etiquette • Mapping and Routing • Working as a team Return to Table of Contents • Observation of how the EMT functions in ALS • Protocol Review Phase V: Phase V shall focus on your Medical roles as an EMT with Pridemark and build on what was learned in Phase IV. This phase shall be completed within one week. Additional time may be granted at the discretion of Clinical Management and Operations. During this phase emphasis shall be placed on the following skills: • Assessment of the BLS and ALS patient. • Obtaining accurate Vital Signs • Developing BLS treatment plans • IV Therapy (Canulation, proper priming of various IV tubing such as Micro, Macro, Blood tubing, & Buretrols, and knowing when each is appropriate) • Monitor usage (4 & 12 lead EKG placement) • Documentation of Patient Care The EMT will successfully pass this phase and be cleared for ALS with the approval of the Field Instructor or Clinical Manager and successful completion of the Final EMT Protocol test. The Field Instructor will then complete the recommendation for action form and return it to the Clinical Manager for processing. While the EMT is now clear to work in the BLS and ALS system, this does not guarantee scheduling in the BLS or ALS system. Scheduling shall be based solely on operational needs and policy. Return to Table of Contents Clinical Division Standard Operating Procedure Effective Date: January 31, 2008 Approval: DOCM_______HR_______ Policy: Paramedic FI Process Objective: To clearly identify the training process for Paramedics to function independently in the Pridemark system. Scope: Clinical Director, Clinical Manager, Team Leaders, Field Instructors, EMT-Paramedics Description: The Paramedic Field Instruction program shall consist of five stages. The following is merely a guide and may at the discretion of the Clinical Manager or Administration be custom tailored to meet individual employee or operational needs. Phase I: Classroom Orientation Phase II: 3rd Rides Phase III: Medical Phase IV: Driving/Operations Phase V: Independent Probation Return to Table of Contents Details: Phase I: Phase I shall consist of general classroom orientation to Pridemark. This includes but is not limited to Human Resource policies, benefits, and mandatory new employee training. Phase I will be managed and administered by the Human Resources Staff, in coordination with the Directors of Operations, Risk, Customer Service, and Clinical Managers. Phase II: Phase II shall consist of 3rd rides with Pridemark Paramedic Field Instructors. This phase in intended to introduce the new employee to Pridemark operations and prepare them for Phase III where they will operate as the 2nd crew member on a two person ambulance (2 UP). During Phase II, the new employee shall be oriented on radio operations and mapping. The new Paramedic should also be oriented on all patient care equipment and ambulance inventory. During this phase the new Paramedic should successfully pass the mapping and radio test. The new Paramedic should also be proficient in map reading. While not being expected to know the entire district at this point, it is expected they be able to locate calls and provide effective verbal navigation cues to the partner driving. This phase is also designed to evaluate the new employees learning style and develop and effective plan for 2 Up Field Instruction. The new Paramedic shall also attend on all Calls. However, the goal of this phase is to prepare for 2 up Field Instruction. Fine tuning of Medicine shall be the goal of Phase 3. During phase 2 we merely want to assure that the new Paramedic is competent to practice medicine under indirect supervision. The focus should be on global type medical issues, for instance the things we won't be able to observe in the two up phase. Phase III: Phase 3 is the medical phase. The Probationary Paramedic will be tasked with attending to all patient care (ALS & BLS) and developing treatment plans. Such treatment plans shall be verbally discussed with the Field Instructor and agreed upon prior to departure from the scene. Changes enroot should be verbally discussed with the FI and/or medical control and appropriate changes made as needed to the original care plan. All trips should be constructively critiqued after the call. Phase 3 shall also serve to allow the new Paramedic to learn the geography of the district, locations and best routes to all hospitals served. It shall be the discretion of the FI as to whether or not to allow driving to calls and around the district. The new Paramedics learning style should be taken into account when making this decision. The new Paramedic should also work on mapping, developing skills to find the quickest route to calls and facilities. During this phase the new Paramedic shall successfully complete the Cardiology, and Procedural Sedation tests. Return to Table of Contents *The new Paramedic, being Colorado State Certified, shall be presumed to be capable of attending any and all patients during this phase unless the Paramedic consistently performs to the contrary, in which case consultation with the Clinical Manager is advised. Phase IV: Phase 4 shall concentrate on driving and Pridemark operations. During this phase the new Paramedic should be able to safely and effectively navigate to and from calls. Additionally, the Field Instructor should attempt to function at the BLS level to simulate what the new Paramedic can expect once cleared. During this portion, the new Medic shall attend on all ALS calls and determine which calls are appropriate to delegate to the FI acting in a BLS role. The FI shall continue to critique each call after it's conclusion to assure continued learning and evolution in the program. The new Paramedic should successfully complete the operations and final protocol test during this Phase. Phase V: The new Paramedic is cleared for independent duty. The new Paramedic shall continue to be considered in orientation until the completion of the 90 day probationary Period. During this phase the new Paramedic will undergo 100% chart review via the Clinical Manager, be assigned self study modules and also participate and present at M&M's. The 90 day probationary period may be extended at the discretion of Human Resources and Administration if needed. The new Paramedic may also be partnered with an EMT FI if additional operational orientation is needed. Return to Table of Contents Target Timeline: In an effort to set motivational goals for the new Paramedic, the following timelines shall be used as targets to complete each phase. For the purpose of these timelines each new Paramedic shall be placed in one of three categories. New Paramedic Any Paramedic with less than one year experience running as a Paramedic in a 911 system. New Company Paramedic Any new Paramedic who was working for Pridemark full-time as an EMT prior to completion of Paramedic School. These individuals should have at least 6 months experience with Pridemark to fall into this category or be ALS cleared. Experienced Paramedic Any Paramedic with more than one year experience running as a Paramedic in a 911 System. Phase I Timeline: New Medic: 5Days Company Medic: 5Days Experienced Paramedic: 5Days Phase II Timeline: New Medic: 4 Weeks Company Medic: 4 Week Experienced Paramedic: 2 Weeks Phase III Timeline: New Medic: 8 Weeks Company Medic: 6-8 Weeks Experienced Paramedic: 3 Weeks Phase IV Timeline: New Medic: 2 Weeks Company Medic: 1 Week Experienced Paramedic: 1-2 Weeks Phase V Timeline: New Medic: Completion of 90 Days Company Medic: Completion of 90 Days Experienced Paramedic: Completion of 90 Days Return to Table of Contents Clinical Division Standard Operating Procedure Effective Date: August 29, 2007 Approval: DOCM_______HR_______ Policy: Certifications Objective: To clearly identify the process and responsibilities of employees as it relates to the obtaining, maintaining, and tracking of all required certifications. Scope: Clinical Director, Clinical Manager, Team Leaders, Field Instructors, RN's, EMT-Paramedics, EMT-Basics Procedure: A. It is the responsibility of all clinical employees' (EMT-B, EMT-I, EMT-P, RN's) to maintain all required certifications. a. Required Certifications/license: i. State EMT-B, I, Paramedic, or RN License ii. NREMT (EMT's and Medics only) certification with 12 months of hire date iii. CPR (AHA or ASHI) iv. ACLS ( AHA or ASHI) for RN's and Paramedics v. PALS or PEPP for RN's and Paramedics with 6 months of hire vi. NIMS ICS 100,200, 300, 400, 700, & 800 as appropriate for position. ICS 100 & 700 are required at a minimum for all clinical employees B. Two copies (front and back) of all required certifications shall be provided to the Clinical Director. a. The Clinical Director shall provide one copy to the Communication Center for entry into CAD. b. The Clinical Director shall maintain the other copy for placement in the employees' clinical file. c. To avoid lapses, all certifications shall be turned in prior to the expiration date to allow adequate time for entry into CAD. 1 week minimum C. All clinical employees seeking continuing education and in house certifications must have a current Clinical Education Application on file. (Available from Clinical Manager) D. Employees seeking assistance with re-certification shall abide and agree with the following: a. As a courtesy, Pridemark Paramedics will assist employees who participate in our Clinical Education Program with re-certification of State and National Registry certifications. Such assistance shall be limited to providing guidance on the application process, providing Return to Table of Contents copies of CE records, and signing of required documents for re- certification should the employee meet the requirements. b. All such requests for assistance with recertification must be made in writing or via email to the Director of Clinical Medicine well in advance of expiration dates. In general, it can take three months to process some re-certifications for in state candidates and in some cases longer from the date the application is submitted to the state. i. Applicants shall allow one month for processing of requested assistance and preparation of applications for submittal. ii. Once the above is processed, applicants shall be responsible for submittal of certification applications to the State or National Registry. iii. In summary, as a general rule of thumb all requests for re- certification should be submitted four months prior to expiration. 1. Example: If your National Registry expires March 31st, 2008, you should request assistance from the Director by December 1st, 2007 and they will have their portion of your application completed by December 31st, and returned to you to deliver. c. Employees seeking such assistance shall obtain at least 50% of CE in house by PPS. i. The Clinical Division shall offer regular monthly CE and annual re-certification classes in BLS, ACLS and PALS or PEPP ii. Such CE shall be posted on www.Pridemark.net on the education calendar. iii. Application and RSVP may be required for certain courses. d. Pridemark Paramedics shall assume no responsibility for lapses in certifications and any assistance provided is done strictly as a courtesy. Ultimately, the responsibility of maintaining required certification is that of the employee. e. Pridemark Paramedic Services has no control over issues related to the States handling or processing of certification applications. At times, the state may take longer than the above timelines to process applications. E. The Clinical Manager shall maintain an accurate record of all in house continuing education and maintain such records for a minimum of four years in an electronic data base. a. To obtain copies of CE records, individuals should make a request in writing or via email to the Clinical Manager and allow up to two weeks processing time. F. When attending any in house continuing education, employees must sign a continuing education roster. a. The Clinical Manager shall enter rosters in a data base within one week or receipt. Return to Table of Contents b. All rosters along with copies of course outlines must be kept on file for a minimum of four years. This is in addition to the data base records. c. Certificates of Completion for individual courses shall be provided on specific request only. Return to Table of Contents Clinical Division Standard Operating Procedure Effective Date: January 31, 2008 Approval: DOCM_______HR_______ Policy: Quality Improvement Guidelines Objective: To establish guidelines for the routine evaluation of patient care in an effort to monitor and improve patient care. Scope: Medical Director, Director of Clinical Medicine, Clinical Manager, Team Leaders, Field Instructors, EMT-Paramedics, EMT-Basics Procedure: A. General Principles a. The Quality Improvement (QI) process is designed to be a constructive process. b. The QI process is the ultimate responsibility of the Medical Director. c. The Medical Director will work in cooperation with the Director of Clinical Medicine. d. The process shall include objective and quantitative tools to track overall quality of patient care. e. The process shall generate monthly reports f. The QI process is a tiered collaborative system that shall include peer review, management review, and Medical Director review. It shall also allow for care provider feedback and loop closure. g. The Medical Director shall have physical and Electronic Access to all Patient Care Reports (PCR). B. Process a. All patient care shall be documented according to Documentation Requirements. b. Documentation shall be reviewed for general compliance by the Clinical Managers. c. The Clinical Managers will distribute all PCR's to the Field Instructor group and/or Medical Director for review. d. These PCR's will be distributed via electronic means on flash drives. e. Each Field Instructor shall be given a flash drive for rotational use, and each Field Instructor shall be assigned set individuals to monitor on a continual basis. The purpose of this assignment is to allow the FI's the ability to watch for patterns that may develop with individuals. f. Field Instructors shall review all assigned PCR's for compliance with Pridemark Protocols and overall quality of patient care and documentation. g. The Field Instructors should follow up directly with individuals on a face to face basis to provide positive as well as any corrective feedback on routine QA/QI matters. This should be a constructive process and allow for two way communication that enables professional growth and education. This shall not be a disciplinary role. h. If the Field Instructor notes patterns of deficiencies with an individual or out of the ordinary protocol violations, the Field Instructor shall report said cases to the Clinical Manager for further follow up. Return to Table of Contents i. The Field Instructors should report all level I-IV protocol violations to the Clinical Manager for tracking and possible follow up. j. The Clinical Managers shall track all Level I-IV protocol violations for quarterly review. k. The Clinical Mangers shall report all Level III-IV violations to the Director of Clinical Medicine as soon as practical. l. The Director of Clinical Medicine shall review all Level III-IV violations with the Medical Director as soon as Practical. m. All Protocol violations will be evaluated on a quarterly basis to review the need for additional education of protocol changes. C. The following procedures or events shall be reported to the Director of Clinical Medicine within 24 hours via email and telephone. The Director shall then consult with the Medical Director regarding these cases as soon as possible. a. Cricothyroidotomy b. Chest Decompression c. Esophageal Intubation d. Medication errors e. Iatrogenic events f. Pediatric Cardiac Arrest g. Major MCI's or cases that draw media attention D. The following qualitative reviews shall be performed on a quarterly basis. a. Intubation success rates b. IV success rates c. Matrix Report (a) A random sampling of 50 ALS trip reports from each division shall be reviewed by a minimum of 3 Field Instructors. These charts shall contain no identifying information regarding the patient or crew involved. (b) These trips shall be placed in one of two categories (Agree with care) or (Disagree with Care) Majority rule will apply to decide which final category chart shall be placed in. (c) The Clinical Manager shall facilitate this process and provide the Director of Clinical Medicine a % of Agree with Care and Disagree with Care breakdowns. (d) The Director of Clinical Medicine will compare the reports from all divisions and provide the Medical Directors, CEO and BOD with the findings. (e) This tool will be used to monitor overall quality of care over long periods. Return to Table of Contents Clinical Division Standard Operating Procedure Effective Date: January 31, 2008 Approval: DOCM_______HR_______ Policy: Out of Protocol Incidents Objective: To provide guidelines for situations when out-of-protocol incidents occur related to Pridemark Protocols, Policies, and Procedures. Scope: Clinical Director, Clinical Manager, Team Leaders, Field Instructors, EMT- Paramedics, EMT-Basics. II. General Principles Adherence to medical and procedural protocols is paramount to providing optimal patient care. Initial education and ongoing training help to ensure the knowledge of, and therefore compliance with, protocols. Our Quality Management Program, Quality Audit System and Field Evaluation and Training Program are designed to ensure compliance with the protocols. There are four levels of Out-of-Protocol Incidents: Level I Out-of-Protocol Incident: Out-of-protocol incidents that are determined to be appropriate and are cleared by a physician order and appropriate documentation Level II Out-of-Protocol Incident: Out-of-protocol incidents that are determined to be appropriate however it is not cleared by a physician order but appropriate documentation as to why there was not physician order is included in the Patient Care Record Level III Out-of-Protocol Incident: Out-of-protocol incident that is determined to be inappropriate medical care or the omission of appropriate medical care but is non-life- threatening Level IV Out-of-Protocol Incident: Out-of-protocol incident that is determined to be inappropriate medical care or the omission of appropriate medical care and is potentially life-threatening Procedure Anytime field personnel are aware they have operated out-of-protocol, they must fill out an Incident Report documenting their out-of-protocol incident and the reasons for going out-of-protocol. The Clinical Manager will review these and route these to the Director of Clinical Medicine as appropriate. Out-of-protocol incidents will be monitored via the Quality Management Program/Quality Audit System and by feedback from hospital or field personnel. In those cases where an out-of-protocol incident is discovered via the Quality Management Program, the individuals involved will be asked to write an Incident Report to describe their reasoning for going out-of-protocol. The out-of-protocol level will be determined and disposition, including education, trending, and/or discipline will be handled according to the level. dleddiy Level I Out-of-Protocol maonnr: ucatiiy is iedicete Return to Table of Contents there was not physician order is included in the Patient Care Record) will be handled in the following manner: The case will be discussed with the personnel involved and appropriate education will be given. The out-of-protocol incident will be trended. No discipline is indicated. Level III Out-of-Protocol (out-of-protocol incident that is determined to be inappropriate medical care or the omission of appropriate medical care but is non-life-threatening) will be handled in the following manner: The case will be handled via the standard quality management process, however, must be reported to the Director of Clinical Medicine and Clinical Manager. Appropriate education and trending are necessary to ensure personnel learn from the situation and repeat episodes are minimized. Discipline will be handled on a case by case basis but may include suspension and/or termination depending on severity and/or history of similar violations at the discretion of the Director of Clinical Medicine in consultation with the Director of Operations, Human Resources, and Medical Director. Level IV Out-of-Protocol (out-of-protocol incident that is determined to be inappropriate medical care or the omission of appropriate medical care and is potentially life- threatening) will be handled in the following manner: The case will be referred to the Director of Clinical Medicine who will meet with the personnel involved. Appropriate education and follow up evaluation prior to return to duty is necessary to ensure personnel learn from the situation and repeat episodes are minimized. Discipline will be handled on a case by case basis but may include suspension and/or termination depending on severity and/or history of similar violations at the discretion of the Director of Clinical Medicine in consultation with the Director of Operations, Human Resources, and Medical Director. Return to Table of Contents Clinical Division Standard Operating Procedure Effective Date: January 31, 2008 Approval: DOCM_______HR_______ Policy: Paramedic School Sponsorship Objective: To provide guidelines for the sponsorship and recommendation of Pridemark EMT-Basics to attend Paramedic School. Scope: Clinical Director, Director of Operations, Clinical Manager, Human Resources, Team Leaders, EMT-Basics. Process: I. General Principles A. Pridemark Paramedic Services, when possible, will sponsor 2 EMT-Basics per division per year to attend Paramedic School. B. Sponsorship shall allow the individual to be eligible for financial reimbursement, remain eligible for certain benefits without loosing seniority, and scheduling assistance to continue working on a limited basis or take time off to attend school without loss of seniority. 1. Sponsored employees shall be responsible for full payment of health insurance premiums while in school should they choose to continue coverage. 2. Such payments shall be for the full premium amount (both employee and company contribution) 3. Full payment shall be made the first of each month to remain on benefits. C. Financial tuition reimbursement shall be paid in two installments at one year intervals following successful completion of Paramedic school and Pridemark Paramedic Field Instruction. To be eligible, the sponsored employee must maintain uninterrupted full time status for two years following graduation. Current total reimbursement is $5000, paid as above in $2500 installments. D. This program is intended to encourage continued full time employment with Pridemark Paramedic Services after completion of paramedic school. It is also the intent of this program to encourage all EMT-Basics to attend Paramedic School. E. Those individuals not eligible for sponsorship may qualify for recommendation. F. Recommendation shall allow the employee to obtain written recommendation as may be required for certain Paramedic programs. However, recommendation does not guarantee a Paramedic Position will be available upon graduation, not does it guarantee the maintenance of seniority or assistance with scheduling. II. Sponsorship Process A. Bi-Annually, two sponsorship positions will be posted utilizing the internal job posting process. B. Minimum preferred qualifications will include: 1. One year of experience in ALS system 2. Team Leader and employee recommendation letter 3. IV & EKG certification Return to Table of Contents C. The selection process will consist of: (Selection will be based on a combination of the below process as well job performance. Seniority will only be taken in to account in the event of a tie.) 1. Panel Interview Process consisting of representatives from: a) Operations b) Clinical Department c) Team Leader Group 2. Written Test 3. Practical Test III. Recommendation Process A. Submit written request via email to the Director of Clinical Medicine. 1. You should submit your request at a minimum of two weeks prior to when it is needed. 2. Enclose the below items and verification with your letter. B. Obtain a letter of recommendation from your Team Leader as well as one other employee whom you have worked with. C. Have one year experience on an ALS ambulance, or one year experience as an EMT with Pridemark. Return to Table of Contents Firefighter Rehab Protocol Purpose of Firefighter Rehab: To ensure that the physical and mental condition of personnel operating at a scene of an emergency or training exercise does not deteriorate to a point that affects the safety of each member or that jeopardizes the safety and integrity of the operation. PPS Role: PPS plays an important role in the rehab process. When an incident occurs – (fire, hazmat, or clandestine lab breakdown), FD may depend on us to staff and/or operate a rehab unit for them. To enable us to smoothly integrate with FD and maintain coverage for the county, the following policies will be followed: Rehab Group Establishment: Staff officers will establish a rehab group at any time during an emergency response. Conditions that will be considered will include: climatic or environmental conditions that result in heat stress index above 90*F or wind chill index below 10*. The rehab group has a rehab officer (RO) who is appointed by the Incident Commander (IC). The RO may be PPS personnel or a firefighter. If you are asked to be the RO, call the TL to come and take over for you. You will then staff the rehab group. The RO is in communication with IC and PPS to request additional EMS personnel, ambulances, request periodic relief for EMS stand-by/rehab crew and other resources as deemed necessary. RO will obtain forms, equipment and supplies form the IC vehicle. Those supplies include: Thermometer, fluids and nourishment. Forms and examples are included in this protocol. Responsibilities of the RO: • Obtain rehab materials from the command vehicle • Establish a rehab area and location • Check in companies as they arrive, check out companies as they leave rehab • Be in communication with the IC and PPS to request additional EMS personnel, ambulances, and other resources as deemed necessary by the situation • Return completed EIRR and Company Check In/Out sheets to IC Selecting a rehab site: It should… • Be far enough away from the scene that personnel may safely remove their turnout gear and SCBA • Provide protection form the environment • Be free of exhaust fumes • Be large enough to accommodate multiple crews • Be easily accessible by EMS units • Allow prompt entry back into the emergency operation Resources: Supplies for the rehab include the following: • Fluids (water, sport drinks, etc.) • Nourishment (broth, soup, granola bars, energy bars, fruit, etc.) • Medical supplies (thermometers, IV fluids, etc.) Return to Table of Contents • Other (awnings, fans, tarps, smoke ejectors, dry clothing, blankets, towels, traffic cones, barrier tape, etc.) Responsibilities of rehab staff: • Report to IC or RO on arrival • Obtain Emergency Incident Rehab Report (EIRR) from RO • Receive incoming crews for rehab, obtain initial and repeat VS • Provide hydration and nourishment for crews as required • Request additional supplies from RO • Notify RO if a firefighter needs transport to a hospital Guidelines: Preventive hydration – a critical factor in the prevention of heat injury is the management of water and electrolytes. Water must be replaced during exercise periods and at emergency incidents. During heat stress, the member should consume at least one quart of water per hour. A re-hydration solution should be a 50/50 mix of sport drink and water given at a temp of about 40*F. Avoid both carbonated and caffeinated beverages because they interfere with the body's water conservation mechanisms. Prfoo-2( a witscenuse a teement )]TJ0.001 Tc -0.00 Nourishment Recommendations – the deumenbp facto • Return to Table of Contents ED Return to Table of Contents Return to Table of Contents Return to Table of Contents Tuberculosis Screening Policy Overview Introduction Who to Test Targeted tuberculin testing for latent TB infection (LTBI) is a strategic component of tuberculosis (TB) control for purposes of identifying persons at high risk for latent TB infection (LTBI) or TB disease who would benefit from treatment. Targeted tuberculin testing should be conducted only among groups at high risk and discouraged in those at low risk. Public Health agencies in Colorado can only provide targeted testing as TB Program resources allow, or if the agency has alternate funding resources. All testing activities should include a plan for follow-up care of persons with LTBI or disease and periodic program evaluation. A local chief medical health officer may conduct required targeted screening programs of populations who are at increased risk of developing tuberculosis or having LTBI, as defined by the Centers for Disease Control and Prevention, and offer treatment as appropriate. Such screening programs shall not be implemented without the prior approval of the local board of health, state board of health and the state chief medical health officer. The Mantoux tuberculin skin test (TST), intradermal injection of purified protein derivative (PPD) is the standard method of identifying persons infected with Mycobacterium tuberculosis (MTB). Multiple puncture tests (MPTs), such as the Tine test, should not be used. The MPTs are not reliable because the amount of tuberculin injected intradermally cannot be precisely controlled. TB skin testing is both safe and reliable throughout the course of pregnancy and during breastfeeding. If previous TST results cannot be provided (measured in mm, not "positive" or "negative"), repeat the test unless there was a severe reaction (e.g. blistering, ulceration, or necrosis) at the previous site of injection. TB skin retesting should NOT be done if there is appropriate documentation of a previous positive TST and/or previous treatment for LTBI or active TB. In general, high-risk groups that should be tested for TB infection include: • persons with HIV infection/AIDS • recent close contacts to persons with infectious pulmonary TB disease • persons with fibrotic lesions on chest x-ray consistent with healed TB • persons who inject drugs or use other high risk substances, such as crack cocaine, and alcoholics • persons with medical conditions which increase the risk of TB disease • residents and employees of high risk congregate settings such as correctional institutions, long-term residential care facilities (nursing homes, mental institutions, etc.), hospitals and other health care facilities, and homeless shelters. • health care workers and volunteers who serve high risk clients who undergo employment screening and cannot provide documentation of a previous TST or information about appropriate follow-up for a "positive" skin test • mycobacteriology laboratory personnel • foreign-born persons who have arrived within five years from countries that have a high TB incidence or prevalence (most countries in Africa, Asia, Latin America, Eastern Europe, and Russia) • children less than 4 years of age, or children and adolescents exposed to adults in high risk categories adult contacts to children with TB infection • persons with a history of inadequately treated TB Return to Table of Contents Pridemark TB Testing Overview Protocol Overview 1. All Pridemark Employees must provide proof of TB testing within 6 months of their annual performance evaluation. 2. All new employees must provide proof of TB testing within 12 months prior to employment and submit to TB testing at time of hire. 3. Any employee that has not had a test within a 12 month period must submit to a 2 stage test. 4. Any employee with a history of previous positive TB test must provide records of the treatment and be willing to submit to a risk assessment screening and if indicated, an additional chest x-ray. (see flow chart at the end of this section) 5. Employees with a history of BCG vaccination must also be skin tested and if positive, referred to employee health for follow up. Subsequent to the initial employee health referral, risk assessments must be done on an annual basis 6 months prior to performance evaluation. 6. Any employee that has a positive skin test must submit to appropriate treatment as deemed necessary by our occupational health provider. 7. Pregnancy does not exempt employees from testing. 8. Failure to comply with these standards poses an unacceptable risk to our patients and the public at large and may result in suspension from duty or other disciplinary action. How to Apply the Tuberculin Skin Test 1. Administer the tuberculin skin test using the Mantoux technique; intradermal injection of purified protein derivative (PPD). NOTE: Some PPD vial stoppers contain 41.6% latex, which could pose a concern for those with latex allergy. For those persons who have a latex allergy, use vials without latex stoppers or remove the stopper prior to drawing up PPD. Mantoux test procedure 1. Equipment needed: gloves, sharps container, PPD tuberculin (Tubersol or Aplisol), tuberculin syringe and safety needle, and alcohol pads. NOTE: Opened PPD tuberculin vials must be dated and discarded after 30 days. Also see package insert for appropriate storage information. 2. Obtain written consent as per agency requirements 3. Follow infection control procedures, including the use of gloves and a sharps container. 4. Clean the injection site, the upper, outer, lateral aspect of the left forearm 1-2 inches below the antecubital fossa, with an alcohol pad or alternative skin cleanser (for those allergic to alcohol). The left forearm is the standard site for TB skin testing. 5. Using a disposable safety needle and syringe, inject 0.1 ml of PPD tuberculin containing 5 TU between the layers of the skin (intradermally) with the needle bevel facing upward. 6. The injection should produce a discrete, pale elevation of the skin (a wheal) 6-10 millimeters (mm) in diameter. NOTE: Repeat the test on the opposite arm or the same arm, 3 inches from the original site, if a 6-10 mm wheal is not produced. 7. Document location of injection, time and date of injection, dose, name of person who administered the test, name and manufacturer of tuberculin product used, lot number, expiration date, and the reason for testing. How to Read/Measure/Record Test Results Return to Table of Contents 9. Read the tuberculin skin test 48 to 72 hours after the injection. 10. If the individual fails to show up for the scheduled reading, positive reactions may still be measurable up to one week after testing. 11. If the results appear negative and more than 72 hours have passed, the test should be repeated. It can be repeated immediately, or after 1 week if two-step testing is required (see page 12, "Two Step Tuberculin Skin Testing"). 12. TST results should be read by designated, trained personnel. Do not accept self- reading of TST results. 13. Measure the tuberculin skin test site crosswise to the axis of the forearm. 14. Measure only induration (swelling that can be felt) around the site of the injection. Do NOT measure erythema (redness). A tuberculin skin test with erythema but no induration is non-reactive. 15. Record the test result in mm, not as "positive" or "negative." An exact reading in mm may be necessary to interpret whether conversions occur on a subsequent test. Record a tuberculin skin test with no induration as "0 mm." 16. Adverse reactions to a TST (e.g. blistering, ulcerations, necrosis) should be reported to the Food and Drug Administration's Med Watch Program at 1-800-FDA-1088 or via the Internet at www.fda.gov/medwatch. 17. All licensed hospitals and nursing home facilities must maintain a register of the TST results of health care workers in their facility, including physicians and physician extenders who are not employees of the facility but provide care to or have face-to- face contact with patients in the facility. The facility must maintain such TST results as confidential. In addition: For persons previously skin tested, an increase in induration of 10 mm within a 2-year period is classified as a conversion to positive. 1. False negative reactions may be due to: a. Anergy (see "Anergy Testing") b. Recent TB infection (within the past 10 weeks) c. Very young age (< 6 months of age-because their immune systems are not fully developed) d. Overwhelming TB disease e. Live virus vaccination (see below) f. Some viral infections (measles, mumps, chickenpox, and HIV) g. Corticosteroids and other immunosuppressive agents at doses of 2 mg/kg/day or greater for 2 or more weeks 2. False positive reactions may be due to: a. Non-tuberculous mycobacteria b. BCG vaccination c. Local latex allergic reactions d. Vaccination with live viruses (e.g. Measles, Mumps, Rubella, Varicella, Oral Polio, and Yellow Fever) may also interfere with TST reactivity and cause false negative reactions. Two-Step Tuberculin Skin Testing (Booster Phenomenon) Introduction Return to Table of Contents Delayed type hypersensitivity (a skin test reaction) may wane over the years in some people who are infected with TB. When these people are skin tested many years after infection, they may have a negative reaction. However, this negative skin test may stimulate (boost) their ability to react to tuberculin, causing a positive reaction to subsequent tests. This boosted reaction may be interpreted as new infection. Two-step testing is used to establish a true baseline skin test. Thus, it is recommended that a baseline two-step tuberculin skin test be performed on workers in health care facilities, correctional institutions and jails, long term care facilities for the elderly, homeless shelters, drug treatment centers, residents of long-term care facilities, and other adults who will be re-tested periodically. Two-step tuberculin skin testing should be performed on these individuals who cannot document a history of a negative tuberculin skin test within the past year. Protocol: 1. Apply the tuberculin skin test. 2. If the initial skin test is positive, consider person infected and refer to "What to do After Interpreting the Skin Test." 3. If the initial tuberculin skin test is negative: It should be repeated within 1-3 weeks using the same dose and strength of tuberculin. 4. An individual who can provide documentation of a TST by the Mantoux technique within the preceding year should have an initial skin test performed, and should be managed on the basis of that result. There is no need for a second test because the earlier test is, in effect, the first of a two-step test. 5. If the second test is negative, the individual is classified as uninfected and retested at routine intervals (two-step testing is not required for subsequent tests unless one or more years have elapsed since the last test). 6. If the second test is positive, consider person infected and refer to "What to do After Interpreting the Skin Test". BCG (Bacillus Calmette-Guerin) Vaccines BCG vaccines are live vaccines derived from a strain of Mycobacterium bovis (M. bovis). Because their effectiveness in preventing infectious forms of TB is uncertain, they are not recommended as a TB control strategy in the U.S. except under rare circumstances (see below). They are, however, used commonly in other countries. Tuberculin Skin Testing of an Individual with a History of BCG Vaccination 1. A history of BCG vaccination is not a contraindication to tuberculin skin testing if the person is at risk of exposure to TB. 2. A false positive reaction may occur in persons vaccinated with BCG. However, tuberculin reactivity caused by BCG vaccination wanes with time and is unlikely to persist > 10 years. 3. A diagnosis of LTBI and the use of therapy should be considered for any BCG-vaccinated person who has a TST reaction of >10 mm induration, especially if: • the vaccinated person is exposed continually to populations in which the prevalence of TB is high (e.g., some health care workers, employees and volunteers at homeless shelters, and workers at drug-treatment centers) • the vaccinated person was born or has resided in a country in which the prevalence of TB is high; or • the vaccinated person is a contact of another person who has infectious TB, particularly if the infectious person has transmitted TB to others Return to Table of Contents Tourniquet Procedure Indications A tourniquet should be used to control potentially fatal hemorrhagic extremity wounds only after other means of stopping blood loss have failed. Precautions 1. A tourniquet applied incorrectly can increase blood loss and lead to death or loss of limb. 2. Applying a tourniquet can cause nerve and tissue damage whether applied correctly or not. 3. Use on appropriate patients only is of utmost importance. 4. Damage is unlikely if the tourniquet is removed within an hour. Low risk to tissue is acceptable over death secondary to hypovolemic shock. 5. A commercially made tourniquet is the standard of care as improvised tourniquets can increase the risk of harm. Technique 1. Use BSI. 2. Attempt to control hemorrhage using direct pressure, elevation and indirect pressure on pressure points prior to considering the application of a tourniquet. 3. If unable to control hemorrhage using above means, apply a tourniquet using the steps below: • Cut away any clothing so that the tourniquet will be clearly visible. The tourniquet should NEVER be obscured by clothing or bandages. • Apply tourniquet proximal to the wound and not across any joints. • Tighten tourniquet until bleeding stops. **Note: Applying a tourniquet loosely will only increase blood loss by inhibiting venous return. • Mark the time and date of application on the patient's skin next to the tourniquet. Use a permanent marker. • Keep tourniquet on for full duration of transport. A correctly placed tourniquet should only removed by the receiving hospital. Complications The possibility of the loss of limb, permanent circulatory, and/or neurological damage to the extremity is very real and should be weighed against the risk of loss of life. Return to Table of Contents Therapeutic Induced Hypothermia (TIH) Overview: For several decades out of hospital cardiac arrest survival rates have remained stagnant despite numerous changes in pre-hospital care. Research published in the New England Journal of Medicine in 2002 as well as the ILCOR statement in 2003 now show strong statistical evidence that therapeutic cooling of medical patients of non-hemorrhagic cardiac arrest is beneficial increasing neurologically intact patient survival rates by 16-23%. Inclusion Criteria 1. Cardiac arrest secondary to suspected medical causes with no evidence of traumatic or hemorrhagic causes. 2. Age >16 3. Initial temperature >34c. Exclusion Criteria 1. Traumatic or hemorrhagic arrest 2. Pregnancy 3. Lack of an advanced airway Protocol: 1. Patients who meet criteria should receive all traditional treatments as per existing cardiac arrest protocols & AHA guidelines. Implementation of the TIH protocol should not delay other therapies. 2. Assure and verify advanced airway (ET tube) 3. Establish two large bore IV's or IO 4. Remove clothing 5. Obtain temperature if possible 6. Infuse cooled 2-4deg. Celcius saline 40ml/kg rapid IV push with Infuser if available as soon as inclusion criteria are met. (80 kg patient = 3200ml's) 7. Upon ROSC a. MIDAZOLAM (VERSED) 2mg prn, q. 5minute intervals to control any shivering b. Maintain hemodynamic stability per current protocols i. Consider Dopamine/Epi drips ii. Consider Cordarone 8. Transport to nearest medical facility that supports continuation of TIH and interventional cardiology. 9. Target patient temperature is 32-34 deg. Celsius 10. Document in PCR to include meeting inclusion criteria Return to Table of Contents ETOH Disposition Policy Overview The purpose of this policy is to give field crews a guideline to help them ensure for the proper disposition of calls involving intoxicated parties. The term intoxicated does not simply mean that an individual has had some alcohol at some point in the last 24 hours. Tolerance levels differ by age, body type, underlying medical conditions, food intake, and the amount ingested over time. There are set blood alcohol levels that have proven to impair judgment and reaction time and are generally accepted by the legal system to determine the level of intoxication. A blood alcohol level of .05% is considered to be impaired under Colorado law and .08% is enough for a DUI conviction. In the pre-hospital setting we are not privy to these types of tests and therefore must make our decision based on clinical assessment and the use of sound judgment. The point at which a person can be taken against their wishes is when they have become "Incapacitated by Alcohol". The legal definition of this condition is defined as: C.R.S. 25-1-302 (9) "Incapacitated by alcohol": means that a person, as a result of the use of alcohol, is unconscious or has his judgment otherwise impaired that he is incapable of realizing and making a rational decision with respect to his need for treatment or is unable to take care of his basic personal needs or safety or lacks sufficient understanding or capacity to make or communicate rational decisions concerning his person. Some basic assessment clues for determining the level of intoxication: Nystagmus Ataxia (loss of muscle coordination/balance) Odor of alcohol Slurred Speech Irrational behavior Loud boisterous speech Understand that apart from the odor of alcohol finding, all of the assessment clues can have a metabolic cause. Some causes can include hypoglycemia, CVA, hypoxia, hyper/hypothermia, and hypo-perfusion. ETOH intoxication should be a diagnosis of exclusion in which you are left with no other reasonable diagnosis. Protocol If a patient is found to have ingested alcohol but is not intoxicated, the normal disposition rules apply. The patient is able to consent to, or refuse treatment or transport. If a patient is found to be intoxicated there are two possible dispositions: 1. Transport to closest appropriate hospital 2. Turn custody of patient over to someone for transport to a detox facility* *Note- Transport to a detox facility will only be done by Pridemark units if the call originates from an emergency department. We DO NOT transport directly to these facilities from the field. If a patient is determined to be intoxicated and has any of the following the disposition should be transport to the closest appropriate ED: 1. Visible signs of injury 2. Involvement with high energy transfer event (accident, fall 2x height, assault, etc.) 3. Abnormal vital signs (BP <90 >180, pulse rates <60 or >100, abnormal ecg, abnormal pulse ox, etc.) 4. New complaints of pain 5. New onset of illness 6. Complaint of exacerbation of current underlying medical condition (COPD worse than usual, old back problems hurting more than usual, etc.) 7. Unable to stand or walk with minimal assistance 8. Obtunded Return to Table of Contents 9. Co-ingestion of Rx medication or recreational drugs 10. Psychiatric component (mania, suicidal ideation, hallucinations, etc) In the absence of these findings in association with the determination that the patient is intoxicated, the patient may be released for transport to a detox facility like Denver CARES, Arapahoe House, or the ARC in Boulder. Most often the police are asked to transport patients to these facilities. If the police cannot or will not transport the patient to a detox facility, the Pridemark unit will initiate transport to the closest appropriate medical facility. BLS may perform these transports provided the patient has been cleared by ALS (and only when appropriate for system status). Outright release of patients that have been determined to be intoxicated is not appropriate. Return to Table of Contents
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