Abdominal Pain - North Fork Ambulance · • The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50. • Appendicitis presents with vague,

Abdominal Pain

Modified Date: 9/1/12 Medical Protocol 1 Page 1 of 1

History:

• Age • Past medical/surgical

history • Medications • Onset • Palliation/ Provocation • Quality (cramps, constant,

sharp, dull, etc.) • Region/Radiation/Referred • Severity (1-10) • Time (duration/repetition) • Fever • Last meal eaten • Last bowel movement/

emesis • Menstrual history

(pregnancy)

Signs and Symptoms: • Pain (location/migration) • Tenderness • Nausea • Vomiting • Diarrhea • Dysuria • Constipation • Vaginal bleeding/discharge • Pregnancy

Associated symptoms: Fever, headache, weakness, malaise, cough, mental status changes, rash

Differential: • Trauma • Pneumonia or PE • Liver (hepatitis, CHF) • Peptic ulcer disease • Gallbladder • Myocardial Infarction • Pancreatitis • Kidney Stone • Abdominal aneurysm • Appendicitis • Bladder/Prostate

disorder • Pelvic (PID, Ectopic

pregnancy, ovarian cyst) • Spleen enlargement • Diverticulitis • Bowel obstruction • Gastroenteritis

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Required Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back,

Extremities, and Neuro. • The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over

50. • Appendicitis presents with vague, peri-umbilical pain that migrates to the RLQ over time.

Universal Patient Care Protocol Signs of Shock?

IV Protocol NS Challenge

No Yes

Consider Chest Pain Protocol Medical Protocol #7

Contact Medical Control

Nausea and/or Vomiting? No Oxygen

Consider ALS Ground Intercept for Anti-emetic

Medication

Consider ALS Ground Intercept for Pain

Medications

Yes

Allergic Reaction


History:

• Onset and location • Insect sting or bite • Food allergy/exposure • New clothing, soap,

detergent • Past history of reactions • Past medical history • Medication history

Signs and Symptoms: • Itching or hives • Coughing/wheezing or

respiratory distress • Chest or throat constriction • Difficulty swallowing • Hypotension or shock • Edema

Differential: • Urticaria (rash only) • Anaphylaxis (systemic

effect) • Shock (vascular effect) • Aspiration / Airway

obstruction • Asthma or COPD • CHF

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, Heart, Lungs • Contact Medical Control prior to administering epinephrine in patients who are > 65

years of age, have a history of cardiac disease, or if the patient’s heart rate is > 150. • Any patient with respiratory symptoms or extensive reaction should receive IV or IM

diphenhydramine (Benadryl).

Universal Patient Care Protocol

Evidence of Acute Respiratory Distress or Shock

Hives / Rash only No respiratory component

Diphenhydramine 25-50 mg IV

IV Protocol- NS Challenge

Diphenhydramine 25-50 mg IV


Hypotension Protocol (Medical #11)

Appropriate Protocol (Medical # 4 15,18,21,22)

Respiratory Distress Protocol (Medical #16)

Reassess Patient


Hypotensive? Respiratory Distress? Dysrhythmia?

Oxygen

3 Lead Non-Interpretive

Epi-pen Adult or Child

Altered Mental Status


History:

• Known diabetic, medic alert tag

• Drugs, drug paraphernalia • Report of illicit drug use or

toxic ingestion • Past medical history • Medications • History of trauma

Signs and Symptoms: • Decreased mental status • Change in baseline mental

status • Bizarre behavior • Hypoglycemia (cool,

diaphoretic skin) • Hyperglycemia (warm, dry

skin; fruity breath; Kussmal respirations; signs of dehydration)

Differential: • Head trauma • CNS (stroke, tumor,

seizure, infection) • Cardiac (MI, CHF) • Infection • Thyroid (hyper, hypo) • Shock • Diabetes • Toxicologic • Acidosis / Alkalosis • Environmental exposure • Pulmonary (hypoxia) • Electrolyte abnormality • Psychiatric disorder

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect

personal safety. • It is safer to assume hypoglycemia than hyperglycemia if doubt exists. • Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia or may have

significant injuries from traumatic events. • Low glucose (< 60), normal glucose (60-120), high glucose (> 250). • Consider Restraints if necessary for patient’s and/or personnel’s protection per the restraint procedure.


IV Protocol

Blood Glucose

Glucose 60 -250 Glucose < 60 Glucose > 250

Naloxone (Narcan) 2 mg IV Administer SLOWLY

Consider other causes: Head injury, Overdose, Stroke, Hypoxia


NS Bolus – 500cc Contact Medical Control for

Repeat Bolus

Consider Repeat D50

Consider 12-Lead ECG

50% Dextrose (D50) 25 G IV

Return to Normal Mental Status?

Yes

No

Oxygen as Appropriate to Patient

Asystole


History:

• Past medical history • Medications • Events leading to arrest • End stage renal disease • Estimated downtime • Suspected hypothermia • Suspected overdose • DNR or Living Will

Signs and Symptoms: • Pulseless • Apneic • No electrical activity on ECG

Differential: • Medical or Trauma • Hypoxia • Potassium (hypo/hyper) • Drug overdose • Acidosis • Hypothermia • Device (lead) error • Death

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Respiratory Status, Circulatory Status • Always confirm asystole in more than one lead. • Contact Medical Control to consider Calcium Chloride for patients with a hx. of renal failure.


Does patient meet Criteria for Death/No Resuscitation?

Yes

No

Withhold Resuscitation

CPR/BLS Airway Management

IV Protocol

Est. Downtime < 8 minutes or previously witnessed perfusing rhythm? Yes

No

External Transcutaneous Pacing

Criteria for Discontinuation Met?

No

Consider Sodium Bicarb 1 meq/kg


Yes Stop

resuscitation

If return of

Spontaneous Circulation or

change in rhythms go to appropriate

protocol

King Tube Procedure Skill # 3

Bradycardia


History:

• Past medical history • Medications

o Beta-Blockers o Calcium Channel

Blockers o Clonidine o Digitalis

• Pacemaker

Signs and Symptoms: • HR < 60/min • Chest pain • Respiratory distress • Hypotension or Shock • Altered Mental Status • Syncope

Differential: • Acute myocardial

infarction • Hypoxia • Hypothermia • Sinus bradycardia • Athletes • Head injury or stroke • Spinal cord lesion • Sick sinus syndrome • AV blocks (1°,2°,3°)

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Neck, Heart, Lungs, Neuro • Pharmacological treatment of Bradycardia is based the patient’s hemodynamic stability. • If the bradycardic patient presents with any of these signs or symptoms (decreased

LOC, Chest Pain, SOB, hypoxia, or hypotension) treat the bradycardia. • If none of the above signs and symptoms are present, continue to monitor patient

condition.


IV Protocol

12-Lead ECG

Presence of Serious Signs/Symptoms?

(Decreased LOC, Chest Pain, SOB, Hypoxia, Hypotension)

Yes

External Transcutaneous Pacing (Consider contacting Medical Control

for sedation)


No

Monitor and Transport


3 Lead Non-Interpretive ECG

Consider ALS Intercept

Cardiac Arrest


History:

• Events leading to arrest • Estimated downtime • Past medical history • Medications • Existence of terminal illness • DNR or Living Will

Signs and Symptoms: • Unresponsive • Pulseless • Apneic • Signs of lividity, rigor mortis

Differential: • Medical vs. Trauma • V-Fib/Pulseless V-Tach. • Asystole • Pulseless electrical

activity

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Respiratory Status, Circulatory Status • Success is based on proper planning and execution. Procedures require space and patient access.

Make room to work. • Reassess airway frequently and with every patient move. • Maternal Arrest – Treat mother per appropriate protocol with immediate notification to Medical

Control and rapid transport.


CPR with BVM, OPA or NPA and Oxygen

No

Yes Withhold

Resuscitation

Un-Witnessed Arrest Witnessed Arrest

Does Patient Meet Criteria for Death/No Resuscitation?

King Tube & Airway Suctioning Procedures King Tube LTSD – Skill # 3

Basic Airway Suctioning – Skill # 8

Automatic External Defibrillator

Automatic External Defibrillator

CPR with BVM, OPA or NPA and Oxygen

GO TO APPROPRIATE PROTOCOL: *Ventricular Fibrillation- Medical #21 *Pulseless Ventricular Tachycardia - Pediatric #11 *Pulseless Electrical Activity – Medical #15 *Asystole – Medical # 4 *Pediatric Pulseless Arrest- Pediatric # 8


ECG Monitor/Quick Look

Initiate Rapid Transport

Request ALS Intercept

IV Protocol

King Tube & Airway Suctioning Procedures King Tube LTSD – Skill # 3

Basic Airway Suctioning – Skill # 8

Chest Pain Suspected Cardiac Event


History:

• Age • Medications • Viagra, Cialus, Levitra • Past medical history (MI,

angina, Diabetes) • Allergies (Morphine,

Lidocaine) • Recent physical exertion • Onset • Palliation/ Provocation • Quality (cramps, constant,

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

Signs and Symptoms: • Chest Pain (pain, pressure,

aching, tightness) • Location (substernal,

epigastric, arm, jaw, neck, shoulder)

• Radiation of pain • Pale, diaphoretic • Shortness of breath • Nausea, vomiting, dizziness

Differential: • Trauma vs. Medical • Angina • Myocardial Infarction • Pericarditis • Pulmonary embolism • Asthma / COPD • Pneumothorax • Aortic dissection or

aneurysm • GE reflux or Hiatal

hernia • Esophageal spasm • Chest wall injury • Pleural effusion

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, Neck, Lungs, heart, Abdomen, Back, Extremities, Neuro • Avoid Nitroglycerin in any patient who has used Viagra, Cialas, Levitra or other erectile

dysfunction meds in the past 48 hours due to potential severe hypotension. • If patient has taken nitroglycerin without relief, consider potency of the medication. • Attempt to establish a second IV while en route to the hospital if time and conditions allow. • Monitor for hypotension after administration of nitroglycerin. • Nitroglycerin may be repeated per dosing guidelines in Drug List. • Diabetics and geriatric patients often have atypical pain, or only generalized complaints.


If patient is Hypotensive or a dysrhythmia is noted,

Go to appropriate Protocol: Hypotensive – Medical 11

Dysrhthmia – Medical 4,15,18,21,22,23

12-Lead ECG

Nitroglycerin 0.4 mg SL If BP Greater Than 90 Systolic

Aspirin 325 mg P.O. (chewable)

Continued Pain?

Contact Medical Control Request Order To Assist with Patient’s Own

Nitroglycerin Nitroglycerin – 0.4 mg SL If BP Greater Than 90 Systolic

Oxygen As Required to Maintain O2 Sat of 95% or Greater

IV Protocol




Re-Contact Medical Control

Dental Problems


History:

• Age • Past medical history • Medications • Onset of pain/injury • Trauma with ‘knocked out”

tooth • Location of tooth • Whole vs. partial tooth

injury

Signs and Symptoms: • Bleeding • Pain • Fever • Swelling • Tooth missing or fractured

Differential: • Decay • Infection • Fracture • Avulsion • Abscess • Facial cellulitis • Impacted tooth

(wisdom) • Myocardial infarction

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, HEENT, Neck, Chest, Lungs, Neuro • Significant soft tissue swelling to the face or oral cavity can represent a cellulitis or abscess. • Scene and transport times should be minimized in complete tooth avulsions. Reimplantation is

possible within 4 hours if the tooth is properly cared for. • All tooth disorders typically need pain control. • Occasionally cardiac chest pain can radiate to the jaw. • All pain associated with teeth should be associated with a tooth which is tender to tapping or touch

(or sensitivity to cold or hot)


Control Bleeding with Pressure Wound Care – Skill # 29

Tooth Avulsion?

No

Yes

Reassess and Monitor Contact Medical Control

Mechanism for C-Spine?

Yes

Spinal Immobilization Skill #21

Pain Control Protocol General # 8

Place Tooth in Milk or Normal Saline, or if no airway

compromise, in patient’s mouth

Epistaxis (Nose Bleed)


History:

• Age • Past medical history • Medications (HTN,

anticoagulants) • Previous episodes of

Epistaxis • Trauma • Duration of bleeding • Quantity of bleeding

Signs and Symptoms: • Bleeding from nasal

passage • Pain • Nausea • Vomiting

Differential: • Trauma • Infection • Allergic rhinitis • Lesions (polyps, ulcers) • Hypertension

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, HEENT, Heart, Lungs, Neuro • It is very difficult to quantify the amount of blood loss with Epistaxis. • Bleeding may also be occurring posteriorly. Evaluate for posterior blood loss by examining the

posterior pharynx. • Anticoagulants include aspirin, coumadin, non-steroidal anti-inflammatory medications (ibuprofen),

and many over the counter headache relief powders.


Control Bleeding:

Signs of Shock? Yes

No IV Protocol

Normal Saline Challenge


Oxygen

1. Clear clots by having patient blow nose 2. If Available, have patient use 2 sprays of

Afrin Nose Spray 3. Compress Nostrils 4. Place Patient in Sitting Position with Head

Forward 5. Ice Packs

Malignant Hypertension


History:

• Documented hypertension • Related diseases: diabetes,

CVA, renal failure, cardiac • Medications • Viagra • Pregnancy

Signs and Symptoms: • One of these:

o Systolic 200 or greater

o Diastolic 120 or greater

• AND at least one of these:

o Headache o Blurred Vision o Nosebleed o Dizziness

Differential: • Hypertensive

encephalopathy • Primary CNS Injury • Myocardial infarction • Aortic dissection • Pre-eclampsia /

eclampsia

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro • Avoid Nitroglycerin in any patient who has used Viagra, Cialas, Levitra or other erectile

dysfunction meds in the past 48 hours due to potential severe hypotension. • Never treat elevated BP based on one set of vital signs, have second attendant confirm. • Nitroglycerin may be given to lower blood pressure in patients who have an elevated diastolic BP of

> 120 and are symptomatic with chest pain, respiratory distress, syncope, headache or altered LOC. • Symptomatic hypertension is typically revealed through end organ damage to the cardiac, CNS or

renal systems. • All symptomatic patients with hypertension should be transported with their head elevated.


IV Protocol

Contact Medical Control to consider

Nitroglycerin 0.4 mg SL

Early transport with Head Elevated

Oxygen

Is patient Symptomatic?

Yes

No

Treatment not indicated

And/Or Lopressor 5 mg slow IV q 5 min to

15mg total dose.

Contact Medical Control Request Order to Assist Patient with

Own Nitroglycerin 0.4 mg SL

Hypotension/Shock (Non-Traumatic)


History:

• Blood loss (vaginal or GI, AAA, ectopic)

• Fluid loss – vomiting, diarrhea, fever

• Infection • Cardiac ischemia • Medications • Allergic reaction • Pregnancy • Baseline “Normal” BP

Signs and Symptoms: • Restlessness, confusion • Weakness, dizziness • Weak, rapid pulse • Pale, cool, clammy skin • Hypotension • Coffee-ground emesis • Tarry stools

Differential: • Shock • Ectopic Pregnancy • Dysrhythmia • Pulmonary embolus • Tension Pneumothorax • Medication

effect/overdose • Vaso-vagal • Physiologic

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Hypotension can be defined as a systolic blood pressure of less than 100. • Consider performing orthostatic vital signs on patients in non-trauma situations if suspected blood or fluid loss. • Consider all possible causes of shock (cardiac, blood loss, septic, neurgenic) and treat per appropriate protocol. • Raise Patient’s feet no more than 8” and maintain body temperature – Do not elevate feet in

suspected cardiac event or head trauma.


IV Protocol

Normal Saline Challenge Treatment per appropriate

Trauma Protocol

Treatment per appropriate

Cardiac Protocol

Trauma Non-cardiac Non-trauma Cardiac

Consider Dopamine 2-20 mcg/kg/min


If no rales present Consider NS Bolus


Oxygen

Overdose Toxic Ingestion


History:

• Ingestion or suspected ingestion of a potentially toxic substance

• Substance ingested, route, quantity

• Emesis after ingestion? • Time of ingestion • Reason (suicidal, accidental,

criminal) • Available medications at

scene • Past medical history

Signs and Symptoms: • Mental status changes • Hypotension / hypertension • Decreased respiratory rate • Tachycardia, dysrhythmia • Seizures

Differential: • Tricyclic antidepressants • Acetaminophen

(Tylenol) • Depressants • Stimulants • Anticholinergic • Cardiac medications • Solvents, alcohols,

cleaning agents • Insecticides

(organophosphates)

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Consider Contacting Poison Control – 1-800-222-1222 • Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Do not rely on patient history of ingestion, especially in suicide attempts. • Bring bottles, contents, emesis to ED. • Tricyclic: 4 major areas of toxicity; Seizures, dysrhythmia, hypotension, decreased mental status. • Acetaminophen: Initially normal or nausea/vomiting. If not detected and treated, causes irreversible

liver failure. • Depressants: Decreased HR, decreased BP, decreased respirations. • Stimulants: Increased HR increased BP, dilated pupils, mental status changes. • Anticholinergic: increased HR, dilated pupils, mental status changes. • Cardiac meds: dysrhythmia and mental status change. • Solvents: Nausea, vomiting, mental status changes. • Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint

pupils.


IV Protocol

Tricyclic Antidepressant Obtain 12-lead ECG

Consider Sodium Bicarb 1 meq/kg IV

Naloxone (Narcan) 0.4-2 mg IV/IM

Contact Medical Control Consider Order for Activated Charcoal

Hypotension, Seizures, Dysrhythmia, or Mental Status

Change


Organophosphate Insure Crew Safety

Atropine 2 mg every 3-5 minutes until desired effect

attained. Beta Blocker

Consider: Glucagon 5-10mg IV

Appropriate Protocol

Contact Medical Control Consider Order for Activated

Charcoal

Respiratory Depression (<8/Min) Assist Ventilations

Oxygen

Known Substance and Antidote? Yes No


Post Resuscitation


History:

• Respiratory Arrest • Cardiac Arrest

Signs and Symptoms: • Return of pulse

Differential: • Continue to address

specific differentials associated with the original dysrhythmia

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro • Most patients immediately post resuscitation will require assistance of ventilations. • The condition of post-resuscitation patients fluctuates rapidly and continuously, and they require

close monitoring. • Appropriate post-resuscitation management can best be planned in consultation with Medical

Control.

Repeat Primary Assessment

Continue ventilations with 100% oxygen

IV Protocol (If not established)

Obtain Vital Signs

Ventricular Ectopy Hypotension Bradycardia

Consider NS Challenge


Lidocaine 1-1.5 mg/kg followed by Lidocaine gtt 2-4 mg/min

Or Amiodarone 150 mg over 10

minutes

If arrest reoccurs, revert to appropriate protocol and/or initial

successful treatment

Go to Bradycardia Protocol – Medical # 5




Cardiac Monitor

Pulmonary Edema


History: • Congestive heart failure • Past medical history • Medications (digoxin, lasix) • Viagra, Cialis, Levitra • Cardiac history, past AMI

Signs and Symptoms: • Respiratory distress,

bilateral rales or wheezing • Apprehension, orthoponea • Jugular vein distension • Pink, frothy sputum • Peripheral edema,

diaphoresis • Hypotension, shock • Chest pain

Differential: • Myocardial infarction • Congestive heart failure • Asthma • Anaphylaxis • Aspiration • COPD • Pneumonia • Pulmonary embolus • Pericardial tamponade

LEGEND

EMT-B

EMT-I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, Neck, Lungs, Heart, Abdomen, Back, Extremities, Neuro • Avoid Nitroglycerin in any patient who has used Viagra, Cialis, Levitra or other erectile

dysfunction meds in the past 48 hours due to possible severe hypotension • The acronym LMNOP can be helpful in remember the treatment for pulmonary edema:

o Lasix o Morphine o Nitroglycerin o Oxygenation o Positive Pressure, Peep

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

closely. • Consider myocardial infarction in all these patients. • Careful monitoring of level of consciousness, BP, and respiratory status with above interventions is

essential. • Allow the patient to be in position to maximize their breathing effort.


Symptoms persist

Symptoms resolved Reassess and Monitor

Oxygen

Cardiac Monitor IV Protocol

Contact Medical Control for:

Patient Assisted Nitroglycerin 0.4 mg SL x 1 If BP is Greater than 110 Systolic

Consider Requesting Albuterol Nebulizer

Nitroglycerin 0.4 mg SL If BP > 100 Systolic

May Repeat in 3-5 Minutes

Request ALS Intercept Lasix 20 mg IV

12 Lead ECG

Re-Contact Medical Control

Pulseless Electrical Activity (PEA)


History:

• Past medical history • Medications • Events leading to arrest • End stage renal disease • Estimated downtime • Suspected hypothermia • Suspected overdose • DNR or Living Will

Signs and Symptoms: • Pulseless • Apneic • Electrical activity on ECG

without corresponding pulses.

Differential: • Tension Pneumothorax • Overdose • Pulmonary Embolus • Hypoxia, Hypovolemia,

Hypothermia, Hypo/Hyperkalemia

• Acidosis • Tamponade

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Respiratory Status, Circulatory Status • Consider each of the possible causes listed in the differential above. Survival is dependant upon

identifying and correcting the cause. • Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and

identifying possible treatment options.


Airway Control/CPR

IV Protocol – NS Bolus

Intubation Procedure Skill # 6

Epinephrine 1:10000 1 mg IV Every 3-5 minutes

Atropine 1 mg every 3-5 minutes (If rate < 60)

Consider early in all PEAs: Reversible Causes

Fluid Challenge Glucose in known Diabetic or BG less than 60

Bicarbonate , Pacing, Chest Decompression

Calcium (Contact Medical Control)

Dopamine

Criteria for Discontinuation Met? Stop

resuscitation Yes

Contact Medical Control No

ALS Intercept

King Tube Procedure Skill # 3

Respiratory Distress


History: • Asthma; COPD, CHF • Home treatments • New meds • Medications (inhalers,

steroids) • Toxic exposure, smoke

inhalation • Foreign Body Obstruction • Allergies • Recent illness • Trauma

Signs and Symptoms: • Shortness of Breath • Pursed lip breathing • Decreased ability to speak • Increased respiratory rate

and effort • Audible wheezing, rhonchi

stridor • Use of accessory muscles • Fever, cough • Tachycardia

Differential: • Asthma • Anaphylaxis • Aspiration • COPD • Pleural effusion • Pneumonia • Pulmonary embolus • Pneumothorax • Cardiac (AMI/CHF) • Pericardial tamponade • Hyperventilation • Inhaled toxin (CO, Smoke)

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro • Contact Medical Control prior to 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. A 12-Lead ECG should be performed on these patients.


Oxygen Therapy as Appropriate to Level of Distress Humidified if High Flow Oxygen for extended periods, and/or

toxins, burns, respiratory infections, inhalation injuries.

IV Protocol

Rales/Signs of CHF ?

Pulmonary Edema Protocol Medical # 14

Wheezes ?

Albuterol Nebulizer 2.5mg in 3cc NS May repeat up to 3 total doses after MEDICAL CONTROL

ORDER

Cardiac Monitor

If No Improvement- ALS Intercept

If no improvement, consider Epi 1:1,000 0.3 mg SQ

Or Epi Pen 1:1,000 IM – Medical Control Contact

Consider Intubation Procedure Skill # 6

Seizure


History:

• Reported/witnessed seizure activity – Describe in detail seizure during report to physician at ED and in PCR

• Previous seizure history • Medical alert tags • Seizure medications • History of trauma, diabetes,

or pregnancy

Signs and Symptoms: • Decreased mental status • Sleepiness • Incontinence • Observed seizure activity • Evidence of trauma to

tongue or head

Differential: • CNS (Head) trauma • Tumor • Metabolic, hepatic, renal

failure • Hypoxia • Electrolyte imbalance • Drugs/medication non-

compliance • Infection/fever • ETOH withdrawal • Eclampsia • Stroke • Hyperthermia • Dysrhythmia

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro • Status Epilepticus is defined as 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 (generalized) are associated with loss of consciousness, incontinence, and tongue trauma.

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

• Be prepared for airway problems and continued seizures. • Assess possibility of occult trauma and substance abuse. • Be prepared to assist ventilations especially if diazepam or midazolam is used. • For any seizure in a pregnant patient, follow the OB Emergencies protocol. • Diazepam (Valium) is not effective when administered IM. It should be given IV or

Rectally. Midazolam (Versed) is well absorbed when administered IM.

Universal Patient Care Protocol Consider Spinal Immobilization

If Significant Mechanism Injury

Airway Protocol/Oxygen

Active Seizures

IV Protocol

Post-ictal

IV Protocol

Diazepam 5-10 mg IV

or Midazolam 2.5-5 mg IV

Glucose Greater Than 60

Glucose Less Than 60

D50 25 G IV Pediatric – D25 25 G IV Contact Medical Control

Cardiac Monitor

Request ALS for Status Epilepticus Blood Glucose

Oral Glucose If Patient can control airway

Supraventricular Tachycardias (A-Fib, A-Flutter, Atrial Tach)


History:

• Medications • Diet (caffeine, chocolate) • Drugs (nicotine, cocaine) • Past medical history • History of palpitations /

heart racing • Syncope/near syncope

Signs and Symptoms: • HR > 150/min • QRS < .12 seconds • Dizziness, CP, SOB • Potential presenting

rhythm: o Sinus Tachycardia o Atrial Fibrillation o Atrial Flutter o Atrial Tachycardia o Junctional Tach

Differential: • Heart

disease/Aberrancy • Sick sinus syndrome • Myocardial infarction • Electrolyte imbalance • Exertion, pain, stress • Fever • Hypoxia • Hypovolemia • Drug effect • Hyperthyroidism • Pulmonary embolus

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, Neck, Lungs, Heart, Abdomen, Back, Extremities, Neuro • Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful. • Monitor for respiratory depression of diazepam or midazolam are used. • Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic

intervention.


IV Protocol

Unstable (Decreased LOC, CP, SOB,

hypotension, hypoxia)

Stable (No serious

signs/symptoms)

Consider Diazepam 2-5mg Or

Midazolam 0.1 mg/kg


Cardioversion PSVT: 50J-100J-200J

A-Fib: 100J-200J-300J A-Flutter: 50J-100J-200J

PSVT: Adenosine 12mg IV (rapid IV push) A-Fib/A-Flutter: Amiodarone 150 mg (over

10 minutes)

Contact Medical Control Vagal Maneuvers

PSVT: Adenosine 6 mg IV (rapid IV push)

Repeat with 12 mg IV if unsuccessful

A-Fib/A-Flutter: Amiodarone 150 mg (over 10 minutes)

Cardiac Monitor

Request ALS Ground Intercept

Fluid Challenge

Suspected Stroke


History:

• Previous CVA, TIA • Previous cardiac / vascular

surgery • Associated diseases:

Diabetes, CAD, hypertension

• Atrial fibrillation • Medications • History of trauma

Signs and Symptoms: • Altered Mental Status • Weakness/paralysis –

especially unilateral • Blindness/sensory loss • Aphasia • Syncope • Vertigo • Vomiting • Headache • Seizures • Respiratory Pattern Change • Hypertension / Hypotension

Differential: • See Altered Mental

Status Protocol • TIA (Transient ischemic

attack) • Seizure • Hypoglycemia • Stroke

o Thrombotic o Embolic o Hemorrhagic

• Tumor • Trauma

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Thrombolytic Check List should be completed for any suspected stroke patient with

duration of symptoms of less than 90 minutes. • Early notification to Medical Control, minimized scene times and rapid transport are

important for suspected stroke patients with duration of symptoms less than 90 minutes.

• Onset of symptoms is defined as the last witnessed time 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. Consider Hypertension Protocol if

diastolic is > 120. • Be alert for airway problems. • Hypoglycemia can present as a localized Neurologic deficit, especially in the elderly. • Consider bringing family member with patient for permission to give Thrombolytics

Universal Patient Care Protocol Insure patent airway, ventilation, and oxygenation

IV Protocol

Glucose Less Than 60

D50 25G IV

Glucose Greater Than 60

Thrombolytic Checklist Appendix B

Contact Medical Control To advise of potential

Thrombolytic Candidate

Consider other protocols as indicated: Altered Mental Status – Medical # 3

Hypertension – Medical # 10 Seizure – Medical # 17

Blood Glucose

Syncope


History:

• Cardiac history, stroke, seizure

• Occult blood loss (GI, Ectopic)

• Females: LMP, vaginal bleeding

• Fluid loss: nausea, vomiting, diarrhea

• Past medical history • Medications

Signs and Symptoms: • Loss of consciousness with

rapid recovery upon supine position

• Lightheadedness, dizziness • Palpitations, slow or rapid

pulse • Pulse irregularity • Decreased blood pressure

Differential: • Vasovagal • Orthostatic hypotension • Cardiac syncope • Psychiatric • Stroke • Hypoglycemia • Seizure • Shock (see Shock

protocol) • Toxicologic • Medication effect

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Orthostatic Vital Signs- Include drop of 30 points systolic, or increase of HR 30 BPM after

standing 2 minutes. • Assess for signs and symptoms of trauma if associated or questionable fall with syncope. • Consider dysrhythmia, GI Bleed, Ectopic pregnancy, and seizure as possible causes of syncope. • These patients should be transported. • More than 25% of geriatric syncope is cardiac dysrhythmia based.


Cardiac Monitor

Blood Glucose

IV Protocol Consider Fluid Challenge


Go to Appropriate Dysrhythmia protocol if relevant.

Go to Hypotension Protocol if Appropriate.

Medical Protocol # 11

Go to Altered Mental Status Protocol if Glucose Less Than 60

Medical Protocol # 3

Oxygen

Ventricular Fibrillation Pulseless Vent. Tachycardia


History:

• Estimated down time • Past medical history • Medications • Events leading to arrest • Renal failure/dialysis • DNR or Living Will

Signs and Symptoms: • Unresponsive, Apneic,

Pulseless • Ventricular fibrillation or

ventricular tachycardia noted on ECG

Differential: • Artifact/Device failure • Myocardial Infarction • Endocrine/Metabolic • Drugs • Pulmonary (Hypoxia)

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Respiratory Status, Circulatory Status • In Unwitnessed arrest with no CPR – Give 2 minutes of Compressions First • Calcium Chloride should be administered if Hyperkalemia is suspected (renal failure, dialysis) • Defibrillation takes precedence over all treatment once the defibrillator is available. • If defibrillation is underway by First Responders with an AED, do not interrupt the initial shock from

the AED. Afterwards, replace AED with manual monitor/defibrillator.

Cardiac Arrest Protocol

AED Procedure

IV Protocol

ACLS Protocols

Ventricular Tachycardia


History:

• Past medical history / medications, diet, drugs

• Syncope / near syncope • Palpitations • Pacemaker • Allergies: Lidocaine

Signs and Symptoms: • Ventricular tachycardia on

ECG (runs or sustained) • Conscious • Rapid pulse • Chest pain, SOB • Rate usually 150-180

Differential: • Artifact/Device failure • Cardiac • Endocrine/Metabolic • Drugs • Hypoxia

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, Skin, Neck, Lungs, Heart, Abdomen, Back, Extremities, Neuro • Polymorphic V-Tach (Torsades de Pointes) may benefit from the administration of magnesium

sulfate. • A run of three or more PVC’s in a row constitutes Ventricular Tachycardia, though be conservative in

treatment if isolated runs are noted.


Palpable pulse

present?

Ventricular Fibrillation Protocol

Medical # 21

No

Yes

IV Protocol Fluid Challenge

Request ALS Ground Intercept

Cardiac Monitor

Monitor Patient’s Condition & Update ALS Crew En route to

ALS Ground Intercept

Vomiting and Diarrhea


History:

• Age • Time of last meal • Last bowel

movement/emesis • Improvement or worsening

with food or activity • Duration of problem • Other sick contacts • Past medical history • Past surgical history • Medications • Menstrual history • Travel history • Bloody emesis or stools

Signs and Symptoms: • Pain • Character of pain • Distention • Constipation • Diarrhea • Anorexia • Radiation

Associated Symptoms: (Helpful to localize source) Fever, headache, blurred vision, weakness, malaise, cough, dysuria, mental status changes, rash

Differential: • CNS • Myocardial infarction • Drugs • GI or Renal disorders • Diabetic ketoacidosis • Gynecologic disease • Infections • Electrolyte

abnormalities • Food or toxin induced • Medication or substance

abuse • Pregnancy • Psychological

LEGEND

EMT-B

EMT-B I/V

EMT-I

EMT-P

MC ORDER

Pearls: • Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Document the mental status and vital signs prior to administration of Phenergan. • Look for blood in emesis or stool


IV Protocol Consider NS Challenge if Signs of

Dehydration are Present

Consider Blood Glucose

Consider Zofran 4mg IV Or Phenergan 12.5 mg IV

If actively vomiting

Oxygen as Appropriate

Contact Medical Control to consider NG Procedure if

extended transport time is anticipated

ALS Ground Intercept

Documents

Abdominal Pain - North Fork Ambulance · • The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50. • Appendicitis presents with vague,