2018 Adult and Pediatric Statewide EMS Treatment Protocols

Calhoun County EMS System Protocols – Adult and Pediatric

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CALHOUN COUNTY EMS

SYSTEM WIDE PROTOCOLS

2018

2018 Adult and Pediatric Statewide EMS Treatment Protocols IOWA DEPARTMENT OF PUBLIC HEALTH BUREAU OF EMERGENCY AND TRAUMA SERVICES MARCH 2018


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Table of Contents Table of Contents ........................................................................................................................... - 1 -

Introduction .................................................................................................................................. - 6 -

IOWA ADMINISTRATIVE CODE 641 - CHAPTER 132: EMERGENCY MEDICAL SERVICES—SERVICE PROGRAM

AUTHORIZATION ....................................................................................................................................... - 6 -

2018 PROTOCOL APPROVAL – SERVICE LEVEL - MEDICATIONS ........................................................................ - 7 -

2018 PROTOCOL APPROVAL ...................................................................................................................... - 8 -

IOWA EMS TREATMENT PROTOCOLS ..................................................................................................9

INITIAL PATIENT CARE PROTOCOL-ADULT AND PEDIATRICS ............................................................................... 10

AIRWAY PROTOCOLS .............................................................................................................................. 16

ADVANCED AIRWAY PLACEMENT / CONFIRMATION / MANAGEMENT ............................................................ 17

CARDIAC PROTOCOLS ............................................................................................................................. 18

ACUTE CORONARY SYNDROME / CHEST PAIN .............................................................................................. 19

ASYSTOLE / PEA ..................................................................................................................................... 22

ATRIAL FIBRILLATION ............................................................................................................................... 23

BRADYCARDIA ........................................................................................................................................ 24

CARDIAC ARREST BLS - AED .................................................................................................................... 25

CONGESTIVE HEART FAILURE / PULMONARY EDEMA.................................................................................... 26

POST RESUSCITATION .............................................................................................................................. 28

TACHYCARDIA: NARROW COMPLEX .......................................................................................................... 30

TACHYCARDIA: WIDE COMPLEX................................................................................................................ 32

TERMINATION OF RESUSCITATIVE EFFORTS ................................................................................................. 33

VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA ........................................................... 34

MEDICAL PROTOCOLS ............................................................................................................................ 36

ABDOMINAL PAIN (NON-TRAUMATIC) ....................................................................................................... 37

ALTERED MENTAL STATUS ........................................................................................................................ 37

APPARENT DEATH-DETERMINATION OF DEATH-WITHHOLDING RESUSCITATIVE EFFORTS .................................. 40

ALLERGIC REACTION ................................................................................................................................ 42

ASTHMA AND COPD ............................................................................................................................... 44

BEHAVIORAL EMERGENCIES ...................................................................................................................... 46

DIABETIC EMERGENCY ............................................................................................................................. 48

EPISTAXIS ............................................................................................................................................... 50

FEVER/INFECTION CONTROL ..................................................................................................................... 51


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HYPERTENSIVE EMERGENCY ...................................................................................................................... 53

HYPOTENSION ........................................................................................................................................ 54

NAUSEA & VOMITING ............................................................................................................................. 55

OVERDOSE / TOXIC INGESTION ................................................................................................................. 56

PAIN CONTROL ....................................................................................................................................... 59

RESPIRATORY DISTRESS ............................................................................................................................ 61

SEIZURE ................................................................................................................................................. 62

SEPSIS ................................................................................................................................................... 64

STROKE .................................................................................................................................................. 65

SYNCOPE / WEAKNESS............................................................................................................................. 68

OB PROTOCOLS ....................................................................................................................................... 70

CHILDBIRTH / LABOR ............................................................................................................................... 71

NEWBORN ............................................................................................................................................. 73

OBSTETRICAL EMERGENCY ........................................................................................................................ 75

PRE-ECLAMPSIA / ECLAMPSIA................................................................................................................... 76

PEDIATRIC PROTOCOLS .......................................................................................................................... 78

INITIAL PATIENT CARE PROTOCOL-ADULT AND PEDIATRICS ........................................................................... 79

Pediatric Airway ................................................................................................................................. 85

PEDIATRIC ALLERGIC REACTION ................................................................................................................. 86

PEDIATRIC ALTERED MENTAL STATUS ........................................................................................................ 87

PEDIATRIC ASTHMA ................................................................................................................................. 88

PEDIATRIC BEHAVIORAL EMERGENCIES....................................................................................................... 89

PEDIATRIC BURNS ................................................................................................................................... 90

PEDIATRIC CARDIAC ARRHYTHMIA ............................................................................................................. 93

PEDIATRIC DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS ............................................. 95

PEDIATRIC NAUSEA AND VOMITING ........................................................................................................... 96

PEDIATRIC NEAR DROWNING .................................................................................................................... 97

PEDIATRIC PAIN CONTROL ........................................................................................................................ 99

PEDIATRIC POISONING ........................................................................................................................... 100

PEDIATRIC SEIZURE ................................................................................................................................ 101

PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION ......................................................................................... 102

PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION CONTINUED ........................................................................ 103

PEDIATRIC SHOCK ................................................................................................................................. 104


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SUSPECTED CHILD ABUSE ....................................................................................................................... 105

PEDIATRIC TRAUMA .............................................................................................................................. 106

ENVIRONMENTAL PROTOCOLS ............................................................................................................ 108

BITES AND ENVENOMATION ................................................................................................................... 109

FROSTBITE ............................................................................................................................................ 111

HYPERTHERMIA .................................................................................................................................... 112

HYPOTHERMIA...................................................................................................................................... 113

TRAUMA PROTOCOLS .......................................................................................................................... 114

ABDOMINAL / PELVIC TRAUMA .............................................................................................................. 115

BURNS ................................................................................................................................................. 116

ELECTRICAL INJURIES ............................................................................................................................. 118

EXTREMITY TRAUMA ............................................................................................................................. 119

HEAD TRAUMA ..................................................................................................................................... 121

MULTI-SYSTEMS TRAUMA ...................................................................................................................... 122

SHOCK - TRAUMA ................................................................................................................................. 123

THORACIC TRAUMA ............................................................................................................................... 124

SELECTIVE SPINAL IMMOBILIZATION ......................................................................................................... 125

SEXUAL ASSAULT .................................................................................................................................. 127

IOWA EMS TREATMENT APPENDICES .......................................................................................................... 128

Appendix A - EMS Out-of-Hospital Do-Not-Resuscitate Protocol .................................................. 129

Appendix B: Adult Out-Of-Hospital Trauma Triage Destination Decision Protocol ....................... 130

Pediatric Out-Of-Hospital Trauma Triage Destination Decision Protocol ...................................... 131

Appendix C: Physician on Scene ...................................................................................................... 132

Appendix D: Air Medical Transport - Utilization Guidelines for Scene Response .......................... 133

Appendix E: Intentionally Left Blank ............................................................................................... 134

Appendix F: Reperfusion Therapy Screening Not Limited to Paramedic Level .............................. 135

Fibrinolytic Checklist ........................................................................................................................ 136

Appendix G: Strategies for Reperfusion Therapy: Acute Stroke .................................................... 137

Appendix H: Simple Triage and Rapid Treatment (START) ............................................................. 139

Simple Triage and Rapid Treatment – Pediatric JumpSTART ......................................................... 140

Appendix I: Suspected Abuse/Assault/Neglect/Maltreatment ..................................................... 141

Appendix J: Guidelines for EMS Provider Initiating Organ and Tissue Donation at the Scene of the Deceased ........................................................................................................................................... 142


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Appendix K: Guidelines for EMS Providers Responding to a patient with special needs .............. 143

Appendix L: EMS Approved Abbreviations...................................................................................... 144

Appendix M: Guidelines for New Protocol Development .............................................................. 145

Appendix N: Rapid Sequence Induction .......................................................................................... 146

Appendix O: Continuous Positive Airway Pressure (CPAP) ............................................................ 148

Appendix P: PEEP Valve Guidelines ................................................................................................. 150

Appendix Q: Special Events .............................................................................................................. 151

Appendix R: Swiss Mountain Society Stages of Hypothermia ........................................................ 152

APGAR Score ..................................................................................................................................... 153

Cincinnati Stroke Scale ..................................................................................................................... 154

Pediatric Glasgow Coma Scale ......................................................................................................... 155

Wong-Baker Faces Pain Rating Scale ............................................................................................... 156

Pediatric Assessment Triangle ......................................................................................................... 157

Rule of Nines ..................................................................................................................................... 158

Dopamine Chart ............................................................................................................................... 159

MEDICATION REFERENCES .......................................................................................................................... 160

ADENOSINE (Adenocard) ................................................................................................................. 160

ALBUTEROL (PROVENTIL, VENTOLIN) .............................................................................................. 160

AMIODARONE .................................................................................................................................. 161

ASPIRIN ............................................................................................................................................. 161

ATROPINE ......................................................................................................................................... 161

CALCIUM CHLORIDE ......................................................................................................................... 162

DEXTROSE (D50W, D25W, D10W) ................................................................................................... 162

DILTIAZEM (CARDIZEM) ................................................................................................................... 162

DIPHENHYDRAMINE (BENADRYL) .................................................................................................... 163

DOPAMINE (INTROPIN) .................................................................................................................... 163

EPINEPHRINE (ADRENALIN) ............................................................................................................. 164

FENTANYL CITRATE (SUBLIMAZE) .................................................................................................... 164

GLUCAGON ....................................................................................................................................... 164

GLUCOSE (ORAL) ............................................................................................................................... 165

Haloperidol (Haldol) ......................................................................................................................... 165

KETAMINE (KETALAR) ....................................................................................................................... 165

LIDOCAINE ........................................................................................................................................ 166


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Lorazepam (Ativan) .......................................................................................................................... 166

MAGNESIUM SULFATE ..................................................................................................................... 167

METHYLPREDNISOLONE (SOLU-MEDROL) ....................................................................................... 167

MIDAZOLAM (VERSED) ..................................................................................................................... 168

Morphine Sulfate.............................................................................................................................. 168

NALOXONE (NARCAN) ...................................................................................................................... 168

NITROGLYCERIN (NTG) ..................................................................................................................... 170

ONDANSETRON HCL (ZOFRAN) ........................................................................................................ 170

OXYGEN ............................................................................................................................................ 170

ROCURONIUM BROMIDE (ZEMURON) ............................................................................................ 171

SODIUM BICARBONATE (BICARB) .................................................................................................... 171


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Introduction Iowa Administrative Code 641 - Chapter 132: Emergency Medical Services—Service Program Authorization 132.8(3) Service program operational requirements. Ambulance and non-transport service programs shall:

b. Utilize department protocols as the standard of care. The service program medical director may make changes to the department protocols provided the changes are within the EMS provider’s scope of practice and within acceptable medical practice. A copy of the changes shall be filed with the department.

132.9(2) The medical director’s duties include, but need not be limited to:

a. Developing, approving and updating protocols to be used by service program personnel that meet or exceed the minimum standard protocols developed by the department.

Purpose

The completed protocol approval page allows for a physician medical director to implement the use of the 2017 Iowa Statewide EMS Treatment Protocols for one or more service programs where they serve as the program’s medical director.

Instructions

Print or type the service name in the space provided. Next select each service’s corresponding service type and level of authorization. If the medical director makes any additions, subtractions, or other changes to the 2017 protocols the changes will need to be noted in the Protocol Revisions space and filed with the Department. This would include the addition, subtraction, or change of any medication listed within the 2017 protocols. If no changes are made to the 2017 protocols check the box for no changes.

Scope of Practice

The Iowa Emergency Medical Care Provider Scope of Practice document outlines the skills each level of certified EMS provider can perform. Some skills will require the approval of the service program’s physician medical director as well as documentation of additional training. Iowa EMS providers may not perform skills outside of their identified scope of practice as documented in the Iowa Emergency Medical Care Provider Scope of Practice. The most current version of the Iowa Emergency Medical Care Provider Scope of Practice document can be viewed and downloaded from the Bureau’s website at: http://idph.iowa.gov/bets/ems/scope-of-practice.

Recommendations

It is recommended that each service program maintain records that document the review/education of all staff members on the program’s most current protocols and the most current version of the Iowa Emergency Medical Care Provider Scope of Practice document.

http://idph.iowa.gov/bets/ems/scope-of-practice


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2018 Protocol Approval – Service level - Medications

Service(s) Name

Calh

oun

Coun

ty

EMS

– Ro

ckw

ell

City

Ca

lhou

n Co

unty

EM

S –

Lake

City

Calh

oun

Coun

ty

EMS

- Man

son

Lohr

ville

EM

S

Farn

ham

ville

EM

S

Service Type Ambulance X X X X X Non transport

Service’s Level of Authorization

EMR EMT X X AEMT X Paramedic X X

Pharmaceuticals Check All Medications Carried by the Service

Medication kit should contain only medications approved by the service’s Medical Director OTC Medications Medications

Aspirin � Adenosine � Lorazepam Glucose Paste � Albuterol � Magnesium Sulfate � Amiodarone � Midazolam Patient Assisted Medications � Atropine � Morphine Sulfate � Auto-injector Epinephrine � Dextrose � Naloxone � Nitroglycerin � Diphenhydramine � Nitroglycerin � Inhaler � Dopamine � Ondansetron

IV Fluids � Epinephrine � Oxygen � Normal Saline � Fentanyl � Sodium Bicarbonate � Ringer’s Lactate � Glucagon � � Dextrose 10% � Lidocaine �

� Medications Added by Service’s Medical Director

Acetaminophen Ketamine Burn Cream Rocuronium Calcium Chloride Methylprednisolone Diltiazem Triple Antibiotic Ointment Haldol


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2018 Protocol Approval � No changes were made to the 2018 Iowa Statewide EMS Treatment Protocols

OR List below or attach copies of all changes made by the physician medical director to the 2018 Iowa

Statewide EMS Treatment Protocols Page Protocol Name Changes Made

All Complete format change

Additional Skills for the EMR, EMT, AEMT

Approval of these additional skills must be within the Service Program’s Level of Authorization and the Iowa EMS Provider’s Scope of Practice

Mark “Yes” if the skill is approved by the medical director to be performed by the identified certification level

Certification Level

Yes

No

Pulse oximetry EMR X Glucose monitor EMT X Service carries auto-inject epi EMT X Central line access AEMT X CPAP EMT, AEMT X

NOTE: Iowa’s Scope of Practice document requires medical director approval and documentation of additional training for these skills. Service program must maintain documentation of the additional training

Medical Director Statement of Approval As the physician medical director I have reviewed both the 2018 Iowa Statewide EMS Treatment Protocols and the Iowa Emergency Medical Care Provider Scope of Practice document and approve the use of the skills, medications, and protocols with revisions as documented above for the authorized Iowa EMS program(s) listed within this document.

Medical Director’s Printed Name Signature Date Dr. James Comstock


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IOWA EMS TREATMENT PROTOCOLS

Initial Patient Care Protocol

Airway Protocols

Cardiac Protocols

Medical Protocols

OB Protocols

Pediatric Protocols

Environmental Protocols

Trauma Protocols


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Initial Patient Care Protocol-Adult and Pediatrics Revised 2018 - This protocol serves to reduce the need for extensive reiteration of basic assessment and other considerations in every protocol.

Assessment

1. Assess scene safety

a. Evaluate for hazards to EMS personnel, patient, bystanders

b. Determine number of patients

c. Determine mechanism of injury

d. Request additional resources if needed and weigh the benefits of waiting for additional resources against rapid transport to definitive care

e. Consider declaration of mass casualty incident if needed

2. Use appropriate personal protective equipment (PPE)

3. Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g. operations at night

or in darkness, on or near roadways) 4. Consider cervical spine stabilization and/or spinal care if trauma

Primary Survey

1. Airway, Breathing, Circulation is cited below; (although there are specific circumstances where Circulation, Airway, Breathing may be indicated such as cardiac arrest or major arterial bleeding) a. Airway (assess for patency and open the airway as indicated)

i. Patient is unable to maintain airway patency—open airway 1. Head tilt chin lift 2. Jaw thrust 3. Suction 4. Consider use of the appropriate airway management adjuncts and devices:

• oral airway, • nasal airway, • blind insertion, or supraglottic airway device, • laryngeal mask airway, • endotracheal tube

5. For patients with laryngectomies or tracheostomies, remove all objects or clothing that may obstruct the opening of these devices, maintain the flow of prescribed oxygen, and reposition the head and/or neck

b. Breathing


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i. Evaluate rate, breath sounds, accessory muscle use, retractions, patient positioning ii. Administer oxygen as appropriate with a target of achieving 94-98% saturation for most acutely ill patients iii. Apnea (not breathing) – open airway-see #4 above

c. Circulation

i. Control any major external bleeding (see Extremity Trauma/External Hemorrhage Management guideline) ii. Assess pulse

1. If none – go to Cardiac Arrhythmia Protocol 2. Assess rate and quality of carotid and radial pulses

iii. Evaluate perfusion by assessing skin color and temperature

1. Evaluate capillary refill

d. Disability i. Evaluate patient responsiveness: AVPU scale (Alert, Verbal, Pain, Unresponsive) ii. Evaluate gross motor and sensory function in all extremities iii. Check blood glucose in patients with altered mental status iv. If acute stroke suspected – go to Stroke Protocol

e. Expose patient as appropriate to complaint

i. Be considerate of patient modesty ii. Keep patient warm

Secondary Survey

1. The performance of the secondary survey should not delay transport in critical patients. Secondary surveys should be tailored to patient presentation and chief complaint. Secondary survey may not be completed if patient has critical primary survey problems a. Head

i. Pupils ii. Naso-oropharynx iii. Skull and scalp

b. Neck

i. Jugular venous distension ii. Tracheal position iii. Spinal tenderness

c. Chest i. Retractions


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ii. Breath sounds iii. Chest wall deformity

d. Abdomen/Back

i. Flank/abdominal tenderness or bruising ii. Abdominal distension

e. Extremities

i. Edema ii. Pulses iii. Deformity

e. Neurologic i. Mental status/orientation ii. Motor/sensory

2. Obtain Baseline Vital Signs (An initial full set of vital signs is required: pulse, blood pressure,

respiratory rate, neurologic status assessment) (see chart below) a. Neurologic status assessment: establish a baseline and note any change in patient neurologic status

i. AVPU (Alert, Verbal, Painful, Unresponsive) or ii. Glasgow Coma Score (GCS)

b. Patients with cardiac or respiratory complaints

i. Pulse oximetry ii. 12-lead EKG should be obtained early in patients with cardiac or suspected cardiac complaints iii. Continuous cardiac monitoring, if available iv. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry

c. Patient with altered mental status

i. Check blood glucose ii. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry

d. Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should be taken shortly before arrival at receiving facility

e. Critical patients should have pertinent vital signs frequently monitored

3. Obtain OPQRST history:

a. Onset of symptoms (circumstances surrounding onset such as gradual, or sudden onset) b. Provocation – location; any exacerbating or alleviating factors c. Quality of pain d. Radiation of pain e. Severity of symptoms – pain scale


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f. Time of onset and circumstances around onset

4. Obtain SAMPLE history:

a. Symptoms b. Allergies – medication, environmental, and foods c. Medications – prescription and over-the-counter; bring containers to ED if possible d. Past medical history

i. look for medical alert tags, portable medical records, advance directives ii. look for medical devices/implants (some common ones may be dialysis shunt, insulin pump, pacemaker, central venous access port, gastric tubes, urinary catheter)

e. Last oral intake f. Events leading up to the 911 call

Treatment and Interventions

1. Administer oxygen as appropriate with a target of achieving 94-98% saturation

2. Tier with an appropriate service if advanced level of care or assistance is needed and can be accomplished in a timely manner

3. Place appropriate monitoring equipment as dictated by assessment, within scope of practice – these may include:

a. Continuous pulse oximetry b. Cardiac rhythm monitoring c. Waveform capnography or digital capnometry d. Carbon monoxide assessment

4. If within scope of practice, establish vascular access if indicated or in patients who are at risk for

clinical deterioration. a. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of lidocaine 0.1mg/mL with slow push through IO needle to a maximum of 40 mg to mitigate pain from IO medication administration

5. Monitor pain scale if appropriate

6. Reassess patient

Patient Safety Considerations

1. Routine use of lights and sirens without documented indication is not warranted


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2. Even when lights and sirens are in use, always limit speeds to level that is safe for the emergency vehicle being driven and road conditions on which it is being operated

3. Be aware of legal issues and patient rights as they pertain to and impact patient care (e.g.

patients with functional needs or children with special healthcare needs)

4. Be aware of potential need to adjust management based on patient age and comorbidities, including medication dosages

5. The maximum weight-based dose of medication administered to a pediatric patient should not

exceed the maximum adult dose except where specifically stated in a patient care guideline

6. Direct medical control should be contacted when mandated or as needed Key Considerations Pediatrics: Use an accurate weight or length-based assessment tool (length-based tape or other system) to estimate patient weight and guide medication therapy and adjunct choices.

a. The pediatric population is generally defined by those patients who weigh up to 40 kg or up to 14-years of age, whichever comes first b. Consider using the pediatric assessment triangle (appearance, work of breathing, circulation) when first approaching a child to help with assessment.

Geriatrics: The geriatric population is generally defined as those patients who are 65 years old or more.

a. In these patients, as well as all adult patients, reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease)

Co-morbidities: reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease).


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Normal Vital Signs

Age Pulse Respiratory Rate

Systolic BP

Preterm less than 1 kg 120-160 30-60 36-58 Preterm 1 kg 120-160 30-60 42-66 Preterm 2 kg 120-160 30-60 50-72 Newborn 120-160 30-60 60-70 Up to 1 year 100-140 30-60 70-80 1-3 years 100-140 20-40 76-90 4-6 years 80-120 20-30 80-100 7-9 years 80-120 16-24 84-110 10-12 years 60-100 16-20 90-120 13-14 years 60-90 16-20 90-120 15 years or older 60-90 14-20 90-130

Glasgow Coma Scale

ADULT GLASGOW COMA SCALE PEDIATRIC GLASGOW COMA SCALE Eye Opening (4) Eye Opening (4) Spontaneous 4 Spontaneous 4 To Speech 3 To Speech 3 To Pain 2 To Pain 2 None 1 None 1 Best Motor Response (6) Best Motor Response (6) Obeys Commands 6 Spontaneous

Movement 6

Localizes Pain 5 Withdraws to Touch

5

Withdraws from Pain

4 Withdraws from Pain

4

Abnormal Flexion 3 Abnormal Flexion 3 Abnormal Extension

2 Abnormal Extension

2

None 1 None 1 Verbal Response (5) Verbal Response (5) Oriented 5 Coos, Babbles 5 Confused 4 Irritable Cry 4 Inappropriate 3 Cries to Pain 3 Incomprehensible 2 Moans to Pain 2 None 1 None 1 Total Total


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AIRWAY PROTOCOLS

Advanced Airway Placement/Confirmation/Management


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ADVANCED AIRWAY PLACEMENT / CONFIRMATION / MANAGEMENT

ADVANCED CARE GUIDELINES

1. If Advanced Airway Placement is necessary a. Perform Orotracheal Intubation

2. If successful confirm with at least 3 methods. One must be ETCO2/waveform monitoring.

b. Secure the tube c. Ventilatory rate should initially 10-12 BPM. Adjust to maintain an ETCO2 of 35-45. d. Consider Midazolam 2mg IV, or Ketamine 1-2 mg/Kg IV, repeat as necessary to sedate the

patient if needed to maintain airway.

3. If unsuccessful, refer to RSI Protocol.

4. If still cannot ventilate, perform needle cricothyrotomy

CONSIDERATIONS:

o Confirmation of intubation include: 1. Visualization of the ETT protruding adequately past the vocal cords and into the trachea 2. ETCO2 / waveform monitoring 3. Auscultation of all lung fields to confirm adequate air exchange 4. Bilateral, symmetrical expansion of the thorax

o Document the following: tube size, depth at the lips/nares, clinical signs of improved oxygenation & ventilation, tube confirmation methods and confirmation at destination.

o Minimally, reconfirmation should occur once the patient is prepared for transport; anytime the patient is moved; anytime dislodgement of the tube is suspected; any changes in patient condition and when responsibility for care is transferred to another provider.


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CARDIAC PROTOCOLS

ACUTE CORONARY SYNDROME/CHEST PAIN

ASYSTOLE/PEA

ATRIAL FIBRILLATION

BRADYCARDIA

CARDIAC ARREST/BLS-AED

CONGESTIVE HEART FAILURE/PULMONARY EDEMA

POST RESUSCITATION

TACHYCARDIA NARROW COMPLEX

TACHYCARDIA WIDE COMPLEX

VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA


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ACUTE CORONARY SYNDROME / CHEST PAIN

HISTORY:

o Age o Medications o Viagra, Levitra, Cialis o Past medical history (MI,

Angina, Diabetes, post-menopausal)

o Allergies (ASA, Morphine) o Palliation/Provocation o Quality (crampy, constant,

sharp, dull, etc.) o Region/Radiation/Referred o Severity (1-10) o Time

(onset/duration/repetition)

SIGNS AND SYMPTOMS:

o Chest pain (pain, pressure, aching, vice-like tightness)

o Location (substernal, epigastric, arm, jaw, neck, shoulder)

o Radiation of pain o Pale, diaphoresis o Shortness of

breath/cough o Nausea, vomiting,

dizziness o Time of Onset

DIFFERENTIAL:

o Trauma vs. Medical o Angina vs. Myocardial

infarction o Pericarditis o Pulmonary embolism o Asthma / COPD o Pneumothorax o Aortic dissection or

aneurysm o GERD or hiatal hernia o Esophageal spasm o Chest wall injury or pain o Pleural pain o Overdose (Cocaine) or

Methamphetamine

1. Follow initial patient care protocol

BASIC CARE GUIDELINES

a) Place patient in position of comfort, loosen tight clothing and provide reassurance. If patient is complaining of shortness of breath, has signs of respiratory distress or pulse oximetry of less than 94%, titrate oxygen to symptom improvement or to maintain saturation of 94-99%.

b) If capability exists, obtain a 12-lead EKG and transmit to the receiving facility and/or medical control for interpretation as soon as possible. An initial management goal is to identify STEMI and transport the patient with cardiac symptoms to the facility most appropriate to needs.

c) If patient is alert and oriented and expresses no allergy to aspirin have patient chew non-enteric coated aspirin 324-325 mg.

d) Evaluate if erectile dysfunction or pulmonary hypertension medications have been taken in the past 48 hours including: Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn), or Avanafil (Stendra), Tadalafil (Cialis, Adcirca).

e) If the patient has not taken any of the medications in (d) in the last 48 hours and has a systolic blood pressure of 90 mmHg or above, have the patient self-administer one dose of nitroglycerin (patient’s nitro only).

f) Repeat one dose of nitroglycerin in 3-5 minutes if pain continues, systolic blood pressure is 90 mmHg or above, up to a maximum of three doses.


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g) Reassess patient and vital signs following each dose of nitroglycerin.

h) Reperfusion Checklist


i) Monitor EKG and treat dysrhythmias.

j) Establish IV access at TKO rate unless otherwise ordered or indicated.

k) Administer nitroglycerin 0.4 mg sublingually if systolic blood pressure 90 mmHg or above for symptoms of chest pain or atypical cardiac pain. Repeat dose every 5 minutes if pain continues and systolic blood pressure is 90 mmHg or above.

l) If pain continues after administration of three doses of nitroglycerin and systolic blood pressure remains above 90 mmHg administer: Morphine 2-4 mg IV may repeat every 5 minutes

OR Fentanyl 25-50 mcg IV may repeat every 5 minutes

m) Consider NS Bolus for Inferior MI

n) Use Protocols as needed

Nausea and Vomiting Protocol Hypotension Protocol

CONSIDERATIONS:

o Chest pain, or “discomfort”, is present in two out of three patients with acute myocardial ischemia/infarction. Atypical presentations (commonly seen in diabetics, females and geriatric patients) include the following angina equivalents: respiratory distress, syncope, unexplained weakness, diaphoresis, palpitations, epigastric pain and nausea.

o Cardiac Risk Factors include: Major-tobacco (packs per day x years), hypertension, hyperlipidemia, genetics (mother, father, brother, or sister had MI or CABG prior to age 55), cocaine use; Minor-obesity, male, physical inactivity, post-menopausal, age > 45

o Assess 12-Lead ECG early – Goal within 10 minutes of first patient contact o Avoid Nitroglycerin in any patient who has used Viagra, Levitra, Cialis, or other ED medications in

the past 48 hours due to potential severe hypotension—contact Medical Control o Patient with STEMI (ST-Elevation Myocardial Infarction) should be transported to the appropriate

destination based on the EMS System STEMI Plan. o If the patient has taken nitroglycerin without relief, consider potency of the medication.


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Dysrhythmia Protocols

o Treat life threatening arrhythmias per the appropriate protocol before initiating the Acute Coronary Syndrome protocol.

POSITIVE ACUTE MI (STEMI = 1 mm ST Segment Elevation in 2 Contiguous Leads)

Transport based on EMS System STEMI Plan with Early Notification. Goal -SCENE TIME < 10 MINUTES


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ASYSTOLE / PEA

HISTORY:

o Events leading to arrest o End stage renal disease o Estimated downtime o Bystander CPR? o Suspected hypothermia o Suspected overdose o DNR, IPOLST

SIGNS AND SYMPTOMS:

o Pulseless o Apneic o Cyanosis o Livor mortis or Rigor

mortis?

DIFFERENTIAL:

o Trauma vs. Medical o Hypoxia o Potassium (hypo / hyper) o Drug overdose o Acidosis o Hypothermia o Device (lead) error o Death

1. Follow initial patient care protocol 2. Withhold Resuscitation as per Apparent Death or Termination of Resuscitation protocol

BASIC CARE GUIDELINES a) Perform high quality CPR immediately, apply AED and follow device prompts

b) Compression-only CPR is appropriate if unable to support airway while applying and using AED

c) May place appropriate airway if unable to adequately ventilate patient noninvasively, if does not

interrupt compressions, or after return of spontaneous circulation

d) May apply mechanical compression device (if available) after ensuring high quality compressions/ventilations and application of AED. Emphasis on minimizing interruption of compressions.

ADVANCED CARE GUIDELINES e) Perform high quality CPR immediately, apply monitor and check rhythm as soon as possible

f) When IV/IO established, give Epinephrine 1 mg every 3-5 minutes following cycle checks

g) Evaluate and treat for underlying causes

h) If pulse returns, go to Post Resuscitation Protocol

CONSIDERATIONS:

• Initial efforts should be concentrated on high quality CPR with minimal interruptions. This has a greater impact on patient outcome than any intervention. Deliver continuous chest compressions (minimum 100 and no more than 120 per minute)

• Once high-quality CPR has been initiated only then shall airway management be attempted. Ventilations with oral airway and BVM is acceptable as long as tidal volume is being delivered. Advanced airway procedures shall only be done when other means do not work. Ventilations should be no more than 10 – 12 per minute. AVOID HYPERVENTILATION!

• IV/IO is the preferred routes of medication administration and initiation of IV/IO takes precedence over intubating. ETT is no longer an acceptable route for medication administration.


23

ATRIAL FIBRILLATION HISTORY:

o Medications (Aminophylline, Diet pills, Thyroid supplements, decongestants, Digoxin)

o Diet (caffeine, chocolate)

o Drugs (nicotine, cocaine, methamphetamine)

o Past medical history o History of palpitations /

heart racing

SIGNS AND SYMPTOMS:

o HR > 130/min o QRS < 0.12 sec o Dizziness, chest pain, SOB o Potential presenting

rhythm Sinus tachycardia Atrial fibrillation / flutter Multifocal atrial tachycardia

DIFFERENTIAL:

o Heart disease (WPW, Valvular) o Sick Sinus Syndrome o Myocardial Infarction o Electrolyte imbalance o Exertion, pain, emotional stress o Fever o Hypoxia o Hypovolemia or anemia o Drug effect / overdose (see Hx) o Hyperthyroidism o Pulmonary embolus

1. Follow initial patient care protocol BASIC CARE GUIDELINES

a) Obtain 12 lead ECG and transmit to receiving facility

ADVANCED CARE GUIDELINES b) History of WPW (Wolff-Parkinson-White)? Follow Tachycardia: Narrow Complex

Protocol

c) Asymptomatic, monitor for changes

d) Symptomatic (Chest pain, Altered Mental Status, etc.) Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min (Max = 20 mg)

e) Pre-Arrest (severely altered mental status, no palpable BP)

Consider sedation for Cardioversion with Versed 2-5 mg IV Synchronized Cardioversion 100 J x 1, then 200 J. Repeat PRN Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min (Max = 20 mg)

f) After rate control or cardioversion obtain repeat 12 Lead ECG

CONSIDERATIONS:

• Exam: Mental Status, Skin, Heart, Lung, Extremities • Adenosine may not be effective in identifiable atrial fibrillation/flutter, yet is not harmful • Monitor for hypotension after administration of Cardizem • Document all rhythm changes with monitor strips. • Continuous Pulse Oximetry is required for all Atrial Fibrillation Patients


24

BRADYCARDIA HISTORY:

o Past medical history – cardiac, thyroid problem

o Pacemaker o Medications Beta-Blockers Calcium channel

blockers Clonidine Digoxin

SIGNS AND SYMPTOMS:

o HR < 60/min with hypotension, acute altered mental status, chest pain, acute CHF, seizures, syncope or shock secondary to bradycardia

o Respiratory distress

DIFFERENTIAL:

o Acute myocardial infarction o Hypoxia o Pacemaker failure o Hypothermia o Sinus bradycardia o Athletes o Head injury (elevated ICP) or

stroke o Spinal cord lesion o Sick Sinus Syndrome o AV Blocks (1˚, 2˚, or 3˚) o Overdose



2. Obtain 12 Lead ECG and transmit to receiving facility 3. If asymptomatic continue to monitor and reassess

ADVANCED CARE GUIDELINES 4. If symptomatic, administer atropine 0.5 mg IV or IO every 3-5 minutes as needed to maximum

dose of 3.0 mg. If in the setting of myocardial infarction, do not give atropine if there is a wide complex rhythm.

5. Consider transcutaneous pacing early in the unstable patient (especially in 2nd or 3rd degree heart block)

6. Consider administering dopamine 5-20 mcg/kg/min IV or IO if patient still hypotensive 7. Consider administering Glucagon 0.5 mg/kg if patient still bradycardic and on beta blockers 8. Consider Calcium Chloride 0.5-1 gram over 10 minutes if patient still bradycardic and on calcium

channel blockers or dialysis patient. CONSIDERATIONS:

• Symptomatic bradycardia is defined as a pulse rate of < 60 bpm with a SBP < 90 mmHg, shortness of breath, altered mental status, and/or other signs of hypoperfusion

• Treatment of choice for 2˚ type II and 3˚ AV heart blocks with serious signs/symptoms is external pacing. Consult Medical Control if serious signs/symptoms do not exist

• Pharmacological treatment of Bradycardia is based upon the presence or absence of symptoms. If symptomatic treat, if asymptomatic, monitor only

• In wide complex slow rhythm consider hyperkalemia. Contact Medical Control. • Transplanted hearts will not respond to Atropine: external pacing is treatment of choice • If hypotension exists, treat bradycardia first. If hypotension persists once HR is normalized,

treat hypotension • Consider treatable causes for Bradycardia (Beta Blocker OD, Calcium Channel Blocker OD,

etc.) • A 12-Lead ECG is essential in assessing for cardiac ischemia


25

CARDIAC ARREST BLS - AED

HISTORY:

o Estimated down time o Events leading to arrest o Cardiac history o Renal failure / dialysis o DNR or IPOST o SAMPLE

SIGNS AND SYMPTOMS:

o Unresponsive, apneic, pulseless

o Ventricular fibrillation or ventricular tachycardia on ECG

DIFFERENTIAL:

o Asystole/VF/VT o Artifact / Device failure o Endocrine / Metabolic o Drugs o Pulmonary

1. Follow initial patient care protocol 2. Withhold Resuscitation as per Apparent Death or Termination of Resuscitation protocol 3. Request ALS unit if not already enroute


4. Initiate high quality compressions 5. Connect AED and Analyze and follow the prompts 6. If shock advised, defibrillate and immediately start compressions for 2 minutes 7. If no shock advised, recheck pulse, if remains pulseless, continue compressions for 2 minutes 8. Consider placement of KING Airway if BVM with oral airway ineffective 9. Once AED has been applied and analyzed consider LUCAS compression device placement 10. At any time Return of Spontaneous Circulation ROSC – Go to Post Resuscitation Protocol

CONSIDERATIONS: • Initial Patient Care incorporates checking responsiveness, airway management including

positive pressure ventilations and high-quality CPR • Initial efforts should be concentrated on high quality CPR with minimal interruptions. This has

a greater impact on patient outcome than any intervention. Deliver continuous chest compressions (minimum 100 and no more than 120 per minute)


• Reassess rhythm after 2 minutes of CPR and shock indicated. Each shock should be immediately followed by two minutes of effective CPR


26

CONGESTIVE HEART FAILURE / PULMONARY EDEMA

HISTORY:

o Congestive heart failure o Past medical history o Medications (digoxin,

Lasix) o Cardiac history – past

myocardial infarction

SIGNS AND SYMPTOMS:

o Respiratory distress, bilateral rales

o Apprehension, orthopnea o Jugular vein distention o Pink, frothy sputum o Peripheral edema,

diaphoresis o Hypotension, shock o Chest pain

DIFFERENTIAL:

o Myocardial infarction o Congestive heart failure o Asthma o Anaphylaxis o COPD o Pleural effusion o Pneumonia o Pulmonary embolus o Pericardial tamponade o Toxic exposure



2. Obtain 12 Lead ECG and transmit to receiving facility 3. Obtain and record pulse oximetry and EtCO2 if available 4. Airway Protocol if needed 5. Consider CPAP Procedure 6. If patient is prescribed Nitroglycerin, contact Medical Control to assist with Nitroglycerin

0.4 mg SL q 5 minutes if BP is > 90 systolic. Up to three times (patient Nitro only) Evaluate if Erectile Dysfunction or Pulmonary Hypertension medications taken in the past 48 hours including: Sildenafil (Viagra, Revatio), Vardenafil (Levitra, Staxyn), or Avanafil (Stendra), Tadalafil (Cialis, Adcirca). Hold nitrates for 48 hours following the last dose.

ADVANCED CARE GUIDELINES 7. If rales or flash pulmonary edema administer Nitroglycerin 0.4 mg SL q 5 minutes if BP >

90 systolic. 8. Consider Lorazepam 0.5-1.0 mg IV if needed to better tolerate CPAP. May repeat once

as needed. 9. If CPAP contraindicated due to hypotension, consider Dopamine infusion then CPAP.

CONSIDERATIONS:


27

• Avoid Nitroglycerin in any patient who has used Viagra, Levitra, Cialis, or other ED medications in the past 48 hours due to potential severe hypotension—contact Medical Control

• Lasix and Narcotics have NOT been shown to improve the outcomes of EMS patients with pulmonary edema, it is no longer recommended.

• If patient has taken nitroglycerin without relief, consider potency of the medication • Contraindications to narcotics include severe COPD and respiratory distress. Monitor the

patient closely. • Consider myocardial infarction in all these patients. Diabetics and geriatric patients often

have atypical pain, or only generalized complaints • Carefully monitor the level of consciousness, BP and respiratory status with the above

interventions • Allow the patient to be in their position of comfort to maximize their breathing effort.


28

POST RESUSCITATION

HISTORY:

o Respiratory arrest o Cardiac arrest

SIGNS AND SYMPTOMS:

o Return of pulse

DIFFERENTIAL:

o Continue to address specific differentials associated with the original dysrhythmia

1. Repeat Primary Assessment


2. Continue ventilatory support as needed to maintain oxygen saturation >94%. Do not hyperventilate.

3. Follow Airway Protocol 4. Obtain 12 Lead ECG and transmit to receiving facility

ADVANCED CARE GUIDELINES 5. Continue anti-arrhythmic if

return of spontaneous circulation was associated with its use

6. If Hypotensive, consider fluid bolus. If remains hypotensive after bolus, consider Dopamine.

7. If Significant Ectopy, treat per Tachycardia: Wide Complex Protocol

8. If Bradycardia, treat per Bradycardia protocol

9. If arrest reoccurs, revert to appropriate protocol and/or initial successful treatment

CONSIDERATIONS:

• Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase and must be avoided

• Most patients immediately post ROSC will require ventilatory assistance

Dose/Details Ventilation/Oxygenation: • Avoid excessive ventilation. • Start at 10-12 breaths/min & titrate to target

PETCO2 of 35-40 mmHg • When feasible, titrate FIO2 to minimum

necessary to achieve SpO2 >94% IV Bolus: • 500cc-1L normal saline. Dopamine IV Infusion: • 5-10 mcg/kg/min


29

• The condition of post-resuscitation patients fluctuates rapidly and continuously and requires close monitoring. Appropriate post-resuscitation management may be best planned in consultation with medical control.

• Common causes of post-resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax and medication reaction to ALS drugs


30

TACHYCARDIA: NARROW COMPLEX


BASIC CARE GUIDELINES 2. Obtain 12 Lead ECG and transmit to receiving facility

ADVANCED CARE GUIDELINES 3. If Heart Rate < 150 bpm – monitor and consider etiology 4. If Heart Rate >150 bpm:

o Stable (no serious signs/symptoms) • Regular rhythm

- Vagal Maneuver - Consider Adenosine 6mg IV/IO rapid IV push - May repeat with Adenosine 12 mg IV/IO rapid IV push - Consider Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) - If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min

(Max = 20 mg) • Irregular rhythm

- (Symptomatic Atrial Fib or Flutter with rapid ventricular response?)

- Consider Diltiazem 0.25 mg/kg over 5-10 minutes (Max = 20 mg) - If unsuccessful after 15 min, Diltiazem 0.35 mg/kg over 5-10 min

(Max = 20 mg) o Unstable (Hypotensive, chest pain, altered level of consciousness)

• Synchronized Cardioversion 100 joules • Repeat at 200 joules each subsequent shock

HISTORY:

o Medications (Digoxin, Aminophylline, Diet pills, Thyroid supplements, Decongestants)

o Diet (caffeine, chocolate) o Drugs (nicotine, cocaine) o History of

palpitations/heart racing

o Syncope/near syncope

SIGNS AND SYMPTOMS:

o Heart rate > 150/min o QRS < 0.12 Sec o Palpitations o Dizziness, CP, SOB, COPD o Altered level of consciousness o Hypotension o S/S of shock, CHF, pulmonary

edema o Potential presenting rhythm:

-Sinus Tachycardia -Atrial fibrillation/flutter -Multifocal atrial tachycardia

DIFFERENTIAL:

o Heart disease (WPW, Valvular)

o Sick sinus syndrome o Myocardial infarction o Electrolyte imbalance o Exertion, Pain, Emotional

stress o Fever o Hypoxia o Hypovolemia or Anemia o Drug effect / overdose o Hyperthyroidism o Pulmonary embolus


31

CONSIDERATIONS:

o If you are unable to determine whether the rhythm is regular or irregular and the QRS is < 0.12, administer Adenosine as a diagnostic tool to slow the rate

o If delta wave is present, consider WPW and withhold Cardizem o Withhold Cardizem for heart rate < 150 or blood pressure less than 90 mm HG


32

TACHYCARDIA: WIDE COMPLEX

HISTORY:

o Syncope/near syncope o Palpitations o Pacemaker o Allergies:

lidocaine/Novocain o SAMPLE

SIGNS AND SYMPTOMS:

o Ventricular tachycardia on ECG (runs or sustained)

o Conscious, rapid pulse o Chest pain, SOB o Dizziness o Rate usually 150-180 bpm

for sustained V-Tach

DIFFERENTIAL:

o Artifact/Device Failure o Cardiac o Endocrine / Metabolic o Drugs o Pulmonary

1. Follow initial patient care protocol 2. If at any time, no pulse follow the ventricular fibrillation/pulseless ventricular tachycardia

protocol


3. Obtain 12 Lead ECG and transmit to receiving facility ADVANCED CARE GUIDELINES

4. If stable: o Polymorphic

• Consider Magnesium Sulfate 1-2 g IV/IO, delivered over 5-20 minutes • If doesn’t convert, consider Amiodarone 150 mg IV/IO.

o Monomorphic • If possible Tricyclic Toxicity administer Sodium Bicarb 50 mEq IV/IO • If not Tricyclic Toxicity administer Adenosine 6mg IV/IO rapid push. • May repeat with Adenosine 12 mg IV/IO rapid push. • If unsuccessful, consider Amiodarone 150 mg IV/IO over 10 min

5. If unstable: o Synchronized cardioversion 100 joules (consider 200 joules if polymorphic) o May repeat at 200 joules

CONSIDERATIONS:

o When uncertain about the rhythm (narrow vs. wide), treat according to this Tachycardia – Wide Complex Protocol and contact Medical Control early

o In the case of an AICD discharging, treat the underlying rhythm as per protocol


33

TERMINATION OF RESUSCITATIVE EFFORTS Revised 2018

Indications to consider termination of resuscitation: 1. Advanced level care (Paramedic level) has been instituted to include rhythm analysis

and defibrillation if indicated, airway management, and medications given per protocol 2. No return of spontaneous circulation or respiration 3. Correctable causes or special resuscitation circumstances have been considered and

addressed 4. Patient does not have profound hypothermia 5. Patient has no other signs of life (no response to pain, non-reactive pupils, no

spontaneous movement) Termination of resuscitation:

1. A valid DNR order, such as IPOST, is obtained by the EMS provider at any level OR

2. Patient meets all criteria under ‘indications’ above and as applicable to scope of practice

a. On-line medical direction is contacted (while advanced care continues) to discuss any further appropriate actions.

b. Advanced care may be discontinued if physician on-line medical direction authorizes.

Other considerations:

1. Documentation must reflect that the decision to terminate resuscitation was determined by physician on-line medical direction.

2. An EMS/health care provider must attend the deceased until the appropriate authorities arrive.

3. All IVs, tubes, etc. should be left in place until the medical examiner authorizes removal.

4. Implement survivor support plans related to coroner notification, funeral home transfer, leaving the body at the scene, and death notification/grief counseling for survivors.

5. See Appendix J -EMS Provider Initiating Organ and Tissue Donation at the Scene of the Deceased.


34

VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA

HISTORY:

o Estimated down time o Events leading to

arrest o Renal failure / dialysis o DNR / IPOST o SAMPLE

SIGNS AND SYMPTOMS:

o Unresponsive, apneic, pulseless

o Ventricular fibrillation or ventricular tachycardia on ECG

o Preceding signs/symptoms of ACS

DIFFERENTIAL:

o Asystole o Artifact/Device Failure o Endocrine / Metabolic o Drugs o Pulmonary

1. Follow initial patient care protocol 2. Withhold Resuscitation as per Apparent Death or Termination of Resuscitation protocol


3. Perform high quality CPR immediately, apply AED and follow device prompts 4. Compression-only CPR is appropriate if unable to support airway while applying and using AED 5. May place appropriate airway if unable to adequately ventilate patient noninvasively, if does not

interrupt compressions, or after return of spontaneous circulation 6. May apply mechanical compression device (if available) after ensuring high quality

compressions/ventilations and application of AED. Emphasis on minimizing interruption of compressions.

ADVANCED CARE GUIDELINES 7. Perform high quality CPR immediately, apply monitor and check rhythm as soon as possible 8. Defibrillate at manufacturer’s specification, immediately resume CPR for two minutes 9. Evaluate and treat for underlying causes 10. Administer epinephrine 1:10,000 concentration 1 mg IV/IO every 3-5 minutes 11. Consider amiodarone for refractory pulseless V-Tach or V-Fib 300 mg IV/IO push, repeat

150 mg IV/IO push in 3-5 minutes 12. At any time ROSC, go to Post Resuscitation Protocol 13. At any time rhythm converts to a non-shockable, pulseless rhythm go to Asystole/PEA

Protocol

CONSIDERATIONS:

• Initial Patient Care incorporates checking responsiveness, airway management including positive pressure ventilations and high-quality CPR

• Initial efforts should be concentrated on high quality CPR with minimal interruptions. This has a greater impact on patient outcome than any intervention. Deliver continuous chest compressions (minimum 100 and no more than 120 per minute)


• Reassess rhythm after 2 minutes of CPR and shock indicated. Each shock should be immediately followed by two minutes of effective CPR


35

• IV/IO are the preferred routes of medication administration and initiation of IV/IO takes precedence over securing an advanced airway. ETT is no longer an acceptable route for medication administration.


36

MEDICAL PROTOCOLS

ABDOMINAL PAIN (NON-TRAUMATIC)

ALLERGIC REACTION

ALTERED MENTAL STATUS

APPARENT DEATH-DETERMINATION OF DEATH-WITHHOLDING RESUSCITATIVE EFFORTS

ASTHMA – COPD

BEHAVIORAL

DIABETIC EMERGENCY

EPISTAXIS

FEVER / INFECTION CONTROL

HYPERTENSIVE EMERGENCY

HYPOTENSION

NAUSEA / VOMITING

OVERDOSE/TOXIC INGESTION

PAIN CONTROL

RESPIRATORY DISTRESS

SEIZURE

SEPSIS

STROKE

SYNCOPE / WEAKNESS


37

ABDOMINAL PAIN (NON-TRAUMATIC)

HISTORY:

o Age o Onset o Palliation / Provocation o Quality (crampy,

constant, sharp, dull, etc.)

o Region / Radiation / Referred

o Severity (0-10) o Time (duration /

repetition) o Fever o Last meal eaten o Last bowel movement o Menstrual history o SAMPLE

SIGNS AND SYMPTOMS:

o Pain o Tenderness o Nausea / Vomiting o Diarrhea / Constipation o Dysuria o Vaginal bleeding /

discharge o Pregnancy o Associated symptoms:

(Helpful to localize source) Fever, headache, weakness, malaise, myalgias, cough, mental status changes, rash

o Absent femoral pulses o Pertinent negatives

DIFFERENTIAL:

o Myocardial infarction o Abdominal aneurysm o Pulmonary embolus or

Pneumonia o Pelvic (PID, Ectopic

pregnancy, cyst) o Gallbladder o Pancreatitis o Kidney stone o Appendicitis o Bladder / Prostate disorder o Spleen enlargement o Diverticulitis o Bowel Obstruction o Gastroenteritis (infectious)

1. Follow initial patient care protocol 2. AT ANY TIME if relevant signs / symptoms found go to appropriate protocol

BASIC CARE GUIDELINES a) Give nothing by mouth b) Obtain 12 lead ECG and transmit

ADVANCED CARE GUIDELINES c) Consider a fluid bolus if indicated. d) Evaluate the need for pain and nausea control. Go to appropriate protocol e) Cardiac monitoring

CONSIDERATIONS:

• Over 25% of acute myocardial infarctions present with ANGINAL EQUIVALENT symptoms, including abdominal pain/discomfort.

• Elderly patients with hypotension and/or major cardiac risk factors should be evaluated for possible Abdominal Aortic Aneurysm (AAA) with dissection and STEMI.

• The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50 years old. • Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise. • Patients over 40 years old with 3 or more major cardiac risk factors i.e. tobacco, hypertension, hyperlipidemia,

genetics, cocaine use, should have a 12 lead ECG performed.

• Advanced treatment is generally not required for patients < 40 years of age who have a soft and non-tender abdomen, are without fever, have stable vital signs, and are not complaining of nausea, vomiting, and/or diarrhea.

• Abdominal assessment may be more accurate when pain control is initiated


38

1. Follow initial patient care protocol BASIC CARE GUIDELINES

a) Obtain blood glucose b) If blood sugar < 60 mg/dl, patient is conscious & able to swallow, administer glucose 15 gm by

mouth c) Evaluate the need for naloxone 4 mg prefilled intranasal if suspect overdose. Follow

Overdose/Toxic Ingestion Protocol d) Obtain 12 lead and transmit e) Monitor airway. Follow Airway Protocol

ADVANCED CARE GUIDELINES f) If blood sugar less than 60 mg/dL, patient is symptomatic, administer D10 IV in incremental

doses until mental status improves or blood glucose level is > 60 mg/dl. g) If no vascular access, administer glucagon 1 mg IM h) Evaluate the need for naloxone 1-2 mg IV/IO or 4 mg IN. May repeat dosage in 3 minutes i) Cardiac monitoring j) Evaluate the need for intubation per Airway Protocol

CONSIDERATIONS:

• Adequate breathing is defined as an acceptable rate and depth of breathing (chest rise and fall)

ALTERED MENTAL STATUS

HISTORY:

o Diabetes o Substance ingested,

route, quantity and time of ingestion

o Reason (suicidal, accidental, criminal)

o Trauma o Seizure o Fever o Organic brain disorder o Available medications

in home o SAMPLE

SIGNS AND SYMPTOMS:

o Mental status changes o Hypotension /

hypertension o Decreased respiratory

rate o Tachycardia,

dysrhythmias o Seizures or Focal motor

or sensory deficit o Nausea, vomiting,

abdominal pain, defecation, urination

o Hypoxia/CO2 retention o Fever o Abnormal blood glucose o Positive Stoke Findings o Pertinent negatives

DIFFERENTIAL:

o Diabetes (Hyper / Hypoglycemia)

o Head trauma o CNS (stroke, tumor, seizure,

infection) o Cardiac (MI, CHF) o Infection o Thyroid (hyper / hypo) o Shock (septic, metabolic,

hypovolemic) o Toxicological (drug, ETOH,

poison) o Acidosis / Alkalosis o Environmental exposure o Respiratory – Hypoxia, CO, CO2

retention o Psychiatric disorder


39

• Naloxone is preferentially administered intranasal even in the presence of established venous access. Side effects such as nausea, vomiting and combativeness are significantly decreased with IN administration. Only give Naloxone for possible opiate overdose or unknown cause of mental status changes.

• Consider mnemonic AEIOU-TIPS • Consider CO poisoning. Use Masimo Carbon Monoxide detector on ZOLL X. • Because an intubated patient has a definitive airway in place, and because naloxone administration

may cause combativeness and vomiting as the patient begins to respond, hold naloxone in order to maintain effective airway management.

• Contact Poison Control if necessary at 1-800-222-1222.

tel:18002221222


40

APPARENT DEATH-DETERMINATION OF DEATH-WITHHOLDING RESUSCITATIVE EFFORTS

HISTORY:

o Person encountered by EMS who meets criteria for obvious death

o Patient with DNR in place who is pulseless and apneic

o Patient with other approved advanced directive requiring no CPR be administered who is pulseless and apneic

o Patient for whom resuscitative efforts are cease on scene

KEY INFORMATION:

o Name of primary care physician

o Known medical conditions

o Last time know to be alive

DIFFERENTIAL:

o Attended Death ( a patient with a primary care physician who apparently died of natural causes (aka “natural death”)

o Unattended Death (a patient without a primary care physician who apparently dies of natural causes (aka “natural death”)

o Suspicious Death (Law Enforcement)

o Traumatic Death


Resuscitation should be started on all patients who are found apneic and pulseless unless the following medical cause, traumatic injury or body condition clearly indicating biological death (irreversible brain death) such as:

Signs of trauma are conclusively incompatible with life o Decapitation o Transection of the torso o 90% of the body surface area with full thickness burns o Massive crush injury o Apneic, pulseless and without other signs of life (movement, EKG

activity, pupillary response) Cardiac and respiratory arrest with obvious signs of death including

o Rigor mortis o Dependent lividity

Physical decomposition of the body

OR A valid DNR order (form, card, bracelet) or other actionable medical order (e.g. I-POLST form) present, when it:


41

Conforms to the state specifications Is intact: it has not been cut, broken or shows signs of being repaired Displays the patient’s name and the physician’s name

If apparent death is confirmed, continue as follows:

a) The county Medical Examiner and law enforcement shall be contacted 712-297-7583. b) When possible, contact Iowa Donor Network at 1-800-831-4131. c) At least one EMS provider should remain at the scene until the appropriate authority is

present d) Provide psychological support for grieving survivors e) Document the reason(s) no resuscitation was initiated f) Preserve the crime scene if applicable

In all other circumstances (except where “NO CPR/DNR” protocol applies; see appendix A) full resuscitation must be initiated

tel:17122977583

tel:18008314131


42

ALLERGIC REACTION

HISTORY:

o Onset and location o Insect sting or bite o Food allergy / exposure o Medication allergy /

exposure o New clothing, soap,

detergent o Past history of reactions o SAMPLE

SIGNS AND SYMPTOMS:

o Itching or hives o Coughing / wheezing or

respiratory distress o Chest or throat constriction o Difficulty swallowing o Hypotension or shock o Edema o Facial or oral mucosal

swelling o Pertinent negatives

DIFFERENTIAL:

o Urticaria (rash only) o Anaphylaxis (systemic effect) o Shock (vascular effect) o Angioedema (drug induced) o Aspiration / Airway

obstruction o Vasovagal event o Asthma or COPD o CHF


BASIC CARE GUIDELINES 2. Assess severity

a. If mild reaction (hives/rash with no respiratory component or hypotension) i. Monitor airway

b. If moderate or severe (wheezing/stridor/impending respiratory failure or shock) i. Administer epinephrine auto injector 0.3 mg IM

ii. Oxygen as needed to maintain spo2 94-99% iii. Obtain 12 lead ECG and transmit

Advanced care guidelines 3. Establish IV/IO access 4. Cardiac monitoring 5. If mild reaction:

a. Administer diphenhydramine 50 mg IV/IM b. Administer methylprednisolone 125 mg IV/IM

6. If moderate/severe: a. Administer epinephrine 1mg/ml (1:1,000) concentration 0.5mg IM b. For severe reactions administer epinephrine 1mg/ml (1:10,000) concentration 0.5 mg

IV c. Administer diphenhydramine 50 mg IV/IM d. Administer methylprednisolone 125 mg IV/IM e. Administer albuterol 5.0 mg via nebulizer. Repeat as indicated. f. Fluid bolus as necessary. Follow Hypotension protocol.

7. Prepare for intubation if necessary


43

CONSIDERATIONS:

Use caution when administering epinephrine in patients who are > 50 years of age, have a history of cardiac disease, or if the patient’s heart rate is > 150. Epinephrine may precipitate cardiac ischemia. These patients should receive a 12 lead ECG.

Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine and methylprednisolone IV/IM.

The shorter the onset from contact to symptoms, the more severe the reaction.

When the use of an epinephrine auto injector is indicated and the patient weighs less than 30 kg (66 lbs.), the pediatric auto injector should be used


44

ASTHMA AND COPD

HISTORY:

o Asthma o COPD: chronic

bronchitis, emphysema o Congestive heart failure o Home treatment

(oxygen, nebulizer) o Medications

(Theophylline, steroids, inhalers)

o Toxic exposure, smoke inhalation

o SAMPLE

SIGNS AND SYMPTOMS:

o Shortness of breath o Pursed lip breathing o Tripod positioning o Use of accessory muscles o Decreased ability to

speak o Increased respiratory

rate and effort o Wheezing, rhonchi o Fever, cough o Tachycardia o Pertinent negatives

DIFFERENTIAL:

o Asthma o Anaphylaxis o Aspiration o COPD (Emphysema, Bronchitis) o Pleural Effusion o Pneumonia o Pulmonary Embolus o Pneumothorax o Cardiac (MI or CHF) o Pericardial Tamponade o Hyperventilation o Inhaled toxin (Carbon

Monoxide, etc.)



a) If patient has a physician prescribed hand-held metered dose inhaler: Assist patient in administering a single dose if they have not done so already Reassess patient and assist with second dose if necessary per medical direction

b) Evaluate the need for CPAP c) Obtain 12 lead ECG and transmit


d) Administer albuterol up to 5.0 mg via nebulizer, repeat as needed e) Evaluate the need for epinephrine 1 mg/ml (1:1,000) concentration 0.3 mg IM. f) Cardiac monitoring g) Vascular access h) Administer methylprednisolone 125 mg IV/IM i) Consider Magnesium Sulfate 2 grams in 50 cc NS over 10-15 minutes for severe asthma j) Evaluate the need for CPAP k) Evaluate the need for intubation

CONSIDERATIONS:

• WHEN IN DOUBT about the cause of the respiratory distress, support, transport and contact Medical Control.

• Patients > 50 years of age with a cardiac history, COPD, and/or renal failure should not be given Magnesium Sulfate without consultation with Medical Control

• CPAP is not indicated when wheezing is secondary to allergic reaction or anaphylaxis.


45

• Mild distress is associated with shortness of breath without any accessory muscle use. Moderate distress includes wheezing, accessory muscle use and nasal flaring. Severe distress includes little or no movement of air, tripod position, nasal flaring and diaphoresis.

• Waveform capnography should be used to assist with a differential diagnosis and to evaluate the effectiveness of treatment.

• Maintain oxygen saturation 94-99%.


46

BEHAVIORAL EMERGENCIES

HISTORY:

o Situational crisis o Psychiatric

illness/mediations o Injury to self or threat to

others o Medic alert tag o Diabetes o SAMPLE o Any weapons

SIGNS AND SYMPTOMS:

o Anxiety, agitation, confusion o Affect change, hallucinations o Delusional thoughts, bizarre

behavior o Combative, violent o Expression of suicidal /

homicidal thoughts o Pertinent negatives

DIFFERENTIAL:

o Alcohol intoxication o Toxin / Substance abuse o Medication effect /

overdose o Depression o Bipolar (manic-

depressive) o Schizophrenia o Anxiety disorders

1. Follow initial patient care protocol 2. If there is evidence of immediate danger, protect yourself and others by summoning law

enforcement to help ensure safety


a) Rule out Medical Causes. Treat suspected medical or trauma problems per appropriate protocol

b) Psychiatric Risk Assessment c) Remove patient from stressful environment d) Verbal techniques (reassurance, calm, establish rapport)


e) Consider the cause of agitation i) Behavioral: Administer Ketamine 1 mg/kg IV or 2 mg/kg IM

OR Midazolam 2mg IV/IM or 5-10 mg IN may repeat

every 5 minutes as needed OR

Haloperidol 5 – 10 mg IM ii) For excited delirium: Ketamine 4 mg/kg IM/IV

OR Midazolam 2mg IV/IM or 5-10 mg IN may repeat

every 5 minutes as needed Consider cooling measures

Psychiatric Risk Assessment

Is the patient presenting with or has presented with any of the following in

recent past?

o Aggressive or agitated behavior o Affect changes or hallucinations o Delusional thoughts or

bizarre behavior o Suicidal or homicidal ideations o Easily agitated o Verbal outbursts o Required handcuffs or

restraints prior arrival


47

Consider ETCO2 monitoring f) Be alert for a dystonic reaction if patient is on Reglan, Phenergan or Compazine at

home. If present give diphenhydramine 25-50 mg IV/IM

CONSIDERATIONS:

• Perform Psychiatric Risk Assessment early. If the patient presents with any of the findings, contact law enforcement. YOUR SAFETY FIRST!

• DO NOT be fooled by the patient’s current demeanor, it can change rapidly. • In the case of threat in the unit. Stop. Exit. Open the side door. Stand with partner.

Communicate. • Keep it simple. Psychotic & stressed patients do not process complicated messages. • Try to have same sex provider in back as patient. Consider third person for safety. • Do not irritate the patient with a prolonged exam. • Be sure to consider all possible medical/trauma causes for behavior. Consider mnemonic

AEIOU-TIPS. • The presence of irrational behavior, hallucinations, and alternating periods of lethargy

followed by excitement, screaming and kicking following ketamine administration may be associated with emergence phenomena and will likely respond better to midazolam instead of additional ketamine.

• Patients in handcuffs cannot be transported without law enforcement in the back with the patient.

• If restraints needed for safety, documentation of distal Pulse, Motor and Sensory is required every 5 minutes with continuous monitoring of the airway.


48

DIABETIC EMERGENCY

HISTORY:

o Known diabetic, medic alert tag

o Medications (Insulin, Diabinese, Orinase, Micronase, etc.)

o Last dose of diabetic medications

o Report of illicit drug use or toxic ingestion

o History of trauma o Onset; duration o Seizure activity o Fever o SAMPLE

SIGNS AND SYMPTOMS:

o Sudden decrease in mental status

o Bizarre behavior; intoxicated appearance

o Cool, diaphoretic skin or

o Flushed, dry skin o Hunger o Anxiety o Combativeness o Lethargy o Headache o Tremors o Faintness o Seizures, coma

DIFFERENTIAL:

o Diabetes (hyper / hypoglycemia) o Head trauma o CNS (stroke, tumor, seizure,

infection) o Cardiac (MI, CHF) o Infection o Thyroid (hyper / hypo) o Shock (septic, metabolic,

traumatic) o Toxicologic o Acidosis / Alkalosis o Environmental exposure o Respiratory-Hypoxia, CO, CO2

retention o Psychiatric disorder

1. Follow Initial Patient care protocol BASIC CARE GUIDELINES 2. Obtain blood glucose level 3. If blood glucose is < 60 mg / dl and the patient is symptomatic, able to swallow, administer 15 gm of

oral glucose 4. Obtain 12 lead ECG and transmit if capability exists ADVANCED CARE GUIDELINES If Patient is unable to swallow with blood glucose less than 60 mg/dl: 5. Obtain vascular access 6. If blood sugar less than 60 mg/dL, patient is symptomatic, administer Dextrose D10W IV in incremental doses until mental status improves or blood glucose level is > 60 mg.dl. 7. If IV access unsuccessful administer Glucagon 1mg IM 8. Cardiac monitoring If blood glucose is > 250 mg / dl consider fluid bolus. 9. S/S DKA or HHNK administer NS or LR 500 cc fluid bolus. Reassess and repeat bolus as needed.

CONSIDERATIONS:

• Hypoglycemia secondary to oral hypoglycemic medications and longer acting insulin is risky; transport is critical because of the potential for recurrence of hypoglycemia

• Pre-hospital treatment of hypoglycemia is a bridge to get the patient to the ER or physician and not considered definitive therapy

• The duration of dextrose and glucagon is relatively short. Reassess the patient and repeat as needed.


49

• A blood glucose level > 250 mg/dl does not mean the patient is in DKA. A blood glucose level alone is only indicative of hyperglycemia. Common s/s associated with DKA includes: abdominal pain or cramping, altered LOC, thirsty, deep rapid respirations, dyspnea, frequent urination, nausea, vomiting.

• It is very common for a patient that has received medication for hypoglycemic event to refuse transport once their LOC improves.


50

EPISTAXIS

HISTORY:

o Age o Past Medical history o Medications (HTN,

anticoagulants, Aspirin, NSAIDS)

o Previous episodes of epistaxis

o Trauma o Duration of bleeding o Quantity of bleeding o SAMPLE

SIGNS AND SYMPTOMS:

o Bleeding from nasal passage

o Pain o Nausea o Vomiting o HTN o Pertinent negatives

DIFFERENTIAL:

o Trauma o Infection (viral URI or

Sinusitis o Allergic rhinitis o Lesions (polyps, ulcers) o Hypertension

1. Follow Initial Patient Care Protocol


2. Compress Nostrils and hold for at least 5-15 minutes 3. Ice packs 4. Tilt head forward, be prepared to suction


5. Consider vascular access 6. For Hypertension cause also follow the Hypertension Protocol

CONSIDERATIONS: o It is very difficult to quantify the amount of blood loss with epistaxis o Bleeding may also be occurring posteriorly. Evaluate for posterior blood loss by examining the

posterior pharynx o Anticoagulants include aspirin, Coumadin, non-steroidal anti-inflammatory medications

(Ibuprofen, Naproxen), and many over the counter headache relief powders or tablets.


51

FEVER/INFECTION CONTROL

HISTORY:

o Age o Duration of fever o Immunocompromised

(transplant, HIV, diabetes, cancer)

o Environmental exposure o Last Acetaminophen or

Ibuprofen o SAMPLE

SIGNS AND SYMPTOMS:

o Warm o Flushed o Sweaty o Chills/Rigor o Malaise, cough, chest pain,

headache, dysuria, abdominal pain, mental status changes, rash/petechial, stiff neck

o Pertinent negatives

DIFFERENTIAL:

o Cocaine/stimulant intoxication

o Heat Stroke o Medication or drug

reaction o Connective tissue disease o Arthritis o Vasculitis o Hyperthyroidism o Cancer / Tumors /

Lymphomas o Meningitis



2. Consider Droplet, Airborne or Contact Precautions 3. Temperature Assessment 4. Cooling Measures

ADVANCED CARE GUIDELINES 5. Consider IV 6. Consider Fluid Bolus

CONSIDERATIONS:

• Temperature may be decreased by a combination of 4 methods: • Radiation: Heat loss to air (unwrap or remove clothing) • Evaporation: Heat loss through the evaporation of sweat or liquid from the skin (tepid water

bath to skin) • Convection: Heat loss through the movement of air currents over the skin (fan air over the

skin) • Conduction: Heat loss through the contact with solid substances (with heat stroke use cool

packs per protocol) • Re-hydration with fluids increases the patient’s ability to sweat and improves heat loss. • Droplet precautions include standard PPE plus a standard surgical mask for providers who

accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplet are suspected

• Airborne precautions include standard PPE plus an N-95 mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient.


52

This level of precaution should be used when TB, measles, varicella or other infections that are spread by droplet nuclei are suspected.

• Contact precautions include standard PPE plus utilization of a gown.


53

HYPERTENSIVE EMERGENCY

HISTORY:

o History of HTN o Related diseases:

o Diabetes o CVA o Renal failure o Cardiac

o Medications (compliance?)

o Viagra, Levitra or Cialis use

o Pregnancy o SAMPLE

SIGNS AND SYMPTOMS:

o Systolic BP 200 or greater o Diastolic BP 120 or greater o Headache o Epistaxis o Blurred Vision o Dizziness o Pertinent Negative

DIFFERENTIAL:

o Hypertensive encephalopathy o Primary CNS Injury (Cushing’s

response = bradycardia with hypertension), Stroke

o Myocardial Infarction o Aortic dissection (aneurysm) o Pre – eclampsia/Eclampsia



2. Obtain 12 lead ECG and transmit 3. Monitor and Reassess vital signs every 5 minutes 4. Appropriate protocol based on patient signs & symptoms


5. Obtain vascular access, TKO rate 6. Cardiac monitor 7. Nitroglycerin 0.4 mg SL every 5 minutes if SBP is > 200 or DBP is > 120 or MAP is > 145 and the

patient is symptomatic (Consult Medical Advice prior to administration if positive stroke assessment or Head Injury)

CONSIDERATIONS:

o NEVER TREAT ELEVATED BLOOD PRESSURE BASED ON ONE SET OF VITALS o ASYMPTOMATIC HYPERTENSIVE PATIENTS DO NOT REQUIRE TREATMENT IN THE

PREHOSPITAL SETTING. o All symptomatic patient should be transported with their head elevated o Attention in the prehospital setting should be on:

o CNS (Central Nervous System ) – Altered LOC, decreased vision, focal motor deficits, seizure and headaches o CVS (Cardiovascular System) – Angina, acute CHF, and aortic dissection.


54

HYPOTENSION

HISTORY:

o Past medical history o Medications o Blood loss – AAA, ectopic

pregnancy, vaginal or gastrointestinal bleeding

o Fluid loss – vomiting &/or diarrhea

o Infection – fever o Pregnancy o History of poor oral

intake o SAMPLE

SIGNS AND SYMPTOMS:

o Restlessness, confusion o Weakness, dizziness o Weak, rapid pulse o Pale, cool, clammy skin o Delayed capillary refill o SBP < 90 o Hematemesis (blood or

coffee-ground) o Hematochezia (blood or

tarry stools) o Pertinent Negatives

DIFFERENTIAL:

o Shock o Hypovolemia o Cardiogenic o Septic o Neurogenic o Anaphylactic

o Ectopic pregnancy o Dysrhythmias o Pulmonary Embolus o Tension Pneumothorax o Medication effect/overdose o Vasovagal o Physiologic (pregnancy)



2. Obtain 12 lead ECG and transmit 3. Monitor and Reassess vital signs every 5 minutes 4. Appropriate protocol based on patient signs & symptoms (Trauma, Cardiac, Anaphylaxis, OB)

ADVANCED CARE GUIDELINES 5. Obtain vascular access, if no signs of CHF/Pulmonary Edema infuse NS 500 ml bolus and

reassess. 6. Cardiac monitor 7. In non – cardiac and non- trauma, consider 2nd 500 ml bolus. 8. Consider Dopamine 5-20 mcg/kg/min IV/IO infusion

Considerations:

• Hypotension is defined as systolic blood pressure of less than 90 mmHg • Consider all possible causes of shock and treat per appropriate protocol


55

NAUSEA & VOMITING

HISTORY:

o Age o Time of last oral intake o Last bowel

movement/emesis o Improvement or

worsening with food or activity

o Duration of event o Other sick contacts o Past medical & surgical hx o Medications o Menstrual history

(pregnancy) o Travel history o Bloody emesis/diarrhea o SAMPLE

SIGNS AND SYMPTOMS:

o Pain (OPQRST) o Associated Symptoms:

Fever, headache, blurred vision, weakness, malaise, myalgias, cough, dysuria, mental status changes, rash

o Pertinent Negatives

DIFFERENTIAL:

o CNS (increased pressure headache, stroke, CNS lesions, trauma or hemorrhage)

o Migraine o Myocardial infarction o Drugs/medications o GI or Renal disorder o Diabetic ketoacidosis o Gynecologic disease

(ovarian cyst, PID) o Infections (pneumonia,

influenza) o Electrolyte abnormalities o Food or toxin induced o Pregnancy o Psychologic



a) Give nothing by mouth b) Obtain 12 lead ECG and transmit c) Check blood glucose level


d) Consider fluid bolus IV/IO if evidence of hypovolemia and lung sounds are clear e) Cardiac monitor f) Administer ondansetron (Zofran) 4 mg IV/IO, may repeat in 15 minutes x 1 dose. g) Consider intubating patients with altered mental status who are vomiting and cannot

protect their airway


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OVERDOSE / TOXIC INGESTION HISTORY:

o Ingestion or suspected ingestion of a potentially toxic substance

o Substance ingested, route, quantity

o Time of ingestion o Reason (suicidal,

accidental, criminal) o Available medications

in home o SAMPLE

SIGNS AND SYMPTOMS:

o Mental status changes o Hypotension /

hypertension o Decreased RR o Tachycardia, dysrhythmias o Seizures o Nausea, vomiting,

abdominal pain, diarrhea o Sweating, tearing, rash o Decreased oxygen

saturation / CO2 retention o Pupil response

DIFFERENTIAL:

o Acetaminophen (Tylenol) o Narcotics/depressants o Tricyclic antidepressants

(TCAs) o Stimulants-cocaine,

amphetamines o Anticholinergic-Benadryl o Cardiac medications o Solvents, Alcohols, Cleaning

agents o Insecticides

(organophosphates)


2. Identify contaminate and call Poison Control and follow directions given to provide care: 1-800-222-1222

3. Contact Medical Direction as soon as possible with information given by Poison Control and care given


1. Attempt to identify substances ingested or exposed by interviewing witnesses. Try to establish the exact time of ingestion, as well as the amount and type of ingestion. Medication containers or chemical labels should be taken with you.

2. Consider Narcan for respiratory depression 4 mg IN


Bradycardia with Unknown Overdose: a. Consider Atropine 0.5 mg IV every 5 minutes as needed up to total dose of 3 mg. b. Consider dopamine (Intropin) 5-15 mcg/kg/min c. Consider transcutaneous pacemaker

Tachycardia with Unknown Overdose:

a. Provide IV fluid bolus with normal saline 1 Liter

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57

b. Consider benzodiazepine FOR agitation/Seizure such as: 1. Midazolam 0.5-2.5 mg IV/IM/IO repeated every 5 minutes as needed to a

maximum of 5 mg OR

2. Lorazepam 2mg IV/IO, repeated every 30 minutes as needed to a maximum of 4 mg. Use for long transports

c. Consider Sodium Bicarbonate 1 mEq/kg IV for dysrhythmias refractory to benzodiazepines (especially those with a wide QRS complex or prolonged QT).

d. Cool patients presenting with agitation, delirium, seizure and elevated body temperature

Suspected Opioid Overdose:

e. Support ventilations via bag-valve-mask and oxygen while preparations are made for Naloxone (Narcan) administration

f. Initial dose of Naloxone (Narcan) is 1 to 2 mg IV/IO over 15-30 seconds or 2 to 4 mg IM, SQ or 4 mg IN. Repeated doses may be required

Calcium Channel Blocker (Norvasc, Cardizem) or Beta Blocker (Atenolol, Lopressor, Inderal) Overdose:

g. Consider Calcium Chloride 10% 0.5-1 gram IV over 10 minutes i. May repeat x 1 in 5 minutes if persistent EKG changes ii. Calcium therapy is contraindicated for patients taking digitalis

h. Consider Glucagon 1 mg slow IV push over 1-2 minutes. Digitalis Overdose:

i. Consider normal saline IV j. Consider Atropine 0.5 mg IV every 5 minutes as needed up to total dose of 3 mg k. Consider transcutaneous pacemaker

Tricyclic Antidepressants (Elavil, Tofranil) Overdose:

l. Consider Sodium bicarbonate 50 mEq IV for wide complex QRS m. Be cautious for seizures

Considerations

• Naloxone is preferentially administered intranasal even in the presence of established venous access. Side effects such as nausea, vomiting and combativeness are significantly decreased with IN administration.

• Do not rely entirely on patient history of ingestion, especially in suicide attempts • Bring bottles, contents, emesis to ED • Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental

status or coma; be aware of rapid progression from alert mental status to death.


58

• Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure

• Depressants: decreased HR, decreased BP, deceased temperature, decreased respirations, non-specific pupils

• Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures • Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes • Cardiac Meds: Hypotension, dysrhythmias and mental status changes • Solvents: nausea, vomiting, and mental status changes • Insecticides: SLUDGE-Salivations, Lacrimation, Urination, Defecation, GI distress & Emesis


59

PAIN CONTROL

HISTORY:

o Age o Location o Duration o Severity (0-10) o Past medical history o Recent pain medication

usage o Medications o Allergies o SAMPLE

SIGNS AND SYMPTOMS:

o Onset o Provocation / Palliation o Quality (Sharp, dull, etc.) o Radiation o Severity o Relation to movement,

inspiration o Increased with palpation o Pertinent Negatives o Pupil response

DIFFERENTIAL:

o Per the specific protocol o Musculoskeletal o Visceral (abdominal) o Cardiac o Pleural/Respiratory o Neurogenic o Renal (colic)



a) First, attempt to manage all painful conditions: Splint extremity injuries Place the patient in a position of comfort

b) Appropriate Protocol per patient’s complaint c) Record pain severity score d) Monitor and Assess vital signs


b) Consider administration of pain medications for patients that have significant pain, do not have a decreased level of consciousness, are hemodynamically stable, and have oxygen saturations above 93% . Morphine 2-4 mg via IV/IO, repeated in 5 min, to a maximum of 10 mg

OR Fentanyl 25 to 50 mcg slow IV/IO every 5 minutes as needed to a maximum of

200 mcg Ketamine 0.1-0.3 mg/kg IV/IO or 0.5 mg/kg IM/IN

c) Administer naloxone 2 mg IV for respiratory depression from narcotics. May repeat. d) For severe pain consider anxiolytic medication

Midazolam 1-2 mg slow IV/IO/IM repeated every 5 minutes as needed to a maximum of 5 mg OR

Lorazepam 1-2 mg slow IV, repeated every 30 minutes as needed to a maximum of 4 mg


60

e) Monitor ECG and O2 saturations f) The patient must have vital signs taken prior to each dose, after each dose, and be

monitored closely. g) After drug administration, reassess the patient using the appropriate pain scale.

Considerations:

• Pain severity is a vital sign to be recorded pre and post IV/IO medication delivery and at disposition

• Vital signs should be obtained pre, 15 min post and at disposition with all pain medications • Pain meds are contraindicated in patients with hypotension. Consider carefully use in

patients with AMS, head injury, or respiratory distress. • If at any time there is a decreased level of consciousness, decrease in oxygen saturation

below 94%, or blood pressure drops to 90 mmHg or less, administration of narcotic medication must stop


61

RESPIRATORY DISTRESS

HISTORY:

o Asthma; COPD; chronic bronchitis, emphysema, congestive heart failure

o Home treatment (oxygen, nebulizer)

o Medications (theophylline, steroids, inhalers)

o Toxic exposure, smoke inhalation

o SAMPLE

SIGNS AND SYMPTOMS:

o Shortness of breath o Pursed lip breathing o Decreased ability to

speak o Increased respiratory rate

and effort o Wheezing, rhonchi, rales,

stridor o Use of accessory muscles o Tripod positioning o Fever, cough o Tachycardia o Pertinent Negatives

DIFFERENTIAL:

o Asthma o Anaphylaxis o Aspiration o COPD (Emphysema,

Bronchitis) o Pleural effusion o Pneumonia o Pulmonary Embolus o Pneumothorax o Cardiac (MI or CHF) o Pericardial Tamponade o Hyperventilation o Inhaled Toxin

1. Follow the Initial Patient Care Protocol


2. If Respiratory Insufficiency follow the Airway – Adult Protocol 3. If no respiratory insufficiency place patient in position of comfort 4. Obtain 12 lead ECG and transmit 5. Monitor and assess vital signs 6. If signs/symptoms found go to the appropriate protocol i.e. Allergic Reaction, Asthma/COPD,

Chest Pain, and Pulmonary Edema. 7. Consider CPAP

ADVANCED CARE GUIDELINES 8. Obtain vascular access 9. Cardiac monitoring 10. Consider Albuterol up to 5.0 mg via nebulizer. May repeat if indicated 11. Consider Epinephrine 0.5 mg 1:1,000 IM 12. Consider methylprednisolone 125 mg IV


62

SEIZURE

HISTORY:

o Reported / witnessed seizure activity

o Previous seizure history

o Medic Alert tag information

o Seizure medications o History of trauma o History of diabetes o History of pregnancy o Recent fever/viral

illness o SAMPLE

SIGNS AND SYMPTOMS:

o Decreased mental status o Lethargy o Incontinence o Observed seizure activity o Evidence of trauma o Unconsciousness o In children, fever, hot dry

skin, altered mental status


DIFFERENTIAL:

o CNS (Head) trauma o Tumor o Metabolic, Hepatic or Renal

Failure o Electrolyte abnormality (NA,

CA, Mg) o Drugs, Medications, Non-

compliance o Infection/fever o Alcohol withdrawal o Eclampsia o Stroke o Hyperthermia o Hypoglycemia o Overdose

1. Follow initial patient care protocol 2. If Associated with Pregnancy, see Eclampsia Protocol

ACTIVE SEIZURE


a) Protect airway


b) Administer benzodiazepine such as: Lorazepam 2 mg IV/IO push, continue with 2 mg increments every 2 minutes

until the seizure stops or until maximum dose of 10 mg is given OR Midazolam 2 mg IV/IO push, continue with 2 mg increments every 2 minutes

until the seizure stops or until maximum dose of 10 mg is given OR Midazolam 5 mg IN. May repeat x 1 after 2 minutes.

c) Check blood glucose level, if available, and treat hypoglycemia if present d) Cardiac monitoring, 12 lead ECG

POSTICTAL



63

a) Protect airway b) Check blood sugar, if available, and treat hypoglycemia if present per diabetic protocol c) Follow Altered Mental Status protocol if indicated d) If associated with Pregnancy follow Eclampsia Protocol


e) Consider monitoring ETCO2

CONSIDERATIONS

• Status Epilepticus is defined as a prolonged seizure greater than 5 minutes or two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment and transport.

• Grand mal seizures (generalize tonic-clonic) are associated with loss of consciousness, incontinence and possible tongue trauma.

• Focal seizures affect only a part of the body and are not usually associated with a loss of consciousness.

• Jacksonian seizures are seizures which start as a focal seizure and become generalized. • Be prepared for airway problems and continued seizures • Assess possibility of trauma, substance abuse, or alcohol/benzo withdrawal. • Be prepared to assist ventilations, especially if midazolam is used. Midazolam can cause

hypotension and respiratory depression. • For any seizure in a pregnant patient, follow the PRE-ECLAMPSIA/ECLAMPSIA Protocol • If febrile, remove clothing and sponge with room temperature water. • In an infant, a seizure is most commonly a febrile seizure, but may be the only evidence of a

closed head injury.


64

SEPSIS

HISTORY:

o Age o Duration of Illness o Past medical history o Medications o Immunocompromised

(transplant, HIV, diabetes, cancer)

o Environmental exposure o Last acetaminophen or

ibuprofen administration o SAMPLE

SIGNS AND SYMPTOMS:

o Warm o Flushed o Diaphoretic o Chills/Rigor o Associated symptoms:

Myalgia’s, cough, chest pain, headache, dysuria, abdominal pain, mental status changes, rash.


DIFFERENTIAL:

o Shock o Hypovolemic o Cardiogenic o Neurogenic o Anaphylactic o Fever o Cancer / Tumors /

Lymphomas o Medication / drug reaction o Hyperthyroidism o Heat Stroke o Meningitis



2. Assess skin temperature 3. Obtain blood glucose 4. Obtain 12 lead ECG and transmit


5. Obtain vascular access 6. Consider NS or LR bolus to reach target of SBP > 90 7. Consider Dopamine 5-20 mcg/kg/min to reach SBP > 90 8. Two or more SIRS criteria and a suspected source of infection &

ETCO2 < 25 probable SEPSIS ALERT

CONSIDERATIONS • If available, report the patient’s actual temperature. Temperatures of >

38˚C (100.4˚F) or < 36˚C (96.8˚F) are positive SIRS criteria • Sepsis is a rapidly progressing, life threatening condition due to

systemic infections. Sepsis must be recognized early and treated aggressively to prevent progression to shock and death

• Hypotension is defined as a SBP <90 • In the presence of hypotension, administer 500 ml bolus of fluid (unless

contraindicated) prior to dopamine administration • In cases of suspected right sided heart failure, contact medical control

for fluid order.

Systemic Inflammatory Response Syndrome (SIRS)

Two or more of the following symptoms

o Pulse > 90 BPM o Respirations > 20 or

mechanically ventilated o Elevated temperature o Altered Mental Status o Hyperglycemia (BS >

120 mg/dl)


65

STROKE

HISTORY:

o Previous CVA, TIA’s o Previous cardiac /

vascular surgery o Associated diseases:

diabetes, hypertension, CAD

o Atrial fibrillation o Medications (blood

thinners) o History of trauma o SAMPLE

SIGNS AND SYMPTOMS:

o Altered mental status o Weakness / Paralysis o Blindness or other sensory loss o Aphasia / Dysarthria o Syncope o Vertigo / Dizziness o Vomiting o Headache o Seizures o Respiratory pattern change o Hypertension / Hypotension o Pertinent Negatives

DIFFERENTIAL:

o See Altered Mental Status

o TIA (transient ischemic attack)

o Seizure o Hypoglycemia o Stroke

Thrombotic ( ̴85%) Hemorrhagic ( ̴15%)

o Tumor o Trauma



2. Prehospital Stroke Screen 3. If positive and Symptoms < 5 hours, transport to the destination as per the EMS System Stroke

Plan. Goal: Scene Time 10 minutes or less and Provide Early Notification. 4. Obtain Blood Glucose If < 60 and the patient is symptomatic and able to swallow administer 15

gm oral glucose 5. Obtain 12 lead ECG and Transmit 6. Consider other protocols as indicated: Altered Mental Status; Hypertension, Seizure,

Overdose/Toxic Ingestion ADVANCED CARE GUIDELINES

7. IV/IO 8. Cardiac Monitoring 9. If Blood Glucose < 60 mg/dl and patient is unable to swallow, See Diabetic Emergency protocol 10. If no vascular access administer Glucagon 1 mg IM

REPORT TO RECEIVING FACILITY o Time of onset/last seen at baseline o Stroke scale findings o Vital signs including Glasgow Coma Scale o Blood Glucose o Any seizure? o Terminal condition exist?


66

CONSIDERATIONS

• Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro, Stroke Scale • Items in Red Text are key performance measures used in the EMS Acute Stroke Care • The reperfusion checklist should be completed for any suspected stroke patient. With a durations of

symptoms of less than 5 hours, scene times should be limited to 10 minutes, early destination notification/activations should be provided and transport times should be minimized based on the EMS System Stroke Plan

• Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke symptoms would be defined as an onset time of the previous night when the patient was symptom free)

• The differential listed on the Altered Mental Status Protocol should also be considered • Elevated blood pressure is commonly present with stroke. See Hypertensive Emergency Protocol • Be alert for airway problems (swallowing difficulty, vomiting / Aspiration • Hypoglycemia can present as a localized neurologic deficit, especially in the elderly • Document the Stroke Screen results in the PCR


67

MEND EXAM


68

SYNCOPE / WEAKNESS

HISTORY:

o Cardiac history, stroke, seizure

o Occult blood loss (GI, ectopic)

o Females: LMP, vaginal bleeding

o Fluid loss: nausea, vomiting, diarrhea

o Past medical history o Medications o Syncope history:

exertional/vasovagal o Anxiety/psychiatric illness o SAMPLE

SIGNS AND SYMPTOMS:

o Loss of consciousness with recovery

o Lightheadedness, dizziness o Palpitations, slow or rapid

pulse o Irregular pulse o Decreased blood pressure o Weakness o “Fainting” o Pertinent Negatives

DIFFERENTIAL:

o Vasovagal o Orthostatic hypotension o Cardiac syncope o Micturition / defecation

syncope o Psychiatric o Stroke o Hypoglycemia o Seizure o Shock (see Shock

Protocol) o Toxicologic (Alcohol,

drugs) o Medication effect (i.e.

beta-blocker)

1. Follow Initial patient care protocol


2. Obtain blood glucose, if < 60 mg/dl and the patient is symptomatic and able to swallow, administer 15 gm glucose orally

3. Obtain 12 lead ECG and transmit 4. If relevant signs / symptoms are found go to the appropriate protocol: Altered Mental Status,

Hypotension, Diabetic Emergency, and Dysrhythmia. ADVANCED CARE GUIDELINES

5. VASCULAR ACCESS 6. CARDIAC MONITOR 7. IF SYSTOLIC BP < 90 CONSIDER FLUID BOLUS UP TO 500 ML NORMAL SALINE IF NO CONTRAINDICATIONS 8. IF BLOOD GLUCOSE , 60 MG/DL AND PATIENT IS SYMPTOMATIC AND UNABLE TO SWALLOW,

FOLLOW THE DIABETIC EMERGENCY PROTOCOL


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CONSIDERATIONS

• Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro

• Assess for signs and symptoms of trauma if associated or questionable fall with syncope • Consider dysrhythmias, GI bleed, ectopic pregnancy and seizure as possible causes of syncope • More than 25% of geriatric syncope is cardiac dysrhythmia based.


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OB PROTOCOLS

CHILDBIRTH / LABOR

NEWBORN

OBSTETRICAL EMERGENCY

PRE-ECLAMPSIA / ECLAMPSIA


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CHILDBIRTH / LABOR

HISTORY:

o Age o Gravida/para/due date o Time contractions started

/ how often o Rupture of membranes o Time / amount of any

vaginal bleeding o Sensation of fetal activity o Color of fluid discharge o Social history (drugs,

smoking, alcohol) o SAMPLE

SIGNS AND SYMPTOMS:

o Spasmodic pain o Vaginal discharge of

bleeding o Crowning or urge to push o meconium

DIFFERENTIAL:

o Abnormal presentation Buttock Foot Hand

o Prolapsed cord o Placenta Previa o Abruptio placenta o Braxton Hicks contractions o Uterine rupture



2. Put patient in left lateral position 3. Inspect perineum (no digital vaginal exam) 4. No crowning – monitor, reassess, document frequency and duration of contractions 5. Normal Delivery –crowning, > 36 weeks gestation

a) If delivery is imminent with crowning, commit to delivery on site and contact medical control.

b) If the amniotic sac does not break, or has not broken, use a clamp to puncture the

sac and push it away from the infant’s head and mouth as they appear.

c) Clamp cord with 2 clamps and cut the cord between the clamps.

d) For newborn management, see newborn protocol.

6. Abnormal Delivery (crowning, < 36 weeks gestation, abnormal presentation, severe vaginal bleeding, multiple gestation) IMMEDIATE TRANSPORT


72

Breech Delivery (Buttocks Presentation) a) Allow spontaneous delivery. b) Support infant's body as it’s delivered. c) If head delivers spontaneously, proceed as in (Normal Delivery). d) If head does not deliver within 3 minutes, insert gloved hand into the

vagina, keeping your palm toward baby's face; form a "V" with your fingers and push wall of vagina away from baby's face, thereby creating an airway for baby. Do not remove your hand until relieved by advanced EMS or hospital staff.

Prolapsed Cord

a) Insert gloved hand into the vagina, keeping your palm toward baby's face; form a "V" with your fingers and push wall of vagina away from baby's face, thereby creating an airway for baby. Do not remove your hand until relieved by advanced EMS or hospital staff.

Contact medical control for any other issues.

CONSIDERATIONS

• Document all times (delivery, contraction frequency and length • If maternal seizures occur, refer to the Obstetrical emergency protocol • After delivery, massaging the uterus will promote uterine contraction and help to control

post-partum bleeding • some perineal bleeding is normal with any childbirth. large quantities of blood > 500 ml is

abnormal


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NEWBORN

HISTORY:

o Due date and gestational age

o Multiple gestation o Meconium o Delivery difficulties o Congenital disease o Medications (maternal) o Maternal substance

abuse & smoking

SIGNS AND SYMPTOMS:

o Respiratory distress o Peripheral cyanosis or

mottling (normal) o Central cyanosis (abnormal) o Altered level of

consciousness o Bradycardia o Tachycardia o Tachypnea

DIFFERENTIAL:

o Airway failure Secretions Respiratory drive

o Infection o Maternal medication effect o Hypovolemia o Hypoglycemia o Congenital defect o Hypothermia



2. Suction the airway using a bulb syringe as soon as the head is delivered and before delivery of the body. Suction the mouth first, then the nose

3. Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap the baby in a thermal blanket or dry towel. Cover the scalp to preserve warmth

4. Open and position the airway. Suction the airway again using a bulb syringe. Suction the mouth first, then the nose

5. Assess breathing and adequacy of ventilation

6. If ventilation is inadequate, stimulate by gently rubbing the back and flicking the soles of the feet

7. If ventilation is still inadequate after brief stimulation, begin assisted ventilation at 40 to 60 breaths per minute using a bag-valve-mask device with room air. If no improvement after 30-60 seconds, apply 100% oxygen

8. If ventilation is adequate and the infant displays central cyanosis, administer oxygen at 5 L via blow-by. Hold the tubing 1/2 to 1 inch from the nose

9. If the heart rate is slower than 60 beats per minute after 30 seconds of assisted ventilation with high-flow, oxygen:


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a) Begin chest compressions at a combined rate of 120/minute (three compressions to each ventilation)


10. If there is no improvement in heart rate after 30 seconds. Perform endotracheal intubation

11. If there is no improvement in heart rate after intubation and ventilation, administer Epinephrine 1:10,000 concentration at 0.01 mg/kg (maximum individual dose 1.0

mg) IV/IO Repeat epinephrine at the same dose every 3 to 5 minutes as needed

k) Initiate transport. Reassess heart rate and respirations enroute

If the heart rate is between 60 & 80 beats per minute, initiate the following actions: a) Continue assisted ventilation with high-flow, 100% concentration oxygen. If there is no

improvement in heart rate after 30 seconds, initiate management sequence described in step H above, beginning with chest compressions

b) Initiate transport. Reassess heart rate and respirations enroute If the heart rate is between 80 & 100 beats per minute, initiate the following actions:

a) Continue assisted ventilation with high-flow, 100% concentration oxygen. Stimulate as previously described

b) Initiate transport. Reassess heart rate after 15 to 30 seconds If the heart rate is faster than 100 beats per minute, initiate the following actions:

a) Assess skin color. If central cyanosis is still present, continue blow by oxygen. Initiate transport. Reassess heart rate and respirations enroute

If thick meconium is present: a) Initiate endotracheal intubation before the infant takes a first breath. Suction the airway

using an appropriate suction adapter while withdrawing the endotracheal tube. Repeat this procedure until the endotracheal tube is clear of meconium. If the infant’s heart rate slows, discontinue suctioning immediately and provide ventilation until the infant recovers

Note: If the infant is already breathing or crying, this step may be omitted

CONSIDERATIONS

• Maternal sedation or narcotics will sedate newborn (Naloxone effective) • Consider hypoglycemia in newborn • Document 1 and 5 minute APGAR scores (see appendix)


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OBSTETRICAL EMERGENCY

HISTORY:

o Hypertension meds o Prenatal care o LMP / Gestational age o Previous complicated

pregnancies o Gravid / Para o SAMPLE o MVC with seatbelt use

/ air bag deployment

SIGNS AND SYMPTOMS:

o Vaginal bleeding / discharge / mucous plug/ ruptured membranes

o Abdominal pain o Seizures o Hypertension o Severe headache o Visual changes o Edema of hand and face

DIFFERENTIAL:

o Pre-eclampsia/Eclampsia o Placenta previa o Placenta abruptio o Spontaneous abortion o Gestational diabetes o Uterine rupture o Trauma



2. If Hypertension – go to Pre-eclampsia / Eclampsia Protocol 3. Vaginal bleeding / abdominal pain / contraction?

Known pregnancy / missed period Estimate gestation 1st or 2nd trimester consult medical control 3rd trimester place in left lateral position and immediate transport. Be

prepared to follow Childbirth Protocol No known pregnancy or missed period

Go to Abdominal Pain protocol

CONSIDERATIONS

• Severe headache, vision changes, or RUQ pain may indicate pre-eclampsia • In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or

greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) blood pressure.

• Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome • Ask patient to quantify bleeding - number of pads used per hour • Any pregnant patient involved in a MVC should be seen immediately by a physician for

evaluation and fetal monitoring


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PRE-ECLAMPSIA / ECLAMPSIA

HISTORY:

o Hypertension meds o Prenatal care o LMP / Gestational age o Previous complicated

pregnancies o Gravid / Para o SAMPLE o MVC with seatbelt use

/ air bag deployment

SIGNS AND SYMPTOMS:

o Vaginal bleeding / discharge / mucous plug/ruptured membranes

o Abdominal pain o Seizures o Hypertension o Severe headache o Visual changes o Edema of hand and face

DIFFERENTIAL:

o Pre-eclampsia/Eclampsia o Placenta previa o Placenta abruptio o Spontaneous abortion o Gestational diabetes o Uterine rupture o Trauma



2. Active Labor – go to Childbirth Labor Protocol 3. If not hypertensive – go to Obstetrical Emergency Protocol


4. If hypertensive

Pre-eclampsia place patient in left lateral position

Eclampsia If Seizure or seizure-like activity

o Administer Magnesium sulfate 4 grams IV over 3 minutes o Consider midazolam 2mg IV if no termination of seizure, may

repeat in 2 mg increments to a maximum of 10 mg o Obtain blood glucose

- Go to Diabetic Emergency Protocol if indicated If no seizure activity place patient in left lateral position

CONSIDERATIONS

• Eclampsia seizures may occur up to 2 months post-partum. Always consider in pregnant / recently pregnant seizing patient

• If no IV and unable to secure an IV/IO due to seizure activity, do not delay administration of midazolam via IN/IM route


77

• Severe headache, vision changes, or rug pain may indicate pre-eclampsia • In the setting of pregnancy, hypertension is defined as a bp greater than 140

systolic or greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) blood pressure.

• Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome


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PEDIATRIC PROTOCOLS

PEDIATRIC INITIAL CARE PROTOCOL

PEDIATRIC AIRWAY

PEDIATRIC ALLERGIC REACTION

PEDIATRIC ALTERED MENTAL STATUS

PEDIATRIC ASTHMA

PEDIATRIC BEHAVIORAL EMERGENCIES

PEDIATRIC BURNS

PEDIATRIC CARDIAC ARRHYTHMIA

PEDIATRIC DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS

PEDIATRIC NAUSEA AND VOMITING

PEDIATRIC NEAR DROWNING

PEDIATRIC PAIN CONTROL

PEDIATRIC POISONING

PEDIATRIC SEIZURE

PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION

PEDIATRIC SHOCK

SUSPECTED CHILD ABUSE

PEDIATRIC TRAUMA


79

INITIAL PATIENT CARE PROTOCOL-ADULT AND PEDIATRICS Revised 2018 - This protocol serves to reduce the need for extensive reiteration of basic assessment and other considerations in every protocol.

Assessment

1. Assess scene safety

a. Evaluate for hazards to EMS personnel, patient, bystanders

b. Determine number of patients

c. Determine mechanism of injury

d. Request additional resources if needed and weigh the benefits of waiting for additional resources against rapid transport to definitive care

e. Consider declaration of mass casualty incident if needed

2. Use appropriate personal protective equipment (PPE)

3. Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g. operations at night

or in darkness, on or near roadways) 4. Consider cervical spine stabilization and/or spinal care if trauma

Primary Survey

1. Airway, Breathing, Circulation is cited below; (although there are specific circumstances where Circulation, Airway, Breathing may be indicated such as cardiac arrest or major arterial bleeding) a. Airway (assess for patency and open the airway as indicated)

i. Patient is unable to maintain airway patency—open airway 1. Head tilt chin lift 2. Jaw thrust 3. Suction 4. Consider use of the appropriate airway management adjuncts and devices:

• oral airway, • nasal airway, • blind insertion, or supraglottic airway device, • laryngeal mask airway, • endotracheal tube

5. For patients with laryngectomies or tracheostomies, remove all objects or clothing that may obstruct the opening of these devices, maintain the flow of prescribed oxygen, and reposition the head and/or neck

b. Breathing


80

i. Evaluate rate, breath sounds, accessory muscle use, retractions, patient positioning ii. Administer oxygen as appropriate with a target of achieving 94-98% saturation for most acutely ill patients iii. Apnea (not breathing) – open airway-see #4 above

c. Circulation

i. Control any major external bleeding [see Extremity Trauma/External Hemorrhage Management guideline] ii. Assess pulse

1. If none – go to Pediatric Cardiac Arrhythmia Protocol 2. Assess rate and quality of carotid and radial pulses

iii. Evaluate perfusion by assessing skin color and temperature 1. Evaluate capillary refill

d. Disability

i. Evaluate patient responsiveness: AVPU scale (Alert, Verbal, Pain, Unresponsive) ii. Evaluate gross motor and sensory function in all extremities iii. Check blood glucose in patients with altered mental status iv. If acute stroke suspected – go to Stroke Protocol

e. Expose patient as appropriate to complaint

i. Be considerate of patient modesty ii. Keep patient warm

Secondary Survey

1. The performance of the secondary survey should not delay transport in critical patients. Secondary surveys should be tailored to patient presentation and chief complaint. Secondary survey may not be completed if patient has critical primary survey problems a. Head

i. Pupils ii. Naso-oropharynx iii. Skull and scalp

b. Neck

i. Jugular venous distension ii. Tracheal position iii. Spinal tenderness

c. Chest

i. Retractions ii. Breath sounds iii. Chest wall deformity

d. Abdomen/Back


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i. Flank/abdominal tenderness or bruising ii. Abdominal distension

e. Extremities i. Edema ii. Pulses iii. Deformity

e. Neurologic i. Mental status/orientation ii. Motor/sensory

2. Obtain Baseline Vital Signs (An initial full set of vital signs is required: pulse, blood pressure,

respiratory rate, neurologic status assessment) (see chart below) a. Neurologic status assessment: establish a baseline and note any change in patient neurologic status

i. Glasgow Coma Score (GCS) (see chart below) or ii. AVPU (Alert, Verbal, Painful, Unresponsive)

b. Patients with cardiac or respiratory complaints

i. Pulse oximetry ii. 12-lead EKG should be obtained early in patients with cardiac or suspected cardiac complaints iii. Continuous cardiac monitoring, if available iv. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry

c. Patient with altered mental status

i. Check blood glucose ii. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry

d. Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should be taken shortly before arrival at receiving facility

e. Critical patients should have pertinent vital signs frequently monitored

3. Obtain OPQRST history:

a. Onset of symptoms b. Provocation – location; any exacerbating or alleviating factors c. Quality of pain d. Radiation of pain e. Severity of symptoms – pain scale f. Time of onset and circumstances around onset

4. Obtain SAMPLE history:


82

a. Symptoms b. Allergies – medication, environmental, and foods c. Medications – prescription and over-the-counter; bring containers to ED if possible d. Past medical history

i. Look for medical alert tags, portable medical records, advance directives ii. Look for medical devices/implants (some common ones may be dialysis shunt, insulin pump, pacemaker, central venous access port, gastric tubes, urinary catheter)

e. Last oral intake f. Events leading up to the 911 call

In patients with syncope, seizure, altered mental status, or acute stroke, consider bringing the witness to the hospital or obtain their contact phone number to provide to ED care team

Treatment and Interventions

1. Administer oxygen as appropriate with a target of achieving 94-98% saturation

2. Tier with an appropriate service if advanced level of care or assistance is needed and can be accomplished in a timely manner

3. Place appropriate monitoring equipment as dictated by assessment and scope of practice – these may include:

a. Continuous pulse oximetry b. Cardiac rhythm monitoring c. Waveform capnography or digital capnometry d. Carbon monoxide assessment

4. If within scope of practice establish vascular access if indicated or in patients who are at risk for

clinical deterioration. a. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of lidocaine 0.1mg/mL with slow push through IO needle to a maximum of 40 mg to mitigate pain from IO medication administration

5. Monitor pain scale if appropriate

6. Reassess patient

Patient Safety Considerations

1. Routine use of lights and sirens is not warranted

2. Even when lights and sirens are in use, always limit speeds to level that is safe for the emergency vehicle being driven and road conditions on which it is being operated

3. Be aware of legal issues and patient rights as they pertain to and impact patient care (e.g.

patients with functional needs or children with special healthcare needs)


83

4. Be aware of potential need to adjust management based on patient age and comorbidities,

including medication dosages

5. The maximum weight-based dose of medication administered to a pediatric patient should not exceed the maximum adult dose except where specifically stated in a patient care guideline

6. Direct medical control should be contacted when mandated or as needed

Key Considerations Pediatrics: ALWAYS use a weight-based assessment tool (length-based tape or other system) to estimate patient weight and guide medication therapy and adjunct choices.

a. The pediatric population is generally defined by those patients who weigh up to 40 kg or up to 14-years of age, whichever comes first b. Consider using the pediatric assessment triangle (appearance, work of breathing, circulation) when first approaching a child to help with assessment.

Geriatrics: The geriatric population is generally defined as those patients who are 65 years old or more.

a. In these patients, as well as all adult patients, reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease)

Co-morbidities: reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease). Normal Vital Signs


84

Age Pulse Respiratory Rate

Systolic BP

Preterm less than 1 kg 120-160 30-60 36-58 Preterm 1 kg 120-160 30-60 42-66 Preterm 2 kg 120-160 30-60 50-72 Newborn 120-160 30-60 60-70 Up to 1 year 100-140 30-60 70-80 1-3 years 100-140 20-40 76-90 4-6 years 80-120 20-30 80-100 7-9 years 80-120 16-24 84-110 10-12 years 60-100 16-20 90-120 13-14 years 60-90 16-20 90-120 15 years or older 60-90 14-20 90-130

Glasgow Coma Scale

ADULT GLASGOW COMA SCALE PEDIATRIC GLASGOW COMA SCALE Eye Opening (4) Eye Opening (4) Spontaneous 4 Spontaneous 4 To Speech 3 To Speech 3 To Pain 2 To Pain 2 None 1 None 1 Best Motor Response (6) Best Motor Response (6) Obeys Commands 6 Spontaneous

Movement 6

Localizes Pain 5 Withdraws to Touch

5

Withdraws from Pain

4 Withdraws from Pain

4

Abnormal Flexion 3 Abnormal Flexion 3 Abnormal Extension

2 Abnormal Extension

2

None 1 None 1 Verbal Response (5) Verbal Response (5) Oriented 5 Coos, Babbles 5 Confused 4 Irritable Cry 4 Inappropriate 3 Cries to Pain 3 Incomprehensible 2 Moans to Pain 2 None 1 None 1 Total Total


85

Pediatric Airway Reviewed 2016


Breathing spontaneous on initial assessment with adequate ventilation


a) Maintain oxygenation with cannula, mask, or blow-by if oxygen saturations are below 94%, titrate to 94% - 99%

Breathing without adequate ventilation or not breathing


a) Open the airway

b) Attempt assisted ventilation using an appropriate adjunct with high-flow 100% oxygen. If unable to ventilate, first reposition airway and attempt to ventilate again

c) If ventilation still unsuccessful, check airway for obstruction and attempt to dislodge with age appropriate techniques


d) If unsuccessful establish direct view of object and attempt to remove it with Magill forceps

If obstruction cleared


a) Assist with ventilation and provide oxygen.


b) If adequate ventilation is NOT maintained proceed to an advanced airway as appropriate for patient size

If obstruction not cleared


a) Attempt endotracheal intubation and try to ventilate the patient

b) If endotracheal intubation is not successful, perform needle cricothyrotomy and needle insufflation


86

PEDIATRIC ALLERGIC REACTION Reviewed 2012



b) Assess airway via Airway Protocol

c) If the patient has a physician prescribed auto-injectable epinephrine assist with administration and monitor for signs of anaphylaxis


d) Administer epinephrine 1 mg/ml (1:1,000) concentration 0.01 mg/kg IM, up to a maximum dose of 0.3 - 0.5 mg

e) Establish IV access

f) Administer diphenhydramine at 1.0 mg/kg IV or deep IM, up to a maximum dose of 50 mg

g) Administer epinephrine 1 mg/10 ml (1:10,000) concentration 0.01 mg/kg IV for profound shock, up to a maximum dose of 0.3 - 0.5 mg

h) Administer albuterol 2.5 mg by nebulizer if in respiratory distress


87

PEDIATRIC ALTERED MENTAL STATUS Revised 2017



a) Obtain blood glucose

b) If conscious & able to swallow, administer glucose 15 gm by mouth for children over 2 years of age.


c) If blood sugar less than 60 mg/dL administer Dextrose based on Pediatric Dosing Reference

d) If patient unconscious and no IV access; administer Glucagon 0.025 mg/kg IM up to 1 mg maximum

e) If no improvement in level of consciousness after glucose administration give naloxone 0.1 mg/kg IV up to maximum dose of 2.0 mg per dose


88

PEDIATRIC ASTHMA Revised 2016



a) Use Airway Protocol to evaluate the airway and adequacy of ventilation

b) If patient has a physician prescribed, hand-held metered dose inhaler, assist with administration

c) Reassess patient and repeat second dose if necessary per medical direction


d) Administer albuterol 2.5.mg via Nebulizer. Repeat as necessary.

e) Evaluate the need for epinephrine 1 mg/ 1 ml (1:1,000) concentration according to length/weight based tape (0.01 mg/kg). Dosage may be repeated once after 5 minutes.

f) Evaluate the need for intubation.


89

PEDIATRIC BEHAVIORAL EMERGENCIES New 2017


2. If there is evidence of immediate danger, protect yourself and others by summoning law enforcement to help ensure safety


a) Consider medical or traumatic causes of behavior problems

b) Keep environment calm


c) For severe anxiety, consider a benzodiazepine such as Lorazepam, with dosages based on Pediatric Dosing Reference


90

PEDIATRIC BURNS Revised 2016


2. Continually monitor the airway for evidence of obstruction

3. Do not use any type of ointment, lotion, or antiseptic

4. Maintain normal patient temperature

5. Transport according to the Out-of-Hospital Trauma Destination Decision Protocol (Appendix B)

Thermal Burns BASIC CARE GUIDELINES

a) Stop the burning process

b) Remove smoldering clothing and jewelry

c) Prevent further contamination of wounds

d) Cover the burned area with a clean, dry dressing or plastic wrap

e) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness


f) Establish an IV of LR or NS. For severe burns, consider administration of 20 ml/kg, not to exceed 500 ml.

g) Contact medical control for further fluid administration

h) Treat pain per pain protocol


91

Pediatric Burns Continued

Chemical Burns BASIC CARE GUIDELINES

a) Brush off powders prior to flushing. Lint roller may also be used to remove powders prior to flushing

b) Immediately begin to flush with large amounts of water. Continue flushing the contaminated area when en route to the receiving facility

c) Do not contaminate uninjured areas while flushing

d) Attempt to identify contaminant

e) Transport according to the Out-of-Hospital Destination Decision Protocol (Appendix B)


f) Treat pain per pain control protocol

Toxin in Eye BASIC CARE GUIDELINES

a) Flood eye(s) with lukewarm water and have patient blink frequently during irrigation. Use caution to not contaminate other body areas

b) Continue irrigation until advanced personnel take over

c) Attempt to identify contaminant

d) Transport to the most appropriate medical facility


e) Treat pain per pain control protocol


92

Pediatric Burns Continued

Electrical Burns BASIC CARE GUIDELINES

a) Treat soft tissue injuries associated with the burn with dry dressing

b) Treat for shock if indicated

c) Transport according to the Out-of-Hospital Destination Decision Protocol (Appendix B)

d) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness


f) Treat pain per pain control protocol


93

PEDIATRIC CARDIAC ARRHYTHMIA Updated 2017


If no pulse BASIC CARE GUIDELINES

a) Perform high quality CPR immediately, apply AED and follow device prompts


b) Perform high quality CPR immediately, apply monitor and check rhythm as soon as possible

Ventricular fibrillation or ventricular tachycardia a) Defibrillate at 2J/kg, immediately resume CPR for two minutes

b) Second defibrillation at 4 J/kg

c) Subsequent defibrillations increasing by 2 J/kg, to a maximum of 10 J/kg, not to exceed

maximum adult dose

d) Evaluate and treat for underlying causes

e) Administer epinephrine 1 mg/ 10 ml (1:10,000) according to Pediatric Dosing Reference every 3-5 minutes

f) Administer anti-arrhythmic

Administer amiodarone according to Pediatric Dosing Reference, may repeat twice


94

Pediatric Cardiac Arrhythmia continued

ASYSTOLE/PEA a) Evaluate and treat for underlying causes

b) Administer epinephrine 1 mg/ 10 ml (1:10,000) according to Pediatric Dosing Reference

every 3-5 minutes as needed

Arrhythmias with pulse BASIC CARE GUIDELINES

a) If patient is complaining of shortness of breath, has signs of respiratory distress, or pulse oximetry of less than 94% then titrate oxygen to symptom improvement or to maintain a saturation of 94-99%

b) Evaluate and treat for underlying causes

Bradycardia with signs of poor perfusion BASIC CARE GUIDELINES

a) Start CPR if pulse is less than 60 and altered mental status


b) Administer epinephrine 1 mg/ 10 ml (1:10,000) according to Pediatric Dosing Reference every 3-5 minutes

c) Consider administration of atropine according to Pediatric Dosing Reference

Tachycardia (rates greater than 180 in children or 210 in infants) ADVANCED CARE GUIDELINES

a) If patient unstable: a. Perform synchronized cardioversion according to Pediatric Dosing Reference b. Consider sedation according to Pediatric Dosing Reference

b) If patient stable: With wide QRS

• If regular and monomorphic, consider administration of adenosine according to Pediatric Dosing Reference

With narrow QRS • Perform vagal maneuvers • Consider administration of adenosine according to Pediatric Dosing

Reference


95

PEDIATRIC DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS Updated 2018

Follow initial patient care protocol

Resuscitation should be started on all patients who are found apneic and pulseless unless the following medical cause, traumatic injury or body condition clearly indicating biological death (irreversible brain death) such as:

• Signs of trauma are conclusively incompatible with life o Decapitation o Transection of the torso o 90% of the body surface area with full thickness burns o Massive crush injury o Apneic, pulseless and without other signs of life (movement, EKG activity,

pupillary response) • Cardiac and respiratory arrest with obvious signs of death including

o Rigor mortis o Dependent lividity

• Physical decomposition of the body

OR A valid DNR order (form, card, bracelet) or other actionable medical order (e.g. I-POST form) that:

• Conforms to the state specifications

If apparent death is confirmed, continue as follows: a) The county Medical Examiner and law enforcement shall be contacted 712-297-7583. b) When possible, contact Iowa Donor Network at 1-800-831-4131.

See Protocol Appendix J c) At least one EMS provider should remain at the scene until the appropriate authority is

present d) Provide psychological support for grieving survivors e) Document the reason(s) no resuscitation was initiated f) Preserve the crime scene if applicable

tel:17122977583

tel:18008314131


96

PEDIATRIC NAUSEA AND VOMITING Reviewed 2011



a) Initiate IV access

b) Consider fluid bolus if evidence of hypovolemia

c) If patient nauseated or is vomiting administer anti-emetic medication such as ondansetron (Zofran) 0.1 mg/kg IV up to 4 mg maximum

d) Consider intubating patients with altered mental status who are vomiting and can’t protect their airway


97

PEDIATRIC NEAR DROWNING Revised 2012



a) Establish patient responsiveness

b) If cervical spine trauma is suspected, manually stabilize the spine

c) Assess airway for patency, protective reflexes and the possible need for advanced airway management. Look for signs of airway obstruction

d) Open the airway using head tilt/chin lift if no spinal trauma is suspected, or modified jaw thrust if spinal trauma is suspected

e) Suction as necessary

f) Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway cannot be maintained with positioning and the patient is unconscious

g) Assess breathing. Obtain pulse oximeter reading

h) If breathing is inadequate, assist ventilation using an appropriate adjunct with high-flow, 100% concentration oxygen

i) Assess circulation and perfusion

j) If breathing is adequate, place the child in a position of comfort and maintain oxygenation with cannula, mask or blow-by if oxygen saturations are below 94% titrate to 94% - 99%

k) Assess mental status

l) Consider CPAP

m) If spinal trauma is suspected, continue manual stabilization, apply a rigid cervical collar, and immobilize the patient on a long backboard or similar device

n) Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature throughout the examination


98

Pediatric Near Drowning Continued

o) If the child’s condition is stable, perform focused history and detailed physical examination on the scene, then initiate transport

p) If the child’s condition is stable, perform focused history and detailed physical examination on the scene, then initiate transport


q) If abdominal distention arises, consider placing a gastric tube to decompress the stomach if available

r) If the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated

a. Perform RSI to aid with intubation, as permitted by medical direction. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring as per medical direction

s) Initiate cardiac monitoring and determine rhythm. Consult the appropriate protocol for

treatment of specific dysrhythmias. Refer to AHA guidelines

t) Obtain vascular access. Administer normal saline at a maintenance rate according to weight

If the child’s condition is critical or unstable, initiate transport as quickly as possible. Perform focused history and detailed physical examination enroute to the hospital if patient status and management of resources permit


99

PEDIATRIC PAIN CONTROL Reviewed 2011


2. First attempt to manage all painful conditions with basic care


a) Splint extremity injuries

b) Place the patient in a position of comfort


c) Consider administration of pain medications for patients that have significant pain, do not have a decreased level of consciousness, are hemodynamically stable, and have oxygen saturations above 94% medication

Examples:

Morphine 0.1 mg/kg (maximum individual dose 10 mg) via intravenous or subcutaneous route or

Fentanyl 1.0 mcg/kg (maximum individual dose 100 mcg) via intravenous route or

Ketamine 0.1 mg/kg – 0.3 mg/kg IV/IO or 0.5 mg/kg IM/IN

d) Monitor ECG and O2 saturations

e) The patient must have vital signs taken prior to each dose and be monitored closely. Administration of narcotic medication must stop if at any time there is a decreased level of consciousness, decrease in oxygen saturation below 92% blood pressure drops to 100 mmHg or less

After drug administration, reassess the patient using the appropriate pain scale


100

PEDIATRIC POISONING Reviewed 2011


2. Identify contaminate and call Poison Control and follow directions given to provide care: 1-800-222-1222

3. Contact Medical Direction as soon as possible with information given by Poison Control and care given


Ingested Poisons

a) Identify and estimate amount of substance ingested

Inhaled Poisons:

a) Remove patient to fresh air

b) Administer high flow oxygen

c) Estimate duration of exposure to inhaled poison

Absorbed Poisons

a) If it will be a hazard to you, use protective clothing and extreme caution

Injected Poisons

a) Be alert for respiratory difficulty. Maintain airway and give high flow oxygen

b) Check patient for marks, rashes, or welts

tel:18002221222


101

PEDIATRIC SEIZURE Revised 2017


Active Seizure


a) Protect airway


b) Administer Lorazepam or Midazolam, dosage according to Pediatric Dosing Reference to stop seizure. May repeat dose in 5 minutes if still seizing

c) Check blood glucose level, if available, and treat hypoglycemia if present

Post Seizure


a) Protect airway b) Check glucose level


102

PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION Revised 2015



Patient Presentation:

a) This protocol is intended for patients who present with a traumatic mechanism of injury.

b) Immobilization is contraindicated for patients who have penetrating trauma who do not have a neurological deficit.

Patient Management:

c) Assessment: a) Assess for mental status, neurological deficits, spinal pain, tenderness, any evidence

of intoxication, or other severe injuries.

b) While maintaining spinal alignment, examine the spine for tenderness on palpation or deformities.

c) Treatment and Interventions: i. Apply cervical restriction if there is any of the following:

Patient complains of neck pain.

Any neck tenderness of palpation.

Any abnormal mental status, including extreme agitation, or neurological

deficit.

Any evidence of alcohol or drug intoxication

There are other severe or painful injuries present.

Any communication barrier that prevents accurate assessment.


103

PEDIATRIC SELECTIVE SPINAL IMMOBILIZATION CONTINUED

ii. Immobilize Patient with cervical collar and a long spine board, full body vacuum splint, scoop stretcher, or similar devise if:

Patient complains of midline back pain

Any midline back tenderness

Note 1: Distracting injuries or altered mental status does not necessitate long spine board use.

Note 2: Patients should not routinely be transported on long boards, unless the clinical situation warrants long board use. An example of this may be facilitation of multiple extremity injuries or an unstable patient where removal of a board will delay transport and/or other treatment priorities. In these rare situation, long boards should be padded or have a vacuum mattress applied to minimize secondary injury to the patient.


104

PEDIATRIC SHOCK Revised 2012



a) Assess airway via Airway Protocol

b) Assess circulation and perfusion

c) Control external bleeding

d) Assess mental status

e) Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature throughout the examination

f) Initiate transport. Perform focused history and detailed physical examination en route to the hospital if patient status and management of resources permit


g) Initiate cardiac monitoring

h) Establish IV access using an age-appropriate large-bore catheter with large-caliber tubing. If intravenous access cannot be obtained in a child younger than six years, proceed with intraosseous access. Do not delay transport to obtain vascular access

i) Administer a fluid bolus of normal saline at 20 ml/kg over 10 to 15 minutes. Reassess patient after bolus. If signs of shock persist, bolus may be repeated at the same dose up to two times for a maximum total of 60 ml/kg


105

SUSPECTED CHILD ABUSE Reviewed 2011



a) Approach child slowly to establish rapport (except in life-threatening situations), then perform exam

b) Treat obvious injuries according to appropriate protocol

c) Genital exam only if indicated in the presence of blood, known or obvious injury and or trauma

d) Interview parents separate from child, if possible

e) Transport if permitted by parents

f) If parents do not allow transport, notify law enforcement for assistance 712-297-7583

g) Communicate vital information only – additional info can be given to attending RN and/or Physician on arrival

h) Record observations and factual information on run report

i) Report all suspected abuse to the National hotline at 1-800-362-2178 within 24 hours of your contact of the patient. This will be an oral report only

j) Within 48 hours of oral reporting, you must submit a written report for all suspected abuse to the Department of Human Services https://dhs.iowa.gov/sites/default/files/470-0665.pdf

tel:17122977583

tel:18003622178

https://dhs.iowa.gov/sites/default/files/470-0665.pdf


106

PEDIATRIC TRAUMA Revised 2016


2. Follow the Out-of-Hospital Trauma Triage Destination Decision Protocol for the identification of time critical injuries, method of transport and trauma facility resources necessary for treatment of those injuries

3. The goal should be to minimize scene time with time critical injuries, including establishing IVs enroute.


a) Follow Shock Protocol if shock is present

Hemorrhage Control BASIC CARE GUIDELINES

a) Control bleeding with direct pressure. Large gaping wounds may need application of a bulky sterile gauze dressing and direct pressure by hand

b) If direct pressure/pressure dressing is ineffective or impractical, apply a tourniquet to extremity

c) If bleeding site is not amenable to tourniquet placement (i.e. junctional injury), apply a topical hemostatic agent with direct pressure


d) Establish large bore IV

e) Cardiac monitor


107

Pediatric Trauma continued

Chest Trauma BASIC CARE GUIDELINES

a) Seal open chest wounds immediately. Use occlusive dressing taped down. If the breathing becomes worse, loosen one side of the dressing to release pressure and then reseal

b) Impaled objects must be left in place and should be stabilized by building up around the object with multiple trauma dressings or other cushioning material

c) Take care that the penetrating object is not allowed to do further damage

Abdominal Trauma BASIC CARE GUIDELINES

a) Control external bleeding. Dress open wounds to prevent further contamination

b) Evisceration should be covered with a sterile saline soaked occlusive dressing

c) Impaled objects should be stabilized with bulky dressings for transport

Head, Neck, and Face Trauma BASIC CARE GUIDELINES

a) Place the head in a neutral in-line position unless the patient complains of pain or the head does not easily move into this position

b) Closely monitor the airway. Provide suctioning of secretions or vomit as needed. Be prepared to log roll the patient if they vomit. Maintain manual spinal stabilization if patient is log rolled

c) Reassess vitals, GCS and pupillary response frequently

d) Consider eye shield for any significant eye trauma. If the globe is avulsed, do not put it back into socket; cover with moist saline dressing and then place cup over it


108

ENVIRONMENTAL PROTOCOLS

BITES AND ENVENOMATION

FROSTBITE

HYPERTHERMIA

HYPOTHERMIA


109

BITES AND ENVENOMATION

HISTORY:

o Type of bite/sting o Description/photo with

patient for identification o Time, locations size of bite /

sting o Previous reaction to bite /

sting o Domestic vs. wild o Tetanus and Rabies risk o Immunocompromised

patient

SIGNS AND SYMPTOMS:

o Rash, skin break, wound o Pain, soft tissue swelling,

redness o Blood oozing from the bite

/ wound o Evidence of infection o Shortness of breath,

wheezing o Allergic reaction, hives,

itching o Hypotension or shock

DIFFERENTIAL:

o Animal bite o Human bite o Snake bite (poisonous) o Spider bite (poisonous) o Insect sting / bite (bee,

wasp, ant, tick) o Infection risk o Rabies risk o Tetanus risk



2. Remove any constricting clothing / bands/ jewelery 3. Type of bite

Insect, Ant, Bee/Wasp Sting Cold application

Snake bite Splinting of extremity

Dog/cat/human bite Cold application

4. Consult Medical Control for additional treatment guidelines


5. Follow Pain Management Protocol as necessary


110

CONSIDERATIONS

o Personal safety is a priority. Do not attempt to capture any snake to transport in with the patient. A photo will do.

o Venomous snakes in the area are generally of the pit viper family: rattlesnake, copperhead and water moccasin.

o Coral snakes are rare in the area: Very little pain but very toxic. “Red on yellow – kill a fellow, red on black – venom lack”

o Even though venomous snakes are rare in Iowa, some individuals keep exotic snakes in their homes.

o Black Widow spider bites have minimal pain initially but may develop muscular pain and severe abdominal pain (spider is black with red hourglass design on underside)

o Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle design on back)

o Mark the margin of the swelling / redness and time o Consider contacting Poison Control for guidance.


111

FROSTBITE



a) Remove the patient from the cold environment

b) Protect the cold injured extremity from further injury (manual stabilization)

c) Remove wet or restrictive clothing

d) Do not rub or massage

e) Do not re-expose to the cold

f) Remove jewelry

g) Cover with dry clothing or dressings


h) Refer to pain control protocol

i) Consider IV access using warm fluid

j) Monitor EKG


112

HYPERTHERMIA

HISTORY:

Age Exposure to increased

temperatures and/or humidity Extreme exertion Time and length of exposure Poor oral intake Fatigue and/or muscle cramps SAMPLE Recent illness / infection Psychiatric history

SIGNS AND SYMPTOMS:

o Altered mental status or unconsciousness

o Hot, dry or sweaty skin o Hypotension or shock o Seizures o Nausea

DIFFERENTIAL:

o Dehydration o Medications o Hyperthyroidism (Storm) o Delirium tremens (DT’s) o Heat cramps o Heat exhaustion o Heat stroke o CNS lesions or tumors



2. Remove from the hot environment and place in a cool environment (back of air conditioned response vehicle)

3. Loosen or remove clothing 4. Place in recovery position 5. Initially cool patient by fanning and cool mist if available 6. Consider cooling patient with cold packs to neck, groin and axilla 7. If alert, stable, and not nauseated, you may have the patient slowly drink small sips of

water or other fluids e.g. sports drinks ADVANCED CARE GUIDELINES

8. Monitor EKG and treat dysrhythmias following the appropriate protocol(s)

CONSIDERATIONS - Heat stroke consists of high body temperature. A change in mental status is the primary assessment

finding to differentiate heat stroke from heat exhaustion. If you have any doubt as to whether the patient is presenting with heat stroke vs. heat exhaustion, err on the side of aggressive cooling and treatment as though the patient is presenting with heat stroke. Sweating generally disappears as body temperature rises above 104˚F.

- Heat exhaustion consists of dehydration and salt depletion. Patients will often present with elevated body temperature, cool moist skin, weakness, anxious and tachypnea.

- Heat cramps consists of benign muscle cramping due to dehydration and is not associated with an elevated temperature.

- Patients can be predisposed by use of tricyclic antidepressants, phenothiazine’s, anticholinergic medications and alcohol

- Active cooling – Remove the patient’s clothing, wet the patient and increase the air flow over the patient. This promotes evaporative and convective cooling.

- Passive cooling - Limited to removing patient from heat/environmental source and removing clothes - Shivering is a normal part of the cooling process and should NOT be an indication to dc cooling measures.


113

HYPOTHERMIA

HISTORY:

o Exposure to environment even in normal temperatures

o Exposure to heat loss conditions (wet, wind, cold)

o Exposure to extreme cold without shelter

o Extremes of age o Drug use: Alcohol, barbiturates o Length of exposure o Trauma, blood loss

SIGNS AND SYMPTOMS:

o Cold victim o Altered mental status,

loss of coordination, slurred speech

o Violent shivering or no shivering in later stages

o Bradycardia o Hypotension or shock o Appearing DOA

DIFFERENTIAL:

o Hypoglycemia o CNS dysfunction

Stroke Head injury Spinal cord injury

o Alcohol, drug, or medication involvement



2. Remove wet clothing. 3. If able, check core temperature 4. Handle patient very gently 5. Cover patient with blankets 6. EKG if available


7. Administer warm IV fluids if available, do not administer cold fluids 8. Monitor EKG and treat dysrhythmias

• If body temp is confirmed or suspected to be below 86 degrees Fahrenheit i. ONLY give epinephrine every 8 minutes if indicated

ii. Defibrillation is indicated ONLY once iii. Consider spacing other medications used for resuscitation

CONSIDERATIONS

- NO HYPOTHERMIA PATIENT IS DEAD UNTIL WARM AND DEAD - Wet patients lose heat rapidly – Dry patient as soon as wet clothing removed - Active rewarming in the field may not be possible without specialized equipment - Extremes of age are more susceptible (i.e. young and old) due to poor thermoregulatory mechanisms - Skin, oral and axillary temperatures are very unreliable in hypothermia and should not be used. Assess

mental status, shivering activity and breathing rate to estimate core temperature. - Shivering stops as hypothermia progresses and obviously cold victims who are not shivering should be

handled gently to avoid precipitating V-fib - In no detectable pulse, begin CPR. Consult with medical control for ACLS interventions.


114

TRAUMA PROTOCOLS

ABDOMINAL / PELVIC TRAUMA

BURNS

ELECTRICAL INJURIES

EXTREMITY TRAUMA

HEAD TRAUMA

MULTI-SYSTEMS TRAUMA

SHOCK – TRAUMA

THORACIC TRAUMA

SELECTIVE SPINAL IMMOBILIZATION

SEXUAL ASSAULT


115

ABDOMINAL / PELVIC TRAUMA

HISTORY:

o Time of injury o Type of injury o Other trauma o Loss of consciousness o SAMPLE

SIGNS AND SYMPTOMS:

o Abdominal pain on palpation

o Penetrating wounds o Impaled objects o Abdominal evisceration o Hematuria, bloody stools o Altered bowel sounds o Hemoptysis, hematemesis o Signs/symptoms of shock

DIFFERENTIAL:

o Blunt visceral injury o Open abdominal/pelvic wound o Impaled object o Pelvic fracture o Multiple trauma



2. At any time go to the related protocol: Shock – Trauma or Multiple Trauma 3. Stabilize any impaled object. Do not remove it 4. Cover evisceration(s) with saline soaked trauma dressing. Consider saran wrap to cover. 5. Immobilize any suspected pelvic fracture


6. Consider Pain Control Protocol 7. IV/IO 8. Cardiac Monitoring 9. Consider 2nd IV

CONSIDERATIONS

- Be vigilant for internal bleeding and signs of shock and prepare for aggressive management for volume replacement.

- IV fluid administration should be administered in 250 cc increments and should be limited to achieve and maintain a systolic blood pressure of 80 mmHg. Patients with a systolic blood pressure of < 80 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.

- Head injured patients may require more aggressive fluid resuscitation - Fluid resuscitation should occur enroute except in cases of entrapment and other extenuating

circumstances. - Never try to remove an impaled object - Place pregnant patients in the left lateral recumbent position, if possible


116

BURNS

HISTORY:

o Type of exposure (heat, gas, chemical)

o Inhalation injury o Time of injury o Other trauma/blast

injury / fall o Loss of consciousness o SAMPLE

SIGNS AND SYMPTOMS:

o Burns, pain, swelling o Dizziness o Loss of consciousness o Hypotension / shock o Airway

compromise/distress o Singed facial or nasal hair o Hoarseness/wheezing

DIFFERENTIAL:

o Superficial (1˚) red & painful o Partial thickness (2˚)

blistering o Full thickness (3˚) painless

and charred or leathery skin o Chemical o Thermal o Electrical o Radiation o C-spine / blunt trauma



2. Remove rings, bracelets, and other constricting items Chemical

If eyes involved, irrigate Remove clothing or expose area Brush off any residue and flush area with copious amounts of water or NS

for a minimum of 5 minutes Thermal

Cover burn with a dry burn sheet or plastic wrap

ADVANCED CARE GUIDELINES 3. Consider Pain Control Protocol 4. IV/IO 5. Cardiac Monitoring

CONSIDERATIONS

- Stop the burning process! - Critical Burns: Partial thickness of > 10% body surface area; burns to face, eyes, hands, genitalia, perineum,

or major joints or feet; electrical burns including lightening injury, inhalation burns; deep chemical burns; burns with extremes of age or chronic disease; and burns associated with major traumatic injury. These burns may require hospital admission or transfer to a burn center.

- Early intubation is required in significant inhalation injuries. - Potential carbon monoxide exposure should be treated with 100% oxygen regardless of oxygen saturation. - Circumferential burns to extremities are dangerous due to potential vascular compromise 2˚ to soft tissue

swelling. - Burn patients are prone to hypothermia – Never apply ice or wet dressings to burns. The patient

compartment of the ambulance should be kept warm when caring for burn patients.


117

- Early hypovolemia is rare. If hypotensive, it may be associated with other traumas. - Do not overlook the possibility for child abuse with children and burn injuries. - Regardless of the extent of injury, chemical burns should be flushed with copious amounts of water after

disrobing the patient. This should NOT be done in the ambulance to reduce the risk of exposure/combination of the medic.


118

ELECTRICAL INJURIES

HISTORY:

o Lightening or electrical exposure

o Single or multiple victims o Trauma secondary to fall

from high wire or MVC into line

o Duration of exposure o Voltage and current (AC /

DC) o SAMPLE

SIGNS AND SYMPTOMS:

o Burns o Pain o Entry and exit wounds o Hypotension or shock o Arrest o Altered level of

consciousness

DIFFERENTIAL:

o Cardiac arrest o Seizure o Burns (see BURNS Protocol) o Multiple trauma



2. At any time go to related protocol: Tachycardia – Wide Complex; Ventricular Fibrillation 3. Obtain 12 Lead ECG and transmit to receiving facility 4. Wound Care


5. IV/IO 6. Cardiac monitoring 7. Consider Pain Control Protocol

CONSIDERATIONS

- Scene safety is of utmost importance when entering areas where these type of victims are found. - Exercise additional caution when responding and caring for patients from motor vehicle crashes

involving hybrid vehicles which have high-voltage electrical systems. - Look for entry and/or exit wounds. - Ventricular fibrillation and asystole are the most common dysrhythmias. - Damage is often hidden; the most severe damage will occur in muscle, vessels and nerves. - In a mass casualty lightning incident, attend to victims in full arrest first. If the victim did not

arrest initially, it is likely they will survive. - Do not overlook other trauma (i.e. falls)


119

EXTREMITY TRAUMA

HISTORY:

o Type of injury o Mechanism: crush /

penetrating / amputation / blunt

o Time of injury o Open vs. closed wound /

fracture o Wound contamination o SAMPLE

SIGNS AND SYMPTOMS:

o Pain, swelling o Deformity o Altered sensation / motor

function o Diminished pulse / capillary refill o Decreased extremity temperature

DIFFERENTIAL:

o Abrasion o Contusion o Laceration o Sprain o Dislocation o Fracture o Amputation

1. Follow initial patient care protocol 2. Follow Multi System Trauma protocol if indicated


3. At any time go to related protocol: Shock – Trauma 4. Wound care 5. Tourniquet if necessary 6. If bleeding site is not amenable to tourniquet placement (i.e. junctional injury), consider

application of a topical hemostatic agent impregnated gauze with direct pressure 7. If amputation:

Locate amputated part if possible Wrap amputated part in saline moistened gauze Place wrapped amputated part in empty plastic bag Place the plastic bag with the amputated part in a water and ice mixture Do not use ice alone or dry ice Label with patient name, the date, and time Make sure the part is transported with the patient, if possible

8. Splinting


9. IV/IO 10. Consider Pain Management Protocol

CONSIDERATIONS

- IV fluid administration should be administered in 250 cc increments and should be limited to achieve and maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood


120

pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.

- Head injured patients may require more aggressive fluid resuscitation. - If distal circulation is not present (no distal pulse, no cap refill, cyanosis) make one attempt to

reposition the fracture or dislocation in an effort to restore distal circulation. - Urgently transport any injury with vascular compromise. - Assess color, pulse, motor, sensory function before splinting, after splinting and on arrival to ED. - In amputations, time is critical. Transport and notify Medical Control immediately, so that the

appropriate destination can be determined. - Hip dislocations and knee and elbow fracture/dislocations have a high incidence of vascular

compromise. - Blood loss may be concealed or not apparent with extremity injuries - Immobilize fracture of dislocated joints by securing the bones above and below the injured joint. - Immobilize fracture for bone by securing the joints above and below the injured bone. - The use of tourniquet is appropriate if bleeding is uncontrollable using direct pressure. Document

time of application.


121

HEAD TRAUMA

HISTORY:

o Time of injury o Mechanism: blunt /

penetrating o Loss of consciousness o Bleeding o Evidence of multi-trauma o Helmet use or damage to

helmet o Seizure o SAMPLE

SIGNS AND SYMPTOMS:

o Pain, swelling, bleeding o Altered LOC, unconscious o Respiratory destress / failure o Vomiting o Decreased reflexes, paralysis

in extremities o Decorticate / decerebrate

posturing o Pupillary changes

DIFFERENTIAL:

o Skull fracture o Brain injury (concussion,

contusion, hemorrhage or laceration)

o Epidural hematoma o Subdural hematoma o Subarachnoid

hemorrhage o Spinal injury o Abuse



2. Assess GCS 3. Utilize Airway protocols to keep SpO2 > 94% 4. Blood glucose 5. If Seizure Activity go to Seizure Protocol


6. Consider intubation per RSI protocol 7. Ventilate to CO2 of 35-45 mmHg if airway management necessary 8. Cardiac monitoring

CONSIDERATIONS

- Consider elevating head of stretcher 30˚ if patient has a systolic blood pressure of 90 mmHg or more - Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing’s Response). Do

NOT attempt to lower blood pressure. - Hypotension usually indicated injury or shock unrelated to the head injury and should be aggressively

treated however; limit IV fluids unless patient is hypotensive (systolic BP < 90). - The most important item to monitor and document is a change in the level of consciousness - Concussions are periods of confusion or LOC associated with trauma which may have resolved by the time

EMS arrives. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP.

- Patients with a normal GCS of 15 may have an underlying brain trauma if the following signs or symptoms are seen: vomiting, severe headache, focal temporal blow or restlessness.

- Patients presenting with a GCS < 14 and one or more of the following will require evaluation by a neurosurgeon if possible: penetrating head injury or depressed skull fracture, open head injury with or without CSF leak, deterioration of GCS, lateralizing signs or paralysis ( i.e. one-sided weakness, motor or sensory deficit).


122

MULTI-SYSTEMS TRAUMA New 2017

HISTORY:

o Time and mechanism of injury

o Damage to structure or vehicle

o Location in structure or vehicle

o Others injured or dead o Speed and details of

MVC o Restraints / protective

equipment used o SAMPLE

SIGNS AND SYMPTOMS:

o Pain, swelling o Deformity, lesions,

bleeding o Altered LOC, unconscious o Hypotension or shock o Cardiac arrest

DIFFERENTIAL (Life threatening):

o Chest - Tension pneumothorax - Flail chest - Pericardial tamponade - Open chest wound - Hemothorax

o Intra-abdominal bleeding o Pelvis / Femur fracture o Spinal fracture/cord injury o Head injury o Extremity fracture/dislocation o HEENT (Airway obstruction) o Hypothermia



2. Appropriate Protocol based on patient condition: Shock-Trauma; Head Trauma; Thoracic Trauma; Seizure

3. Utilize Airway protocol to keep SpO2 > 94%


4. Cardiac monitoring 5. IV/IO Consider Fluid Bolus 6. Consider 2nd IV/IO

CONSIDERATIONS - Keys for survival of major trauma includes minimizing scene time and expeditious transport to a trauma

center - IV fluid administration should be administered in 250 cc increments and should be limited to achieve and

maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.

- Head injured patients may require more aggressive fluid resuscitation. - Fluid resuscitation should occur enroute except in cases of entrapment and other extenuating

circumstances. - Consider Mechanism of Injury carefully - A thorough secondary assessment is critical to finding occult injuries - For persistent hypotension, not responsive to 1,500 ml of fluid, consider the possibility of underlying

tension pneumothorax and chest decompression. - Keep the patient warm to prevent hypothermia. Keep the patient compartment warm to prevent heat loss.


123

SHOCK - TRAUMA Revised 2017

HISTORY:

o Blood loss (quantify) – vaginal or gastrointestinal bleeding, AAA, ectopic pregnancy

o Pregnancy o SAMPLE

SIGNS AND SYMPTOMS:

o Restlessness, confusion o Weakness, dizziness o Weak, rapid pulse o Pale, cool, clammy skin o Delayed capillary refill o Hypotension – SBP <90

mmHg

DIFFERENTIAL:

o Uncontrolled hemorrhage o Tension pneumothorax o Neurogenic shock

(vasogenic)



2. Assess GCS 3. Utilize Airway protocol to keep SpO2 > 94%


4. Cardiac monitoring 5. Administer fluid bolus 20 ml/kg up to 250 ml NS/LR. Repeat as necessary. 6. For Spinal Trauma not responsive to fluid bolus, consider Dopamine infusion

- Don’t delay transport of life or limb threatening injuries to obtain refusals.

CONSIDERATIONS

- Minimize scene time when possible - IV fluid administration should be administered in 250 cc increments and should be limited to

achieve and maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.


circumstances. - Shock is defined as decreased effective circulation with inadequate delivery of oxygen to tissues

(see Signs and Symptoms section above). - Unlike shock associated with other trauma, spinal trauma resulting in neurogenic shock may not

be associated with tachycardia - Consider a 12 Lead ECG for patients with chest trauma when time permits (enroute).


124

THORACIC TRAUMA Revised 2017

HISTORY:

o Time of injury o Type of injury o Other trauma o Loss of consciousness o SAMPLE

SIGNS AND SYMPTOMS:

o Penetrating wounds o Decreased/unilateral breath

sounds o Impaled objects o Tracheal deviation o Respiratory distress o Signs/Symptoms of shock

DIFFERENTIAL:

o Flail chest o Open chest wound o Impaled object o Pulmonary contusion o Cardiac contusion



2. At any time go to related protocol: Shock – Trauma; Cardiac; Multi-Systems Trauma 3. Utilize Airway protocols to keep SpO2 94-99% 4. Stabilize impaled object. Do Not Remove


5. Open pneumothorax – Chest Seal 6. Tension pneumothorax – Needle Chest Decompression 7. Cardiac monitoring 8. IV/IO

CONSIDERATIONS

- Reassess patient frequently for signs/symptoms of a tension pneumothorax. - Minimize scene time when possible. - IV fluid administration should be administered in 250 cc increments and should be limited to

achieve and maintain a systolic blood pressure of 90 mmHg. Patients with a systolic blood pressure of < 90 mmHg with normal mental status do not require aggressive fluid administration. Pregnant patients are NOT candidates for permissive hypotension and the goal should be to keep these patients normotensive.


circumstances - Signs of a tension pneumothorax include hypotension (the most important), jugular venous

distension, diminished breath sounds, hypoxia, tachycardia, and lastly tracheal deviation. - For pediatric patients younger than 13, do not use an IV larger than an 18 gauge - Consider a 12 Lead ECG for patients with chest trauma when time permits (enroute). - If Asherman seal is unavailable , seal the wound with an occlusive dressing.


125

SELECTIVE SPINAL IMMOBILIZATION Revised 2018



1. Patient Presentation:

a) This protocol is intended for patients who present with a traumatic mechanism of

injury.

b) Spinal motion restriction is contraindicated for patients who have penetrating

trauma who do not have a neurological deficit.

2. Patient Management:

a) Assessment while maintaining spinal alignment:

mental status,

neurological deficits,

spinal pain,

evidence of intoxication,

tenderness on palpation or deformities.

b) Treatment and Interventions:

Apply cervical restriction if there is any of the following:

Patient complains of neck pain.

Any neck tenderness on palpation.

Any abnormal mental status, including extreme agitation, or neurological deficit.

Any evidence of alcohol or drug intoxication

There are other severe or painful injuries present.

Any communication barrier that prevents accurate assessment.


126

SPINAL CARE CONTINUED

c) Spinal and cervical motion restriction and a long spine board, full body vacuum splint, scoop stretcher, or similar device if: Patient complains of midline back pain Any midline back tenderness

Note 1: Distracting injuries or altered mental status does not necessitate long spine board use.

Note 2: Patients should not routinely be transported on long boards, unless the clinical situation warrants long board use. An example of this may be facilitation of multiple extremity injuries or an unstable patient where removal of a board will delay transport and/or other treatment priorities. In these rare situation, long boards should be padded or have a vacuum mattress applied to minimize secondary injury to the patient.


127

SEXUAL ASSAULT Reviewed 2011



a) Identify yourself to the patient, assure patient that they are safe and in no further danger

b) Do not burden patient with questions about the details of the crime; you are there to provide emergency medical care

c) Be alert to immediate scene and document what you see. Touch only what you need to touch at the scene

d) Do not disturb any evidence unless necessary for treatment of patient. (If necessary to disturb evidence, document why and how it was disturbed.)

e) Preserve evidence; such as clothing you may have had to remove for treatment, and make sure that it is never left unattended at any time, to preserve "chain of evidence"

f) Contact local law enforcement if not present

g) Treat other injuries as indicated

h) Treat for shock if indicated


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Iowa EMS Treatment Appendices

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Appendix A - EMS Out-of-Hospital Do-Not-Resuscitate Protocol

Purpose: This protocol is intended to avoid unwarranted resuscitation by emergency care providers in the out-of-hospital setting for a qualified patient. There must be a valid Out-Of-Hospital Do-Not-Resuscitate (OOH DNR) order signed by the qualified patient’s attending physician or the presence of the OOH DNR identifier indicating the existence of a valid OOH DNR order.

No resuscitation: Means withholding any medical intervention that utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function, including but not limited to:

1. Chest compressions 2. Defibrillation, 3. Esophageal/tracheal/double-lumen airway; endotracheal intubation, or 4. Emergency drugs to alter cardiac or respiratory function or otherwise sustain life.

Patient criteria: The following patients are recognized as qualified patients to receive no resuscitation:

1. The presence of the uniform OOH DNR order or uniform OOH DNR identifier, or 2. The presence of the attending physician to provide direct verbal orders for care of the patient.

The presence of a signed physician order on a form other than the uniform OOH DNR order form approved by the department may be honored if approved by the service program EMS medical director. However, the immunities provided by law apply only in the presence of the uniform OOH DNR order or uniform OOH DNR identifier. When the uniform OOH DNR order or uniform OOH DNR identifier is not present contact must be made with on-line medical control and on-line medical control must concur that no resuscitation is appropriate.

Revocation: An OOH DNR order is deemed revoked at any time that a patient, or an individual authorized to act on the patient’s behalf as listed on the OOH DNR order, is able to communicate in any manner the intent that the order be revoked. The personal wishes of family members or other individuals who are not authorized in the order to act on the patient’s behalf shall not supersede a valid OOH DNR order.

Comfort Care (♥): When a patient has met the criteria for no resuscitation under the foregoing information, the emergency care provider should continue to provide that care which is intended to make the patient comfortable (a.k.a. ♥ Comfort Care). Whether other types of care are indicated will depend upon individual circumstances for which medical control may be contacted by or through the responding ambulance service personnel.

♥ Comfort Care may include, but is not limited to: 1. Pain medication. 2. Fluid therapy. 3. Respiratory assistance (oxygen and suctioning).

Qualified Patient means an adult patient determined by an attending physician to be in a terminal condition for which the attending physician has issued an Out of Hospital DNR order in accordance with the law. Iowa Administrative Code 641-142.1 (144A) Definitions.


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Appendix B: Adult Out-Of-Hospital Trauma Triage Destination Decision Protocol The following criteria shall be utilized to assist the EMS provider in the identification of time critical injuries, method of transport and trauma care facility resources necessary for treatment of those injuries Step 1 - Assess for Time Critical Injuries: Level of Consciousness & Vital Signs Glasgow Coma Score ≤13 Respiratory rate <10 or >29 breaths per minute, or need for ventilatory support. Systolic B/P (mmHg) less than <90 mmHg If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes, ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 1 does not apply, move on to step 2 Step 2 - Assess for Anatomy of an Injury All penetrating injuries to head, neck, torso and extremities

proximal to elbow or knee Chest wall instability or deformity (e.g., flail chest) Suspected two or more proximal long-bone fractures Suspected pelvic fractures Crushed, degloved, mangled, or pulseless extremity

Open or depressed skull fracture Amputation proximal to wrist or ankle Paralysis or Paresthesia Partial or full thickness burns > 10% TBSA or involving

face/airway

If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 2 does not apply, move on to step 3 Step 3 - Consider Mechanism of Injury & High Energy Transfer Falls

o Adult: > 20 ft. (one story is equal to 10 feet) High-risk auto crash:

o Interior compartment intrusion, including roof: >12 inches’ occupant site; >18 inches any site

o Ejection (partial or complete) from automobile

o Death in same passenger compartment o Vehicle telemetry data consistent with high risk of injury

Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact

Motorcycle crash >20 mph

Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If step 3 does not apply, move on to step 4 Step 4 - Consider risk factors: Older adults

o Risk of injury/death increases after age 55 years o SBP<110 might represent shock after age 65 years

EMS provider judgment Low impact mechanisms (e.g. ground level falls) might result in

severe injury

ETOH/Drug use Pregnancy > 20 weeks Anticoagulants and bleeding disorders Patients with head injury are at high risk for rapid deterioration

Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If none of the criteria in the above 4 steps are met, follow local protocol for patient disposition. When in doubt, transport to nearest trauma care facility for evaluation. For all Transported Trauma Patients: 1. Patient report to include: MOI, Injuries, Vital Signs & GCS, Treatment, Age, Gender and ETA 2. Obtain further orders from medical control as needed.


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Pediatric Out-Of-Hospital Trauma Triage Destination Decision Protocol The following criteria shall be utilized to assist the EMS provider in the identification of time critical injuries, method of transport and trauma care facility resources necessary for treatment of those injuries Step 1 - Assess for Time Critical Injuries: Level of Consciousness & Vital Signs Abnormal Responsiveness: abnormal or absent cry or speech. Decreased response to parents or environmental stimuli. Floppy or rigid muscle

tone or not moving. Verbal, Pain, or Unresponsive on AVPU scale. OR Airway/Breathing Compromise: obstruction to airflow, gurgling, stridor or noisy breathing. Increased/excessive retractions or abdominal

muscle use, nasal flaring, stridor, wheezes, grunting, gasping, or gurgling. Decreased/absent respiratory effort or noisy breathing. Respiratory rate outside normal range.

OR Circulatory Compromise: cyanosis, mottling, paleness/pallor or obvious significant bleeding. Absent or weak peripheral or central pulses;

pulse or systolic BP outside normal range. Capillary refill > 2 seconds with other abnormal findings. Glasgow Coma Score ≤13 If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes, ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 1 does not apply, move on to step 2 Step 2 - Assess for Anatomy of an Injury All penetrating injuries to head, neck, torso and extremities

proximal to elbow or knee Chest wall instability or deformity (e.g., flail chest) Suspected two or more proximal long-bone fractures Suspected pelvic fractures Crushed, degloved, mangled, or pulseless extremity

Open or depressed skull fracture Amputation proximal to wrist or ankle Paralysis or Paresthesia Partial or full thickness burns > 10% TBSA or involving

face/airway

If ground transport time to a Resource (Level I) or Regional (Level II) Trauma Care Facility is less than 30 minutes, transport to the nearest Resource (Level I) or Regional (Level II) Trauma Care Facility. If greater than 30 minutes ground transport time to Resource (Level I) or Regional (Level II) Trauma Care Facility, transport to the nearest appropriate Trauma Care Facility. If time can be saved or level of care needs exist, tier with ground or air ALS service program If step 2 does not apply, move on to step 3 Step 3 - Consider Mechanism of Injury & High Energy Transfer Falls >10 feet or two times the height of the child High-risk auto crash:

o Interior compartment intrusion, including roof: >12 inches occupant site; >18 inches any site

o Ejection (partial or complete) from automobile

o Death in same passenger compartment o Vehicle telemetry data consistent with high risk of injury

Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact

Motorcycle crash >20 mph

Transport to the nearest appropriate Trauma Care Facility, need not be the highest level trauma care facility. If step 3 does not apply, move on to step 4 Step 4 - Consider risk factors: Pregnancy > 20 weeks Anticoagulants and bleeding disorders Patients with head injury are at high risk for rapid deterioration

EMS provider Judgment ETOH/Drug use

Transport to the nearest (Any Level) Trauma Care Facility. If none of the criteria in the above 4 steps are met, follow local protocol for patient disposition. When in doubt, transport to nearest trauma care facility for evaluation. For all Transported Trauma Patients: 1. Patient report to include: MOI, Injuries, Vital Signs & GCS, Treatment, Age, Gender and ETA 2. Obtain further orders from medical control as needed


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Appendix C: Physician on Scene Your offer of assistance is appreciated. However, this EMS service, under law and in accordance with nationally recognized standards of care in Emergency Medicine, operates under the direct authority of a Physician Medical Director. Our Medical Director and physician designees have already established a physician-patient relationship with this patient. To ensure the best possible patient care, and to prevent inadvertent patient abandonment or interference with an established physician-patient relationship, please comply with our established protocols.

Please review the following if you wish to assume responsibility for this patient:

1. You must be recognized or identify yourself as a qualified physician.

2. You must be able to provide proof of licensure and identify your specialty.

3. If requested, you must speak directly with the on-line medical control physician to verify transfer of responsibility for the patient from that physician to you.

4. EMS personnel, in accordance with state law, can only follow orders that are consistent with the approved protocols.

5. You must accompany this patient to the hospital, unless the on-line medical control physician agrees to re-assume responsibility for this patient prior to transport.


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Appendix D: Air Medical Transport - Utilization Guidelines for Scene Response These guidelines have been developed to assist with the decision making for use of air medical transport by the emergency medical services community. The goal is to match the patient’s needs to the timely availability of resources in order to improve the care and outcome of the patient from injury or illness. Clinical indicators:

1. Advanced level of care need (skills or medications) exists that could be made available more promptly with an air medical tier versus tiering with ground ALS service, and further delay would likely jeopardize the outcome of the patient

2. Transport time to definitive care hospital can be significantly reduced for a critically ill or

injured patient where saving time is in the best interest of the patient

3. Multiple critically ill or injured patients at the scene where the needs exceed the means available

4. EMS Provider ‘index of suspicion’ based upon mechanism of injury and patient

assessment

Difficult access situations:

1. Wilderness or water rescue assistance needed

2. Road conditions impaired due to weather, traffic, or road construction / repair

3. Other locations difficult to access The local EMS provider must have a good understanding of regional EMS resources and strive to integrate resources to assure that ground and air services cooperate as efficiently and effectively as possible in the best interest of the patient. Medical directors for ambulance services should assure that EMS providers are aware of their own service’s abilities and limitations given the level of care and geographic response area being served. Audits should be conducted on an ongoing basis to assure that utilization of regional resources (ground and air) is appropriate in order to provide the level of care needed on a timely basis.


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Appendix E: Intentionally Left Blank


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Appendix F: Reperfusion Therapy Screening Not Limited to Paramedic Level

This form should be completed for patients suffering from Acute Coronary Syndromes. This tool will be used to triage patients to the appropriate receiving facility, and provide a template for passing information on to the receiving facility. Fibrinolytic screening may be done at the EMT level; however, the decision to bypass a local hospital to transport to a Percutaneous Coronary Intervention (PCI) capable facility is reserved for the PS and Paramedic levels.

1. If available, obtain 12-Lead EKG and transmit to receiving facility

2. EMT level – Transport patient to closest appropriate facility. Contact medical control for decision on completing thrombolytic checklist.

3. Paramedic Level – Evaluate 12-Lead for evidence of STEMI.

If STEMI is present, determine appropriate destination. If transport time to a facility capable of providing emergency PCI care is 60 minutes or less, it is

recommended that all of these patients be transported directly to the emergency PCI capable facility. If transport time to a facility capable of providing emergency PCI care is between 60 - 90 minutes,

transport to the PCI capable facility should be considered. If transport is initiated to a non-PCI facility:

Complete fibrinolytic therapy checklist on next page.

If a local protocol for fibrinolytic therapy in the field has been established, then proceed with fibrinolytic protocol if:

o Authorized by voice contact with medical control, and o The Paramedic has received training and has the approval of their physician medical director

In all instances those patients requiring immediate hemodynamic or airway stabilization should be transported to the closest appropriate facility. If STEMI is not present, transport patient to closest appropriate facility. Note: See Fibrinolytic Checklist on the following page

If directed by medical control, complete fibrinolytic checklist below


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Fibrinolytic Checklist

Any YES findings will be relayed to medical control. Absolute Contraindications preclude the use of fibrinolytics. Relative Contraindications require consultation with medical control.

DATE: PATIENT AGE: MALE FEMALE INCIDENT/RECORD #: YES NO

ABSOLUTE CONTRAINDICATIONS

Any known intracranial hemorrhage?

Known structural cerebral vascular lesion?

Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours?

Suspected aortic dissection?

Active bleeding or bleeding diathesis (excluding menses)?

Significant closed head trauma or facial trauma within 3 months?

RELATIVE CONTRAINDICATIONS

History of chronic, severe, poorly controlled hypertension?

Severe, uncontrolled hypertension on presentation (S >180mmHg or D>110mmHg)

History of prior ischemic stroke >3 months, dementia, or known intracranial pathology?

Traumatic or prolonged (>10 min) CPR or major surgery (<3 weeks)

Non-compressible vascular punctures?

Pregnancy?

Active peptic ulcer?

Current use of anticoagulants?

EMS Provider Print Name: Signature:


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Appendix G: Strategies for Reperfusion Therapy: Acute Stroke Revised 2017

Reperfusion Therapy Screening Not Limited to Paramedic Level

This appendix should be used for suspected acute stroke. This tool will be used to triage patients to the appropriate receiving facility, and provide a template for passing information to the receiving facility.

1. Perform a validated stroke assessment such as the MEND exam.

2. If assessment is positive for stroke, and onset of symptoms can be established within the past 4.5 hours, then determine the appropriate destination:

a. If transport time to a Primary Stroke Center is less than 30 minutes, it is recommended that all of these patients be transported directly to the Primary Stroke Center

b. If transport time to a Primary Stroke Center is greater than 30 minutes, then transport to the nearest stroke capable hospital.

3. Consider the use of air transport if it will facilitate the arrival of the acute stroke patient for treatment within 4.5 hours to a Primary Stroke Center or stroke capable hospital.

4. If transport to a Primary Stroke Center or stroke capable hospital cannot be achieved to arrive within 4.5 hours, then transport to the closest appropriate facility.

5. In all instances, those patients requiring immediate hemodynamic or airway stabilization should be transported to the closest appropriate facility.

6. Complete the fibrinolytic checklist on next page.

Levels of Stroke Care Capacity:

Comprehensive Stroke Center: Hospitals that have been certified by the Joint Commission-accredited acute care hospitals and must meet all the criteria for Primary Stroke Certification

Primary Stroke Center: Hospitals that have been certified by the Joint Commission on Hospital Accreditation or an equivalent agency to meet Brain Attack Coalition and American Stroke Association guidelines for stroke care

Stroke capable hospital: Hospitals that have the following:

• rt-PA readily available for administration • Head CT, laboratory and EKG capabilities 24/7 • Process in place for transporting appropriate patients to a Primary Stroke Center • Stroke protocol in place that follows American Stroke Association guidelines • Emergency department coverage by physician, or advanced practitioner

The list of Iowa Hospital Triage Designations is available on the Iowa Healthcare Collaborative web site at:

https://www.ihconline.org/additional-tools/initiatives/coverdell-stroke-project/

https://www.ihconline.org/additional-tools/initiatives/coverdell-stroke-project/


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If directed by medical control, complete fibrinolytic checklist below

Fibrinolytic Checklist

Any YES findings will be relayed to medical control. Absolute Contraindications preclude the use of fibrinolytics. Relative Contraindications require consultation with medical control.

DATE: PATIENT AGE: MALE FEMALE INCIDENT/RECORD #: YES NO

ABSOLUTE CONTRAINDICATIONS

Any known intracranial hemorrhage?

Known structural cerebral vascular lesion?

Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours?

Suspected aortic dissection?

Active bleeding or bleeding diathesis (excluding menses)?

Significant closed head trauma or facial trauma within 3 months?

RELATIVE CONTRAINDICATIONS

History of chronic, severe, poorly controlled hypertension?

Severe, uncontrolled hypertension on presentation (S >180mmHg or D>110mmHg)

History of prior ischemic stroke >3 months, dementia, or known intracranial pathology?

Traumatic or prolonged (>10 min) CPR or major surgery (<3 weeks)

Non-compressible vascular punctures?

Pregnancy?

Active peptic ulcer?

Current use of anticoagulants?

EMS Provider Print Name: Signature:


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Appendix H: Simple Triage and Rapid Treatment (START)

S T A R T

The following are guidelines for initial tactical triage using the START method. START is most useful in initially clearing the disaster zone where there are numerous casualties. It focuses on respiration rate, perfusion, and mental status and takes under one minute to complete. Once the patient moves toward a higher level of care (evacuation), a more detailed approach to triage may be needed.

Respirations Perfusion Mental Status

Green = Minor/Ambulatory Yellow = Delayed Red = Immediate Black = Deceased/Expectant


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Simple Triage and Rapid Treatment – Pediatric JumpSTART


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Appendix I: Suspected Abuse/Assault/Neglect/Maltreatment

k) Provide reassurance l) Contact local law enforcement if not present m) Provide appropriate medical care per protocol n) Do not burden patient with questions about the details of the assault o) Be alert to immediate scene and document what you see. p) Touch only what you need to touch at the scene q) Do not disturb any evidence unless necessary for treatment of patient. (If necessary to disturb

evidence, document why and how it was disturbed.) r) Preserve evidence; such as clothing you may have had to remove for treatment, and make sure that it

is never left unattended at any time, to preserve "chain of evidence" s) Provide local referrals as available t) Communicate vital information only – additional info can be given to receiving RN and/or Physician on

arrival u) Record observations and factual information on run report

Pediatric Considerations:

a) Approach child slowly in order to establish rapport (except in life-threatening situations), then perform exam

b) Provide appropriate medical care per protocol c) Genital exam only if indicated in the presence of blood, known or obvious injury and or trauma d) Interview parents separate from child, if possible e) Transport if permitted by parents f) If parents do not allow transport, notify law enforcement for assistance

Report all suspected abuse to the pediatric and dependent adult hotline at 1-800-362-2178 within 24 hours of your contact of the patient. This will be an oral report only. Within 48 hours of oral reporting, you must submit a written report for all suspected abuse to the Iowa Department of Human Services


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Appendix J: Guidelines for EMS Provider Initiating Organ and Tissue Donation at the Scene of the Deceased

1. All appropriate patient care protocols will be enacted to assure patient care is provided according to

prevailing standards.

2. If resuscitation efforts are unsuccessful or if upon arrival the patient is deceased and without indications to initiate resuscitation, then on-line medical direction will be contacted to confirm that no further medical care is to be given.

3. As per Iowa Code 142C.7 a medical examiner or a medical examiner’s designee, peace officer, fire

fighter, or emergency medical care provider may release an individual’s information to an organ procurement organization, donor registry, or bank or storage organization to determine if the individual is a donor.

4. As per Iowa Code 142C.7 any information regarding a patient, including the patient’s identity,

however, constitutes confidential medical information and under any other circumstances is prohibited from disclosure without the written consent of the patient or the patient’s legal representative.

5. At least one EMS provider should remain at the scene until the appropriate authority (medical

examiner, funeral home, public safety, etc.) is present.

6. Contact Iowa Donor Network at 800-831-4131


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Appendix K: Guidelines for EMS Providers Responding to a patient with special needs This protocol is not intended for interfacility transfers These guidelines should be used when an EMS provider, responding to a call, is confronted with a patient using specialized medical equipment that the EMS provider has not been trained to use, and the operation of that equipment is outside of the EMS provider’s scope of practice. The EMS provider may treat and transport the patient, as long as the EMS provider doesn’t monitor or operate the equipment in any way while providing care. When providing care to patients with special needs, EMS personnel should provide the level of care necessary, within their level of training and certification. When possible, the EMS provider should consider utilizing a family member or caregiver who has been using this equipment to help with monitoring and operating the special medical equipment if necessary during transport. Some examples of special medical devices:

• PCA (patient controlled analgesic) • Chest Tube


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Appendix L: EMS Approved Abbreviationsā before ABC airway, breathing,

circulation ALS advanced life support AMI acute myocardial

infarction amps ampules ASA aspirin AT atrial tachycardia AV atrioventricular bicarb sodium bicarbonate BID twice a day BLS basic life support BP blood pressure BS blood sugar c ̅ with CAD coronary artery

disease CC chief complaint cc cubic centimeter CCU coronary care unit CHB complete heart block CHF congestive heart

failure cm centimeter CNS central nervous system c/o complains of CO carbon monoxide C02 carbon dioxide COPD chronic obstructive

pulmonary disease CPR cardiopulmonary

resuscitation CSF cerebral spinal fluid CVA cerebral vascular

accident D/C discontinue DOA dead on arrival D5W 5% dextrose in water Dx diagnoses ED emergency

department EKG/ECG electrocardiogram Epi epinephrine ER emergency room

ET endotracheal ETOH alcohol fib fibrillation fl fluid fx fracture GI gastrointestinal gm gram gr grain gt(t) drop(s) h, hr hour hx history ICU intensive care unit IM intramuscular IV intravenous Kg kilogram KVO keep vein open L liter LOC level of

consciousness LR lactated ringers Mgtt microdrip MD medical doctor mEq milliequivalents mg milligram MI myocardial

infarction min minute ml milliliter mm millimeter MS morphine sulfate NaCI sodium chloride NaHCO3 sodium bicarbonate NG,N/G nasogastric nitro nitroglycerine NPO nothing by mouth NS normal saline NSR normal sinus rhythm NTG nitroglycerine 02 oxygen OB obstetrics OD overdose OR operating room P pulse p after PAC premature atrial

contraction

PAT paroxysmal atrial tachycardia

PCR patient care record PE physical exam,

pulmonary edema pedi pediatric PERL pupils equal, reactive to

light PJC premature junctional po by mouth pr per rectum prn whenever necessary,

as needed PVC premature ventricular

contraction q every QID four times a day R respirations R/O rule out RN registered nurse Rx treatment s without SC subcutaneous Sec second SL sublingual SOB shortness of breath SQ subcutaneous STAT immediately s/s sign, symptoms SVT supraventricular

tachycardia Sx symptoms TIA transient ischemic

attack TID three times a day TKO to keep open VF ventricular fibrillation w/s watt second setting x times y/o years old


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Appendix M: Guidelines for New Protocol Development

Making a decision to develop a new protocol or evaluate an existing one should be based on a rational process. Questions that should be asked and answered when considering a new drug therapy or procedure are as follows:

Key Questions for any New Protocol

1. Is the drug therapy or procedure medically indicated and safe? 2. Is it within the scope of practice for the provider? 3. How specifically will this protocol benefit patient care? 4. What specifically is needed to implement this protocol (education/training, medical director protocol

development/authorization, equipment needs, etc.)? 5. How will this protocol impact operation? 6. What is the opinion of providers concerning this protocol? 7. Does the medical community support this protocol change? 8. What are all the costs versus benefits associated with implementation and maintenance? 9. What are the medical-legal implications? 10. What ongoing provider involvement such as skills maintenance and continuous quality improvement is

necessary? 11. How will success be measured?

Rational Protocol Development Process to Make the Right Protocol Decision

1. Study the issue thoroughly 2. Identify key questions 3. Compare with goals 4. Assess fit with system 5. Cost benefit analysis 6. Identify measuring tools

Stakeholders in this process are recognized to include, but not be limited to:

1. Medical direction (on-line and off-line) 2. Educators/training programs 3. Regulators of policy and rules 4. Service directors 5. Service providers 6. Consumers 7. Third party payers


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Appendix N: Rapid Sequence Induction

This skill is to be performed only by Paramedics who have demonstrated competencies in medication administration and airway management as determined by the service Medical Director.

INDICATIONS

1. Decreased level of consciousness, combativeness or severe agitation secondary to trauma.

2. Suspected CVA with GCS of 8 or less with a gag reflex where loss of airway is presumed inevitable.

3. Acute respiratory distress requiring ventilatory assistance or control. 4. Burn patient with potential or existing respiratory or airway compromise. 5. Prolonged seizure activity 6. CHF, COPD, or Asthma patients with hypoxia and/or respiratory crisis who cannot be

intubated nasally CONTRAINDICATIONS

1. Contraindications to the medications being used in the RSI procedure. 2. Patient has known valid DNR or DNI

PROCEDURE

1. Determine need for intubation 2. Ensure IV access 3. Monitor cardiac rhythm and vital signs including oxygen saturation 4. Provide oxygen as necessary to preoxygenate and maintain > 93% SPO2 5. Determine that all necessary equipment is available and in working order including

alternative airway 6. Follow Cardiac Arrhythmia Protocol for presence of arrhythmia 7. Follow Seizure protocol for presence of seizure 8. Sedate patient: Administer 1-2 mg/kg ketamine IV/IO. 9. Paralyze patient: Administer 1-1.5 mg/kg rocuronium. 10. Once induced, intubate patient and verify tube placement by auscultation and CO2

monitoring i. If further sedation is needed after intubation:

Administer 1-2 mg/kg ketamine q15 min or Administer 2-4 mg Midazolam IV/IO every 15 minutes (0.1 mg/kg pediatric) if systolic blood pressure greater than 90.

11. If further paralytic is needed after intubation: Administer 1-1.5 mg/kg rocuronium

IF Intubation is unsuccessful (no more than 2 attempts), manage airway with supraglottic airway, IF supraglottic airway is unsuccessful manage airway using percutaneous cricothyrotomy


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LBS KGS LBS KGS100 - 150 45 - 68 90 mg 0.9 cc 70 mg 7 cc 100 - 150 45 - 68150 - 200 68 - 91 120 mg 1.2 cc 100 mg 10 cc 150 - 200 68 - 91200 - 250 91 - 113 170 mg 1.7 cc 130 mg 13 cc 200 - 250 91 - 113250 - 293 113 - 133 220 mg 2.2 cc 170 mg 17 cc 250 - 293 113 - 133

ConcentrationOnset/duration 9/27/18

Sedate > Paralyze >

RSI Dosage ChartRepeat q15min

Ketalar ZemuronRepeat q15 PRN

(ketamine) (rocuronium)

olor coded length based dosage advised for pediatric

mgcc/mlmg

1 - 2 mg/kg 1 - 1.5 mg/kg

100mg per 1ml 10mg per 1ml

cc/ml

30 sec / 20 min 45 sec / 25 min


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Appendix O: Continuous Positive Airway Pressure (CPAP) Indications:

Any patient presenting in respiratory distress who is aged 12 years or older, able to follow commands, with the ability to maintain a patent airway and adequate mask seal displaying findings in the medical history or assessment suggestive of any of the following conditions: 1. Asthma 2. COPD 3. CHF 4. Pulmonary edema

AND meets two or more of the following criteria: 1. Respiratory rate of 25 / minute or greater 2. Initial or subsequent SpO2 of less than 95% 3. Skin signs suggestive of hypoxia such as pallor, mottling or cyanosis 4. Presence of abnormal breath sounds or frothy sputum 5. Notable increased work of breathing

Contraindications:

1. Insufficient spontaneous ventilatory effort 2. Systolic blood pressure less than 90 mmHg 3. Suspected pneumothorax or has suffered trauma to the chest 4. Tracheostomy 5. Active vomiting 6. Upper GI or upper airway bleeding

Special Considerations:

1. CPAP is designed to be a continuous therapy and should only be discontinued in the case of the patient being unable to tolerate the mask or in case of progression to spontaneous ventilatory failure

2. Advise the receiving facility of your patient’s CPAP therapy as soon as practical so they may prepare for continuation of therapy

3. Observe patients for signs of gastric distention 4. Monitor patients closely for changes in hemodynamic or respiratory status 5. Procedure may be performed on patient with Do Not Resuscitate Order.

Procedure:

1. Explain the procedure to the patient. 2. Ensure adequate oxygen supply to ventilation device 3. Place the patient on continuous pulse oximetry 4. Place the patient on cardiac monitor and record rhythm strips 5. Place the delivery device over the mouth and nose and secure the mask with provided straps 6. Use 10 cm of H2O of PEEP valve initially


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7. Check for air leaks 8. Monitor and document the patient’s respiratory response to treatment 9. Due to changes in preload and afterload of the heart during CPAP therapy, a complete set of vital sings must be obtained and documented every 5 minutes 10. Administer appropriate medication as certified (continuous nebulized Albuterol for COPD/Asthma and repeated administration of nitroglycerin for CHF)

Removal Procedure:

1. Do not remove CPAP until hospital therapy is ready to be placed on the patient. 2. CPAP therapy needs to be continuous and should not be removed unless the patient cannot tolerate the mask or experiences respiratory arrest or begins to vomit. 3. Intermittent positive pressure ventilation with a Bag-Valve-Mask, placement of a non-visualized airway and/or endotracheal intubation should be considered if the patient is removed from CPAP therapy.


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Appendix P: PEEP Valve Guidelines

Indications:

PEEP should be considered if equipment is available in pulsatile intubated patients of all age groups to increase alveolar recruitment, reduce risk of repetitive alveolar collapse injury, and increase oxygenation.

Patients presenting with the following history or signs may benefit from PEEP:

• Conditions prior to respiratory arrest would indicate CPAP. • Hypoxia • Lung disease prior to intubation such as ARDS, Asthma or COPD • Atelectasis (alveoli collapse) • Extended duration of artificial respiration such as interfacility transfer (Greater than 30 minutes) • Pulmonary contusion or flail chest

Contraindications:

• Hypotension (Systolic BP less than 90) • Cardiac Arrest (reduces effectiveness of CPR) • Pneumothorax

Special Considerations:

• Patients should be monitored closely for pneumothorax. • The airway should be monitored closely for the need to suction. • Higher levels of PEEP can decrease ETCO2. • Monitor for stacked breaths (Auto-PEEP) due to incomplete exhalation. • If at any time ventilation becomes difficult, or hypotension occurs, the PEEP valve should be removed. • Decreased tidal volumes are often required to achieve adequate chest rise with PEEP. • Nebulized medications can be administered during PEEP use.

Procedure:

• Connect PEEP valve to exhalation port of BVM or ventilator circuit. • If CPAP was used prior to intubation, set PEEP valve to last CPAP level. • If no previous CPAP, initially set PEEP valve at 5 cmH2O (physiologic PEEP) • Titrate PEEP in 5 cmH2O increments as needed to achieve SPO2 >93% and reduce adventitious lung

sounds. • Medical direction should be sought when PEEP greater than 15 cmH2O is indicated.

If abrupt decrease in O2 saturation, evaluate for potential causes DOPES: Tube Displacement, Obstruction, Pneumothorax, Equipment, Stacked Breaths


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Appendix Q: Special Events The Special Events Protocol is for occasions that the service may be called to stand-by or perform First Aid. This protocol is for those patients seeking minor first aid. If a medical emergency exists, follow the appropriate protocol for that condition. If no medical emergency exists, but the person wants further care, continue with:

MINOR ACHES AND PAINS

Provide Acetaminophen 500mg -1000mg following directions on label.

TREATMENT OF MINOR SUNBURN

Apply over counter First Aid Burn Cream to burned area following instructions on label.

MINOR ABRASIONS

Clean area with sterile water or saline, stop bleeding and apply a thin layer of antibiotic ointment. Cover the wound to control bleeding and prevent infection.

All individuals seeking first aid shall have documentation on appropriate forms of treatments given.


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Appendix R: Swiss Mountain Society Stages of Hypothermia

Stage Mental Status Shivering Breathing Est. Core Temperature

0 Alert, Oriented Yes Yes >95°F (37°C)

I Responsive to voice -confused, slurred speech, may appear disoriented or agitated

Yes Yes 95-89.6 (35-32)

II Drowsy -inappropriately responsive to pain or voice No Yes 89.5-82.4 (31.9- 32)

III Unresponsive to most stimuli – may respond slowly to deep pain

No Yes 82.3-75.2 (27.9- 24)

IV Unresponsive No No <75.2 (<24)


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APGAR Score The Apgar score should be obtained and recorded 1 minute and again at 5 minutes after the birth or delivery of any infant.

Sign 0 1 2 Heart Rate Absent <100 min. >100 min.

Respiratory Effort Absent Weak Cry Strong Cry

Muscle Tone Limp Some Flexion Good Flexion

Reflex Irritability (when feet stimulated)

No Response Some Motion Cry

Color Blue; Pale Body Pink Extremities Blue

Pink


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Cincinnati Stroke Scale

FACIAL DROOP (have patient show teeth or smile)

-Normal – both sides of face move equally -Abnormal – one side of face does not move as well as the other side

ARM DRIFT (patient closes eyes and hold both arms straight out for 10 seconds)

-Normal – both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful)

-Abnormal – one arm does not move or one arm drifts down compared with the other

ABNORMAL SPEECH (have the patient say “you can’t teach an old dog new tricks”

-Normal – patient uses correct words with no slurring

-Abnormal – patient slurs words, uses the wrong words, or is unable to speak

Considerations: o If any one of the 3 signs is abnormal, the probability of a stroke is approximately 72%.


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Pediatric Glasgow Coma Scale


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Wong-Baker Faces Pain Rating Scale


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Pediatric Assessment Triangle


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Rule of Nines


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Dopamine Chart


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Medication References

ADENOSINE (Adenocard)

1. Classification: antiarrhythmic 2. Physiologic Effect: depresses the activity of the SA and AV nodes; interrupts re-entry; immediate

onset, duration <10 seconds. 3. Major Indications: SVT refractory to common vagal maneuvers 4. Primary Contraindications:

4.1. second or third-degree AV block 4.2. sick sinus syndrome (except in patients with functioning pacemakers) 4.3. hypersensitivity 4.4. symptomatic bradycardia

5. Relative Contraindications: 5.1. pregnancy 5.2. pts taking theophylline, dipyridamole or carbamazepine

6. Side Effects: 6.1. flushing 6.2. dyspnea 6.3. chest pain 6.4. transient periods of asystole, sinus bradycardia, or ventricular ectopy 6.5. hypotension 6.6. palpitations

7. Additional Information: 7.1. large (14-18 gauge) IV access 7.2. administer through injection port closest to patient. 7.3. follow with rapid saline flush

ALBUTEROL (PROVENTIL, VENTOLIN) 1. Classification: bronchodilator (sympathomimetic) 2. Physiologic Effect: stimulates the sympathetic beta-2 adrenergic receptors in the bronchial tree

causing bronchial smooth muscle relaxation; stimulates heart 3. Major Indications: relieve bronchospasms in patients with asthma, chronic bronchitis, emphysema,

and acute attacks of bronchospasm 4. Primary Contraindication: hypersensitivity 5. Relative Contraindications:

5.1. cardiovascular disease 5.2. diabetes mellitus 5.3. convulsive disorders 5.4. cerebrovascular disease 5.5. beta blocker medications

6. Side Effects: 5.6. nervousness, tremors 5.7. dizziness, seizures, headache 5.8. tachycardia, palpitations 5.9. hypertension


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AMIODARONE 1. Classification: Anti-dysrhythmic 2. Physiologic Effects: It acts on all cardiac tissues. It is thought to prolong the duration of the action

potential and refractory period without significantly affecting the resting membrane potential. The IV formulation relaxes vascular smooth muscle, decreases peripheral vascular resistance, and increases coronary blood flow.

3. Major Indications: 3.1. wide complex tachycardia 3.2. ventricular fibrillation

4. Primary Contraindications: 4.1. cardiogenic shock 4.2. severe sinus bradycardia

5. Side Effects: 5.1. fatigue 5.2. dizziness 5.3. bradycardia 5.4. sinus arrest 5.5. cardiogenic shock 5.6. CHF

6. Additional Information: Use with caution in patients with severe liver damage

ASPIRIN 1. Classification: non-steroidal anti-inflammatory, analgesic and antipyretic agent 2. Physiologic Effects: inhibits platelet aggregation 3. Major Indications: to inhibit clot formation in acute MI patients 4. Primary Contraindications:

4.1. gastrointestinal disease (hemorrhagic or non-hemorrhagic) 4.2. bleeding disorders 4.3. hypersensitivity

5. Relative Contraindications: asthma 6. Side Effects:

6.1. nausea/vomiting 6.2. stomach pain 6.3. tinnitis or decreased auditory acuity 6.4. hyperventilation

7. Additional Information: 7.1. children and teenagers should not use this medication without consulting a physician; this

drug may precipitate Reye’s Syndrome 7.2. use caution in patients with allergies to other NSAIDS and other bleeding disorders

ATROPINE 1. Classification: anticholinergic (Parasympatholytic) 2. Physiologic Effects: blocks the parasympathetic nervous system's action on the heart, resulting in

increased heart rate 3. Major Indications:

3.1. symptomatic bradycardia 3.2. organophosphate poisoning

4. Relative Contraindications: 4.1. glaucoma 4.2. mitral valve stenosis 4.3. bronchial asthma

5. Side Effects: 5.1. blurred vision, headache, and pupillary dilation


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5.2. dry mouth and thirst 5.3. flushing 5.4. seizures 5.5. if given too slowly, a transient slowing of the heart rate may result 5.6. hypertension 5.7. dysrhythmias

CALCIUM CHLORIDE 1. Classification: electrolyte 2. Physiologic Effect: increases the cardiac contractile state and enhances ventricular automaticity 3. Major Indications:

3.1. hyperkalemia 3.2. calcium channel blocker toxicity

4. Primary Contraindications: 4.1. hypercalcemia 4.2. hypersensitivity

5. Relative Contraindication: patients taking digitalis 6. Side Effect: may slow the heart rate 7. Additional Information: calcium chloride is incompatible with all other drugs; be sure to

adequately flush the IV line before and after administration

DEXTROSE (D50W, D25W, D10W) 1. Classification: Carbohydrate-hypertonic dextrose solution 2. Physiologic Effect: elevates blood glucose 3. Major Indication: hypoglycemia-blood glucose < 60 4. Primary Contraindication: intracranial hemorrhage 5. Relative Contraindications:

5.1. acute alcohol related emergencies (should be used in conjunction with thiamine) 5.2. hyperglycemia

6. Side Effect: extravasation causes tissue necrosis 7. Additional Information:

7.1. do not occlude the IV line while giving IV D50W DILTIAZEM (CARDIZEM)

1. Classification: antihypertensive, calcium channel blocker 2. Physiologic Effect: inhibits calcium influx into myocardial cells and arterial smooth muscle 3. Major Indications:

3.1. acute hypertension 3.2. angina 3.3. rapid atrial fibrillation or atrial flutter

4. Primary Contraindications: 4.1. hypersensitivity 4.2. heart blocks 4.3. hypotension

5. Side Effects: 5.1. hypotension 5.2. bradycardia 5.3. headache 5.4. dizziness 5.5. arrhythmias 5.6. nausea/vomiting

6. Additional information:


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6.1. monitor heart rate and blood pressure closely

DIPHENHYDRAMINE (BENADRYL) 1. Classification: antihistamine 2. Physiologic Effect: blocks the cellular histamine receptors resulting in decreased capillary

permeability; decreases itching, edema, bronchoconstriction, and vasodilation. 3. Major Indication: allergic reaction 4. Primary Contraindications:

4.1. pregnancy 4.2. nursing mothers 4.3. newborns 4.4. hypersensitivity

5. Relative Contraindications: 5.1. bronchial asthma 5.2. hyperthyroidism

6. Side Effects: drowsiness

DOPAMINE (INTROPIN) CHART

1. Classification: sympathomimetic agent 2. Physiologic Effects: varies according to dosage

2.1. low doses, (1-2 mcg/kg/min) dopaminergic effects dilate renal and mesenteric blood vessels and increase renal perfusion

2.2. intermediate doses (2-10 mcg/kg/min) beta-adrenergic effects increase heart’s force of contraction and rate

2.3. high doses (>10 mcg/kg/min) alpha-adrenergic effects cause peripheral vasoconstriction and elevation of blood pressure

3. Major Indications: 3.1. cardiogenic shock 3.2. hemodynamically significant hypotension not resulting from hypovolemia

4. Primary Contraindications: 4.1. pheochromocytoma (adrenal gland tumor) 4.2. hypersensitivity

5. Relative Contraindications: 5.1. hypovolemia 5.2. uncorrected tachyarrhythmias and v-fib

6. Side Effects: 6.1. cardiac dysrhythmias 6.2. nausea and vomiting 6.3. dyspnea 6.4. extravasation causes tissue necrosis


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EPINEPHRINE (ADRENALIN) 1. Classification: sympathomimetic agent 2. Physiologic Effects: increases myocardial contractility, decreases the threshold for defibrillation,

elevates perfusion pressure, and may restore electrical activity in asystole; acts as a potent bronchodilator

3. Major Indications: 3.1. cardiac arrest 3.2. severe allergic reactions and anaphylaxis 3.3. status asthmaticus 3.4. bradycardia refractory to pacing or atropine

4. Primary Contraindications: 4.1. hypertension 4.2. hypothermia 4.3. hypersensitivity

5. Side Effects: 5.1. hypertension 5.2. palpitations 5.3. anxiety 5.4. cardiac dysrhythmias 5.5. tremors

FENTANYL CITRATE (SUBLIMAZE) 1. Classification: narcotic analgesic 2. Physiologic Effect: binds to receptors in the brain to change or alter the perception of pain 3. Major Indications: for analgesic purposes 4. Primary Contraindications:

4.1. hypersensitivity to fentanyl 4.2. head injuries

5. Side Effects: 5.1. respiratory depression 5.2. hypotension 5.3. nausea and vomiting

6. Additional information: 6.1. use with caution in patients who are debilitated or have COPD 6.2. fentanyl can be administered in various ways including through a patch or a lollipop for

pediatric cases 6.3. be prepared to assist ventilation if needed

7. Additional Information: 7.1. For IV Administration Only: Dilute Fentanyl 100 mcg / 2 ml in 8 ml of normal saline to yield a

concentration of 10 mcg / ml. 7.2. Do not dilute Fentanyl for intranasal (IN) or intramuscular (IM) administration.

GLUCAGON 1. Classification: hormone-hyperglycemic agent 2. Physiologic Effect: increases blood glucose levels through the release of glycogen stores from

the liver 3. Major Indications:

3.1. blood glucose determination <60 3.2. beta blocker overdose

4. Primary Contraindications: 4.1. pheochromocytoma (adrenal gland tumor)


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4.2. hypersensitivity 5. Side Effects:

5.1. nausea and vomiting 5.2. hypotension

6. Additional Information: 6.1. should always be followed by administration of dextrose 50% or glucose. 6.2. use with caution in patients with a history suggestive of insulinoma (tumor of Islets

of Langerhans) and/or pheochromocytoma

GLUCOSE (ORAL) 1. Classification: monosaccharide 2. Physiologic Effect: increases blood serum glucose level by absorption through mucous membranes 3. Major Indication: hypoglycemia 4. Primary Contraindication: none

Haloperidol (Haldol) 1. Classification: Butyrophenone antipsychotic 2. Physiologic Effect: blocks the effects of dopamine and increases its turnover rate 3. Major Indications:

3.1. Schizophrenia 3.2. Manic episodes

4. Primary Contraindications: 4.1. Use in patient with history of Parkinson’s 4.2. Use during pregnancy

5. Side Effects: 5.1. Tachycardia 5.2. Hypotension 5.3. Hypertension

6. Additional Information: 6.1. Risk of Tardive Dyskinesia 6.2. Risk of Q-T prolongation

KETAMINE (KETALAR) 1. Classification: NMDA receptor antagonist, 2. Physiologic Effect: primarily used for the induction and maintenance of general anethesia usually

in combination with a sedative and can be used in the treatment of bronchospasms. 3. Major Indications:

3.1. Sedation prior to intubation in RSI procedure 3.2. Chemical extrication (Air Med) 3.3. Anxiety and agitation associated with behavioral emergencies and excited delirium 3.4. Refractory pain

4. Primary Contraindications: 4.1. Hypersensitivity 4.2. Hypertension

5. Relative Contraindications: 5.1. Caution if CAD 5.2. Caution if CHF 5.3. Caution if chronic alcohol/substance abuse

6. Side Effects: 6.1. Respiratory depression 6.2. Hypotension 6.3. Bradycardia 6.4. Arrhythmias


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6.5. Hallucinations 6.6. Tonic-Clonic movements

7. Additional Information: 7.1. Closely monitor the patients level of consciousness and respiratory rate

LIDOCAINE 1. Classification: Anti-dysrhythmic 2. Physiologic Effect: increases fibrillatory threshold thereby decreasing ventricular ectopy and

increasing the likelihood of successful electrical cardioversion of ventricular dysrhythmias 3. Major Indication:

3.1. To minimize discomfort associated with EZ-IO infusion/administration 4. Primary Contraindication:

4.1. allergy to related local anesthetics of the amide type 4.2. WPW syndrome 4.3. Stokes-Adam syndrome

5. Side Effects: 5.1. CNS disturbances; convulsions 5.2. tinnitus 5.3. blurred or double vision 5.4. bradycardia 5.5. hypotension 5.6. anaphylaxis 5.7. respiratory depression

6. Additional Information: 6.1. halve the dose for the elderly, individuals with liver dysfunction, and patients weighing less

than 25 kg 6.2. use with extreme caution in patients with second or third degree heart blocks 6.3. do not use to treat ectopic beats if heart rate is less than 60; increase the heart rate instead

Lorazepam (Ativan) 1. Classification: benzodiazepine-sedative 2. Physiologic Effects: Depresses subcortical levels of CNS (e.g., limbic and reticular formation),

possibly by increasing activity of GABA. 3. Major Indication: Severe pain, Seizure activity 4. Primary Contraindication: hypersensitivity 5. Relative Contraindications:

5.1. shock 5.2. hypotension, especially in the head injured patient 5.3. coma 5.4. alcohol intoxication, use of barbiturates, narcotics or CNS depressants 5.5. pregnancy 5.6. chronic renal failure 5.7. congestive heart failure 5.8. chronic obstructive pulmonary disease 5.9. hepatic function impairment

6. Side Effects: 6.1. respiratory depression 6.2. respiratory arrest 6.3. hypotension 6.4. cardiac arrhythmias 6.5. headache 6.6. blurred vision


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MAGNESIUM SULFATE 1. Classification: anticonvulsant; electrolyte 2. Physiologic Effects:

2.1. depresses the CNS and blocks peripheral neuromuscular transmission by decreasing the amount of acetylcholine released by the motor nerve impulse

2.2. slows formation of SA impulses and prolongs conduction time 2.3. in severe asthma: Antagonizes translocation of Ca across cell membrane, leads to smooth

muscle relaxation & bronchodilation 2.3.1. Inhibits degranulation of mast cells (that release histamine) 2.3.2. Decreases release of acetylcholine (decreases excitability of muscle fiber membranes)

3. Major Indications: 3.1. seizure activity due to eclampsia 3.2. refractory ventricular fibrillation and pulseless v-tach 3.3. ventricular tachycardia (often torsades de pointes) due to hypomagnesemia 3.4. hypomagnesemia associated with AMI 3.5. severe asthma

4. Primary Contraindications: 4.1. severe renal impairment 4.2. heart blocks 4.3. hypersensitivity

5. Side Effects: 5.1. hypotension 5.2. respiratory paralysis 5.3. cardiac depression or asystole 5.4. CNS depression and paralysis 5.5. flushing and sweating

6. Additional Information: 6.1. toxic accumulation may occur in renal failure 6.2. check patellar reflex to avoid intoxication 6.3. calcium salts used as the antidote for intoxication

METHYLPREDNISOLONE (SOLU-MEDROL) 1. Classification: steroid-glucocorticoid; a potent anti-inflammatory 2. Physiologic Effect: suppression of acute and chronic inflammation of the immune system 3. Major Indications:

3.1. bronchodilation 3.2. asthma & COPD 3.3. allergic reactions 3.4. anaphylaxis

4. Relative Contraindications: 4.1. immune suppressing drugs 4.2. active infectious processes 4.3. peptic ulcer disease or gastrointestinal bleeding 4.4. pregnant or nursing mothers 4.5. sepsis

5. Side Effects: 5.1. headache 5.2. hypertension 5.3. CHF 5.4. hypokalemia 5.5. GI bleed

6. Additional Information: 6.1. reconstituted medication must be used within 48 hours. 6.2. methylprednisolone may interfere with the performance of hypoglycemic agents 6.3. use with caution in patients receiving potassium-depleting agents


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MIDAZOLAM (VERSED) 1. Classification: Short acting benzodiazepine-sedative 2. Physiologic Effects: Depresses subcortical levels of CNS (e.g., limbic and reticular formation),

possibly by increasing activity of GABA. Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Also useful for its amnestic effects.

3. Major Indications: 3.1. status epilepticus 3.2. premedication before transcutaneous pacing 3.3. anxiety and agitation 3.4. facilitated intubation

4. Absolute Contraindications: 4.1. hypersensitivity

5. Relative Contraindications: 5.1. shock 5.2. hypotension, especially in the head injured patient 5.3. coma 5.4. alcohol intoxication, use of barbiturates, narcotics or CNS depressants 5.5. pregnancy 5.6. chronic renal failure 5.7. congestive heart failure 5.8. chronic obstructive pulmonary disease 5.9. hepatic function impairment

6. Side Effects: 6.1. respiratory depression 6.2. respiratory arrest 6.3. hypotension 6.4. cardiac arrhythmias 6.5. headache 6.6. blurred vision 6.7. nausea and vomiting

7. Additional Information 7.1. Dilute for IV administration: Draw 10 mg (2 ml) in 10 ml syringe and dilute with 8 ml of saline for

1.0 mg/ml

7.2. Do not dilute for intramuscular administration: Draw 10 mg (2 ml) in 5-10 ml syringe give deep intramuscular injection

7.3. Do not dilute for intranasal administration: draw in 1 ml syringe and administer via the M.A.D.

Morphine Sulfate 7. Classification: Opioid agonist 8. Physiologic Effects: Provides analgesia by potentiating opioid receptors 9. Major Indication: Pain control 10. Primary Contraindications: Hypersensitivity, hypotension, respiratory depression 11. Side Effects:

11.1. Antihistamine mediated vasodilation 11.2. Respiratory depression 11.3. Nausea

NALOXONE (NARCAN) 1. Classification: narcotic antagonist 2. Physiologic Effects: causes reversal of narcotic depression induced by opioids by acting as an

antagonist in the opioid receptor sites 3. Major Indication: narcotic induced respiratory depression 4. Primary Contraindication: hypersensitivity


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5. Side Effects: 5.1. withdrawal symptoms (especially in neonates) 5.2. combativeness 5.3. hyperventilation

6. Additional Information: 6.1. Naloxone is sensitive to light, steps should be taken to shield the vial from UV light until ready

for usage 6.2. The smallest dose should be used to reverse respiratory depression, not to fully awake patient. 6.3. Common opioids include; morphine, methadone, codeine, Demerol, dilaudid, fentanyl,

and hydrocodone


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NITROGLYCERIN (NTG) 1. Classification: vasodilator 2. Physiologic Effects: relaxes smooth muscle producing vasodilator effects on

arteries and veins in the peripheral and core circulation thus reducing preload and afterload; causes coronary artery dilation

3. Major Indications: 3.1. To increase coronary perfusion in angina and acute myocardial infarction 3.2. To reduce preload in acute pulmonary edema 3.3. hypertensive crisis

4. Primary Contraindications: 4.1. patients having taken Viagra, Levitra, or Cialis or other erectile dysfunction

medications in the past 24-36 hours 4.2. hypovolemia 4.3. hypersensitivity

5. Side Effects: 5.1. headache 5.2. hypotension 5.3. palpitations 5.4. SL burning

6. Additional Information: 6.1. monitor blood pressure after each dose 6.2. use gloves for application 6.3. do not allow medication to come in contact with your skin or mucous membrane

ONDANSETRON HCL (ZOFRAN) 1. Classification: antiemetic 2. Physiologic Effects: blocks the release of chemicals in the brain that stimulate

the impulse to vomit. 3. Major Indications: prevent nausea and vomiting 4. Primary Contraindications: known hypersensitivity to ondansetron 5. Side Effects:

5.1. constipation 5.2. drowsiness 5.3. dry mouth

6. Additional Information: 6.1. No adequate and well-controlled studies in pregnant patients. 6.2. It is unknown if ondansetron is excreted in breast milk. Because many drugs

are excreted in human milk, extreme caution should be exercised before administering to a nursing mother.

OXYGEN 1. Classification: gas 2. Physiologic Effects: increases arterial oxygen tension and hemoglobin saturation to

improve tissue oxygenation 3. Major Indications:

3.1. hypoxia 3.2. cardiopulmonary or respiratory arrest 3.3. shock 3.4. CNS injuries 3.5. decreased level of consciousness 3.6. acute chest pain which may be due to cardiac ischemia

4. Primary Contraindications: none 5. Relative Contraindications:

5.1. chronic obstructive pulmonary disease


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5.2. hyperventilation syndrome 6. Administration and Dosage:

6.1. adult and pediatric patients without COPD 24% - 100% based on patient’s condition

6.2. COPD patients: 2-6 lpm via nasal cannula to SPO2 level of 92-93% 7. Side Effects:

7.1. respiratory arrest in patients with hypoxic drive 7.2. drying of respiratory mucosa 7.3. possible bronchospasm if the gas is extremely cold and dry

8. Additional Information: use unhumidified oxygen unless: 8.1. administration time > 20 min 8.2. patient is on humidified oxygen at home 8.3. medical control orders humidified oxygen

9. Device Information:

Device Concentration Flow Rate in liters per minute nasal cannula 24-44% 1-6 simple face mask 40-60% 6-10 non-rebreather mask 90-100% 10-15 BVM (no reservoir) 40-60% 12-15 BVM (with reservoir) 90-100% 12-15

O2 Saturation Reading

Range Recommended O2 Flows

95-100% Normal O2 PRN for Comfort 91-94% Mild Hypoxia O2 to improve to Normal 86-90% Moderate

Hypoxia 100% FiO2, evaluate respiratory rate and consider assist BVM/ intubation if outside normal range

<85% Severe Hypoxia

100% FiO2 Assist Ventilation and Intubate if improvement is not rapid or LOC is decreased

ROCURONIUM BROMIDE (ZEMURON) 1. Classification: non-depolarizing neuromuscular blocking agent 2. Physiologic Effect: competitively blocks acetylcholine from binding to post

synaptic sites and prevents muscle depolarization 3. Major Indications: to facilitate rapid sequence intubation 4. Primary Contraindications: hypersensitivity to rocuronium 5. Side Effects: malignant hypertension 6. Additional information:

6.1. must be accompanied with a sedating agent such as Versed or Etomidate 6.2. eye lubrication is required for prolonged paralysis

SODIUM BICARBONATE (BICARB) 1. Classification: systemic alkalizer, electrolyte buffer 2. Physiologic Effect: buffers H+ ions in metabolic acidosis 3. Major Indications:

3.1. preexisting metabolic acidosis (perfusing patient) 3.2. hyperkalemia 3.3. tricyclic, phenobarbital, or aspirin overdoses 3.4. during cardiac arrest, after prolonged resuscitative efforts

4. Primary Contraindications: 4.1. metabolic alkalosis 4.2. hypokalemia


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4.3. simultaneously with calcium chloride 4.4. simultaneously with catecholamines

5. Side Effects: 5.1. metabolic alkalosis 5.2. CHF (edema secondary to sodium overload) 5.3. hypernatremia

6. Additional Information: administration should be guided by arterial blood gas analysis in a perfusing patient

Documents

2018 Adult and Pediatric Statewide EMS Treatment Protocols