1 January 2018

Aurora Fire Rescue / Falck Rocky Mountain

Authorized Version of

Denver Metropolitan Prehospital Protocols

January 2018

Version 1.8

2 January 2018

Introduction Confidentiality Consent Decision Making Capacity Physician at the Scene / Medical Direction Physician at the Scene / Medical Direction Algorithm Adult Pulseless Arrest - General Termination of Resuscitation Advanced Medical Directives Patient Determination: Patient or No Patient Algorithm Patient Non-Transport or Refusal Algorithm Emergency Department Divert and Advisory Emergency Department Capabilities Chart Emergent vs. Non-Emergent Patient Transport Prehospital Trauma Triage Guideline for patients 15 years and older Prehospital Trauma Triage Guideline for patients less than 15 years old Multiple Patient Incident Criteria Free-Standing ED as EMS Destination Alternate Disposition of Acutely Intoxicated Patients START Triage JumpSTART Pediatric MCI Triage Multiple Patient Incident-Distribution Worksheet Procedures: 10 Orotracheal Intubation 15 Nasotracheal Intubation 20 Percutaneous Cricothyrotomy 25 i-gel Airway 30 Continuous Positive Airway Pressure Algorithm 35 Capnography 40 Synchronized Cardioversion Algorithm 45 Transcutaneous Cardiac Pacing 55 Restraint 60 Tourniquet 65 Needle Thoracostomy for Tension Pneumothorax 70 Intraosseous Catheter 75 Vascular Access Devices 80 Hemostatic Gauze Agents

Table of Contents

Index

3 January 2018

Protocols: Respiratory 100 Adult Epistaxis Management Algorithm 105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations 110 Adult Obstructed Airway Algorithm: Conscious Patient 111 Adult Obstructed Airway Algorithm: Unconscious Patient 115 Adult Respiratory Distress Algorithm 120 Adult Asthma 121 Adult COPD 125 Adult CHF / Pulmonary Edema Algorithm 130 Adult Allergy and Anaphylaxis Algorithm Cardiac 2000 Adult Cardiac Arrest-ACLS 2001 Adult Cardiac Arrest Algorithm-ACLS 2002 Ventricular Assist Device 2010 Adult Pulseless Arrest – BLS Algorithm-AED 2020 Adult Pulseless Arrest – VF / VT 2021 Adult Pulseless Arrest – Asystole / PEA 2025 Adult Return of Spontaneous Circulation (ROSC) 2030 Adult Tachyarrhythmia Algorithm-ACLS 2040 Adult Bradycardia Algorithm-ACLS 2050 Adult Chest Pain 2051 Adult Cardiac Alert 2100 Adult Hypertension Neuro 3000 Adult Syncope 3010 Adult Stroke Algorithm 3011 Adult Mobile Stroke Treatment Unit 3020 Adult Altered Mental Status Algorithm 3030 Adult Seizure Algorithm

Medical 4010 Adult Abdominal Pain / Vomiting Algorithm 4020 Adult Overdose and Acute Poisoning Algorithm 4025 Adult Hypoglycemia Algorithm 4030 Adult Medical Hypotension / Shock Algorithm 4031 Adult Adrenal Insufficiency 4040 Adult Drowning Algorithm 4050 Adult Hypothermia Algorithm 4060 Adult Hyperthermia Algorithm 4070 Adult Insect / Arachnid Bite and Stings Algorithm 4080 Adult Snake Bite Algorithm Behavioral 5000 Adult Psychiatric / Behavioral Emergency 5010 Adult Combative Patient Algorithm 5020 Adult Transport of the Handcuffed Patient 5030 Adult Tasered Patients 5040 Adult Drug / Alcohol Intoxication Algorithm

Table of Contents 2

Index

4 January 2018

Obstetrics 6000 Pre-Eclampsia / Eclampsia Algorithm 6010 Emergency Childbirth Algorithm 6020 Abnormal Delivery Algorithm 6030 Postpartum Hemorrhage Algorithm Trauma 7000 Adult General Trauma Care Algorithm 7005 Adult Special Trauma Scenarios Algorithm 7010 Adult Trauma in Pregnancy Algorithm 7015 Adult Traumatic Pulseless Arrest Algorithm 7020 Adult Traumatic Shock Algorithm 7025 Adult Amputations Algorithm 7026 Adult Extremity Injuries 7029 Adult Head Trauma 7030 Adult Face and Neck Trauma Algorithm 7035 Adult Spinal Trauma Algorithm 7036 Suspected Spinal Injury with Protective Athletic Equipment in Place 7040 Adult Selective Spinal Stabilization Algorithm 7045 Adult Chest Trauma Algorithm 7050 Adult Abdominal Trauma Algorithm 7055 Adult Burns Algorithm Pediatrics 001p General Guidelines for Pediatric Patients 002p Pediatric Assessment Algorithm 003p Pediatric Shock 004p Transport of the Pediatric Patient Pediatric Respiratory 100p Pediatric Epistaxis Management 105p Pediatric Respiratory Failure / Arrest Algorithm 110p Pediatric Obstructed Airway Algorithm: Conscious Patient 110p Pediatric Obstructed Airway Algorithm: Unconscious Patient 115p Pediatric Respiratory Distress 120p Pediatric Asthma 125p Pediatric Croup 126p Pediatric Bronchiolitis 130p Pediatric Allergy and Anaphylaxis Pediatric Cardiac 2000p Pediatric Cardiac Arrest General Principles 2010p Pediatric Pulseless Arrest BLS / AED Algorithm 2020p Pediatric Pulseless Arrest - VF / VT 2021p Pediatric Pulseless Arrest – Asystole / PEA 2025p Pediatric Return of Spontaneous Circulation (ROSC) 2030p Pediatric Tachycardia 2040p Pediatric Bradycardia 2050p Pediatric Non-Traumatic Pulseless Arrest 2200p Newborn Resuscitation Algorithm

Table of Contents 3

Index

5 January 2018

Pediatric Neuro 3000p Pediatric Syncope 3010p Pediatric Stroke Algorithm 3020p Pediatric Altered Mental Status 3030p Pediatric Seizure Algorithm Pediatric Medical 4010p Pediatric Abdominal Pain / Vomiting 4020p Pediatric Overdose and Acute Poisoning Algorithm 4025p Pediatric Hypoglycemia 4031p Pediatric Adrenal Insufficiency 4040p Pediatric Drowning 4050p Pediatric Hypothermia 4060p Pediatric Hyperthermia 4070p Pediatric Insect/Arachnid Bite and Sting 4080p Pediatric Snake Bite 4090p Brief Resolved Unexplained Event (BRUE) Algorithm 4095p Care of the Child with Special Needs Pediatric Behavioral 5000p Pediatric Psychiatric / Behavioral Emergencies 5040p Pediatric Alcohol Intoxication

Pediatric Trauma 7000p Pediatric General Trauma Care 7010p Pediatric Special Trauma Scenarios 7015p Pediatric Traumatic Pulseless Arrest 7020p Pediatric Traumatic Shock 7025p Pediatric Amputations 7029p Pediatric Head Trauma 7030p Pediatric Face and Neck Trauma 7035p Pediatric Spinal Trauma 7040p Pediatric Spinal Immobilization Considerations 7045p Pediatric Chest Trauma 7050p Pediatric Abdominal Trauma 7055p Pediatric Burns

Table of Contents 4

Index

6 January 2018

Medications: Albuterol Sulfate (Proventil,Ventolin) Adenosine (Adenocard) Amiodarone (Cordarone) Aspirin (ASA) Atropine Sulfate Calcium Gluconate Calcium Chloride Dextrose 50% Diphenhydramine (Benadryl) Epinephrine (Adrenalin) Fentanyl (Sublimaze) Glucagon Ipratropium Bromide (Atrovent) Magnesium Sulfate Methylprednisolone (Solu-Medrol) Midazolam (Versed) Naloxone (Narcan) Nerve Agent Kit (DuoDote) Nitrogylcerine (NitroStat) Odansetron (Zofran) Oral Glucose (Glutose, Insta-Glucose) Oxygen Phenylephrine (Intranasal) Racemic Epinephrine (Vaponephrine) Sodium Bicarbonate Topical Ophthalmic Anesthetics Core Competencies: Adult Medical Arrest – Compressor Adult Medical Arrest – Ventilator Adult Medical Arrest – Lead Paramedic Adult Traumatic Arrest – Compressor Adult Traumatic Arrest – Ventilator Adult Traumatic Arrest – Lead Paramedic Pediatric Medical Arrest – Compressor Pediatric Medical Arrest – Ventilator Pediatric Medical Arrest – Lead Paramedic Pediatric Traumatic Arrest – Compressor Pediatric Traumatic Arrest – Ventilator Pediatric Traumatic Arrest – Lead Paramedic

Index

Table of Contents 5

7 January 2018

INTRODUCTION The following protocols have been developed and approved by the Aurora Fire Rescue Medical Directors and is based on the consensus document produced by the Denver Metropolitan EMS Medical Directors (DMEMSMD) group. These protocols define the standard of care for EMS providers in the City of Aurora, and delineate the expected practice, actions, and procedures to be followed. No protocol can account for every clinical scenario encountered, and the Medical Directors recognize that in rare circumstances deviation from these protocols may be necessary and in a patientʼs best interest. Variance from protocol should always be done with the patientʼs best interest in mind and backed by documented clinical reasoning and judgment. Whenever possible, prior approval by direct verbal order from base station physician is preferred. Additionally, all variance from protocol should be documented and submitted for review in a timely fashion. The protocols have a new look and are presented in an algorithm format. An algorithm is intended to reflect real-life decision points visually. An algorithm has certain limitations, and not every clinical scenario can be represented. Although the algorithm implies a specific sequence of actions, it may often be necessary to provide care out of sequence from that described in the algorithm if dictated by clinical needs. An algorithm provides decision-making support, but is no substitute for sound clinical judgment. In order to keep protocols as uncluttered as possible, and to limit inconsistencies, individual drug dosing has not been included in the algorithms. It is expected the EMTs will be familiar with standard drug doses. Drug dosages are included with the medications section of the protocols as a reference. If viewing protocol in an electronic version, it will be possible to link directly to a referenced protocol by clicking on the hyperlink, which is underlined. PROTOCOL KEY Boxes without any color fill describe actions applicable to all levels of EMT.

Boxes with blue fill are for EMT-paramedic level. When applicable, actions requiring base contact are identified in the protocol:

Teaching points deemed sufficiently important to be included in the protocol are on the second page of the applicable protocol. PEDIATRIC PROTOCOLS For the purposes of these clinical care protocols, pediatric patients are those < 12 years of age, except where identified in a specific protocol.

General Guidelines: Introduction

Index

12 lead ECG to identify STEMI if present

Splint with bulky dressing

CONTACT BASE for consideration of field pronouncement

8 January 2018

A. The patient-physician relationship, the patient-registered nurse relationship, and the patient-EMT relationship are recognized as privileged. This means that the physician, nurse, or EMT may not testify as to confidential communications unless:

1. The patient consents 2. The disclosure is allowable by law (such as Medical Board or Nursing Board

proceedings, or criminal or civil litigation in which the patient's medical condition is in issue)

B. The prehospital provider must keep the patient's medical information confidential. The patient likely has an expectation of privacy, and trusts that personal, medical information will not be disclosed by medical personnel to any person not directly involved in the patient's medical treatment.

1. Exceptions i. The patient is not entitled to confidentiality of information that does not

pertain to the medical treatment, medical condition, or is unnecessary for diagnosis or treatment.

ii. The patient is not entitled to confidentiality for disclosures made publicly. iii. The patient is not entitled to confidentiality with regard to evidence of a

crime. C. Additional Considerations:

1. Any disclosure of medical information should not be made unless necessary for the treatment, evaluation or diagnosis of the patient.

2. Any disclosures made by any person, medical personnel, the patient, or law enforcement should be treated as limited disclosures and not authorizing further disclosures to any other person.

3. Any discussions of prehospital care by and between the receiving hospital, the crewmembers in attendance, or at in-services or audits are done strictly for educational or performance improvement purposes. Further disclosures are not authorized.

4. Radio communications should not include disclosure of patient names. 5. This procedure does not preclude or supersede the Aurora Fire Department’s

HIPAA policy and procedures.

General Guidelines: Confidentiality

Index

9 January 2018

General Principles A. Consent is a legal concept. Decision Making Capacity (DMC) is a medical concept. B. A person is deemed to have decision-making capacity if he/she:

(Must meet all criteria)

1. Is not clinically intoxicated with alcohol or drugs (ref. clinical intoxication/incapacitation) 2. Understands nature and risk of illness or injury 3. Understands the possible consequences of refusal of care or delay of treatment 4. Given the risks and options, voluntarily refuses treatment or transport 5. Criteria that does NOT meet a Mental Health Hold:

a. Not homicidal or suicidal b. Not gravely disabled or psychotic c. Not a danger to self or others

General Principles: Adult A. An adult in the State of Colorado is 18 years of age or older.

B. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient. C. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient with DMC

may refuse medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, and treat to the extent possible.

D. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment.

E. Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening injuries/illnesses.

F. Involuntary Consent: a person other than the patient in rare circumstances may authorize Consent. This may include a court order (guardianship), authorization by a law enforcement officer for prisoners in custody or detention, or for persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled.

G. Consent may be inferred by the patient's actions or by express statements. If you are not sure that you have consent, clarify with the patient or CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock). This may include consent for treatment decisions or transport/destination decisions.

H. If the patient lacks decision-making capacity and the patient's life or health is in danger, and there is no reasonable ability to obtain the patient's consent, proceed with transport and treatment of life-threatening injuries/illnesses. If you are not sure how to proceed, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock).

I. For patients who refuse medical treatment, if you are unsure whether or not a situation of involuntary consent applies, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock).

General Guidelines: Consent/Decision Making Capacity

Index

10 January 2018

General Principles: Minors A. A parent, including a parent who is a minor, may consent to, or refuse medical or emergency

treatment of his/her child. There are exceptions: 1. Neither the child nor the parent may refuse medical treatment on religious grounds

if the child is in imminent danger as a result of not receiving medical treatment, or when the child is in a life-threatening situation, or when the condition will result in serious handicap or disability.

2. If a minor has an injury or illness, but not a life-threatening medical emergency, you should attempt to contact the parent(s) or legal guardian. If this cannot be done promptly, transport.

3. If the minor has a life-threatening injury or illness, transport and treat per protocols. If the parent objects to treatment, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) immediately and treat to the extent allowable, and notify police to respond and assist.

4. The consent of a parent is not necessary to authorize hospital or emergency health care when an EMT in good faith relies on a minor's consent in any of the following circumstances:

i. Minor is pregnant, regardless of age. (Ref: Colo. Rev. Stat. § 13-22-103.5.) 1. Once the minor is no longer pregnant, they can no longer consent

to treatment for themselves, but can consent to treatments for their child.

ii. Minor is married. iii. Minor is in the military. iv. A minor fifteen years of age or older and:

1. They are living separate and apart from his or her parent, parents, or legal guardian, with or without the consent of his or her parent, parents, or legal guardian,

AND 2. They are managing his or her own financial affairs, regardless of

the source of his or her income. (Ref: Colo. Rev. Stat. § 13-22-103(1).)

v. Minors may seek treatment for abortion, drug addiction, and venereal disease without consent of parents. (Ref: Colo. Rev. Stat. § 25-4-409)

vi. Minors > 15 years may seek treatment for mental health. (Ref: Colo. Rev. Stat. § 27-65-103)

5. BASE CONTACT (AIP, Children’s TMCA, CMP, SaddleRock) is required any time a minor patient is left on scene.

B. When in doubt, your actions should be guided by what is in the minor's best interests and base contact.

General Guidelines: Consent

11 January 2018

Purpose A. To provide guidelines for prehospital personnel who encounter a physician at the scene of

an emergency

General Principles A. The prehospital provider has a duty to respond to an emergency, initiate treatment, and

conduct an assessment of the patient to the extent possible. B. A physician who voluntarily offers or renders medical assistance at an emergency scene is

generally considered a "Good Samaritan." However, once a physician initiates treatment, he/she may feel a physician-patient relationship has been established.

C. Good patient care should be the focus of any interaction between prehospital care providers and the physician.

Procedure A. See algorithm below and sample note to physician at the scene Special notes A. Every situation may be different, based on the physician, the scene, and the condition of the

patient. B. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) when any question(s) arise.

General Guidelines: Physician at the scene / Medical Direction

Index

12 January 2018

NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMS PROVIDERS

THANK YOU FOR OFFERING YOUR ASSISTANCE. The prehospital personnel at the scene of this emergency operate under standard policies, procedures, and protocols developed by their Medical Director. The drugs carried and procedures allowed are restricted by law and written protocols. After identifying yourself by name as a physician licensed in the State of Colorado and providing identification, you may be asked to assist in one of the following ways:

1. Offer your assistance or suggestions, but the prehospital care providers will remain under the medical control of their base physician, or

2. With the assistance of the prehospital care providers, talk directly to the base physician and offer to direct patient care and accompany the patient to the receiving hospital. Prehospital care providers are required to obtain an order directly from the base physician for this to occur.

THANK YOU FOR OFFERING YOUR ASSISTANCE DURING THIS EMERGENCY. _____________________________ ___________________________________ Medical Director Agency

General Guidelines: Physician at the scene/Medical Direction

Index

13 January 2018

EMT attempts patient care

EMS arrives on scene

Physician reports on patient and relinquishes patient care

Provide care per protocol

Physician wants to help or is involved in or will not relinquish patient care

Prehospital provider identifies self and level of training

Physician willing to just help out

Provide general instructions and utilize

physician assistance

Physician requests or performs care inappropriate or

inconsistent with protocols

Shares Physician At The Scene/Medical Direction Note with physician and advise physician of your

responsibility to the patient

Physician does not relinquish patient

care and continues with

care inconsistent with protocols

CONTACT BASE for Medical

Consult

Physician complies

Provide care per protocol

General Guidelines: Physician at the scene/Medical Direction

Index

14 January 2018

Index

Place patient on cardiac monitor

Dependent lividity Or

Rigor mortis Or

Decomposition

Advanced Directives indicating DNR

CONTACT BASE for consideration of field

pronouncement

Asystole * Not Asystole

Ref. Asystole / PEA or VF / VT if medical cause

OR Ref. Adult Traumatic Pulseless Arrest if

traumatic cause

Cardiac arrest from the following causes should approached as a medical cardiac arrest:

Overdose Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage

Adult Pulseless Arrest - General

Yes No

Yes No

* Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. Include the AFR incident number on the strip.

15 January 2018

Purpose

A. To provide guidelines for resuscitation and field pronouncement of patients in cardiac arrest in the prehospital setting

General Principles

A. Attempt resuscitation for all patients found pulseless and apneic, unless any of the following are present:

1. Physician orders as specified on the Colorado Medical Orders for Scope of Treatment (MOST) form: “No CPR. Do Not Resuscitate/DNR/Allow Natural Death”, present with the patient

2. A valid CPR directive present with the patient LIMB LEADS MANDATORY 3. Dependent lividity with Asystole:

OR 4. Rigor Mortis with Asystole:

OR 5. Decomposition with Asystole

NO LIMB LEADS NECESSARY 6. Decapitation 7. 3° burns over 90% of the body

Medical Pulseless Arrest: A. Continue Resuscitation until:

1. ROSC 2. No ROSC after at least 30 minutes of ALS care. If shockable rhythm is

present, transport to closest appropriate emergency department. 3. Contact base for TOR if further resuscitation efforts are considered

futile despite adequate CPR and ventilation and no reversible causes of death identified.

a. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for consideration of TOR if no ROSC after 30 minutes of ALS care. b. Regardless of cardiac rhythm, the following patients should be aggressively resuscitated and transported as soon as possible:

i. Hypothermia ii. Drowning with hypothermia and submersion < 60 minutes iii. Pregnant patient with estimated gestational age ≥ 20 weeks iv. Lightning strikes

c. After pronouncement, do not alter condition in any way or remove equipment (lines, tubes, etc.), as the patient is now a potential coroner’s case.

Traumatic Pulseless Arrest:

A. Follow guidelines per 7015 Adult Traumatic Pulseless Arrest

Termination of Resuscitation

Index

16 January 2018

A. These guidelines apply to both adult and pediatric patients. B. There are several types of advance medical directives (documents in which a patient

identifies the treatment to be withheld in the event the patient is unable to communicate or participate in medical treatment decisions).

C. Some patients may have specific physician orders on a Colorado Medical Orders for Scope of Treatment (MOST) form. A MOST form order to withhold CPR or resuscitation should be honored by EMS.

D. Resuscitation may be withheld from, or terminated for, a patient who has a valid CPR Directive, Do Not Resuscitate Order (DNR), or other advance medical directive when:

1. It is clear to the prehospital provider from the document that resuscitation is refused by the patient or by the patient's attending physician who has signed the document; and

2. Base physician (AIP, Children’s, TMCA, CMP, SaddleRock) has approved withholding of or ceasing resuscitation.

E. Suspected suicide does not necessarily negate an otherwise valid CPR Directive, DNR order or other advanced medical directive. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock)

F. The Colorado CPR Directive directs EMS providers to withhold CPR in the event of cardiac or respiratory arrest or malfunction.

1. “Cardiopulmonary Resuscitation” (CPR) means measures to restore cardiac function or to support breathing in the event of cardiac or respiratory arrest or malfunction. “CPR” includes, but is not limited to, artificial ventilation, chest compression, delivering electric shock, placing tubes in the airway to assist breathing or other basic and advanced resuscitative therapies.

2. CPR Directive bracelet or necklace may be used by an individual and shall be complied with in the same manner as a written CPR Directive.

3. A signed CPR directive form that has been photocopied, scanned, faxed is valid. G. A Living Will ("Declaration as to Medical or Surgical Treatment") requires a patient to have a

terminal condition, as certified in the patient's hospital chart by two physicians. H. Other types of advance directives may be a "Durable Medical Power of Attorney," or "Health

Care Proxy". Each of these documents can be very complex and require careful review and verification of validity and application to the patient's existing circumstances. Therefore, the consensus is that resuscitation should be initiated until a physician can review the document or field personnel can discuss the patient’s situation with the base physician. If there is disagreement at the scene about what should be done, CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for guidance.

I. Verbal DNR "orders" are not to be accepted by the prehospital provider. In the event family or an attending physician directs resuscitation be ceased, the prehospital provider should immediately CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock). The prehospital provider should accept verbal orders to cease resuscitation only from the Base physician.

J. There may be times in which the prehospital provider feels compelled to perform or continue resuscitation, such as a hostile scene environment, family members adamant that "everything be done," or other highly emotional or volatile situations. In such circumstances, the prehospital provider should attempt to confer with the BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for direction and if this is not possible, the prehospital provider must use his or her best judgment in deciding what is reasonable and appropriate, including transport, based on the clinical and environmental conditions, and establish base contact as soon as possible.

General Guidelines: Advanced Medical Directives

Index

17 January 2018

Additional Considerations: A. Patients with valid DNR orders or advanced medical directives should receive supportive or

comfort care, e.g. medication by any route, positioning and other measures to relieve pain and suffering. Also the use of oxygen, suction and manual treatment of an airway obstruction as needed for comfort.

B. Mass casualty incidents are not covered in detail by these guidelines. C. If the situation appears to be a potential crime scene, EMS providers should disturb the

scene as little as possible and communicate with law enforcement regarding any items that are moved or removed from the scene.

D. In all cases of unattended deaths occurring outside of a medical facility, the Aurora Police Department should be contacted immediately.

General Guidelines: Advanced Medical Directives

Index

18 January 2018

General Guidelines: Patient Determination: “Patient or No Patient”

Index

Person has a complaint resulting in a call for help

Person lacks decision-making capacity

ref. Consent ref. Adult Drug/Alcohol Intoxication

Acute illness or injury possible based on history, appearance,

or mechanism

3rd party* indicates individual is ill, injured or gravely disabled

Individual meets definition of a

Patient (PCR Required)

Person does not meet definition of a patient, and does not require PCR or refusal of care

Person is a minor (< 18)

*Cell phone call by concerned citizen driving by a perceived emergency excluded.

No

No

No

No

No

This protocol is intended to refer to individual patient contacts. In the event of a multiple party incident, such as a multi-vehicle collision, it is expected that a reasonable effort will be made to identify those parties with acute illness or injuries. Adult patients indicating that they do not wish assistance for themselves or dependent minors in such a multiple

party incident do not necessarily require documentation as patients.

No protocol can anticipate every scenario and providers must use best judgment. When in doubt as to whether individual is a “patient”, err on the side of caution and

perform a full assessment and documentation

Yes

Yes

Yes

Yes

Yes

For anyone determined to be a patient, vital signs should be obtained every 5 minutes or after the completion of any

intervention.

19 January 2018

Dispatch

Cancelled PTA

Arrived on scene

Patient

Not a patient ref. Patient Determination

Pt refusing transport

Pt requesting transport

If ANY criteria are met:

<5 years old and a parent or guardian is present

<18 years old without a parent or guardian present

If uncertain about patient’s decision-making capacity

If ALL criteria met:

≥18 years old

or

≥5 years old with

parent/guardian present

Patient has decision-

making capacity*

General Guidelines: Patient Non-Transport or Refusal

Index

*A person who has decision-making capacity may refuse examination, treatment and transport Ref: GENERAL GUIDELINES: CONSENT for Decision-Making Capacity guidelines

Documentation Requirements for Refusal

Clarify calling to document vs authorization

Confirm decision-making capacity

EMS assistance offered and declined

Risks of refusal explained to patient

Patient understands risks of refusal

Name of Base Station physician authorizing refusal of care unless standing order refusal

Signed refusal of care and against medical advice document, if applicable.

Any minor with any complaint/injury is a patient and requires a PCR

Base Contact Required (AIP, Children’s, TMCA,

CMP, Saddle Rock)

Standing Order Refusal

High Risk Patients

Base contact is

strongly recommended whenever, in the

clinical judgement of the EMS provider, the

patient is at high risk of deterioration without medical intervention.

20 January 2018

Purpose

A. To provide a standard approach to ambulance diversion that is practical for field use B. To facilitate unobstructed access to hospital emergency departments for ambulance

patients C. To allow for optimal destination policies in keeping with general EMS principles and

Colorado State Trauma System Rules and Regulations

General Principles

A. EMSystem, an internet-based tracking system, is used to manage diversion in the Denver Metro area

B. The only time an ambulance can be diverted from a hospital is when that hospital is posted on EMSystem as being on official divert (RED) status.

C. Overriding factors: the following are appropriate reasons for a paramedic to override ED Divert and, therefore, deliver a patient to an emergency department that is on ED divert:

1. Cardiopulmonary arrest 2. Imminent cardiopulmonary arrest 3. Unmanageable airway emergencies 4. Unstable trauma and burn patients transported to Level I and Level II

Trauma Centers 5. Patients meeting “Cardiac Alert“ criteria (participating hospitals) 6. Patients meeting “Stroke Alert“ criteria (participating hospitals) 7. Imminent delivery

D. Prehospital personnel should honor advisory categories, when possible, considering patient’s condition, travel time, and weather. Patients with specific problems that fall under an advisory category should be transported to a hospital not on that specific advisory when feasible.

E. There are several categories that are considered advisory (yellow) alert categories. These categories are informational only and should alert field personnel that a hospital listed as being on an advisory alert may not be able to optimally care for a patient that falls under that advisory category.

F. The following are advisory (yellow) categories recognized by the State. Individual facilities may not utilize these categories often, or ever:

1. ICU (Intensive Care Unit) 2. Psych (Psychiatric)

G. Zone saturation exists when all hospitals within that zone are on ED Divert. H. A Zone Master is the designated hospital within a Zone responsible for determining

and tracking hospital assignments when the zone is saturated. I. When an ambulance is transporting a patient that the paramedic feels cannot go

outside the zone due to patient acuity or other concerns, the paramedic should contact the Zone Master and request a destination assignment.

J. In general, patients contacted within a zone should be transported to an appropriate facility within the zone. Patients may be transported out of the primary zone at the paramedic’s discretion, if it is in the patient’s best interest or if the transport to an appropriate facility is shorter.

K. The zones, hospitals in each zone, Zone Masters, and the Zone Master contact phone numbers are listed on EMSystem.

General Guidelines: Emergency Department Divert and Advisory

Index

21 January 2018

Purpose A. To provide a set of guidelines to help ensure proper disposition of the various patients

encountered in the field.

Philosophy

A. Critical patients with a special medical need should be taken to the nearest facility that can best provide for that need.

B. Critical patients without a special need (i.e., cardiopulmonary arrest) should be taken to the closest emergency department.

C. All other patients should have their request accommodated, consistent with the ability of the system to meet that request.

D. Aurora Fire Rescue Paramedics are required to accompany any patient(s) that require or may require advanced life support care who are being transported by ambulance to any hospital emergency department.

Special Needs

A. Burns 1. Patients 15 years of age or older, with second degree or third degree burns greater than

20% body surface area, should be transported directly to the AIP emergency department. Patients 14 years of age and younger, with second degree or third degree burns greater than 20% body surface area, should be transported directly to The Children's Hospital emergency department.

2. Special Considerations. Complications of airway compromise or cardiovascular instability, require transport to the nearest appropriate emergency department. Burns associated with multi-system trauma should be transported to the closest appropriate Trauma Center.

B. Trauma 1. Trauma patients should be transported to the closest appropriate Trauma Center.

C. Psychiatric patients 1. Patients placed on a MHH shall be taken to the closest appropriate facility. 2. Patients with psychiatric problems not on an MHH shall be taken to the closest

appropriate facility. 3. Patients with psychiatric problems who have an acute medical or traumatic concern

shall be treated according to the appropriate medical or trauma protocol. 4. MHH may be placed by a state-certified EMT-P under the auspices of the receiving

physician. D. Obstetric/Gynecologic

1. For patients in uncomplicated labor: a. Delivery not imminent:

i. If the patient has a private obstetrician or gynecologist, then follow the patient's request for destination, when possible.

b. If the patient has no private physician, then follow the patient's request for destination (if expressed), or transport to the closest hospital.

2. Imminent delivery a. If the patient has a private obstetrician/care giver, then follow the patient's request

for destination, when appropriate. If the requested facility does not meet these time constraints and the patient still requests the facility, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) physician.

b. If the patient has no private physician, then transport to the closest appropriate hospital.

General Guidelines: Emergency Department Divert and Advisory

Index

22 January 2018

Hospital Cardiac Alert

Stroke Alert

Trauma Level

Pediatrics OB/GYN >20 weeks

Special Considerations

AIP YES YES II > 40kg YES > 20% burns at 14 year or older

Children's (< 21 yrs) NO

YES (<12yo)

Ped - I YES NO

> 20% burns 13 years or younger

Littleton YES YES II YES YES

DHMC NO NO I YES YES

Parker Adventist YES YES II YES YES

Porter Denver YES YES NO NO NO

PSL YES YES IV YES YES

Rose YES NO NO YES YES

Saint Joseph's YES NO NO NO YES Swedish YES YES I YES YES

TMCA YES YES II YES YES

Sky Ridge YES YES II YES YES

FREE-STANDING EMERGENCY DEPARTMENTS (FSEDs)

Centennial NO NO NO YES NO

Southlands NO NO NO YES NO

Saddlerock NO NO NO YES NO

SCL Health NO NO NO YES NO

General Guidelines: Emergency Department Capabilities

Index

23 January 2018

Background: 1. Emergent (“lights and sirens”) transport of patients has not been demonstrated to improve patient outcomes. 2. Emergent patient transports place EMS providers and the public at risk.

Emergent patient transports should be reserved for situations that meet the following two criteria.

1. Patient has injury or illness that requires emergent hospital intervention not immediately available to the EMS providers.

AND 2. Benefit to the patient of emergent transport outweighs risks to the patient, EMS providers, and the public that are created by emergency transport.

Criteria 1 Patient is has injury or illness that may require emergent hospital intervention. Examples:

1. Airway a. Inability to establish or maintain a patent airway b. Upper airway stridor

2. Breathing a. Severe respiratory distress

3. Circulation a. Cardiac Arrest b. Hemodynamic instability c. Severe, uncontrolled hemorrhage

4. Neurologic a. GCS <8 b. Seizure activity unresponsive to treatment

5. Obstetric a. Complicated Delivery

6. Trauma a. Penetrating/blunt trauma to head, neck, or torso b. Two or more suspected proximal long bone fractures with symptoms of shock or absence of distal pulses after manipulation

Criteria 2 Benefit to the patient of emergent transport outweighs risks to the patient, EMS providers, and the public that are created by emergency transport. Notes:

In most situations time saved by emergent transport will not outweigh risks when transport time is short (< 10 minutes)

Emergent transport should never be used solely to “get the attention” of the receiving facility.

The decision to transport emergent should be made jointly by the primary treating EMS provider (who must consider patient condition and availability of treatments enroute) and the Emergency vehicle operator (who must consider time of day, anticipated transport time, and road/traffic conditions at time of call).

General Guidelines: Emergent vs. Non-Emergent Patient Transport

Index

24 January 2018

Index

Patients 15 years old and over

Transport to a Level I or II Trauma Center

Transport to a Level I or II Trauma Center

25 January 2018

Index

Patients less than 15 years old

Transport to a designated pediatric Level I or II Trauma Center.

Transport to a designated pediatric Level I or II Trauma Center.

Transport to a designated pediatric Level I or II Trauma Center.

Transport to a designated pediatric Level I or II Trauma Center.

26 January 2018

The Multiple Patient Incident Criteria should be used on all incidents involving more than one patient. If the total number of patients in any one category exceeds the maximum number indicated, the event should be considered a Mass Casualty Incident (MCI). If START Triage criteria have been utilized to initially triage patients, the Multiple Patient Criteria should be used as a secondary triage method and the Multiple Patient Incident Distribution Worksheet should be utilized. Category: CRITICAL Injury Types: GCS Motor < 5 (Pt. can’t localize pain) Assisted Ventilations Respiratory rate <10 or >29 Uncontrolled, severe bleeding Traumatic Shock / Absent radial pulse Penetrating injury to neck / torso Maximum Number: 12 (2 per Trauma Center) Category: SERIOUS Injury Types: Altered Mental Status Suspected femur fracture Open long bone fracture Motor or sensory deficits No critical criteria (see above) Maximum Number: 24 (4 per Trauma Center) Category: MODERATE Injury Types: Closed, single extremity fracture Isolated soft tissue injury No critical criteria (see above) No serious criteria (see above) Maximum Number: 56 (8 per Emergency Dept.)

Multiple Patient Incident – Patient Criteria

Index

27 January 2018

The term “free-standing emergency department” (FSED) may refer to both licensed emergency departments that accept EMS traffic as an extension of an affiliated hospital, as well as independent emergency departments unaffiliated with a hospital. The following recommendations apply to those FSEDs that accept EMS traffic as an extension of its affiliated hospital: Patients may be considered for transport to a hospital-affiliated FSED with the following exceptions:

1. No OB patients > 20 weeks estimated gestational age. 2. No trauma patients meeting RETAC trauma center destination guidelines. 3. No Alerts (e.g. STEMI, Stroke). 4. No cardiac arrest or post-cardiac arrest patients unless unable to oxygenate

or ventilate. 5. No unstable arrhythmias.

Patients that are likely to exceed the level of care the FSED can provide:

1. Elderly patients with falls, weakness, syncope, etc. 2. Combative patients 3. Potentially combative – psychiatric and behavioral problems

Hospital-affiliated free-standing emergency departments accepting EMS traffic include: Centennial Medical Plaza (The Medical Center of Aurora) Saddle Rock ER (The Medical Center of Aurora) Southlands ER (Parker Adventist) SCL Health (South of Southlands Mall)

Free-Standing Emergency Departments as EMS Destination

Index

28 January 2018

Purpose

1. To provide an alternative destination for which to transport acutely intoxicated patients by ambulance.

2. To provide direction and criteria for patients who are eligible to be transported by ambulance to EMDR.

3. To ensure patients who are in need of a higher level of emergency care are transported to an appropriate receiving facility.

General Principles

1. East Metro Detoxification and Recovery Services (EMDR) located at 1290 South Potomac Street, and formerly known as the Arapahoe House, will accept acutely intoxicated patients transported by ambulance when all specified criteria are met and verbal confirmation of the facility’s ability to receive a new patient has been given by phone.

2. Patients who are determined to be clinically intoxicated, but according to the Adult Drug/Alcohol Intoxication protocol (5040), do not require transport to an emergency department, can be transported by ambulance to EMDR if all of the criteria are met and the associated work sheet is complete.

3. Send the completed form to the battalion chief. 4. In the event the patient meets all of the criteria for transport to EMDR, however, the

attending EMS providers determine care in the emergency department is warranted, and/or if during the assessment, the patient’s condition deteriorates, then the patient should be transported to the nearest appropriate emergency departmen.

Alternate Disposition of Acutely Intoxicated Patients

Index

Patient is acutely into intoxicated with drugs or alcohol and has no acute injury or illness

requiring treatment in an emergency room, and cannot remain on scene. Ref. Adult Drug/Alcohol

All criteria are met for direct transport to EMDR

Transport to appropriate emergency department

Contact EMDR by phone to confirm bed availability. Does EMDR accept the patient?

Complete EMDR checklist form Transport patient directly to EMDR Give verbal handoff to EMDR staff and

give them pink copy of EMDR checklist

Yes

Yes

Yes

No

No

No

29 January 2018

All criteria must be a NO for direct transport to EMDR Vitals:

Systolic BP < 90 or > 180 Diastolic BP >110 Pulse < 60 or >130 Respirations <12 or > 30 Pulse oximetry < 90% on room air or prescribed oxygen BGL < 60 or > 250

Assessment:

Suspected acute illness or injury requiring medical attention

Respiratory difficulty as evidenced by labored breathing or wheezing

Decreased level of consciousness (must respond appropriately to verbal stimuli)

Aggressive or combative behavior

Patient is incapacitated due to intoxication (unable to stand from seated position and walk

independently)

Bizarre behavior not explained by intoxication

History:

Seizure within the past 48 hours

Untreated GI bleeding in last 24 hours

Medical Device (Colostomy, Trach, G-Tube, Foley)

(Can be taken to detox if they can perform self care of the device and have 48 hours of

supplies if needed)

Currently on Mental Health Hold

Alternate Disposition of Acutely Intoxicated Patients

Index

30 January 2018

Index

START Triage

31 January 2018

Index

32 January 2018

Multiple Patient Incident – Destination Distribution Worksheet

Index

33 January 2018

Indications: In general the primary goals of airway management are adequate oxygenation and ventilation,

and these should be achieved in the least invasive manner possible. Inability to oxygenate / ventilate via BVM using two person technique with OPA / NPA

AND Inability to oxygenate / ventilate via i-gel O2.

Contraindications:

Endotracheal intubation is contraindicated in pediatric patients (< 12 years) Endotracheal intubation is contraindicated prior to attempting i-gel O2 Airway. Endotracheal intubation is contraindicated prior to reattempting via BVM and OPA/NPA with

corrective actions after i-gel Endotracheal intubation is contraindicated in the absence of measurable Waveform

Capnography by continuous wave form capnography/capnometry o An atypical report is required and to be submitted to the Medical Branch at the

conclusion of the incident if Intubation is performed without measureable CO2 General:

Orotracheal intubation is associated with worse outcomes among pediatric patients and head injured patients when compared to BLS airway maneuvers.

Intubation is associated with interruptions in chest compressions during CPR, which is associated with worse patient outcomes. Additionally, intubation itself has not been shown to improve outcomes in cardiac arrest

Technique:

1. Continue BLS airway sequence 2. Suction airway and pre-oxygenate with BVM ventilations using two person technique and

capnography 3. Check equipment and position patient:

a. If trauma: have assistant hold in-line spinal immobilization in neutral position b. If no trauma, sniffing position or slight cervical hyperextension is preferred

4. Perform laryngoscopy a. To improve laryngeal view, use right hand to manipulate larynx, or have assistant

apply backwards, upwards, rightward pressure (BURP) 5. Place ETT. Confirm tracheal location and appropriate depth and secure tube

a. Correct tube depth may be estimated as 3 times the internal diameter of tube at teeth or gums (e.g: 7.0 ETT is positioned at 21 cm at teeth)

6. Confirm and document tracheal location by: a. Waveform Capnography b. Presence and symmetry of breath sounds c. Rising SpO2 d. Other means as needed

7. Ventilate with Ambu Bag. Assess adequacy of ventilations 8. During transport, continually reassess ventilation, oxygenation and tube position with

continuous Waveform Capnography and SpO2

10 Procedure Protocol: Orotracheal Intubation

Index

34 January 2018

Precautions: Ventilate at age-appropriate rates. Do not hyperventilate If the intubated patient deteriorates, think “DOPE”

o Dislodgement o Obstruction o Pneumothorax o Equipment failure (no oxygen)

Reconfirm and document correct tube position before and after moving patient

Index

10 Procedure Protocol: Orotracheal Intubation

35 January 2018

Indications:

In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible

Age ≥ 12 years spontaneously breathing patient with indication for intubation who cannot tolerate either supine position or laryngoscopy

Nasotracheal Intubation may be considered for failure to oxygenate and ventilate in the presence of:

a. Respiratory failure b. Absence of protective airway reflexes c. Present or impending complete airway obstruction

Contraindications:

Age < 12 years Absence of measurable Waveform Capnography Apnea Severe mid-face trauma

Technique:

1. Initiate BLS airway sequence 2. Suction airway and pre-oxygenate with BVM ventilations and Waveform Capnography 3. Check equipment, choose correct ETT size (usually 7.0 in adult, limit is size of naris) 4. Position patient with head in midline, neutral position 5. If trauma: cervical collar may be in place, or assistant may hold in-line stabilization in

neutral position 6. If no trauma, patient may be sitting upright 7. Administer phenylephrine nasal drops in each nostril 8. Lubricate ETT with Lidocaine jelly or other water-soluble lubricant 9. With gentle steady pressure, advance the tube through the nose to the posterior pharynx.

Use the largest nostril. Abandon procedure if significant resistance is felt 10. Keeping the curve of the tube exactly in midline, continue advancing slowly 11. There will be slight resistance just before entering trachea. Wait for an inspiratory effort

before final passage through cords. Listen for loss of breath sounds 12. Continue advancing tube until air is definitely exchanging through tube, then advance 2 cm

more and inflate cuff 13. Note tube depth and tape securely 14. Confirm and document endotracheal location by:

a. Waveform Capnography b. Presence and symmetry of breath sounds c. Rising SpO2 d. Other means as needed

15. Ventilate with Ambu Bag. Assess adequacy of ventilations 16. During transport, continually reassess ventilation, oxygenation and tube position with

continuous Waveform Capnography and SpO2

15 Procedure Protocol: Nasotracheal Intubation

Index

36 January 2018

Precautions:

Before performing BNTI, consider if patient can be safely ventilated with non-invasive means such as CPAP or BVM

Ventilate at age-appropriate rates. Do not hyperventilate If the intubated patient deteriorates, think “DOPE”

o Dislodgement o Obstruction o Pneumothorax o Equipment failure (no oxygen)

Reconfirm and document correct tube position after moving patient and before disconnecting from monitor in ED

Blind nasotracheal intubation is a very gentle technique. The secret to success is perfect positioning and patience.

15 Procedure Protocol: Nasotracheal Intubation

Index

37 January 2018

Introduction: Percutaneous cricothyrotomy is a difficult and hazardous procedure that is to be used only in

extraordinary circumstances as defined below. An atypical with the reason for performing this procedure must be documented and submitted for review to the Medical Branch at conclusion of the incident.

Indications: A life-threatening condition exists AND advanced airway management is indicated, AND

adequate oxygenation and ventilation cannot be accomplished by other less invasive means. Contraindications: Age < 12 is a contraindication Technique: Perform cricothyrotomy according to manufacturer’s instructions for Rusch Quick Trach (Rusch Quick Trach Training Video Link 1. Place the patient in a supine position. Assure stable positioning of the neck and hyperextend the neck (unless cervical spine injury suspected) 2. Secure the larynx laterally between the thumb and forefinger. Find the cricothyroid membrane (in the midline between the thyroid cartilage and the cricoid cartilage). This is puncture site. 3. Prep the site by vigorously scrubbing with alcohol or iodine preps. 4. Using the scalpel make a 3mm vertical incision into the skin 5. Firmly hold device and puncture cricothyroid membrane at a 90-degree angle.

a. After puncturing the cricothyroid membrane, check the entry of the needle into the trachea by aspirating air through the syringe. b. If air is present, needle is within trachea, change the angle of insertion to 60 degrees (from the head) and advance the device forward into the trachea to the level of the stopper. The stopper reduces the risk of inserting the needle too deeply and causing damage to the rear wall of the trachea. c. Should no aspiration of air be possible because of an extremely thick neck, it is possible to remove the stopper and carefully insert the needle further until entrance into the trachea is made.

6. Remove the stopper. After the stopper is removed, be careful not to advance the device further with the needle still attached.

7. Hold the needle and syringe firmly and slide only the plastic cannula along the needle into the trachea until the flange rests on the neck. Carefully remove the needle and syringe.

8. Secure the cannula with the neck strap 9. Apply the connecting tube to the 15 mm connection and connect the other end to the bagvalve-

mask with supplemental oxygen. 10. Continue ventilation with 100 percent oxygen and periodically assess the airway Complications: 1. Respiratory arrest and patient demise due to: a. Severity of patient's airway injury. b. Lack of attention to other potential airway maneuvers. c. Subcutaneous air due to improper tube or catheter positioning, along with positive ventilation. d. Bleeding from superficial neck vessels is very common. Use direct pressure after QuickTrach is in place. e. Perforations of the back wall of the trachea and the esophagus from excessively deep penetration by the QuickTrach. With stopper in place, this should be an extremely rare complication.

20 Procedure Protocol: Percutaneous Cricothyrotomy

Index

38 January 2018

Precautions: Success of procedure is dependent on correct identification of cricothyroid membrane Bleeding will occur, even with correct technique. Straying from the midline is dangerous and

likely to cause hemorrhage

Index

39 January 2018

Indications: In general the primary goals of airway management are adequate oxygenation and ventilation, and

these should be achieved in the least invasive manner possible. Cardiac arrest:

o The i-gel O2 Airway is the primary advanced airway for adult and pediatric cardiac arrest patients

Respiratory Failure/Arrest requiring assisted ventilations o Primary advanced airway if less invasive ventilation measures are ineffective

Contraindications: Intact gag reflex Caustic ingestion Suspected esophageal disease

Technique: 1. Initiate BLS airway sequence 2. For adult patients select proper size i-gel O2 based on IDEAL patient body weight (not what

the pt actually weighs) : a. # 3 Small adult 30-60kg (65-130 lbs) b. # 4 Medium adult 50-90kg (110-200 lbs) c. # 5 Large adult 90 + kg (200 + lbs)

3. For Pediatric patients refer to length based tape and AFR pediatric field guide a. #1 Neonate 2-5 kg b. #1.5 Infant 5-12 kg c. # 2 Small pediatric 10-25 kg d. # 2.5 Large pediatric 25-35 kg

4. Open packaging and remove inner tray, setting the support strap (adult) and packet of lubricant to

one side within easy reach. Remove the i-gel O2.

5. Open the packet of lubricant and place a small bolus on the inner side of the main shell of the packaging.

6. Grasp the i-gel O2 along the integral bite block and lubricate the back, sides and front of the cuff with a thin layer of lubricant. (Ensuring any excess is removed prior to insertion.)

7. Grasp the lubricated i-gel O2 firmly along the bite block. The patient should be in the ‘sniffing the

morning air’ position with head extended and neck flexed. * Unless suspected spinal trauma.

8. Position the device so that the i-gel O2 cuff outlet is facing towards the chin of the patient. Introduce the leading soft tip into the mouth of the patient towards the hard palate.

9. Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a definitive resistance is felt.

10. Once insertion has been completed, the tip of the airway should be located into the upper esophageal opening, with the cuff located against the laryngeal framework. The incisors should be resting on the bite block.

11. Secure the device underneath the patient’s neck with a head strap (or tape). Take care to ensure there is sufficient tension to hold the i-gel O2 securely in place, but not excessive tension that may cause trauma. Some adjustment of the strap may be needed to ensure optimal positioning.

12. For pediatric patients secure with tape 13. Place extension elbow and Waveform Capnography sensor on the end of i-gel O2 14. Confirm tube placement by auscultation, chest movement and Waveform Capnography. 15. Lubricate and insert appropriate size suction catheater into gastric lumen.

a. Size # 5 use 14F b. Size # 2 through # 4 use 12F c. Size # 1.5 use 10F d. Size # 1 not applicable

16. Once the i-gel O2 has been correctly prepared, inserted and secured, positive pressure ventilation can commence.

Precautions: 1. Do not remove a properly functioning i-gel O2 Airway in order to attempt intubation.

25 Procedure Protocol: i-gel Airway

Index

40 January 2018

30 Procedure Protocol: Continuous Positive Airway Pressure (CPAP)

Routine Medical Assessment

Moderate to severe respiratory distress as evidenced by at least two (2) of the following:

Rales (crackles)

Dyspnea with hypoxia (SpO2 < 90% despite O2)

Dyspnea with verbal impairment – i.e. cannot speak in full sentences

Accessory muscle use

Respiratory rate > 24/minute despite O2

Diminished tidal volume

Talk pt through procedure

Adjust oxygen flow to 15 Lpm initially. Monitor patient continuously, recording vital signs every 5 minutes

Start with the lowest continuous pressure that appears to be effective. Adjust pressure following manufacturer instructions to achieve the most stable respiratory status

Assess patient for improvement as evidenced by the following:

Reduced dyspnea

Reduced verbal impairment, respiratory rate and heart rate

Increased SpO2

Stabilized blood pressure

Increased tidal volume

Observe for signs of deterioration or failure of response to CPAP:

Decrease in level of consciousness

Sustained or increased heart rate, respiratory rate or increased blood pressure

Sustained low or decreasing SpO2 readings

Diminished or no improvement in tidal volume

Contraindications:

Respiratory or cardiac arrest

Systolic BP < 90mmHg

Lack of airway protective reflexes

Significant altered level of consciousness such that unable to follow verbal instructions or signal distress

Vomiting or active upper GI bleed

Suspected pneumothorax

Trauma

Patient size or anatomy prevents adequate mask seal

Index

41 January 2018

Indications: Symptomatic patients with moderate-to-severe respiratory distress as evidenced by at least

two (2) of the following: o Rales (crackles) o Dyspnea with hypoxia (SpO2 < 90% despite O2) o Dyspnea with verbal impairment – i.e. cannot speak in full sentences o Accessory muscle use o Respiratory rate > 24/minute despite O2 o Diminished tidal volume

Contraindications:

Respiratory or cardiac arrest Systolic BP < 90mmHg Lack of airway protective reflexes Significant altered level of consciousness such that unable to follow verbal instructions or

signal distress Vomiting or active upper GI bleed Suspected pneumothorax Trauma Patient size or anatomy prevents adequate mask seal

Technique: 1. Place patient in a seated position and explain the procedure to him or her 2. Assess vital signs (BP, HR, RR, SpO2, and Waveform Capnography) 3. Apply the CPAP mask and secure with provided straps, progressively tightening as tolerated

to minimize air leak 4. Operate CPAP device according to manufacturer specifications 5. For oxygen flow driven devices:

a. Adjust oxygen flow to 15 Lpm initially. Monitor patient continuously, recording vital signs every 5 minutes

b. Start with the lowest continuous pressure that appears to be effective. Adjust pressure following manufacturer instructions to achieve the most stable respiratory status utilizing the signs described below as a guide

6. Assess patient for improvement as evidenced by the following: a. Reduced dyspnea b. Reduced verbal impairment, respiratory rate and heart rate c. Increased SpO2 d. Stabilized blood pressure e. Appropriate Waveform Capnography values and waveforms f. Increased tidal volume

7. Observe for signs of deterioration or failure of response to CPAP: a. Decrease in level of consciousness b. Sustained or increased heart rate, respiratory rate or increased blood pressure c. Sustained low or decreasing SpO2 readings d. Diminished or no improvement in tidal volume

Precautions: Should patient deteriorate on CPAP:

o Troubleshoot equipment o Consider other means of ensuring oxygenation and ventilation o Assess need for possible chest decompression due to pneumothorax o Assess for possibility of hypotension due to significantly reduced preload from

positive pressure ventilation In-line nebulized medications may be given during CPAP as indicated and in accordance with

manufacturer guidelines

30 Procedure Protocol: Continuous Positive Airway Pressure (CPAP)

Index

42 January 2018

Indications: MANDATORY to be used any time patient is being ventilated. To monitor ventilation and perfusion on patients in severe respiratory distress or critically ill. Patients who show decreased responsiveness after receiving midazolam or fentanyl

Contraindications:

None Technique:

1. In patient with ETT or advanced airway: place Waveform Capnography detector in-line between airway adaptor and BVM after airway positioned and secured

2. Patients without ETT or advanced airway in place: place ETCO2 cannula on patient. May be placed under CPAP or NRB facemask.

3. Assess and document both Waveform Capnography value and waveform Precautions:

1. To understand and interpret Waveform Capnography, remember the 3 determinants of Waveform Capnography:

a. Alveolar ventilation b. Pulmonary perfusion c. Metabolism

2. Sudden loss of Waveform Capnography: a. Tube dislodged b. Circuit disconnected c. Cardiac arrest

3. High ETCO2 (> 45) a. Hypoventilation/CO2 Retention

4. Low ETCO2 (<25) a. Hyperventilation b. Hypoperfusion: sepsis, DKA, shock, PE

5. Cardiac Arrest: a. In low-pulmonary blood flow states, such as cardiac arrest, the primary determinant

of Waveform Capnography is blood flow, so Waveform Capnography is a good indicator of quality of CPR

b. If Waveform Capnography is dropping, change out person doing chest compressions c. In cardiac arrest, if ETCO2 not > 10 mmHg after 20 minutes of good CPR, this likely

reflects very low CO2 production and is associated with poor outcome d. Sudden rise in EtCO2 may be an indicator of ROSC

35 Procedure Protocol: Waveform Capnography

Index

43 January 2018

40 Procedure Protocol: Synchronized Cardioversion

Tachyarrythmia with poor perfusion

Check: O2 via NRBM

IV Suction

Airway equipment ready

ref. Midazolam

Perform synchronized cardioversion

Adult: 150J Pediatric: CONTACT BASE

Refer to Pediatric Field Guide 1-2J/Kg

Repeat cardioversion x1 Adult: 150J

Pediatric: Refer to Pedatric Field Guide. Double initial energy

Contact Base

Index

Reassess pt Reassess cardiac rhythm

Reassess pt Transport

Tachyarrythmia with poor perfusion

YES NO

44 January 2018

This procedure protocol applies to conscious patients with signs of poor perfusion due to tachyarrhythmia in whom synchronized cardioversion is indicated according to Tachyarrhythmia with a Pulse protocol.

If defibrillator does not discharge in “synch” mode, then deactivate “synch” and

reattempt If sinus rhythm achieved, however briefly, then dysrhythmia resumes

immediately, repeated attempts at cardioversion at higher energies are unlikely to be helpful. First correct hypoxia, hypovolemia, etc. prior to further attempts at cardioversion

If pulseless, treat according to Asystole / PEA or VF / VT Algorithm Chronic atrial fibrillation is rarely a cause of hemodynamic instability, especially if

rate is <150 bpm. First correct hypoxia, hypovolemia, before considering cardioversion of chronic atrial fibrillation, which may be difficult, or impossible and poses risk of stroke

Sinus tachycardia rarely exceeds 150 bpm in adults or 220 bpm in children < 8 years and does not require or respond to cardioversion. Treat underlying causes.

If cardioverting Peds, round up to the nearest energy selectable on the monitor Transient dysrhythmias or ectopy are common immediately following

cardioversion and rarely require specific treatment other than supportive care

40 Procedure Protocol: Synchronized Cardioversion

Index

45 January 2018

Indications Symptomatic bradyarrhythmias not responsive to medical therapy

Precautions

Conscious patient will experience discomfort; ref. midazolam if blood pressure allows. Technique

1. Apply limb leads, and pacing pads as per manufacturer specifications: (-) left anterior, (+) left posterior. 2. Turn pacer unit on. 3. Set initial current to 40 mAmps . 4. Select pacing rate at 80 beats per minute (BPM) 5. Select “Fixed” mode 6. Start pacing unit. 7. Increase current 10 mAmps every 10-15 seconds until capture or 200 mAmps (usually captures around 100 mAmps). 8. If there is electrical capture, check for femoral pulse. 9. If no capture occurs with maximum output, discontinue pacing and resume ACLS.

Complications

1. Ventricular fibrillation and ventricular tachycardia are rare complications, follow appropriate protocols if either occur.

2. Pacing is rarely indicated in patients under the age of 12 years. 3. Muscle tremors may complicate evaluation of pulses, femoral pulse may be more

accurate. 4. Pacing may cause diaphragmatic stimulation and apparent hiccups.

45 Procedure Protocol: Transcutaneous Cardiac Pacing

Index

46 January 2018

Indications:

A. Physical restraint of patients is permissible and encouraged if the patient poses a danger to him/her self or to others. Only reasonable force is allowable, i.e., the minimum amount of force necessary to control the patient and prevent harm to the patient or others. Try alternative methods first (e.g., verbal de-escalation should be used first if the situation allows).

B. Restraints may be indicated for patients who meet any of the following criteria: 1. A patient who is significantly impaired (e.g. intoxication, medical illness, injury,

psychiatric condition, etc) and lacks decision-making capacity regarding his or her own care.

2. A patient who exhibits violent, combative or uncooperative behavior who does not respond to verbal de-escalation.

3. A patient who is suicidal and considered to be a risk for behavior dangerous to his/ herself or to healthcare providers.

4. A patient who is on a Mental Health Hold C. Paramedic: Consider pharmacological treatment (sedation) of agitation in patients that

require transport and are behaving in a manner that poses a threat to him/her-self or others and in whom physical restraint is not possible or effective.

1. ref. Combative Patient Protocol: (The term “chemical restraint” is no longer preferred)

Precautions: A. When appropriate, involve law enforcement B. Restraints shall be used only when necessary to prevent a patient from seriously injuring him/

herself or others (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be accomplished without restraints. They may not be used as punishment, or for the convenience of the crew.

C. Any attempt to restrain a patient involves risk to the patient and the prehospital provider. Efforts to restrain a patient should only be done with adequate assistance present.

D. Be sure to evaluate the patient adequately to determine his/ her medical condition, mental status and decision-making capacity.

E. Do not use hobble restraints and do not restrain the patient in the prone position or any position that is impairing the airway or breathing.

F. Search the patient for weapons. G. Handcuffs are not appropriate medical restraints and should only be placed by law

enforcement personnel. ref. Handcuffed Pt Protocol.

Technique: A. Treat the patient with respect. Attempts to verbally reassure or calm the patient should be done prior to the use of restraints. To the extent possible, explain what is being done and why. B. Have all equipment and personnel ready (restraints, suction, a means to promptly remove restraints). C. Use assistance such that, if possible, 1 rescuer handles each limb and 1 manages the head or supervises the application of restraints. D. Apply restraints to the extent necessary to allow treatment of, and prevent injury to, the patient. Inadequate-restraint may place patient and provider at greater risk. E. After application of restraints, check all limbs for circulation. During the time that a patient is in restraints, continuous attention to the patient’s airway, circulation and vital signs is mandatory. A restrained patient may never be left unattended.

55 Procedure Protocol: Restraint Protocol

Index

47 January 2018

Documentation : Document the following in all cases of restraint:

A. Description of the facts justifying restraint B. Efforts to de-escalate prior to restraint C. Type of restraints used D. Condition of the patient while restrained, including reevaluations during transport E. Condition of the patient at the time of transfer of care to emergency department staff F. Any injury to patient or to EMS personnel

Complications:

A. Aspiration: continually monitor patients airway B. Nerve injury: assess neurovascular status of patients limbs during transport C. Complications of medical conditions associated with need for restraint

1. Patients may have underlying trauma, hypoxia, hypoglycemia, hyperthermia, hypothermia, drug ingestion, intoxication or other medical conditions.

D. Excited Delirium Syndrome. This is a life-threatening medical emergency. These patients are truly out of control. They will have some or all of the following symptoms: paranoia, disorientation, hyper-aggression, hallucination, tachycardia, increased strength, and hyperthermia.

55 Procedure Protocol: Restraint Protocol

Index

48 January 2018

Indications

A. A tourniquet may be used to control potentially fatal hemorrhage only after other means of hemorrhage control have failed.

Precautions

A. A tourniquet applied incorrectly can increase blood loss. B. Applying a tourniquet can cause nerve and tissue damage whether applied correctly or not. Proper patient selection is of utmost importance. C. Injury due to tourniquet is unlikely if the tourniquet is removed within 1 hour. In cases of life threatening bleeding benefit outweighs theoretical risk. D. A commercially made tourniquet is the preferred tourniquet. If none is available, a blood pressure cuff inflated to a pressure sufficient to stop bleeding is an acceptable alternative. Other improvised tourniquets are not allowed. E. Do not place tourniquet to control bleeding from a Fistula or port. Control those bleeds with direct pressure or “pinching” the line directly.

Technique

A. First attempt to control hemorrhage by using direct pressure over bleeding area. B. If a discrete bleeding vessel can be identified, point pressure over bleeding vessel is more effective than a large bandage and diffuse pressure. C. If unable to control hemorrhage using direct pressure, apply tourniquet according to manufacturer specifications and using the steps below:

1. Cut away any clothing so that the tourniquet will be clearly visible. NEVER obscure a tourniquet with clothing or bandages. 2. Apply tourniquet proximal 2-4” above the wound and not across any joints. 3. Tighten tourniquet until bleeding stops. Applying tourniquet too loosely will only increase blood loss by inhibiting venous return. 4. Mark the time and date of application on the patient’s skin next to the tourniquet. 5. Keep tourniquet on throughout hospital transport – a correctly applied tourniquet should only be removed by the receiving hospital.

60 Procedure Protocol: Tourniquet Protocol

Index

49 January 2018

Indication: A. Needle decompression of tension pneumothorax is a standing order for Paramedics. B. All of the following clinical indicators must be present:

1. Severe respiratory distress / Hypotension / Unilateral, absent, or decreased breath sounds

OR 2. Traumatic Pulseless arrest with trauma to trunk (perform bilateral needle

thoracostomy)

Technique: A. Expose entire chest B. Clean skin overlying site with available skin prep C. > 12 year old:

Insert Air Release System (ARS) catheter at 2nd intercostal space at midclavicular line. D. < 12 year old use 18g 1 ½ “ angiocath at 2nd intercostal space at midclavicular line. E. Notify receiving hospital of needle decompression attempt

Precautions: A. A simple pneumothorax is NOT an indication for needle decompression

65 Procedure Protocol: Needle Thoracostomy for Tension Pneumothorax Decompression

Index

50 January 2018

Indications A. Primary vascular access device in a patient with critical illness defined as:

1. Cardiopulmonary arrest or impending arrest 2. Profound shock (systolic BP < 80) with poor perfusion (Adult patient) 3. Decompensated shock (adult patient) 4. Decompensated shock based on hypotension for age. (pediatric patient)

B. Utilization of IO access for all other patients requires BASE CONTACT WITH (AIP, Chilren’s, TMCA, CMP, SaddleRock)

E.g.: Hypoglycemia with severe symptoms (e.g. unresponsive) and no venous access

Technique:

A. Site: tibial plateau, 2 fingerbreadths below the tibial tuberosity on the anteromedial surface of tibia. B. Clean skin with povidone-iodine. C. Place intraosseous needle perpendicular to the bone. D. Follow manufacturer’s guidelines specific to the device being used for insertion. E. Entrance into the bone marrow is indicated by a sudden loss of resistance. F. Flush line with 10 cc saline. Do not attempt to aspirate marrow G. Secure line

1. Even if properly placed, the needle will not be secure. The needle must be secured and the IV tubing taped. The IO needle should be stabilized at all times.

H. Observe for signs of limb swelling, decreased perfusion to distal extremity that would indicate a malpositioned IO catheter or other complication. If limb becomes tense or malperfused, disconnect IO tubing immediately and leave IO in place. I. A person should be assigned to monitor the IV at the scene and en route to the hospital. J. Do not make more than one IO placement attempt per bone. K. Do not remove IO needles in the field. L. Notify hospital staff of all insertion sites/attempts and apply patient wristband included with kit to identify IO patient.

Complications:

A. Fracture B. Compartment syndrome C. Infection

Contraindications:

A. DO NOT USE EZ IO Drill for patients less than 3kg (Shorter than grey color on Broselow) – Pink EZ IO needle should be placed by hand. B. DO NOT USE EZ IO Drill for newborns (pts less than 24 hours old)

– Pink EZ IO needle should be placed by hand. C. Fracture of target bone D. Cellulitis (skin infection overlying insertion site) E. Osteogenesis imperfecta (rare condition predisposing to fractures with minimal trauma) F. Total knee replacement (hardware will prevent placement)

Side Effects and Special Notes: A. Aspiration of marrow fluid or tissue to confirm needle location is not recommended for field procedures, as it increases the risk of plugging the needle. B. Expect flow rates to be slower than peripheral IVs. Pressure bags may be needed. Any drug or IV fluid may be infused.

70 Procedure Protocol: Intraosseous Catheter Protocol

Index

51 January 2018

Specific Information Needed: A. Obtain pertinent medical history if possible. B. Obtain any information possible regarding the type of Vascular Access Device (VAD),

number of lumens, purpose of the VAD, etc.

Indications

A. To obtain rapid venous access for the critical patient when peripheral access cannot be obtained.

Precautions

A. Obtain information and assistance from family members or home health professionals who are familiar with the device.

B. Discontinue any intermittent or continuous infusion pumps. C. Assure placement and patency of the VAD prior to infusing any fluids or medications. D. Flush the catheter completely with sterile normal saline. E. Use aseptic technique.

Central Venous Catheters or PICC Lines

A. Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of VAD.

B. Identify the location and type of VAD (i.e. central venous catheter, peripheral inserted central catheter).

C. Utilize knowledgeable family members, significant others or home visiting nurse if available. D. Discontinue and/or disconnect any pumps or medications. E. Clamp the VAD closed to prevent air embolus. F. If multiple lumen, identify the lumen to be used. G. Utilize aseptic technique. H. Briskly wipe the injection cap with an alcohol and/or povidone-iodine pad. I. Insert the needle (attached to syringe) into the cap. Aspirate slowly for a positive blood

return. Obtain blood samples if necessary. Then flush the line with solution. J. Insert the needle (attached to a medication syringe or IV tubing) and infuse medications or

fluids. K. Secure the IV tubing. L. Reassess the infusion site. M. Reassess patient condition.

Implanted Ports

A. Attempt peripheral or external jugular access first unless patient or patient's family insist on the direct usage of the VAD.

B. Identify the location and type of VAD (e.g. implanted port). C. Utilize knowledgeable family members, significant others or home visiting nurse if available. D. Discontinue and/or disconnect any pumps or medications. E. Carefully palpate the location of the implanted port. F. If multiple ports, identify the port to be used. G. Using sterile technique, prep the site with alcohol and/or povidone-iodine pad. Wipe from

the center outward three times in a circular motion. H. Using a sterile gloved hand, press the skin firmly around the edges of the port. I. Using a syringe filled with solution, insert the needle perpendicular to the skin. J. Aspirate slowly for blood return, then flush the port prior to infusion. When aspirating blood

from a VAD, use a syringe that is 10cc or less to avoid complications. K. Secure the IV tubing. L. Reassess the infusion site. M. Reassess the patient.

75 Vascular Access Devices

Index

52 January 2018

Complications

A. Patients with VADs are very susceptible to site infection or sepsis. Use sterile techniques at all times.

B. Sluggish flow or no flow may indicate a thrombosis. If a thrombosis is suspected, do not utilize the lumen.

C. Rarely, a catheter will migrate. The symptoms may include the following: 1. burning with infusion 2. site bleeding 3. shortness of breath 4. chest pain 5. tachycardia 6. hypotension

D. If a catheter migration is suspected, do not use the VAD and treat the patient according to symptoms.

E. Catheters are durable but may leak or be torn. Extravasation of fluids or medications occurs and may cause burning and tissue damage. Clamp the catheter and do not use.

F. Air embolism may occur if the VAD is not clamped in between infusions. Avoid this by properly clamping the catheter and preventing air from entering the system.

75 Vascular Access Devices

Index

53 January 2018

HEMOSTATIC AGENT (QuickClot, Celox, Bloodstop, Actcel, HemCon, ChitoGauze) Description QuickClot Combat Gauze is a standard roller or Z-fold gauze impregnated with a clotting agent such

as kaolin (a clay containing the active ingredient aluminum silicate) which works on contact with blood to initiate the clotting process (intrinsic pathway) by activating factor XII. This reaction leads to the transformation of factor XII to its’ activated form XIIa, which triggers the clotting cascade. Mucoadhesive agents such as HemCon, ChitoGauze and Celox utilize a granular chitosan salt derived from the shells of marine arthropods (which are positively charged) to react with and bind to negatively charged red blood cells rapidly forming a cross-linked barrier clot to seal the injured vessels. Used in conjunction with direct pressure and wound packing these products lead to hemostasis.

Onset and Duration

Onset of action is 3-5 minutes after wound exposure and clotting action remains unless the dressing and/or the clot is disturbed.

Indications

Active bleeding from open wounds with that cannot be controlled with direct pressure. Most often involving wounds to the scalp, face, neck, axilla, groin or buttocks.

Contraindications

Not to be used to treat internal bleeding such as intra-abdominal, intra-thoracic or vaginal bleeding. Not to be used for minor bleeding that can be controlled by direct pressure.

Precautions

Bleeding control is achieved via combination of direct pressure and hemostatic gauze packing for a minimum of 3-5 minutes. Stabilize patient per Adult General Trauma Care Protocol. If a tourniquet is indicated (refer to Tourniquet Protocol), it should be applied first, before application of hemostatic agent. DO NOT USE LOOSE GRANULAR OR POWDERED HEMOSTATIC AGENTS. These are out date and will produce exothermic reactions that may cause burns and additional tissue damage.

Procedure

1. Manufacturers may have different recommendations on application of their products. Follow specific manufacturer guidelines for the particular product carried.

80 Hemostatic Gauze Agents

Index

54 January 2018

100 Adult Epistaxis Management

IV access and IV fluid bolus if signs of ref. hypoperfusion/shock.

Index

Active Nosebleed

ABCs

Tilt Head Forward Have pt blow nose to expel clots

Spray both nares with ref. Phenylephrine

Compress nostrils with clamp or fingers, pinching over fleshy part of nose, not bony nasal bridge, for 10 minutes

Transport in position of comfort, usually sitting upright

Reapply clamp or fingers pinching over fleshy part of not, not bony nasal bridge

for 10 minutes.

55 January 2018

General Guidelines: • Most nose bleeding is from an anterior source and may be easily controlled • Avoid phenylephrine in pts with known CAD • Anticoagulantion with aspirin, clopidogrel (Plavix), warfarin (Coumadin) will make epistaxis much harder to control. Note if your patient is taking these or other anticoagulant medications • Posterior epistaxis is a true emergency and may require advanced ED techniques such as balloon tamponade or interventional radiology. Do not delay transport. Be prepared for potential airway issues. • Patients using nasal cannula oxygen may have cannula placed in mouth while nares are clamped or compressed for nosebleed.

100 Adult Epistaxis Management

Index

56 January 2018

Index

105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations

In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible

2 Person BVM with OPA/NPA and Waveform Capnography

Yes No

Yes

No

Yes

No

Effective oxygenation and ventilation? *

Ref. i-gel O2 Airway

Effective oxygenation and ventilation? *

Ref. Orotracheal Intubation, Nasotracheal Intubation

Effective oxygenation and ventilation? *

Ref. Cricothyrotomy

Continue Oxygenating and Ventilating patient

* Signs of adequate oxygenation / ventilation

Examples include: a. Good CO2 Waveform b. Compliance with BVM c. Chest rise and fall d. Bilateral breath sounds e. Positive response to therapy

Ref. i-gel O2 Airway in all cases of cardiac arrest

Effective oxygenation and ventilation? *

2 Person BVM with OPA/NPA and Waveform Capnography

Yes

No

2 Person BVM with OPA/NPA and Waveform Capnography

Effective oxygenation and ventilation? *

No

Yes

57 January 2018

Indications

A. Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory depression.

B. To apply positive pressure ventilation in patients with pulmonary edema and severe fatigue. C. To ventilate patients in respiratory arrest. D. To ventilate patients in cardiac arrest.

Precautions

A. Two people are required to obtain an adequate mask fit and also ventilate. B. Assisted ventilation will not hurt a patient, and should be used whenever the breathing

pattern seems shallow, slow, or otherwise abnormal. Do not be afraid to be aggressive about assisting ventilation, even in patients who do not require or will not tolerate advanced airways.

Technique

A. Open the airway. Check for ventilation. B. Administer ventilations. If unsuccessful, go to Airway Obstruction protocol. C. Check pulse. If absent, go to Cardiac Arrest protocol. D. Attach oxygen to BVM. E. Attach Waveform Capnography sensor to BVM. F. Measure and insert OPA / NPA as indicated / tolerated G. Position yourself above patient's head, continue to hold airway position, seat mask firmly on

face, and begin assisted ventilation. H. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust mask fit as

needed. I. If patient resumes spontaneous respirations, ref. oxygen. Intermittent assistance with

ventilation may still be needed. J. Continuous monitoring of pulse oximetry is required.

Complications

A. Continued aspiration of blood, vomitus, and other upper airway debris B. Inadequate ventilations due to poor seal between patient's mouth and ventilatory device C. Gastric distention, possibly causing vomiting D. Trauma to the upper airway from forcible use of airways E. Pneumothorax

Signs of Adequate oxygenation / ventilation

A. Compliance with bag B. Chest rise and fall C. Bilateral breath sounds D. Good CO2 waveform E. Positive response to therapy

105 Adult Respiratory Failure / Arrest Requiring Assisted Ventilations

Index

58 January 2018

110 Adult Obstructed Airway: Conscious Patient

Does patient show signs of choking?

Attempt to determine cause of obstruction

Assess severity of obstruction

Severe or Complete Obstruction

(mute, silent cough, severe stridor)

Mild or Partial Obstruction

(patient can speak)

Do not interfere with a spontaneously breathing or coughing patient

Position of comfort

Give high flow oxygen

Suction if needed

Is obstruction cleared?

Supportive care and rapid transport

If patient deteriorating or develops worsening distress proceed as for complete

obstruction

Transport POC

O2 via NRB 15 Lpm

Monitor ABCs, SpO2, vital signs

Suction PRN and be prepared for vomiting, which commonly occurs after obstruction relieved

Perform abdominal thrusts until obstruction relieved or patient loses consciousness

For visibly pregnant or obese patients perform chest thrusts instead

Consider chest thrusts in any patient if abdominal thrust ineffective

If patient loses consciousness. Ref. Adult Obstructed Airway: Unconscious

No Yes

Index

59 January 2018

111 Adult Obstructed Airway: Unconscious Patient

Ability to ventilate?

Open airway with head tilt-chin lift

Open airway with jaw thrust if craniofacial trauma present / suspected

Ventilate pt with BVM / Waveform Capnography using two person technique.

Perform 30 chest compressions

Open pt mouth and remove obstruction if seen.

Open airway and ventilate pt with BVM / Waveform Capnography using two person technique.

Ability to ventilate?

Perform laryngoscopy

Use McGill forceps to remove object if possible

Ability to ventilate?

Ref. oral intubation & attempt to push object into mainstem bronchus with ETT if suspected subglottic obstruction.

Pull back ETT to normal depth and attempt ventilation w/ BVM

If unable to ventilate through ETT, withdraw ETT

Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation

Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation

Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation

Ability to ventilate?

Ref. Adult Resp. Failure / Arrest Requiring Assisted Ventilation

If cause of airway obstruction is readily apparent, attempt removal

Ref. percutaneous cricothyrotomy if suspected supraglottic obstruction.

Transport

Notify medial branch of Cricothyrotomy attempt

Index

Yes

Yes

Yes

Yes

No

No

No

No

60 January 2018

Index

115 Adult Respiratory Distress

Are ventilations adequate for physiologic state?

For all patients: While assessing ABCs: give

supplemental O2, monitor vital signs, cardiac rhythm, and SpO2.

Consider capnography if indicated.

Respiratory Distress

Is SpO2 > 90% with high flow O2

Transport • Provide supportive care • Maximize oxygenation and ventilation • CONTACT BASE if needed for consult • 12 lead ECG q 5 min

Patent Airway?

Is anaphylaxis likely?

Is CHF/Pulmonary edema likely?

Ref. Adult Respiratory Failure / Arrest

ref. CPAP

ref. Obstructed Airway Protocol: Conc.

Obstructed Airway Protocol: Unconc.

ref. Allergy/Anaphylaxis

ref. Asthma

ref. CHF or Pulmonary edema

YES

YES

NO

Is COPD likely?

NO

ref. COPD

NO

YES

NO

Is Asthma likely?

NO

NO

YES

YES

YES

NO

YES

61 January 2018

Consider pulmonary and non-pulmonary causes of respiratory distress: • Pulmonary embolism • Pneumonia • Heart attack • Pneumothorax • Sepsis • Metabolic acidosis (e.g.: DKA) • Anxiety Mixed picture may exist: • Goal is maximization of oxygenation and ventilation in all cases • CPAP may be particularly useful in mixed picture with hypoxia and/or hypoventilation • Avoid albuterol in suspected pulmonary edema Don’t over-diagnose psychogenic causes of respiratory distress in the field. Your patient could have a pulmonary embolus or other serious problem; give him/her the benefit of the doubt. Treatment with oxygen will not harm the “hyperventilator”, and it will keep you from underestimating the problem.

115 Adult Respiratory Distress

Index

62 January 2018

Index

Routine Medical Assessment

Respiratory Distress Protocol and prepare for transport

Moderate Attack Marked increase in respiratory rate, wheezes easily heard and accessory muscle breathing.

Severe Attack Grossly abnormal respiratory rate, loud wheezes, or so tight no wheezes are heard, anxiety, gray or ashen skin color, diaphoresis

Mild Attack Slight increase in respiratory rate, mild wheezes, good skin color.

ref. Albuterol + ref. Ipratropium

Concern for impending respiratory failure?

ref. CPAP ref. Adult Resp Failure/Arrest

ref. Methylprednisone IV

ref. Magnesium IV

120 Adult Asthma

ref. Epinephrine IM ref. Albuterol + ref. Ipratropium

Monitor response to treatment

Continue cardiac monitoring and SPO2 en route

Be prepared to assist ventilations as needed

Transport

Adequate response to treatment?

Adequate response to treatment?

No

Yes

ref. Epinephrine IM ref. Capnography measurement

Yes No

Adequate response to treatment?

Yes

Yes

No

Adequate response to treatment?

No

Monitor response to treatment

Continue cardiac monitoring, capnography, and SPO2 en

route Be prepared to assist

ventilations as needed Transport

Therapeutic Goals: Maximize oxygenation / ventilation Decrease work of breathing Identify cardiac ischemia (Obtain

12 lead ECG q 5 min) Identify complications, e.g.

pneumothorax

63 January 2018

Routine Medical Assessment

Respiratory Distress Protocol and prepare for transport

Moderate Attack Marked increase in respiratory rate, wheezes easily heard and accessory muscle breathing.

Severe Attack Grossly abnormal respiratory rate, loud wheezes, or so tight no wheezes are heard, anxiety, gray or ashen skin color, diaphoresis

Mild Attack Slight increase in respiratory rate, mild wheezes, good skin color.

ref. Albuterol + ref. Ipratropium

Concern for impending respiratory failure?

ref. CPAP ref. Adult Resp Failure/Arrest

ref. Capnography

ref. Methylprednisone IV

121 Adult COPD

Adequate response to treatment?

No

Yes

Adequate response to treatment?

No

Monitor response to treatment

Continue cardiac monitoring and SPO2 en route

Be prepared to assist ventilations as

needed Transport

Yes

Index

64 January 2018

Therapeutic Goals: Maximize oxygenation / ventilation Decrease work of breathing Identify cardiac ischemia (Obtain 12 lead ECG q 5 min) Identify complications, e.g. pneumothorax NOTES: • Correct hypoxia: do not withhold maximum oxygen for fear of CO2 retention • Consider pulmonary and non-pulmonary causes of respiratory distress: Examples: pulmonary embolism, pneumonia, pulmonary edema, anaphylaxis, heart attack, pneumothorax, sepsis, metabolic acidosis (e.g.: DKA), Anxiety • Patients with COPD are older and have comorbidities, including heart disease. • Wheezing may be a presentation of pulmonary edema, “cardiac asthma” • Common triggers for COPD exacerbations include: Infection, dysrhythmia (e.g.: atrial fibrillation), myocardial ischemia • CPAP may be very helpful in severe COPD exacerbation, however these patients are at increased risk of complications of CPAP such as hypotension and pneumothorax. Cardiopulmonary monitoring is mandatory.

121 Adult COPD

Index

65 January 2018

125 Adult CHF / Pulmonary Edema

ref. Nitroglycerine

Is oxygenation and ventilation adequate?

ref. CPAP ref. Capnography 12 lead ECG q 5 min: rule out unstable rhythm, ACS

Is response to treatment adequate?

Routine Medical Assessment

Respiratory Distress Protocol and prepare for immediate transport

If failing above therapy: Remove CPAP and ventilate with BVM Assess for Pneumothorax Consider alternative causes/complications

Monitor response to treatment Continue cardiac monitoring (12 lead ECG q 5 min), SPO2 en route

Be prepared to assist ventilations as needed

Therapeutic Goals: Maximize oxygenation Decrease work of breathing Identify cardiac ischemia (Obtain 12 lead ECG q 5 min)

Yes

Yes

No

No

Index

66 January 2018

Index

Allergic reaction, anaphylaxis or angioedema

Assess ABCs, give oxygen

If possible, determine likely trigger

Determine PMH, medications, allergies

Classify based on symptom severity and systems involved

Other specific protocols may apply: e.g.: obstructed airway, bites & envenomations

Generalized or Systemic Reaction

Multisystem involvement: skin, lungs, airway, etc

Does patient have any 2 of the following signs or symptoms of anaphylaxis?

Hypotension

Signs of poor perfusion

Bronchospasm, stridor

Altered mental status

Urticaria

ref. epinephrine IM, then:

Start IV and give IV fluid bolus 20cc/kg NS

ref. diphenhydramine

ref. methylprednisolone

ref. albuterol if wheezing

Monitor ABCs, SpO2, cardiac rhythm

Reassess for signs of deterioration

ref. diphenhydramine

Localized Reaction

Including isolated tongue, airway

Airway involvement? Tongue or uvula swelling, stridor

Impending airway obstruction?

Immediately ref. epinephrine IM & manage

airway and ref. Adult Resp Failure/Arrest

Start IV

ref. diphenhydramine

ref. methylprednisolone

If persistent signs of severe shock with hypotension not

responsive to IM epinephrine and fluid bolus:

Repeat IM ref. epinephrine

Contact Base

No

Yes

No

Yes

Yes No

Transport and reassess for signs of deterioration

130 Adult Allergy and Anaphylaxis

67 January 2018

Definitions: Anaphylaxis: severe allergic reaction that is rapid in onset and potentially life-threatening.

Multisystem signs and symptoms are present including skin and mucus membranes o Mainstay of treatment is epinephrine

Angioedema: deep mucosal edema causing swelling of mucus membranes of upper airway. May accompany hives

Document: History of allergen exposure, prior allergic reaction and severity, medications or treatments

administered prior to EMS assessment Specific symptoms and signs presented: itching, wheezing, respiratory distress, nausea, weakness,

rash, anxiety, swelling of face, lips, tongue, throat, chest tightness, etc.

EMT-B may use pt prescribed Epipen auto injector if available.

130 Adult Allergy and Anaphylaxis

Index

68 January 2018

General Considerations

Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime before CPR and duration of CPR

Past History: medications, medical history, suspicion of ingestion, trauma, environmental factors (hypothermia, inhalation, asphyxiation)

Penetrating and Blunt trauma arrest: Ref. Trauma Arrest Cardiac arrest from the following causes should approached as a medical cardiac arrest:

overdose, respiratory arrest, airway obstruction, asphyxiation, hanging, drowning, electrocution, and lightning/high voltage

Document Specific Objective Findings

Unconscious, unresponsive Agonal, or absent respirations Absent pulses Any signs of trauma, blood loss Skin temperature

General Guidelines Chest Compressions

Push hard and push fast (at least 100/minute) Ensure full chest recoil Rotate compressors every 2 minutes with rhythm checks During CPR, any interruption in chest compressions deprives heart and brain of necessary

blood flow and lessens chance of successful defibrillation Continue CPR while defibrillator is charging, and resume CPR immediately after all shocks.

Do not check pulses except at end of CPR cycle and if rhythm is organized at rhythm check Mechanical Compression Devices

DO NOT stop mechanical compression devices used by outlying agencies. Devices are being found to provide such effective CPR that pulseless and apneic patients will

occasionally perform acts and behaviors such as spontaneous eye openings and arm movements that “fool” providers into believing ROSC has been achieved.

DO NOT DISCONTINUE use of the mechanical CPR device until ROSC is truly confirmed with pulses, spontaneous respirations, etc.

Defibrillation

In unwitnessed cardiac arrest, give first 2 minutes of CPR. If arrest is witnessed by EMS, immediate defibrillation is first priority All shocks should be given as single maximum energy shocks

o Manual biphasic: 150J (Phillips MRx) o AED: device specific

Pacing

Pacing is not indicated for asystole and PEA. Instead start chest compressions according to Ref. Asystole / PEA

Pacing should not be undertaken if it follows unsuccessful defibrillation of VT/VF as it will only interfere with CPR and is not effective

2000 Adult Cardiac Arrest General Principles - ACLS

Index

69 January 2018

ICD/Pacemaker patients

If cardiac arrest patient has an implantable cardioverter defibrillator (ICD) or pacemaker: place pacer/defib pads at least 1 inch from device (anterior / posterior).

Ventilation during CPR

EMS personnel must use good judgment in assessing likely cause of pulseless arrest. In patients suspected of having a primary respiratory cause of cardiopulmonary arrest, (e.g.: COPD or status asthmaticus), adequate ventilation and oxygenation are a priority

In general, patients with cardiac arrest initially have adequately oxygenated blood, but are in circulatory arrest. Therefore, chest compressions are initially more important than ventilation to provide perfusion to coronary arteries

Do not interrupt chest compressions and do not hyperventilate. Hyperventilation decreases effectiveness of CPR and worsens outcome.

Compressions should be given continuously and breaths given asynchronously at 8-10 per minute

Always confirm ventilator effectiveness with Waveform Capnography I-gel O2 is preferred for adult patients in cardiac arrest and should be placed according to

Adult Cardiac Arrest Core Competencies

2000 Adult Cardiac Arrest General Principles - ACLS

Index

70 January 2018

IF VF/VT SHOCK

Treat Reversible Causes

Oxygenate and Ventilate

Quantitative waveform capnography

Drug Therapy

IV/IO Access

Epi q 3-5 minutes

Amiodarone for refractory VF/VF

START CPR

Give Oxygen

Attach monitor/defibrillator

CHECK RHYTHM

2001 Adult Cardiac Arrest General Principles – ACLS

Index

4

71 January 2018

2002 Ventricular Assist Device (LVAD)

• Unstable VAD patients should be transported to the nearest appropriate facility. University of Colorado Hospital is the only facility in the region that definitively treats VAD patients—and is therefore the preferred destination when patient condition is stable and conditions/operational factors allow transport.

• Contact VAD Coordinator as soon as possible at 24/7 pager # (303) 266-4522. For pediatric patients contact the Children’s Hospital Colorado transplant coordinator pager at (303) 890-3503. Provide patient name, DOB, condition & ETA at destination for consultation and/or if transporting to University of Colorado Hospital. VAD coordinator will call back.

• VAD patient family members are excellent resources to assist with patient history and evaluation/repair of VAD alarms/faults.

• It is vital to transport the patient’s back-up batteries and emergency equipment with the patient. • Device specific information for EMS can be found at: https://www.mylvad.com/medical-professionals/ems

A Ventricular Assist Device(VAD) is a mechanical device used to support circulation in a patient with significant cardiac ventricular dysfuntion. The Left Ventricular Assist Device (LVAD) is commonly used to support the left suide of the heart and to provide extra cardiac output to the body. This device can be placed short term to bridge patients until they can receive a heart transplant or long term for people who are not candidates for a transplant. LVAD patients can be identified by an electric driveline cable that comes directly out of their abdomen and connects to an external control pack powered by two external batteries they will be wearing with a bag, harness, or vest. The patient still has underlying heart function and rhythm that can be assessed and treated as appropriate per protocols.

Assess the patient Typically, LVAD patients have no discernible pulse. Blood pressure measurement requires manual BP cuff and Doppler which the patient may have. Utilize other parameters for patient assessment:

Level of consciousness Respiratory rate and work of breathing Signs of perfusion: skin color/temperature, capillary refill (HR>100 is hemodynamically unstable) Cardiac monitor, SpO2, blood glucose level

UNSTABLE Determine if VAD is running and

functionaing properly Auscultate chest for whirling sounds Examine VAD control unit for

alarms

STABLE Address any medical problems

according to protocol Transport to AIP for further

treatment Contact VAD Coordinator

VAD RUNNING 250 mL fluid bolus Consider chest compressions if

apneic with no clinical evidence of perfusion

Consider defibrillation with no clinical evidence of perfusion

Notify destination of VAD patient inbound

VAD NOT RUNNING Consider chest compressions if

required Address VAD alarms/faults Consider defibrillation if required Notify destination of VAD patient

inbound

Common VAD Complications CVA TIA Arrhythmias Infections Sepsis Obstructions Pump Failure

Index

72 January 2018

2010 Adult Pulseless Arrest– BLS / AED

No movement or response?

Open airway and check breathing

If not breathing give 2 breaths that cause chest to rise

If still not responsive, check pulse. Is there a DEFINITE pulse?

Give 200 uninterrupted chest compressions (2 minutes) Continue compressions and ventilations until AED arrives, ALS assumes care, or patient starts to move.

AED arrives

Turn AED on, follow voice prompts.

Give 1 breath every 6 seconds.

Recheck pulse every 2 minutes.

Yes

NO

Index

73 January 2018

2020 Adult Pulseless Arrest – VF / VT

A

Start chest compressions Consider circumstances of arrest:

Witnessed by EMS = immediate rhythm check Unwitnessed by EMS = 2 minutes CPR

o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator

Routine medical assessment

VF / VT

2 min CPR Ref. Adult Respiratory Failure/Arrest

2 min CPR ref. IO / IV

2 min CPR ref. Epinephrine q 4 min

VF / VT

Rhythm Check

Rhythm Check ROSC

SHOCK

SHOCK

VF / VT

Rhythm Check ASYSTOLE/PEA

ROSC

SHOCK

2 min CPR ref. Amiodarone

VF / VT

SHOCK

ASYSTOLE/PEA ROSC

Ref. ROSC Ref. Asystole / PEA

Go To Box “A”

After 15 minutes of ALS Care: Continue resuscitation and

Transport

Index

A

ASYSTOLE/PEA

74 January 2018

Shock energy: All shocks at 150joules (Philips MRx) Reversible Causes: Hypovolemia Tamponade (cardiac) Hypoxia Toxins H+ (Acidosis) Thrombosis: PE, AMI Hypo/Hyperkalemia Hypothermia Tension Pneumothorax

Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history

Calcium gluconate or Calcium chloride and Sodium bicarbonate. Flush IV line between meds

Suspected Torsades de Pointe: Ref. Magnesium Suspected Hypothermia: Single dose of Epinephrine IV/ IO for Pulseless Arrests associated with Asystole, Vfib/ VT. For Vfib/ VT: single attempt defibrillation only

2020 Adult Pulseless Arrest – ALS – ACLS

Index

75 January 2018

Rhythm Check

Index

2021 Adult Pulseless Arrest Asystole / PEA

ROSC VF / VT

ROSC

Start chest compressions Consider circumstances of arrest:

2 minutes CPR o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator

Routine medical assessment Treat reversible causes

Asystole / PEA

2 min CPR Ref. Adult Respiratory Failure/Arrest

2 min CPR ref. IO / IV

2 min CPR ref. Epinephrine q 4 min

Asystole / PEA

Asystole / PEA

Go To Box “A”

Ref. VF / VT

After 30 minutes of ALS Care:

Consider Termination of Resuscitation if no shockable rhythm

Rhythm Check

VF / VT

Ref. ROSC

A

76 January 2018

Continue to monitor cardiac rhythm / pulse

YES

YES

2025 Adult Return of Spontaneous Circulation

ROSC after Cardiac Arrest

STEMI? Initiate Cardiac Alert

Place head of bed at 30degrees elevation

Systolic BP <90 If NOT hypervolemic, administer 1000 ml Normal Saline bolus

If persistent SBP < 90 after 1000ml saline bolus, ref. Epinephrine

Assess for purposeful response

Purposeful Response?

Recurrent dysrhythmia? Treat per protocol

YES

Reassess ABCs Obtain baseline vitals

12 lead EKG q 5 minutes

Index

77 January 2018

Index

2030 Adult Tachyarrhythmia

Assess appropriateness for clinical condition Heart rate typically > 150/min if tachyarrhythmia

Routine Medical Assessment Identify and treat underlying cause

Search for and treat underlying cause:

e.g.: dehydration, fever,

hypoxia, hypovolemia, pain

IS PATIENT UNSTABLE? Unstable signs include any two of the following:

Altered mental status Symptoms compatible with Acute Coronary

Syndrome (ACS) (chest pain, diaphoresis, dyspnea, etc)

Hypotension

YES

Wide QRS > 0.12sec

NO

REGULAR Valsalva

maneuver ref. Adenosine if

suspected AVNRT (formerly known as PSVT)

Sinus Tachycardia?

If regular and polymorphic

(Torsades de Pointes) Magnesium

Narrow QRS < 0.12sec

Ref. Synchronized Cardioversion

12 Lead EKG q 5 minutes

IRREGULAR A-Fib, A-Flutter or MAT Do NOT give Adenosine If pt. becomes unstable

go to box B

IRREGULAR Contact Base for consult Do NOT give adenosine If pt becomes unstable

go to box B

REGULAR V-Tach (>80%) or

SVT with aberrancy Contact Base ref.

Amiodarone

Does rhythm convert?

CONVERTS Monitor in Transport

If recurrent dysrhythmia go to box A

DOESN’T CONVERT Contact base for consult

Monitor in transport If unstable, go to box B

A UNSTABLE

STABLE

B

YES

NO

YES NO

Monitor in transport

78 January 2018

2040 Adult Bradycardia

HR <50 and inadequate for clinical condition

Routine Medical Assessment Identify and treat underlying cause

NO

12 lead EKG q 5 minutes Transport and Monitor

for deterioration

Index

IS PATIENT UNSTABLE? Unstable signs include any of the following:

Altered mental status Symptoms compatible with Acute Coronary Syndrome (ACS) (chest

pain, diaphoresis, dyspnea, etc) Hypotension Signs of shock

ref. Atropine If Atropine ineffective begin pacing

ref. Epinephrine if pacing ineffective

If the pt is not being paced perform 12 lead EKG q 5 minutes

Transport and Monitor for deterioration

Prepare for immediate pacing If pacing ineffective ref. Atropine

ref. Epinephrine if Atropine ineffective

YES NO

Vascular Access?

YES

79 January 2018

2050 Adult Chest Pain

Consider life threatening causes of chest pain* in all patients.

While assessing ABCs ref. Oxygen, monitor vital signs, cardiac rhythm, start IV.

12 lead EKG q 5 min if possible acute coronary syndrome

Ref. Aspirin if possible acute coronary syndrome

STEMI? Initiate Cardiac Alert

Ref. Nitroglycerine if suspected acute coronary syndrome.

For hypotension following NTG administration give 250mL NS bolus. Reassess and repeat bolus as needed.

Do not administer additional NTG.

Ref. Fentanyl for persistent pain that is not relieved by 3 doses of SL Nitroglycerine in non-

inferior wall MIs and without prior Nitroglycerin in inferior wall MIs.

*Life Threatening Causes of Chest Pain Acute coronary syndrome (ACS)

Pulmonary embolism Thoracic aortic dissection

Tension Pneumothorax

YES

Considerations:

20-30% of patients in the cath. lab, who have confirmed AMI’s, have reproducible chest pain upon palpation Only 30% of patients experiencing an Acute Myocardial Infarction will present with ST Segment Elevation.

Index

80 January 2018

General: A. Consider life-threatening causes of chest pain first in all patients:

1. Acute coronary syndromes (ACS) 2. Pulmonary embolism (PE) 3. Thoracic aortic dissection (TAD) 4. Tension pneumothorax (PTX)

B. Do not delay obtaining 12 lead ECG, if available, and notify receiving facility immediately if Cardiac Alert criteria met.

Document specific findings:

A. Complete set of vital signs B. General appearance: skin color, diaphoresis C. Cardiovascular exam: presence of irregular heart sounds, JVD, murmur, pulse asymmetry, dependent edema D. Pulmonary exam: crackles/râles and/or wheezes/rhonchi E. Chest wall and abdominal tenderness

Treatment:

A. ABCs B. Reassure patient and place in position of comfort C. Place patient on cardiac monitor D. Ref. oxygen E. Start IV F. Paramedics:

1. Obtain 12-lead ECG. a. If patient has at least 1 mm ST segment elevation in at least 2 anatomically contiguous leads (STEMI), notify receiving hospital and request CARDIAC ALERT (ref. Cardiac Alert Protocol). 2. If history and physical exam suggest possible ACS:

a. ref. aspirin b. ref. nitroglycerine c. ref. fentanyl for persistent pain that is not relieved by 3 doses SL nitroglycerine

3. Consider CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for additional medication orders if pain persists.

G. EMTs: 1. CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) for verbal order for patient-assisted and supplied nitroglycerine if applicable

Contraindications:

A. If hypotension develops following nitroglycerine administration in any patient, treat with 250cc NS boluses. B. Nitroglycerine is contraindicated in patients taking medication for erectile dysfunction (phosphodiesterase inhibitors, e.g.: Viagra, Cialis, Revatio). C. Nitroglycerine is contraindicated in patients with pulmonary hypertension who are taking Revatio. D. Nitroglycerine is contraindicated in patients with Inferior STEMI pattern (Lead II, III, aVF)

2050 Adult Chest Pain

Index

81 January 2018

Goal: A. To identify patients with ST-segment elevation myocardial infarction (STEMI) in the prehospital setting and provide advanced receiving hospital notification in order to minimize door-to-balloon times for percutaneous coronary intervention (PCI)

Inclusion Criteria: (MUST MEET ALL 3 CRITERIA)

A. Chest discomfort consistent with Acute Coronary Syndrome (ACS) or post ROSC (and) B. 12-lead ECG showing ST-segment elevation (STEMI) at least 2 mm in two or more anatomically contiguous leads (and) C. Age 35 years or older

*If STEMI patient outside inclusion criteria, advise receiving hospital of assessment/ findings*

Exclusion Criteria: A. Paced rhythm, Left Bundle Branch Block B. If unsure if patient is appropriate for Cardiac Alert, discuss with receiving hospital MD

Actions:

A. ref. chest pain protocol en route B. Notify receiving hospital ASAP with ETA and request CARDIAC ALERT. Do not delay hospital notification. If possible, notify ED before leaving scene C. Start 2 large bore peripheral IVs D. Transport E. Acute coronary syndrome may present without chest discomfort and include symptoms such as upper abdominal pain, back/ shoulder/ arm pain, nausea/ vomiting, or shortness of breath. One should have a low threshold to obtain EKG in patients with such symptoms are reflective of ACS. CONTACT APPROPRIATE RECEIVING HOSPITAL PHYSICIAN for consultation and possible initiation of Cardiac Alert.

Additional Documentation Requirements: A. Time of first patient contact B. Time of first ECG

2051 Adult Cardiac Alert

Index

82 January 2018

Intent: 1. Even with extremes of blood pressure, treat the medical emergency associated with

hypertension (“treat the patient, not the number”) a. Treat chest pain, pulmonary edema, or stroke according to standard protocols (pain

control will usually improve BP significantly) 2. Do not use medication to treat hypertension 3. Obtain a 12 lead ECG for the hypertensive patient.

2100 Adult Hypertension

Index

83 January 2018

Specific Information Needed

A. History of the event: onset, duration, seizure activity, precipitating factors. Was the patient sitting, standing, or lying? Pregnant?

B. Past history: medications, diseases, prior syncope C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache,

palpitations

Specific Objective Findings

A. Vital signs B. Neurological status: level of consciousness, residual neurological deficit C. Signs of trauma to the head or mouth or incontinence D. Neck stiffness

Treatment

A. Place patient in position of comfort: do not sit patient up prematurely; supine or lateral positioning if not completely alert

B. Monitor vital signs and level of consciousness closely for changes or recurrence. C. Establish venous access and administer Normal Saline if indicated. D. Consider hypoglycemia. If signs of hypoglycemia are present ref. Hypoglycemia E. If vital signs unstable or age > 40 years:

1. Ref. Oxygen 2. Keep patient supine. 3. Establish venous access. 4. Monitor cardiac rhythm (12-lead EKG)

Specific Precautions

A. Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the patient is still unconscious, treat as coma. If the patient is confused, treat according to Altered Mental Status protocol.

B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes. Recumbent position should be sufficient to restore vital signs and level of consciousness to normal.

C. Syncope that occurs without warning or while in a recumbent position is potentially serious and often caused by an arrhythmia.

D. Patients with syncope, even though apparently normal, should be transported. In middle-aged or elderly patients, syncope can be due to a number of potentially serious problems. The most important of these to monitor and recognize are arrhythmias, occult GI bleeding, seizure, or ruptured abdominal aortic aneurysm.

E. Any elderly patient with syncope and back pain should be considered to have a ruptured abdominal aortic aneurysm until proven otherwise.

3000 Adult Syncope

Index

84 January 2018

Rule out or treat ref. hypoglycemia

Determine when last KNOWN to be normal and document specific time

“At 2:15 PM”, not “1 hour ago”

Obtain medical history

Document medications

Identify family or friend who may assist with history and decision-making, get contact info and strongly encourage to come to ED as they may be needed for consent for treatments

Fully monitor patient and continually reassess:

Improvement or worsening of deficit

Adequacy of ventilation and oxygenation

Cardiovascular stability

POSSIBLE STROKE (Acute onset neurological deficit not likely

due to trauma)

Start IV and draw blood

Obtain 12 lead ECG and document cardiac rhythm

Ensure full monitoring in place: cardiac, SpO2

Assess and stabilize ABCs, ref.O2

Assess Cincinnati Prehospital Stroke Scale

(Presence of single sign sufficient)

Transport to CHC for pts < 12 years old.

Notify receiving hospital of Stroke Alert

3010 Adult Stroke

Index

85 January 2018

Stroke Mimics Hypoglycemia Post-ictal paralysis Complex migraine Overdose Trauma Bell’s palsy

Cincinnati Prehospital Stroke Scale Think “FAST” (face, arm, speech, time) Assess Facial Droop Say: “Smile for me”, or “Show me your teeth” Assess Arm Pronator Drift Demonstrate, and say: “Put your arms up for me like this and hold them while I count to 10” Assess Speech Say: “Repeat after me: you can’t teach on old dog new tricks”, or “No ifs, ands, or buts”

The Cincinnati Prehospital Stroke Scale (CPSS) is designed to be very reproducible and identify those strokes most likely to benefit from reperfusion therapy, but does not identify all strokes. The CPSS is highly specific for stroke, but is not extremely sensitive, meaning if you have a positive

CPSS, you are almost certainly having a stroke, but if you do not have a positive CPSS, you still may be having a stroke

Stroke signs may be very subtle, therefore it is important to know other signs of stroke, which include:

o Impaired balance or coordination o Vision loss o Headache o Confusion or altered mental status o Seizure

3010 Adult Stroke

Index

Stroke Alert Criteria 1. Last known normal 12 hours or less 2. BGL > 60 3. No seizure at onset or recent head trauma

AND

Must have one or more new clinical signs

1. New Speech impairment or aphasia 2. Unequal smile or obvious facial asymmetry 3. Arm weakness or drift

86 January 2018

MSTU team ACCEPTS transfer of care

NO YES

Index

3011 Mobile Stroke Treatment Unit – Activation and Transfer of Care

AFD Dispatched to Incident

Review of CAD notes reveals possible Stroke patient AND

Pt > 18 years old

Do not request MSTU Response

Treat and transport per protocol

Request dispatch of MSTU via Aurora Comm. Center

AFD arrival on scene Request 10 minute ticker

Treat per protocol

Cancel MSTU response

Treat and transport per protocol

Treat per protocol Prepare pt for transport

10 minutes after AFD arrival

MSTU on scene

Pt report made to MSTU team

Does pt. meet Stroke Alert Criteria AND

Pt > 18 years old

MSTU NOT on scene

Cancel MSTU Response Treat and transport per protocol

Treat and transport per protocol

MSTU Team DOES NOT accept transfer of care

Assist MSTU team loading pt into MSTU

Pt care transferred to MSTU team

YES NO

87 January 2018

Persistent AMS?

Altered Mental Status (AMS)

Assess ABCs ref. Asystole / PEA or . VF / VT, respiratory distress or obstructed airway protocol as

appropriate.

Determine character of event Consider seizure, syncope and TIA Monitor and transport with

supportive care

BGL < 60 mg/dL or clinical condition suggests hypoglycemia?

Perform rapid neurologic assessment including LOC and Cincinnati Prehospital

Stroke Scale (CPSS)

ref. Seizure protocol protocolprotocol

ref. Stroke protocol

Consider other causes of AMS: ref. overdose, Shock, heat emergency, cold emergency, EtOH Intoxication

During transport: ref.O2, monitor vital signs, airway, breathing, and 12 lead ECG.

Give fluid bolus if volume depletion or sepsis suspected

Check BGL

ref. Hypoglycemia protocol

Seizure activity present?

Focal neuro deficit or positive CPSS?

Yes

No

No

Yes

No

3020 Adult Altered Mental Status

Index

No

Yes

Yes

88 January 2018

Check pulse and reassess ABC Give supplemental oxygen

CONTACT BASE

If seizure < 5 min medication not necessary

If > 5 min or recurrent seizure then treat as follows:

ref. Midazolam via most readily available route

Actively Seizing?

Actively Seizing?

Actively Seizing?

ref. Midazolam via most readily available route, IV preferred

Transport and monitor ABCs, vital signs, and neurological condition

Complete head to toe assessment

Support ABCs: ref.O2 Seizure precautions Check BGL and ref. hypoglycemia

Identify and treat reversible causes

3030 Adult Seizure

Index

Common Causes of Seizures

Epilepsy

EtOH withdrawal or intoxication

Hypoglycemia

Stimulant use

Trauma

Intracranial hemorrhage

Overdose (TCA)

Eclampsia

Infection: Meningitis, sepsis

Yes

No

No

89 January 2018

Seizure Precautions:

Ensure airway patency, but do not force anything between teeth. NPA may be useful Give oxygen Suction as needed Protect patient from injury Check pulse immediately after seizure stops Keep patient on side

Document:

Document: Seizure history: onset, time interval, previous seizures, type of seizure Obtain medical history: head trauma, diabetes, substance abuse, medications, compliance with

anticonvulsants, pregnancy Pregnancy and Seizure:

If 3rd trimester pregnancy or post-partum: ref. pre eclampsia / eclampsia

3030 Adult Seizure

Index

90 January 2018

Abdominal pain and/or vomiting

Assess ABCs

ref.O2

Complete set of Vital Signs

Physical exam

Ref. Hypotension / Shock as indicated

Monitor and transport

Frequent reassessment for deterioration and response to treatment

Cardiac monitor and 12 lead ECG q 5 min if any one or more of the following: 1. Age > 50 2. Diabetic 3. Upper abdominal pain 4. Unstable vital signs

ref.Ondansetron

ref. Fentanyl

4010 Adult Abdominal Pain / Vomiting

Index

91 January 2018

Abdominal exam:

Gently palpate 4 quadrants, noting areas of tenderness, guarding, rigidity or distension Note any pulsatile mass Note surgical scars

History:

Onset, location, duration, radiation of pain Associated sx: vomiting, GU sx, hematemesis, coffee ground emesis, melena, rectal

bleeding, vaginal bleeding, known or suspected pregnancy, recent trauma

Elderly Patients:

Much more likely to have life-threatening cause of symptoms Always consider vascular emergencies: AAA, MI Shock may be occult, with absent tachycardia in setting of severe hypovolemia

4010 Adult Abdominal Pain / Vomiting

Index

92 January 2018

4020 Adult Overdose and Acute Poisoning

Index

PPE and decontaminate when appropriate

ABCs IV, ref.O2, monitor

ref. Naloxone

Airway adjuncts and BVM ventilations as needed

Altered Mental Status Protocol

IV fluid bolus ref. hypotension/shock protocol

Stimulant

Tachycardia, HTN, agitation,

sweating,

psychosis

Tricyclic antidepressant

Wide complex

tachycardia, seizure

Organophosphate or nerve agent

DUMBELS/SLUDGE

syndrome

Calcium Channel Blocker

Bradycardia, heart

block, hypotension

ß-Blocker

Bradycardia, heart block, hypotension

ref. Sodium bicarb for QRS > 120 msec

ref.Nerve Agent Antidote Kit

ref.Atropine

ref. Epi if no response to 20cc/kg NS bolus

20 cc/kg NS bolus

ref. Calcium and ref.

Epinephrine

Ref. Epinephrine

20 cc/kg NS bolus

Yes

No

Yes

No

Yes Consider specific ingestions

No

Need for airway management?

Hypotension?

Altered mental status?

Known Specific ingestion?

ref.Glucagon

Ref. Seizure

ref.Combative Pt

ref. resp.failure protocol

ref.Glucagon

Yes

No Monitor

Transport

93 January 2018

Obtain specific information: Type of ingestion(s) What, when and how much ingested? Bring the poison, container, all medication and other questionable substances to the ED Note actions taken by bystanders or patient (e.g.: induced emesis, “antidotes”, etc) Supportive Care is key to overdose management

4020 Adult Overdose and Acute Poisoning

Index

94 January 2018

Is BGL < 60?

Check blood glucose level in ANY patient with signs or symptoms consistent with hypoglycemia. Use

Capilarry blood for BGL sample

Examples: Altered MS, agitation, focal neurologic deficit, seizure, weakness, diaphoresis, decreased motor tone, pallor

ref. Oral Glucose Reassess patient

No

Monitor and transport or CONTACT BASE for

refusal if indicated

ref. Glugacon IM

Yes

Yes

If hypoglycemia still most likely despite normal reading on

glucometer, administer sugar while considering other causes

of ref. altered mental status

Symptoms resolved?

Yes

No

Still symptomatic?

Are you able to establish IV access?

ref. dextrose IV & reassess patient

No

Recheck BGL and consider other causes of

altered mental status

Can the patient safely tolerate oral glucose?

intact gag reflex, follows

verbal commands

No

4025 Adult Hypoglycemia

Yes

Yes

No

Index

95 January 2018

Regarding refusals after a hypoglycemic episode:

ref. Patient Non Transport protocol

Transport is always indicated for the following patients:

All pts with unexplained hypoglycemia

Pts taking oral hypoglycemic meds

Pts not taking PO

Pts who do not have competent adult to monitor

4025 Adult Hypoglycemia

Index

96 January 2018

Yes

Yes

No

No

Index

If patient is at risk for adrenal insufficiency, ref. Adrenal Insufficiency

Signs of poor perfusion?

Altered mental status Tachycardia

Cool, clammy skin

Consider etiology of shock state

Give 20cc/kg NS bolus and reassess

Adult with SBP < 90 mmHg AND/OR signs of poor perfusion

Repeat 20cc/kg boluses, reassessing for pulmonary edema, up to 2 liters total or until goal of SBP > 90 mmHg and signs

adequate perfusion

Recheck and monitor If patient remains

asymptomatic and clinically stable, further treatment may not be necessary

ABCs

Complete set of vital signs

Full monitoring

O2 via NRB facemask @ 15L/min

IV access

Transport

Life-threatening bradycardia or tachycardia?

Ref. bradycardia Ref. tachycardia

For ongoing hypotension, poor perfusion or pulmonary edema, CONTACT BASE

ref. Epinephrine

4030 Adult Medical Hypotension / Shock

97 January 2018

Shock is a state of decreased tissue oxygenation. Significant vital organ hypoperfusion may be present without hypotension. Home medications and/or comorbidities may also limit development of tachycardia Goal is to maximize oxygen delivery with supplemental oxygen and assisted ventilations (if needed), and to maximize perfusion with IV fluids Consider the etiology of your patient’s shock state:

Sepsis

Hemorrhage

Anaphylaxis

Overdose

Cyanide or Carbon Monoxide Poisoning

Other: PE, MI, tension pneumothorax

4030 Adult Medical Hypotension

Index

98 January 2018

All symptomatic patients:

Check blood glucose and treat hypoglycemia, if present

Start IV and ref.O2

Give NS bolus IV 20 cc/kg up to 2 liters

Ref. Methylprednisolone

Patient at risk for adrenal insufficiency:

Identified by family or medical alert bracelet

Chronic steroid use

Congenital Adrenal Hyperplasia

Addison’s disease

Assess for signs of acute adrenal crisis:

Pallor, weakness, lethargy

Vomiting, abdominal pain

Hypotension, shock

Congestive heart failure

Does patient have hypotension and signs of poor

perfusion?

Altered mental status

Tachycardia

Cool, clammy skin

Monitor 12 lead ECG q 5 min for signs of hyperkalemia

4031 Adult Adrenal Insufficiency

Yes

No

Index

20 cc/kg NS bolus, as needed

Continue to monitor for development of Hypoglycemia

If otherwise considering administration of corticosteroid, CONTACT BASE for consult.

99 January 2018

Notes: If the patient is confirmed to have a disease (such as congenital adrenal hyperplasia or

chronic use of systemic steroids) that could lead to acute adrenal insufficiency or Addisonian crisis, then the administration of steroids may be life-saving and necessary for reversing shock or preventing cardiovascular collapse.

Patients at risk for adrenal insufficiency may develop Addisonian crisis when under physiologic stress which would not lead to cardiovascular collapse in normal patients. Such triggers may include trauma, dehydration, infection, myocardial ischemia, etc.

If no corticosteroid is available during transport, notify receiving hospital of need for immediate corticosteroid upon arrival.

4031 Adult Adrenal Insufficiency

Index

100 January 2018

Ref; Spinal Stabilization before moving patient if trauma suspected

Monitor cardiac rhythm

Remove wet garments, dry and insulate patient

Transport, even if initial assessment normal

Monitor ABC, VS, mental status

Remove wet garments, dry and insulate patient

Heimlich maneuver NOT indicated

Consider all causes of Altered Mental Status

Suction as needed

Start IV, obtain BGL and ref.O2

Monitor ABC, VS, mental status

Remove wet garments, dry and insulate patient

Suction as needed

Start IV, check BGL, ref.O2

Transport

Monitor ABC, VS, mental status

ABCs

Awake and alert

Assess mental status

Awake but altered LOC Comatose or unresponsive

Yes No

Monitor cardiac rhythm

Pulse Present?

• Start CPR • Attach AED/monitor/defibrillator • Single defibrillation attempt only if hypothermic • Treat Ref. Asystole / PEA or . VF / VT

If suspected hypothermia ref. Hypothermia

4040 Adult Drowning

Index

101 January 2018

Specific Information Needed:

Length of submersion Degree of contamination of water Water temperature Diving accident and/or suspected trauma

Notes: Drowning/submersion commonly associated with hypothermia. Even profound bradycardias may be sufficient in setting of severe hypothermia and decreased

O2 demand Good outcomes after even prolonged hypothermic arrest are possible Patients should not be pronounced dead until rewarmed in hospital BLS: pulse and respirations may be very slow and difficult to detect if patient is severely

hypothermic. If no definite pulse, and no signs of life, begin CPR If not breathing, start rescue breathing ALS: Resuscitation medications are indicated

4040 Adult Drowning

Index

102 January 2018

Index

Systemic hypothermia Presumed to be primary problem

based on clinical scenario

Monitor cardiac rhythm

Remove wet garments, dry and insulate patient

Transport, even if initial assessment normal

Monitor ABC, VS, mental status

Dress injured area lightly in clean cloth to protect from further injury

Do not rub, do not break blisters

Do not allow injured part to refreeze. Repeated thaw freeze cycles are especially harmful

Monitor for signs of systemic hypothermia

Remove wet garments, dry and insulate patient

ref. Altered Mental Status

Suction as needed

Start IV, check BGL and give oxygen

Transport

Monitor ABC, VS, mental status

Remove wet garments, dry and insulate patient

Suction as needed

Start IV, BGL, oxygen

Transport

Monitor ABC, VS, mental status

High flow O2

ABCs

Awake but altered LOC Comatose or unresponsive

Yes

No

PEA Asystole or V-fib/VT

Handle very gently

Start IV w. warm IVF

Insulate patient

ref. Resp Failure

Localized cold injury

Frostbite, frostnip

Hypothermia and Frostbite

Pulse Present?

Start CPR, attach AED/monitor/defibrillator and treat per Pulseless Arrest VF / VT or Pulseless Arrest Asystole / PEA

with following changes:

Single dose ref. Epinephrine IV/IO

For Vfib/VT: single attempt defibrillation only

4050 Adult Hypothermia

Monitor cardiac rhythm

ref. Resp Failure

Monitor cardiac rhythm

103 January 2018

Regardless of cardiac rhythm, the following patients should be aggressively resuscitated and transported as soon as possible: (per Termination of Resuscitation protocol)

i. Hypothermia ii. Drowning with hypothermia and submersion < 60 minutes

Even profound bradycardias may be sufficient in setting of severe hypothermia and decreased O2 demand Good outcomes after even prolonged hypothermic arrest are possible Patients should not be pronounced dead until rewarmed in hospital BLS: pulse and respirations may be very slow and difficult to detect if patient is severely hypothermic. If no

definite pulse, and no signs of life, begin CPR If not breathing, start rescue breathing One round of ALS resuscitation medications are indicated only on V-Fib/ VT or Asystole NOT used in PEA

for hypothermia

4050 Adult Hypothermia

Index

104 January 2018

Heat Cramps

Normal or slightly elevated body temperature

Warm, moist skin

Generalized weakness

Diffuse muscle cramping

Index

Heat Exhaustion

Elevated body temperature

Cool, diaphoretic skin

Generalized weakness

Anxiety

Headache

Tachypnea

Possible syncope

Heat Stroke

Very high core body temperature

Hot, dry skin w. cessation of sweating

Hypotension

Altered mental status

Seizure

Coma

Immediate Transport indicated

Adequate airway and breathing?

No Yes

Ref. adult respiratory failure

Start IV, ref.O2 20cc/kg bolus NSL unless signs of volume overload

Remove excess clothing

For heat stroke, consider external cooling measures if prolonged transport

ref. seizures, cardiac arrhythmias per protocol

Monitor and transport

20cc/kg bolus NSL

Monitor VS and transport

Hyperthermia

Classify by clinical syndrome

Consider non-environmental causes (see below)

4060 Adult Hyperthermia

105 January 2018

Consider other causes of hyperthermia besides environment exposure, including:

Neuroleptic malignant syndrome (NMS): patients taking antipsychotic medications

Sympathomimetic overdose: cocaine, methamphetamine

Anticholingergic toxidrome: overdose (“Mad as a hatter, hot as a hare, blind as a bat, red as a beet”)

common w. ODs on psych meds, OTC cold medications, Benadryl, Jimson weed, etc.

Infection: fever (sepsis)

Thyrotoxicosis: goiter (enlarged thyroid)

Excited Delirium

4060 Adult Hyperthermia

Index

106 January 2018

Index

4070 Adult Insect/Arachnid Bite and Stings Protocol

ref.O2

Start IV

Assess for localized vs. systemic signs and symptoms

and depending on animal involved

Localized Symptoms:

Pain, warmth and swelling

Systemic Symptoms:

Hives, generalized erythema, swelling, angioedema

Hypotension

Altered mental status

Other signs of shock

Initiate general care for bites and stings

ref.allergy & anaphylaxis protocol

ref. fentanyl for black widow spider and /or ref. diphenhydramine if needed for itching

107 January 2018

4070 Adult Insect/Arachnid Bite and Stings Protocol

Specific Information Needed: Timing of bite/sting Identification of spider, bee, wasp, other insect, if possible History of prior allergic reactions to similar exposures Treatment prior to EMS eval: e.g. Epipen, diphenhydramine, etc.

General Care For bees/wasps:

Remove stinger mechanism by scraping with a straight edge. Do not squeeze venom sac For spiders:

Bring in spider if captured or dead for identification

Specific Precautions: For all types of bites and stings, the goal of prehospital care is to prevent further

envenomation and to treat allergic reactions BLS personnel may assist patient with administering own Epipen and oral antihistamine Anaphylactoid reactions may occur upon first exposure to allergen, and do not require prior

sensitization Anaphylactic reactions typically occur abruptly, and rarely > 60 minutes after exposure

Index

108 January 2018

Index

4080 Adult Snake Bite

Assess ABCs, mental status ref.O2 Start IV Monitor Vital signs

Remove patient from proximity to snake Remove all constricting items from bitten limb (e.g.: rings, jewelry, watch, etc.) Immobilize bitten part Initiate prompt transport

• Do NOT use ice, refrigerants, tourniquets, scalpels or suction devices • Mark margins of erythema and/or edema with pen or marker and include time measured.

Transport

Assess for localized vs. systemic signs and symptoms

Localized Symptoms: • Pain and swelling • Numbness, tingling to bitten part • Bruising/ecchymosis

Systemic Symptoms: • Metallic or peculiar taste in mouth • Hypotension • Altered mental status • Widespread bleeding • Other signs of shock

Monitor pt and ref. Adult Respiratory Distress as indicated

ref. Fentanyl

ref. Hypotension/Shock as indicated

Immobilize bitten part

109 January 2018

Obtain specific information: • Appearance of snake (rattle, color, thermal pit, elliptical pupils) • Appearance of wound: location, # of fangs vs. entire jaw imprint • Timing of bite • Prior 1st aid • To help with identification of snake, photograph snake, if possible. Include image of head, tail, and any distinctive markings. • Do not bring snake to ED Specific Precautions: • The prairie rattlesnake is native to Denver Metro region and is most common venomous snake bite in the region • Exotic venomous snakes, such as pets or zoo animals, may have different signs and symptoms than those of pit vipers. In case of exotic snake bite, CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) and consult zoo staff or poison center for direction. • Never pick up a presumed-to-be-dead snake by hand. Rather, use a shovel or stick. A dead snake may reflexively bite and envenomate. • > 25% of snake bites are “dry bites”, without envenomations. • Conversely, initial appearance of bite may be deceiving as to severity of envenomation. • Fang marks are characteristic of pit viper bites (e.g. rattlesnakes). • Jaw prints, without fang marks, are more characteristic of non-venomous species.

4080 Adult Snake Bite

Index

110 January 2018

Scene Safety

A. Scene safety and provider safety are a priority. Consider police contact if scene safety is a concern.

B. Refer to restraint protocol as needed, especially as it relates to A.

Specific Information Needed A. Obtain history of current event; inquire about recent crisis, toxic exposure, drugs, alcohol,

emotional trauma, and suicidal or homicidal ideation. B. Obtain past history; inquire about previous psychiatric and medical problems, medications.

Specific Objective Findings

A. Evaluate general appearance 1. E.g.: Well groomed, disheveled, debilitated, bizarrely dressed

B. Evaluate vital signs. 1. Is a particular toxidrome suggested, e.g.: symphathomimetic?

C. Note medic alert tags, breath odors suggesting intoxication. D. Determine if patient has decision making capacity. E. Note behavior. Consider known predictors of violence:

1. Is the patient male, clinically intoxicated, paranoid or displaying aggressive or threatening behavior or language?

Treatment A. If patient combative, see Combative Patient Protocol B. Attempt to establish rapport C. Assess ABCs D. Transport to closest Emergency Department E. Be alert for possible elopement F. Consider organic causes of abnormal behavior (trauma, overdose, intoxication,

hypoglycemia) G. If patient restraint considered necessary for patient or EMS safety, refer to Restraint

Protocol. H. Check blood sugar ref. Hypoglycemia I. If altered mental status or unstable vital signs:

1. Ref. Oxygen. 2. Establish venous access. 3. Refer to Altered Mental Status Protocol.

5000 Adult Psychiatric / Behavioral Emergency

Index

111 January 2018

Mental Health Holds A. If a patient has an isolated mental health complaint (e.g. suicidality), and does not have a

medical complaint or need specific medical intervention, then that patient may be appropriately transported by law enforcement according to their protocols.

B. If a patient has a psychiatric complaint with associated illness or injury (e.g. overdose, altered mental status, chest pain, etc), then the patient should be transported by EMS

C. If a patient with a psychiatric complaint is clinically intoxicated or otherwise lacks decision making capacity for any other reason, no Mental Health Hold is needed and such a patient should be brought to an emergency department for evaluation and stabilization with implied consent.

D. If EMS is called to evaluate a patient with an isolated psychiatric complaint who is not clinically intoxicated, or otherwise lacking decision making capacity, and who refuses treatment or transport, and law enforcement are not willing to transport patient, then EMS should CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for medical consult with BASE PHYSICIAN.

E. If there is a reasonable concern for suicidal or homicidal ideation, or grave disability from

another mental health condition, then BASE PHYSICIAN may give a verbal order placing the patient on a Mental Health Hold and direct EMS personnel to transport the patient against his or her will in accordance with Colorado State statutes. The physician’s name, and time and date of the Mental Health Hold must be recorded on the PCR. Effort should be made to obtain consent for transport from the patient, and to preserve the patient’s dignity throughout the process.

F. A patient being transported on a Mental Health Hold may be transported to any appropriate receiving emergency department, as it may not be operationally feasible to transport exclusively to the Base Station hospital, although this is preferred if time and conditions allow.

G. It is expected that receiving facilities will receive such patients and perform an appropriate evaluation to determine if continuation of a Mental Health Hold is indicated at the time of their assessment.

H. Although there is always a risk of accusations of kidnapping or assault in such cases, such accusations are extremely rare, and the Aurora Fire Department EMS Medical Directors feel strongly that the risk of abandonment of a potentially suicidal or otherwise gravely impaired patient far outweigh any theoretical risk of allegations of kidnapping when actions are taken in the interest of patient safety.

Specific Precautions

A. Psychiatric patients often have an organic basis for mental disturbances. Be suspicious of hypoglycemia, hypoxia, head injury, intoxication, or toxic ingestion.

B. If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Try not to violate the patient's personal space.

C. If the situation appears threatening, consider a show of force involving police before attempting to restrain.

D. Beware of weapons. These patients can become very violent. E. An EMT or paramedic may initiate a Mental Health Hold only by direct verbal order from the

BASE PHYSICIAN (AIP, Children’s, TMCA, CMP, SaddleRock). F. Document name of BASE PHYSICIAN.

5000 Adult Psychiatric / Behavioral Emergency

Index

112 January 2018

Yes

Index

Treat reversible causes

Still significantly combative?

Patient is combative and a danger to self or others

Attempt to reasonably address patient concerns

Assemble personnel

Patient does not respond to verbal de-escalation techniques

ref. Restraint Protocol Obtain IV access as soon as may be

safely accomplished

Sedate

Consider cause of agitation

ref.Midazolam

Still significantly combative?

CONTACT BASE for re-sedation

After re-sedation and if still significantly combative CONTACT BASE for further consultation

Does patient have signs of the Excited Delirium Syndrome?

No

Excited Delirium Syndrome

These patients are truly out of control and have a life-threatening medical emergency

they will have some or all of the following sx:

Hyper-aggression Disorientation

Paranoia Hallucination

Tachycardia Hyperthermia

Increased strength

ref. midazolam

Reassess ABCs post sedation

High flow O2 & prepare to assist Ventilations

Start 2 large bore IVs as soon as may be safely accomplished

Administer 2 liters NS bolus

Start external cooling measures

Limb lead and SpO2, monitoring and transport.

5010 Adult Combative Patient

Monitor Patient Transport

Yes

Yes

Yes

No

No

113 January 2018

General Guideline:

Emphasis should be placed on scene safety, appropriate use of restraints and aggressive treatment of the patient’s agitation.

Restraints: Do not transport in hobble or prone position. Do not inhibit patient breathing / ventilations

5010 Adult Combative Patient

Index

114 January 2018

Purpose:

1. Guideline for transport of patients in handcuffs placed by law enforcement Guideline:

1. Handcuffs are only to be placed by law enforcement. EMS personnel are not permitted to use handcuffs.

2. Request that law enforcement remain with the patient in the ambulance, if possible. If not possible, request that police ride behind ambulance so as to be readily available to remove handcuffs if needed in an emergency situation to facilitate medical care of the patient.

3. EMS personnel are not responsible for the law enforcement hold on these patients. 4. Handcuffed patients will not be placed in the prone position. 5. Handcuffs may be used with spinal immobilization. Medical priorities should take priority in

the positioning of the handcuffs.

5020 Adult Transport of the Handcuffed Patient

Index

115 January 2018

Indications:

Patient with TASER probe(s) embedded in skin. Contraindications:

1. TASER probe embedded in the eye or genitals. In such cases, transport patient to an emergency department for removal.

Precautions:

The prehospital provider should consider the nature of the incident, potential mechanism(s) of injury, as well as patient complaints.

The prehospital provider is responsible for a reasonable assessment of the patient to determine if there is an injury/illness or reason for transport or treatment.

Use of the Taser device does not necessarily require the patient to be transported.

Use of the Taser device does not relieve the prehospital provider of the responsibility to assess and treat the patient in a manner consistent with the body of the Aurora Authorized version of the Denver Metropolitan Emergency Medical Directors protocol. TASER Barb Removal Technique:

1. Confirm the TASER has been shut off and the barb cartridge has been disconnected. 2. Using a pair of shears cut the TASER wires at the base of the probe. 3. Place one hand on the patient in area where the probe is embedded and stabilize the skin

surrounding the puncture site. Using the other hand (or use pliers/forceps) firmly grasp the probe.

4. In one uninterrupted motion, pull the probe out of the puncture site maintaining a 90° angle to the skin. Avoid twisting or bending the probe.

5. Repeat the process for any additional probes. 6. Once the probes are removed, inspect and assure they have been removed intact. In the

event the probe is not removed intact or there is suspicion of a retained probe, the patient must be transported to the emergency department for evaluation.

7. Cleanse the probe site and surrounding skin with alcohol swab and apply sterile dressing. (TASER barb removal demonstration) 8. Advise patient to watch for signs of infection including increased pain at the site, redness

swelling or fever. 9. Patients refusing transport must meet criteria for refusal in protocol. Often these patients

are in police custody, and the jail will require clearance by a physician prior to accepting the patient into the jail. Patient can be transported by police for physician medical clearance provided the patient meets the refusal protocol.

5030 Adult Tasered Patients

Index

116 January 2018

No

No

Yes

Transport to ED

No

Clinically Intoxicated Patient

Ataxia or

Slurred Speech or

Slow motor response

Clinical impression of provider that patient is clinically intoxicated means patient does not have decision making capacity. EMS Provider must make medical decisions for pt.

Yes

Acute illness or injury suspected based on appearance, MOI, etc. or signs/symptoms/history of acute illness or injury?

Can patient be released to responsible person in a safe environment?

Yes No

Document on PCR Base Contact not

required

Does patient meet criteria to directly to

detox facility? Ref. Alt Dispo Protocol

Yes

Transport to ED Transport to detox

Yes No

Incapacitated due to intoxication

Inability to stand from seated position and

walk independently or

unable to maintain airway

5040 Adult Drug / Alcohol Intoxication

Refer to appropriate section of protocol

Index

117 January 2018

Introduction:

When applying this protocol please remember: A. This protocol does not replace current protocols pertaining to Altered Mental Status,

Overdose and Poisonings, Trauma etc. which supersede any and all applications of the alcohol protocol.

B. A clear understanding that this protocol requires a thorough assessment of the situation to determine if there is any history, signs, or symptoms of an injury or illness.

C. There remains a very low threshold for checking a blood sugar level as hypoglycemia may mimic and/or co-exist with intoxication.

D. A clinically intoxicated person should never be left in an unsafe environment, and will not be left on scene in the absence of a responsible person who assures patient safety (e.g. law enforcement, family, friend) unless approved by BASE CONTACT (AIP, Children’s TMCA, CMP, SaddleRock) physician.

E. This protocol is intended to aid with the disposition of acutely intoxicated patients. The criteria set forth are not all-inclusive, and do not take the place of a thorough patient assessment or sound clinical judgment.

F. A thorough patient assessment is essential in every case as many medical and psychiatric conditions can mimic intoxication.

G. In general, if a patient lacks decision-making capacity for reasons of clinical intoxication with alcohol and there is reasonable concern about the possibility of an acute illness or injury, then the patient should be transported to an emergency department for evaluation, including against the patient’s will if necessary.

H. Clinical judgment about who does or does not have decision-making capacity may be difficult and consultation with On-line Medical Control is prudent if there is any question.

Special Notes:

A. Not every clinically intoxicated patient requires transport to an emergency department. Every effort should be made to determine the capacity of a patient to care for his or herself if transport is not immediately indicated.

B. Direct transportation to a detox facility is an option for these patients if the they meet the approved criteria and if the facility has capacity. Please refer to the applicable protocol.

Definitions:

Acute Illness or Injury

Abnormal vital signs Physical complaints that might indicate an underlying medical emergency, e.g.: chest pain Seizure or hypoglycemia Signs of trauma or history of acute trauma

5040 Adult Drugs / Alcohol Intoxication

Index

118 January 2018

6000 Pre-Eclampsia / Eclampsia

Routine medical assessment

IV

BGL

Patient Seizing?

NO

(Pre-Eclamptic) Yes

(Eclamptic)

Position of Comfort (if supine elevate right side)

ref. Resp Distress / ref. Resp Failure

ref. Midazolam Give immediately via most

readily available route

ref. Magnesium

Index

119 January 2018

Routine medical assessment

Imminent Delivery?

ref. Abnormal Delivery Ominous signs?

Transport Place mother supine and prepare delivery equipment

Have mother “pant” during each contraction and relax

between contractions.

As head emerges, check for cord around neck (If it can’t be slipped overhead, clamp

x2 and cut immediately)

If signs of obstruction present immediately suction mouth then nose.

Spontaneous respirations and HR >100 within 30

seconds?

Ref. Newborn Resuscitation

Dry newborn and keep at level of mother’s vagina until cord stops pulsating and is double clamped.

Double clamp cord 6” from newborn’s abdomen and cut between clamps with sterile scalpel.

Put newborn on mother’s abdomen and prevent heat

loss. Record APGAR at 1 and 5 minutes.

Transport

6010 Emergency Childbirth

NO Yes

NO

Yes

NO

Abnormally heavy bleeding?

ref. Postpartum Hemorrhage

Yes

NO

Index

120 January 2018

Overview:

1. EMS providers called to a possible prehospital childbirth should determine if there is enough time to transport expectant mother to hospital or if delivery is imminent

2. If imminent, stay on scene and immediately prepare to assist with the delivery

Specific Information Needed: Obstetrical history:

Number of pregnancies (gravida) Live births (PARA) Expected delivery date Length of previous labors Narcotic use in past 4 hours

Emergency Childbirth Procedure

1. If there is a prolapsed umbilical cord or apparent breech presentation, go to abnormal delivery protocol and initiate immediate transport

2. For otherwise uncomplicated delivery:

1. Position mother supine on flat surface, if possible

2. Do not attempt to impair or delay delivery

3. Support and control delivery of head as it emerges

4. Protect perineum with gentle hand pressure

5. Check for cord around neck, gently remove from around neck, if present

6. If signs of obstruction present, suction mouth, then nose of infant

7. If delivery not progressing, baby is “stuck”, see obstetrical complications protocol and begin immediate transport

8. As shoulders emerge, gently guide head and neck downward to deliver anterior shoulder. Support and gently lift head and neck to deliver posterior shoulder. Rest of infant should deliver with passive participation – get a firm hold on baby

9. Keep newborn at level of motherʼs vagina until cord stops pulsating and is double clamped

Critical Thinking:

1. Normal pregnancy is accompanied by higher heart rates and lower blood pressures 2. Shock will be manifested by signs of poor perfusion 3. Labor can take 8-12 hours, but as little as 5 minutes if high PARA 4. The higher the PARA, the shorter the labor is likely to be 5. High risk factors include: no prenatal care, drug use, teenage pregnancy, DM, htn, cardiac

disease, prior breech or C section, preeclampsia, twins 6. Note color of amniotic fluid for meconium staining

6010 Emergency Childbirth

Index

121 January 2018

6010 Emergency Childbirth

For All Patients with obstetrical complications

Do not delay: immediate rapid transport Give high-flow oxygen Start IV en route if time and conditions allow. Treat signs of shock w. IV fluid boluses per Medical Hypotension/Shock

Protocol Possible actions for specific complications

The actions listed may not be feasible in every case, nor may every obstetrical complication by anticipated or effectively managed in the field. These should be considered “best advice” for rare, difficult scenarios. In every case, initiate immediate transport to definite care at hospital

Postpartum Care Infant

Suction mouth and nose only if signs of obstruction by secretions Respirations should begin within 15 seconds after stimulating reflexes. If not,

begin artificial ventilations at 30-40 breaths/min If apneic, cyanotic or HR < 100, ref. Newborn resuscitation Dry baby and wrap in warm blanket After umbilical cord stops pulsating, double clamp 6” from infant abdominal wall

and cut between clamps with sterile scalpel. If no sterile cutting instrument available, lay infant on mother’s abdomen and do not cut clamped cord

Document 1 and 5 minute APGAR scores

Postpartum Care Mother

Placenta should deliver in 20-30 minutes. If delivered, collect in plastic bag and bring to hospital. Do not pull cord to facilitate placenta delivery and do not delay transport awaiting placenta delivery

If the perineum is torn and bleeding, apply direct pressure with sanitary pads Ref. Postpartum Hemorrhage Initiate transport once delivery of child is complete and mother can tolerate movement

Complications of Late Pregnancy 3rd Trimester Bleeding (6-8 months)

High flow O2 via NRB, IV access Suspect placental abruption or placenta previa Initiate rapid transport Position patient on left side Note type and amount of bleeding IV NS bolus for significant bleeding or shock

Pre Eclampsia/Eclampsia/Toxemia

High flow O2 via NRB, IV access SBP > 140, DBP > 90, peripheral edema, headache, seizure Transport position of comfort Ref. Eclampsia

Index

Index

122 January 2018

Routine medical assessment

Ominous signs?

Multiple Births

Quickly tie and cut 1st

cord.

With gloved hand, push presenting

part off of vaginal wall to

decompress cord.

Proceed with subsequent deliveries.

Transport

6020 Abnormal Delivery

Meconium Staining

Prolapsed Cord Breech (Buttocks)

Limb presentation

Suction prior to stimulation

and ventilation.

Cover exposed cord with moistened

towel.

Deliver baby to waist then

rotate to face-down position.

Do not pull on presenting

part.

Put mother in Trendelenburg in

knee-chest position

Create breathing

space around baby’s face with gloved

hand.

Cover exposed part

with moistened

towel.

Place mother left side down.

ref. Newborn Resus Algo

Shoulder Dystocia

Do not pull on baby’s head.

Support baby’s head Suction oral and nasal passages

Flex mother’s thighs upward, apply gentle open hand pressure above the pubic bone

Place mother with buttocks just off the end of bed.

Monitor Pts.

Index

123 January 2018

6030 Postpartum Hemorrhage

Check BP ref. Hypotension Protocol

IV NS (2 Lines if possible)

Use vigorous external uterine massage to promote uterine tone.

Transport

Routine medical assessment

ref. Resp Distress ref. Resp Failure as indicated

Index

124 January 2018

BSI Scene safety Consider mechanism Consider need for

additional resources

Ref. Oxygen ref. Resp Distress as indicated ref. Resp Failure as indicated ref. Spinal Stabilization as indicated

Control exsanguinating hemorrhage: Direct pressure ref. Hemostatic gauze if indicated ref. Tourniquet protocol if indicated Pelvic stabilization if indicated

Assess disability and limitation: Brief neuro assessment Ref. Extremity splinting if indicated

Transport to closest appropriate facility Large bore IV, 2nd if unstable Consider IV fluid bolus 20cc/kg if unstable

or suspected significant injuries. ref. Traumatic Shock Protocol

Monitor vital signs, ABCs, neuro status, GCS

General impression ABCs and LOC Rapid Trauma Assessment Ref. Adult Traumatic Pulseless

Arrest Prepare for immediate transport SAMPLE history

7000 Adult General Trauma Care

Index

125 January 2018

Sexual Assault Abuse / neglect

Confine history to pertinent medical needs

Respect patient’s emotional needs

Protect evidence: No washing or

changing clothes

Transport

Observe pt’s behavior around caregivers

Watch out for:

Injury inconsistent with stated mechanism

Delayed treatment

Spreading blame

Conflicting stories

Prior/ healing injuries Don’t judge, accuse or confront victim

Transport patient if suspected abuse or neglect, no matter how minor the injury may

appear.

ref. General Trauma Care

7005 Adult Special Trauma Scenarios

Index

Notify Aurora Police Department of all suspected

abuse / assault

Request APD officer to respond to receiving facility if not on scene

prior to patient transport.

Don’t judge, accuse or confront victim or

suspected assailant

126 January 2018

Avoid supine position: o Place in left lateral recumbent

position if possible o If immobilized tilt backboard 15 to

30 degrees to the left side

ref. General Trauma Care Protocol

Pregnant Trauma

(EGA > 20 weeks)

Interpret VS with caution. Pregnant patient has:

Increased heart rate

Decreased blood pressure

Increased blood volume

Pregnant Trauma

(EGA < 20 weeks)

Priority is mother.

Assure hospital is aware of pregnancy and EGA

Patients with any thoracic, abdominal,

or pelvic complaint or injury may require prolonged fetal monitoring in hospital,

even if asymptomatic at time of evaluation, and even for seemingly

minor mechanism. Encourage transport of all patients.

Priority is mother.

Patients with any thoracic, abdominal, pelvic injury or complaint who are refusing transport require base contact for AMA refusal.

7010 Adult Trauma in Pregnancy

Index

127 January 2018

Estimated Gestational Age (EGA)

If EGA > 20 weeks, consider two patients: mother and fetus. Estimation of gestational age may be made based on fundal height by palpating for top of

uterus:

If uterus is at umbilicus then EGA > 20 weeks

Estimation by Last Menstrual Period: Due Date = LMP + 9 months + 7 days

EGA = due date – current date

7010 Adult Trauma in Pregnancy

Index

128 January 2018

No

Monitor cardiac rhythm

Index

1Load and go is always a reasonable approach to penetrating trauma arrest.

7015 Adult Traumatic Pulseless Arrest

Immediate transport to closest appropriate trauma center Control life threatening external bleeding Ref. Adult General Trauma Care Begin continuous compressions – change compressors q 2

min 1 breath every 6 seconds

o OPA/NPA/Capnography/BVM

Asystole? *

CONTACT BASE for consideration of Field

Pronouncement

CPR until cardiac monitor applied

Ref. bilateral needle thoracostomy on all traumatic arrests with trauma to trunk

Traumatic pulseless arrest is a unique situation.

Do not apply “combo pads” Do not defibrillate

Do not administer ACLS medications Do not treat as medical arrest

Place pt on Cardiac Monitor1

Yes

Cardiac arrest from the following causes should approached as a medical cardiac arrest:

Overdose Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage

Ref. Adult Respiratory Failure/Arrest

Transport to closest Trauma Center

IV. ref. IO access with NS bolus enroute

* Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. Include the AFR incident number on the strip.

129 January 2018

ref. General Trauma Care Pelvic sheet if indicated Control external hemorrhage Ref. Tourniquet, Hemostatic Gauze

ref.O2

Large bore IV

2nd IV preferred

SBP < 90 and/or definite signs of shock?

Evaluate breath sounds, respiratory effort, and

consider tension pneumothorax

x

ref. needle thoracostomy if arrest or impending

arrest

Treat en route

Keep patient warm

Ref. Intraosseous Access

Monitor:

ABCs, VS, mental status

Rapid transport to appropriate trauma center

Repeat 20 cc/kg bolus as needed

IV NS bolus 20 cc/kg

Reassess

Trauma w. suspected serious injury and/or

signs of shock

7020 Adult Traumatic Shock

Index

Yes

No

Monitor cardiac rhythm

130 January 2018

Prehospital End-Points of Fluid Resuscitation: Over aggressive resuscitation with IV fluid before hemorrhage is controlled may worsen bleeding, hypothermia and coagulopathy. Do not withhold IV fluids in a critically injured patient, but give judiciously with goal to improve signs of perfusion and mental status rather than to achieve a “normal” blood pressure.

Shock is defined as impaired tissue perfusion and may be manifested by any of the following:

Altered mental status Tachycardia Poor skin perfusion Low blood pressure Traditional signs of shock may be absent early in the process, therefore, maintain a high index of suspicion and be vigilant for subtle signs of poor perfusion

7020 Adult Traumatic Shock

Index

131 January 2018

ref. General Trauma Care

Uncontrolled Bleeding

Control with direct pressure to bleeding area or vessel

Bleeding Controlled

If bleeding not controlled with direct pressure, ref. Tourniquet

Large bore IV

If hypotensive, ref. Traumatic Shock

Document neurovascular exam

Amputated part:

Wrap in moist, sterile dressing

Place in sealed plastic bag

Place bag in ice water

Do not freeze part

Stump:

Cover with moist sterile dressing covered by dry dressing

ref. fentanyl

Cover with moist sterile dressing

Splint near-amputated part in anatomic position

Monitor and transport to appropriate Trauma Center

Treat other injuries per protocol

Complete Amputation Partial/Near-Amputation

7025 Adult Amputations

Index

132 January 2018

Specific Information Needed

A. Mechanism of injury: direction of forces, if known B. Areas of pain, swelling or limited movement C. Treatment prior to arrival: realignment of open or closed fracture, or dislocations,

movement of patient D. Past medical history: medications, medical illnesses

Specific Objective Findings

A. Vital signs B. Observe: localized swelling, discoloration, angulation, lacerations, exposed bone fragments,

loss of function, guarding C. Palpate: tenderness, crepitation, instability, quality of distal pulses, sensation D. Note estimated blood loss at scene.

Treatment

A. Treat airway, breathing, and circulation as first priorities. B. Immobilize cervical spine when appropriate. C. Examine for additional injuries to head, face, chest, and abdomen; treat those problems with

higher priority first. D. If patient unstable, transport rapidly, treating life threatening problems en route. Splint

patient to minimize fracture movement by securing to long board. E. If patient stable, or isolated extremity injury exists:

1. Check and record distal pulses and sensation prior to immobilization of injured extremity.

2. Apply sterile dressing to open fractures. Note carefully wounds that appear to communicate with bone.

3. Splint areas of tenderness or deformity: apply gentle traction throughout treatment and try to immobilize the joint above and below the injury in the splint.

4. Realign angulated fractures by applying gentle axial traction if necessary to restore circulation distally or to immobilize adequately, i.e., realign femur fracture.

5. Check and record distal pulses and sensation after reduction and splinting. 6. Elevate simple extremity injuries. Apply ice pack if time and extent of injuries allow. 7. Monitor circulation (pulse and skin temperature), sensation, and motor function distal

to site of injury during transport. 8. Establish venous access. 9. ref. Fentanyl

Special precautions

A. Patients with multiple injuries have a limited capacity to recognize areas which have been injured. A patient with a femur fracture may be unable to recognize that he has other areas of pain. Be particularly aware of missing injuries proximal to the obvious ones (e.g., a hip dislocation with a femur fracture, or a humerus fracture with a forearm fracture).

B. Do not use ice or cold packs directly on skin or under air splints. Pad with towels or leave cooling for hospital setting.

C. Injuries around joints may become more painful and circulation may be lost with attempted realignment. If this occurs, stabilize the limb in the position of most comfort with the best distal circulation.

7026 Adult Extremity Injuries

Index

133 January 2018

7029 Head Trauma

ref. General Trauma Care

Yes No

Index

ref. Oxygen ref. Spinal Stabilization as indicated ref. Seizure as indicated ref. Combative patient as indicated

Ref. Adult Respiratory Failure / Arrest Requiring Assisted Ventilations as indicated

Systolic BP < 90 and/or definite signs of shock?

Ref. Adult Traumatic Shock Rapid Trauma Assessment

Treat other injuries per protocol

Watch for status changes

Cushing’s Triad is a sign of increased intracranial pressure and consists of:

Hypertension (often with a widening pulse pressure)

Bradycardia

Irregular respirations

Transport to appropriate Trauma Center

Continue to monitor for developing hypoxemia and shock

GCS < 8?

Head of bed should be elevated 300 unless BP < 90

Yes

No

Monitor cardiac rhythm

IV Access

134 January 2018

Yes

No

Yes

Spinal Immobilization not routinely indicated for penetrating neck injury Penetrating injury is very rarely associated with unstable spinal column *Suspect laryngeal trauma with:

Laryngeal tenderness, swelling, bruising

Voice changes

Respiratory distress

Stridor

7030 Adult Face and Neck Trauma

Index

ref. General Trauma Care

Clear airway

Rapid trauma assessment

ref. Spinal immobilization

ref. Resp Distress as indicated

ref. Resp Failure as indicated

Laryngeal trauma* Transport

Severe airway Bleeding?

No

Complete neuro exam

Asses for subcutaneous air

Cover/protect eyes as indicated

Do not try to block drainage from ears, nose

Save avulsed teeth in saline-soaked gauze, do not scrub clean

Transport ASAP to closest appropriate facility

IV access en route

Treat other injuries per protocol

Suction airway as needed

Direct pressure if appropriate

Monitor ABCs, VS, mental status, SpO2

ref. Fentanyl

135 January 2018

Full spinal immobilization if suspected spine injury

Document neuro assessments before and after immobilization

Complete patient assessment

Treat other injuries per protocol

Monitor for status changes

Large bore IV and consider 2nd line

Rapid transport to appropriate Trauma Center

ref. General Trauma Care

If BP < 90 and/or signs of shock, resuscitate ref. Traumatic Shock

Monitor ABCs, VS, mental status, SpO2.

ref. Fentanyl

7035 Adult Spinal Trauma

Index

136 January 2018

7036 Spinal Injury With Protective Athletic Equipment In Place

Suspected Spinal Injury

Are helmet and pads in place?

Are helmet and pads properly fitted and snug?

Do helmet and pads allow for neutral alignment of

spine?

Is facemask removable in timely manner?

Is airway accessible with helmet in place?

Immobilize/Transport with helmet and pads in

place

Standard immobilization techniques

Remove helmet and pads prior to transport

Index

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

137 January 2018

Special Precautions:

Do not remove helmet or shoulder pads prior to EMS transport unless they are interfering with the anagement of acute life threatening injuries.

The helmet and pads should be considered one unit. Therefor, if one is removed then the other should be removed as well so as to assure neutral spine alignment.

All athletic equipment is not the same. Athletic Trainers on scene should be familiar with equipment in use and be able to remove facemask prior to, or immediately upon, EMS arrival.

Index

138 January 2018

7040 Adult Selective Spinal Stabilization

Mechanism of injury with potential need for spinal stabilization

No Yes

Yes

Yes

No

No

Spinal stabilization is only indicated in penetrating trauma when there is obvious motor or sensory deficit on exam.

Stabilize and secure unconscious blunt trauma patients

Elderly patients are more susceptible to spinal injury

Do not remove previously placed stabilization device(s).

Does the pt have /complain of any of the following? Clinical intoxication with ETOH or drugs Altered mentation Barrier to evaluate for spinal injury (e.g. language or development barrier) Distracting injury Midline C/T/L spine tenderness on palpation Subjective: (numbness, tingling, or weakness) Objective: (motor or sensory deficit)

Place appropriately sized c-collar or utilize improvised c-spine techniques if the rigid c-collar

cannot be effectively utilized.

*

If NONE of above, spinal stabilization not indicated.

Obvious motor or sensory deficit on exam consisting of:

Lack of Equal Bilateral grip, push/pull and/or

Lack of Light touch sensation to extremity(s)

Is pt able to cooperate and lay still?

Stabilize and secure torso/head utilizing scoop or backboard. Transport to closest Level I or Level II Trauma Center

Manual in line stabilization may be released. Scoop/backboard NOT indicated.

If the patient is capable, self-extrication is preferred.

Place patient in position of comfort on gurney.

Stabilize and secure torso/head utilizing scoop or backboard.

Establish manual in-line cervical stabilization

Index

139 January 2018

ref. General Trauma Care Rapid transport to Trauma Center

Penetrating trauma?

SBP < 90 and/or shock?

Occlusive dressings for sucking wounds

Rapid transport & stabilize in route

Large bore IV and consider 2nd line

Yes

No

No

Yes

Flail Chest?

Are you able to oxygenate and ventilate effectively?

No Airway management and

assisted ventilations as indicated

Yes

Splint with bulky dressing

ref. Resp Distress as indicated ref. Resp Failure as indicated

No

Yes

ref. needle thoracostomy

ref. traumatic shock enroute

Assess for need for assisted ventilations

ref. Fentanyl

Monitor ABCs, VS, mental status, SpO2.

7045 Adult Chest Trauma

Index

No

140 January 2018

Tension pneumothorax should be suspected with presence of the following:

Unilateral absent breath sounds AND: JVD, hypotension, difficult/unable to ventilate

Needle decompression is NEVER indicated for simple pneumothorax End points of fluid resuscitation should be improved mental status and pulses, not necessarily a normal blood pressure. This is especially true for penetrating chest trauma.

7045 Adult Chest Trauma

Index

141 January 2018

IV access

Consider 2nd line if MOI significant

Penetrating trauma?

SBP < 90 and/or shock?

Cover wounds, viscera with saline moistened gauze dressing

Do not attempt to repack exposed viscera

ref. Traumatic Shock

Yes

No

No

Yes

Monitor ABCs, VS, mental status, SpO2.

ref. Fentanyl

ref. General Trauma Care Transport to closest appropriate Trauma Center

7050 Adult Abdominal Trauma

Index

142 January 2018

Documentation MOI Time of injury Initial GCS

Penetrating trauma Weapon/projectile/trajectory

Blunt vehicular trauma Condition of vehicle Speed Ejection Airbag deployment Restraints, helmets

End points of fluid resuscitation should be improved mental status and pulses, not necessarily a normal blood pressure. This is especially true for abdominal trauma.

7050 Adult Abdominal Trauma

Index

143 January 2018

Stop burning process:

Remove clothes if not adhered to patient’s skin

Flood with water only if flames/smoldering present

Respiratory Distress?

Critical Burn?*

O2 NRB 15 lpm

ref. Resp Distress as indicated

ref. Resp Failure as indicated

Evaluate degree and body surface area involved

If hypotensive ref. Shock

IV NS TKO

Remove rings, jewelry, constricting items

Dress burns with dry sterile dressings

Do not apply Vaseline gauze, ointments, or oils to the burn

Treat other injuries per protocol

Cover patient to keep warm

Yes

Yes

No

No

Ref. Fentanyl

Monitor ABCs, VS, mental status, SpO2

ref. General Trauma Care

Transport to Trauma Center

7055 Adult Burns

Index

Start 2 large-bore IVs

Fluids per ABA recommendations below** *Critical Burn:

2º > 30% BSA 3º > 10% BSA Respiratory injury, facial burn Associated injuries, electrical or deep chemical

burns, underling PMH (cardiac, DM), age > 50

**ABA Recommendations for Prehospital Fluid Therapy 14 and older 500 mL/hr NS or LR 5 – 13 years 250 mL/hr NS or LR Age < 5 125 mL/hr NS or LR If no clinical signs of hypovolemia or shock, large volume of fluid not needed. Typical IVF bolus will be 250 mL for patients 14 and older.

144 January 2018

7055 Adult Burns

Types of Burns:

Thermal: remove from environment, put out fire Chemical: brush off or dilute chemical. Consider HAZMAT Electrical: make sure victim is de-energized and suspect

internal injuries Consider CO if enclosed space Consider CN if plastics, shock, pulseless arrest

*Critical Burn:

2º > 30% BSA 3º > 10% BSA Respiratory injury, facial burn Associated injuries, electrical or deep chemical burns,

underling PMH (cardiac, DM), age < 10 or > 50 yrs

Document:

Type and degree of burn(s) % BSA Respiratory status Singed nares, soot in mouth SpO2 PMH Confined space

Designated Regional Burn Centers Consider direct transport of isolated burns if time and

conditions allow

Age ≤ 14 Children’s Hospital Colorado Age ≥ 15 University of Colorado Hospital Any age for Swedish Medical Center

Index

145 January 2018

General Guideline:

A. Pediatric patients, defined as age < 12 years for the purpose of these protocols, have unique anatomy, physiology, and developmental needs that affect prehospital care. Because children make up a small percentage of total calls and few pediatric calls are critically ill or injured, it is important to stay attuned to these differences to provide good care. Therefore, CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) early for guidance when treating pediatric patients with significant complaints, including abnormalities of vital signs. Pediatric emergencies are usually not preceded by chronic disease. If recognition of compromise occurs early, and intervention is swift and effective, the child will often be restored to full health.

Specific Considerations:

A. The following should be kept in mind during the care of children in the prehospital setting:

1. Airways are smaller, softer, and easier to obstruct or collapse. 2. Respiratory reserves are small. A minor insult like improper position, vomiting,

or airway narrowing can result in major deficits in ventilation and oxygenation. 3. Circulatory reserves are also small. The loss of as little as one unit of blood can

produce severe shock in an infant. Conversely, it is difficult to fluid overload most children. You can be confident that a good hands-on circulation assessment will determine fluid needs accurately.

4. Assessment of the pediatric patient can be done using your knowledge of the anatomy and physiology specific to infants and children.

5. Listen to the parents' assessment of the patient's problem. They often can detect small changes in their child's condition. This is particularly true if the patient has chronic disease.

6. The proper equipment is very important when dealing with the pediatric patient. A complete selection of pediatric airway management equipment, IV catheters, cervical collars, and drugs has been mandated by the state. This equipment should be stored separately to minimize confusion.

001p General Guidelines for Pediatric Patients

Index

146 January 2018

Ref. Pediatric Field Guide and

Refer to appropriate protocol

002p Pediatric Assessment

Airway / Appearance

Abnormal Abnormal or absent cry

or speech Decreased response to

parents or environmental stimuli

Floppy or rigid muscle tone or not moving

Normal Normal cry or speech Responds to parents or to

environmental stimuli Good muscle tone Moves extremities well

Work of Breathing

Abnormal Increased: nasal flaring retractions abdominal muscle use

OR Decreased/absent respiratory

effort noisy breathing

Normal Breathing appears regular without

excessive respiratory muscle effort

Audible respiratory sounds

Normal RR by age

o neonates > 40

o infants > 20

o children > 12

Circulation / Color

Abnormal Cyanosis mottling paleness/pallor obvious, significant

bleeding Unexplained tachycardia

Normal Color appears normal for racial

group of child. No significant bleeding

Index

147 January 2018

003p Pediatric Shock

Ref. Oxygen Ref. Pediatric Field Guide

Compensated Normal Mental Status Tachycardia1

Normotensive2

Delayed Peripheral Cap. Refill

Decompensated Altered Mental Status Hypotensive2

Weak Femoral or Brachial Pulses

Obtain IV access If unable to start IV after 2

attempts, Contact Base for ref. IO

(refer to Pediatric Field Guide)

Pull/Push 20ml/kg NS bolus Use a 60cc syringe and 3-way

Begin transport Reassess

Repeat 20ml/kg boluses up to 60ml/kg total until goal met of:

Threshold heart rate for age Normal Systolic Blood Pressure for age and Capillary refill < 2 seconds

2 Hypotension for age: <1 mo <60mmHg 1mo-1y <70mmHg 1y-10y <70+ (2 x age in years) >10y <90mmHg

1 Tachycardia for age: <1 y >160bpm 1y-2y >150bpm 2y-5y >140bpm 5y-12y >120bpm >12y >100bpm

Normal RR by age:

neonates / infants = 40-60 per min children > 12 = < 20 breaths per minute

Index

If patient is at risk for adrenal insufficiency, ref. Adrenal Insufficiency

Ref. IO

REFERENCE PEDIATRIC FIELD GUIDE FOR NORMAL VALUES

<40kg or

shorter than broselow?

Yes No

20ml/kg NS bolus Begin transport Reassess Ref. Shock

148 January 2018

Specific Information Needed

A. History: onset and progression of symptoms, frequency of vomiting and diarrhea, urine output, oral intake, recent trauma, possible drug ingestion

B. Past medical history

Document Specific Physical Findings

A. General appearance: LOC, muscle tone, color B. ABCs and vital signs C. Skin: warmth of distal extremities, color, skin turgor, blood pressure, pulses D. Mucous membranes: wetness of mouth, presence of tears E. Musculoskeletal: evaluate for trauma F. The signs of dehydration are:

1. EARLY - tachycardia and tachypnea for age, decreased LOC, cool skin, mucous membranes dry, sunken eyes and fontanelle;

2. LATE - loss of skin turgor, diminished pulses, hypotension, and shock

Treatment

A. Use appropriate airway adjuncts as indicated. B. Ref. Oxygen C. Breathing: ventilation as indicated D. Circulation:

1. Obtain pulse rate and blood pressure 2. Establish peripheral venous access or IO if necessary. 3. Administer fluid bolus as a push/pull with a 60cc syringe and 3-way stop-cock. 4. Do not delay transport for IV attempts. 5. The patient with simple dehydration is not a candidate for intraosseous infusion,

CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) for approval of IO if shock is present.

Specific Precautions

A. Assessment of dehydration is primarily by physical exam. Vital signs may be abnormal, but they are nonspecific.

B. Determination of tachycardia or hypotension is based on age. C. Monitor carefully for signs of decreased tissue perfusion (shock). Early shock is present if

there are poor pulses, muscle tone and color, or decreased mental status. Decompensated shock is present if systolic BP is < normal for age

Adrenal Insufficiency A. Patients at risk for adrenal insufficiency include:

1. Chronic steroid use 2. Addison’s disease 3. Congenital adrenal hyperplasia 4. Other patients identified as such by family, medical record, or physician note

003p Pediatric Shock

Index

149 January 2018

General Principles: For the purpose of the protocols, pediatric patients are defined as <12 years of age. The unique anatomy, physiology and developmental needs of children in this age range affect prehospital care. Several specific differences include:

A. Airways are smaller, softer and easier to obstruct or collapse. Actions such as neck hyperflexion, hyperextension, or cricoid pressure may create an upper airway obstruction in a child

B. Respiratory reserves are small, resulting in the possibility of rapid desaturation in the setting of increased demand. One of the earliest signs of physiologic stress in a child may be an unexplained increase in respiratory rate

C. Infants and young children utilize their abdominal musculature to assist with respirations. Tight, abdominally-placed straps used to secure children to spine boards may result in onset of or worsening respiratory distress

D. Circulatory reserves are small. The loss of as little as one unit of blood can produce severe shock in an infant. Conversely, it is difficult to fluid overload most children

E. Fluid boluses of 20 ml/kg is the initial fluid resuscitation amount and is considered safe. This amount does not cause fluid overload concerns.

F. Pediatric medication dosing and equipment size recommendations vary by length and/or weight. As such, an assessment tool such as a length-based tape should be utilized on every pediatric patient to guide medication dosing and equipment size

G. The developmental stage of a child impacts their ability to cooperate and their fear of strangers. The perception and memory of pain is escalated by anxiety. Discuss or forewarn of what will be done with any child over 2 years of age. Infants, especially those under 6 months of age, tolerate painful procedures better if allowed to suck on a pacifier (especially if dipped in D25W) during the procedure. Utilize the parent or familiar guardian whenever possible to distract/comfort (tell a story, sing a song, etc) for all pediatric patients during painful procedures.

H. Vital signs on every pediatric patient should include a blood pressure. At least one attempt should be made to obtain a blood pressure on all pediatric patients.

004p General Guidelines: Transportation of the Pediatric Patient

Index

150 January 2018

Specific Considerations: A. Transportation safety Children represent a unique challenge for safe transportation in emergency vehicles. The National Highway Traffic Safety Administration has established guidelines to ensure the safe restraint and positioning of children in emergency vehicles. Children should never be transported unrestrained or held in an adult’s arms. Transportation of children on the side bench seat in the rear compartment is also not recommended. The published goals are to prevent forward motion/ejection of the child, secure the torso, and protect the head, neck and spine in each of the following scenarios:

1. For a child who is uninjured/not ill, but requires transport to a facility If transport in a vehicle other than a ground ambulance is not possible, transport in a size-appropriate child restraint system in the front passenger seat (with air bags off) or rear-facing EMS provider’s seat in the ground ambulance

2. For a child who is injured/ill and whose condition does not require continuous monitoring or interventions: Transport child in a size-appropriate child restraint system secured appropriately on a cot (rear-facing) or in an integrated seat in the EMS provider’s seat. Do not use a rear-facing child restraint system in a rear-facing EMS provider’s seat. If no child restraint system is available, secure the child on the cot using three horizontal restraints across the child’s chest, waist and knees and one vertical restraint across each of the child’s shoulders.

3. For a child whose condition requires continuous or intensive monitoring or interventions: Transport child in a size-appropriate child restraint secured appropriately on a cot. If no child restraint system is available, secure the child on the cot using three horizontal restraints across the child’s chest, waist and knees and one vertical restraint across each of the child’s shoulders.

4. For a child whose condition requires spinal immobilization or lying flat Secure the child to a size-appropriate spineboard and secure the spineboard to the cot, head first, with a tether at the foot to prevent forward movement. Use three horizontal restraints across the chest, waist (not abdomen), and knees, and a vertical restraint across each shoulder. We do not recommend utilizing the child restraint system if spinal immobilization is required, as upright positioning places additional axial load on the patient’s neck and emergent airway intervention is not possible.

5. For a child requiring transport as part of a multiple patient transport (newborn with mother, multiple children, etc) If possible, transport each as a single patient. When available resources prevent single patient transportation, transport patients using safe, designated space available exercising extreme caution and driving at reduced speeds. For mother and newborn, the newborn should be transported in a rear-facing EMS provider seat using a convertible or integrated child restraint system. Do not use a rear-facing child restraint system in a rear-facing EMS provider’s seat.

004p General Guidelines: Transportation of the Pediatric Patient cont.

Index

151 January 2018

B. Transportation of the child with special health care needs

1. Treat the child, not the equipment. Starting with the ABCs still applies to medically complicated or medical technology-dependent children.

2. The parent/guardian of a special needs child is the expert on that child and knows the details of that illness, typical responses, and baseline interactions better than anyone. Utilize and trust his/her knowledge and concerns. This may include vital signs, medication responses, or physical positioning (ie of contracted limbs) that may not be typical.

3. Medically complicated children are often given healthcare notes describing their unique medical history and emergency healthcare needs. Ask the parent/guardian for an emergency information sheet or emergency healthcare form

4. Ask the parent/guardian for the “go bag” for medical technology-dependent children. This will contain the child’s spare equipment and supplies that may be needed on scene, during transport or in the hospital

5. Transport the child to their medical “home” hospital whenever possible

Index

004p General Guidelines: Transportation of the Pediatric Patient cont.

152 January 2018

IV access and IV fluid bolus if signs of ref. hypoperfusion/shock based on age

Index

100p Pediatric Epistaxis Management

Active Nosebleed

ABCs

Tilt Head Forward Have pt blow nose to expel clots

Spray both nares with ref. phenylephrine

Compress nostrils with clamp or fingers, pinching over fleshy part of nose, not bony nasal bridge for 10 minutes. Transport in position of comfort, usually sitting upright

153 January 2018

No

Yes

Ref i-gel O2

Place i-gel ONLY if unable to adequately ventilate with BVM and oral airway*

105p Pediatric Respiratory Failure / Arrest Requiring Assisted Ventilations

In general the primary goals of airway management are adequate oxygenation and ventilation, and these should be achieved in the least invasive manner possible

Begin BVM ventilations with OPA and capnography – use two rescuers

If no indication for spinal immobilization, place towel roll under shoulders for pts <8 y.o. to optimize airway positioning

BVM rate: o Neonates 30 - 40/min, o Infants 20-30/min o Children 12-20/min

Able to adequately oxygenate and ventilate with BVM?*

Signs of adequate oxygenation / ventilation? Examples include:

Good CO2 Waveform Compliance with BVM Chest rise and fall Bilateral breath sounds Positive response to therapy

Complete assessment Transport

Reposition airway Ensure adequate mask seal

Reassess airway adjunct (OPA/NPA/Mask size)

No

Yes

Possible FBAO?

Yes Ref FBAO

Index

Signs of adequate oxygenation / ventilation? Examples include:

Good CO2 Waveform Compliance with BVM Chest rise and fall Bilateral breath sounds Positive response to therapy

Yes

No

No

* Ref i-gel O2 in all cases of cardiac arrest.

Ref. Pediatric Field Guide

154 January 2018

110p Pediatric Obstructed Airway: Conscious Patient

Does patient show signs of choking?

Attempt to determine cause of obstruction

Assess severity of obstruction

Severe or Complete Obstruction

(mute, silent cough, severe stridor) Mild or Partial Obstruction

(patient can speak / cry)

Do not interfere with a spontaneously breathing or coughing patient

Position of comfort

Give high flow oxygen

Suction if needed

Is obstruction cleared?

Supportive care and rapid transport

If patient deteriorating or develops worsening distress proceed as for

complete obstruction

Transport POC

O2 via NRB 15 Lpm

Monitor ABCs, SpO2, vital signs

Suction PRN and be prepared for vomiting, which commonly occurs after obstruction relieved

Yes

No

CHILD (> 1yr)

Abdominal thrusts until object expelled.

INFANT (< 1 yr)

5 Back slaps, 5 Chest thrusts until object is expelled.

Index

Is obstruction cleared?

Ref. Pediatric Obstructed Airway: Unconscious

Yes

No

155 January 2018

111p Pediatric Obstructed Airway: Unconscious Patient

Ability to ventilate?

Open airway with head tilt-chin lift

If no indication for spinal immobilization, place towel roll under shoulders for pts < 8 y.o. to optimize airway positioning

Open airway with jaw thrust if craniofacial trauma present / suspected

Ventilate pt with BVM / capnography using two person technique.

Ability to ventilate?

Perform laryngoscopy

Use McGill forceps to remove object if possible Ref. Pediatric Resp. Failure / Arrest

Requiring Assisted Ventilation

If cause of airway obstruction is readily apparent, attempt removal

Ref. Pediatric Resp. Failure / Arrest Requiring Assisted Ventilation

Open pt mouth and remove obstruction if seen.

Open airway and ventilate pt with BVM / capnography using two person technique.

Ability to ventilate?

Perform direct visualization with laryngoscope

Ability to ventilate?

Ref. Pediatric Resp. Failure / Arrest Requiring Assisted Ventilation

Yes

Yes

No

No Yes

No

Foreign body seen below vocal cords

Foreign body seen above vocal cords

Foreign body not seen

Use appropriate ETT to push FB into right mainstem bronchus

Pull back ETT to normal depth and attempt ventilation w/ BVM

If unable to ventilate through ETT, withdraw ETT and reattempt to ventilate using BLS techniques

Use McGill forceps to remove foreign body

Reattempt to ventilate using BLS techniques

Remove laryngoscope and reattempt to ventilate using BLS

techniques.

Transport

Base Contact for consult

Ref. Pediatric Resp. Failure / Arrest Requiring Assisted Ventilation

No

Yes

30 Chest compressions

Index

156 January 2018

Transport • Provide supportive care • Maximize oxygenation and ventilation • CONTACT BASE if needed for consult

115p Pediatric Respiratory Distress

Are ventilations adequate for age?

For all patients: While assessing ABCs: ref.O2,

monitor vital signs, cardiac rhythm, and SpO2

Patent Airway?

Is anaphylaxis likely?

Is asthma likely?

Ref. Pediatric Respiratory Failure/Arrest

Ref. Pediatric Obstructed Airway

ref. Pediatric Allergy/Anaphylaxis

ref. Pediatric Asthma

YES

YES

YES

NO

NO

NO

YES

Is Croup likely?

ref. Pediatric Bronchiolitis

Index

YES

NO

NO

Is Bronchiolitis likely?

ref. Pediatric Croup

NO

YES

157 January 2018

General Assessment: Attempt to determine cause of respiratory distress based on clinical scenario, age, past history and exam Assess Airway, Breathing, perfusion and mental status in all patients

Airway Assessment If obstructed, see Obstructed Airway Protocol Observe for stridor, hoarseness, drooling Consider foreign body if sudden onset stridor in young child Early suctioning of secretions may dramatically improve respiratory distress in bronchiolitis

Breathing Assessment Note rate and effort (“work of breathing”) Listen for upper airway abnormal sounds which may mimic wheezing: stridor, hoarseness, barky cough (suggests

croup) Note grunting, nasal flaring, head bobbing, chest wall movement, retractions, accessory muscle use Auscultate breath sounds for wheezing, crackles, decreased air movement (suggests bronchospasm)

115p Pediatric Respiratory Distress

Index

158 January 2018

Ref. Pediatric Assessment

Respiratory Distress Protocol and prepare for transport

Moderate Attack Marked increase in respiratory rate, wheezes easily heard and accessory muscle breathing.

Severe Attack Grossly abnormal respiratory rate, loud wheezes, or so tight no wheezes are heard, anxiety, gray or ashen skin color, diaphoresis

Mild Attack Slight increase in respiratory rate, mild wheezes, good skin color.

ref. Epinephrine IM

120p Pediatric Asthma

Adequate response to treatment?

Monitor response to treatment

Continue cardiac monitoring and SPO2

en route Be prepared to assist

ventilations as needed

Transport

No

Yes

Concern for impending respiratory failure? Worsening mental status Pt becoming tired (accessory muscle usage

decreases) Ref. Pediatric Respiratory Failure/Arrest Start IV / ref. IO

Contact Base

ref. Methylprednisone IV

ref. Magnesium IV

ref. Albuterol + ref. Ipratropium

Adequate response to treatment?

Index

Adequate response to treatment?

Adequate response to treatment?

No

Monitor response to treatment

Continue cardiac monitoring and SPO2 en route

Be prepared to assist ventilations as needed

Transport

No

Yes

Yes

Yes

ref. Epinephrine IM ref. Albuterol + ref. Ipratropium

159 January 2018

125p Pediatric Croup

Ref. Pediatric Assessment

Respiratory Distress Protocol and prepare for transport

Severe Symptoms?

SpO2 < 90% despite O2

Stridor at rest

Severe retractions

Cyanosis

Altered LOC

Mushroom tip Nasal suctioning if indicated

Give nebulized racemic epinephrine

Inadequate response to treatment? CONTACT BASE for consult

Transport in position of comfort appropriately secured

ref.O2

Yes

No Monitor SPO2 en route Be prepared to assist ventilations as needed

Transport

Croup Age 6 months to 5 years w. stridor, barky cough, URI sx. Sx often rapid, nocturnal onset Consider pulmonary and non-pulmonary causes of respiratory distress in all cases: Common: croup, bronchiolitis, asthma. Less common: foreign body aspiration, allergic reaction, pneumonia. Rare: epiglottitis, bacterial tracheitis. Also: Congenital heart disease (CHF), sepsis, other metabolic acidosis (e.g.: DKA, inborn error of metabolism)

Index

160 January 2018

125p Pediatric Bronchiolitis

Ref. Pediatric Assessment

Respiratory Distress Protocol and prepare for transport

Severe Symptoms?

SpO2 < 90% despite O2

Severe retractions

Cyanosis

Altered LOC

Mushroom tip Nasal suctioning if indicated

Inadequate response to treatment? CONTACT BASE for consult

Transport in position of comfort appropriately secured

ref.O2

Monitor SPO2 en route Be prepared to assist ventilations as needed

Transport

Bronchiolitis Age < 2 yrs w. cough, fever, resp. distress, copious secretions, November-April Consider pulmonary and non-pulmonary causes of respiratory distress in all cases: Common: croup, bronchiolitis, asthma. Less common: foreign body aspiration, allergic reaction, pneumonia. Rare: epiglottitis, bacterial tracheitis. Also: Congenital heart disease (CHF), sepsis, other metabolic acidosis (e.g.: DKA, inborn error of metabolism)

Index

Yes

No

161 January 2018

Assess ABCs, ref.O2

If possible, determine likely trigger

Determine PMH, medications, allergies

Classify based on symptom severity and systems involved

Other specific protocols may apply: e.g.: obstructed airway, bites & envenomations

Generalized or Systemic Reaction

Multisystem involvement: skin, lungs, airway, etc

Does patient have any 2 of the following signs or symptoms of

anaphylaxis?

Hypotension for age

Signs of poor perfusion

Bronchospasm, stridor

Altered mental status

Urticaria

ref. epinephrine IM, then:

Start IV Ref. IO and give IV fluid bolus 20cc/kg NS

ref. diphenhydramine

ref. methylprednisolone

ref. albuterol if wheezing

Monitor ABCs, SpO2, cardiac rhythm

Reassess for signs of deterioration

ref. diphenhydramine

Localized Reaction

Including isolated tongue, airway

Airway involvement? Tongue or uvula swelling,

stridor

Impending airway obstruction?

Immediately ref. epinephrine IM & manage airway

ref. Ped respiratory failure

Start IV / Ref. IO

ref. diphenhydramine

ref. methylprednisolone

If persistent signs of severe shock with hypotension not

responsive to IM epinephrine and fluid bolus:

Repeat ref. epinephrine IM

Contact Base

No

Yes

No

Yes

Yes No

Transport and reassess for signs of deterioration

130p Pediatric Allergy and Anaphylaxis

Index

162 January 2018

General Guideline: A. Pediatric cardiac arrest more frequently represents progressive respiratory deterioration

or shock rather than primary cardiac etiologies. Unrecognized deterioration may lead to bradycardia, agonal breathing, and ultimately asystole. Resulting hypoxic and ischemic insult to the brain and other vital organs make neurologic recovery extremely unlikely, even in the doubtful event that the child survives the arrest. Children who respond to rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much more likely to survive neurologically intact. Therefore, it is essential to recognize the child who is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention before asystole occurs

B. Onset (witnessed or unwitnessed), preceding symptoms, bystander CPR, downtime before CPR and duration of CPR • Past History: medications, medical history, suspicion of ingestion, trauma, environmental factors (hypothermia, inhalation, asphyxiation) Penetrating and Blunt trauma arrest: Ref. Pediatric Trauma Arrest Cardiac arrest from the following causes should approached as a medical cardiac arrest:

overdose, respiratory arrest, airway obstruction, asphyxiation, hanging and ref. Pediatric drowning

Document Specific Objective Findings

A. Unconscious, unresponsive B. Agonal, or absent respirations C. Absent pulses D. Any signs of trauma, blood loss E. Skin temperature

General Treatment Guidelines

A. Treat according to Pediatric BLS and ALS pulseless arrest algorithms B. Primary cardiac arrest from ventricular arrhythmia, while less common than in adults,

does occur in children. If history suggests primary cardiac event (e.g.: sudden collapse during exercise), then rapid defibrillation is most effective treatment

C. Most pediatric pulseless arrest is the result of primary asphyxial event, therefore initial sequence is chest compressions with ventilations, unlike adult pulseless arrest

D. Call for ALS assistance if not already on scene or responding

Index

2000p Pediatric Cardiac Arrest – General Principles

163 January 2018

General Guidelines: Chest Compressions for 2 Rescuers Newborn (≤ 1 month old)

A. 1 cycle of CPR = 3:1 chest compressions: breaths. Infant and Child (1 month to 12 years old)

A. 1 cycle of CPR = 15:2 chest compressions: breaths B. Utilize CPR feedback device “puck” on all patients with a Broselow measurement of Purple or greater B. Push hard and fast at a compression rate of 100/minute C. Minimize interruption to chest compressions

a. Continue CPR while defibrillator is charging, and resume CPR immediately after all shocks. Do not check pulses except at end of CPR cycle and if rhythm is organized at rhythm check b. Increase in compression interruption correlates with decrease in likelihood of successful defibrillation

D. Ensure full chest recoil a. Represents diastolic phase for cardiac filling due to negative intrathoracic pressure

E. Avoid hyperventilation a. Associated with barotrauma and air trapping b. Makes CPR less effective by inhibiting cardiac output by increasing intrathoracic pressure and decreasing venous return to the heart

F. Rotate compressors every 2 minutes during rhythm checks General Guidelines: Defibrillation

A. First shock delivered at 2 J/kg biphasic B. All subsequent shocks delivered at 4 J/kg biphasic

General Guidelines: Ventilation during CPR

A. Do not hyperventilate B. Contrary to adult cardiac arrest, pediatric arrest is much more likely to be from asphyxia. During this period, blood continues to flow to the tissues causing oxygen saturation to decrease and carbon dioxide to increase. Pediatric patients need both prompt ventilation and chest compressions. C. Hyperventilation decreases effectiveness of CPR and worsens outcome

General Guidelines: Timing Of Placement Of Advanced Airway

A. No intubation for cardiac arrest < age 12 B. i-gel O2 Airway preferred for all patients < 12 years old and should be placed according

to ref. Pediatric Medical Arrest Core Competencies to allow for continuous chest compressions

C. If advanced airway(i-gel O2) in place, ventilate continuously at 10 breaths/minute D. If no advanced airway (i-gel O2), alternate ventilations and compressions in 15:2 ratio E. Avoid hyperventilation

General Guidelines: Pacing

A. Effectiveness of transcutaneous pediatric pacing has not been established and is not Recommended

General Guidelines: Transport

A. Outcomes for non-shockable pulseless arrest are improved with timely transport.

2000p Pediatric Cardiac Arrest General Principles

Index

164 January 2018

Special Notes: Consider reversible causes of cardiac arrest (“Hs And Ts”):

Hypovolemia = IV Fluid bolus Hypoxia = Ventilation Hydrogen Ion (acidosis) = Ventilation Hyperkalemia = Sodium bicarbonate Hypothermia = See hypothermia protocol Toxins: e.g.: opioid overdose = Naloxone 2mg IVP Tamponade (cardiac) Tension pneumothorax = Needle thoracostomy Thrombosis (coronary) Trauma

2000p Pediatric Cardiac Arrest General Principles

Index

165 January 2018

Unresponsive and not breathing or only gasping

Check pulse (< 10 sec)

Is there a definite pulse?

Pulse > 60

Give 1 breath every 3 seconds

Recheck pulse every 2 minutes

Pulse < 60

Infant/child: start CPR

Age < 12: start CPR if signs of poor perfusion

ref. Peds Bradycardia

Definite Pulse Check Rate

No Pulse

Neonate (< 1 month)

Start CPR cycles in 3:1

ref. Newborn resuscitation

Infant/Child (> 1 month)

Start CPR cycles in 15:2

Patient > 12 years

Follow adult ref. Asystole / PEA or . VF / VT algorithm

Apply AED/Defibrillator

Use pediatric system if available for ages 1 year to 8 years

Check Rhythm Shockable rhythm?

Shockable Not Shockable

Resume CPR immediately for 2 minutes

Check rhythm every 2 minutes

Give 1 shock

Resume CPR immediately for 2 minutes after shock

Check rhythm every 2 minutes

2010p Pediatric Pulseless Arrest BLS / AED

Index

Use CPR feedback device “puck” for all patients with Broselow measurement of purple or greater.

High quality CPR

Rate > 100/min

Compression depth 1 ½ inches in infants, 2 inches in children

Allow complete chest recoil after compression

Minimize interruptions of chest compressions

Avoid excessive ventilation

166 January 2018

Index

2020p Pediatric Pulseless Arrest – VF / VT

Start chest compressions Consider circumstances of arrest:

Witnessed by EMS = immediate rhythm check Unwitnessed by EMS = 2 minutes CPR

o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator

Routine medical assessment

VF / VT

2 min CPR Ref. Pediatric Respiratory Failure / Arrest

2 min CPR ref. IO / IV

2 min CPR ref. Epinephrine q 4 min

VF / VT

Rhythm Check

Rhythm Check ROSC

SHOCK

ASYSTOLE/PEA

DEFIB at Pediatric Field Guide Recommended Joules

VF / VT

Rhythm Check

ASYSTOLE/PEA ROSC

2 min CPR ref. Amiodarone

VF / VT

ASYSTOLE/PEA

ROSC

Ref. PediatricROSC Ref. Asystole / PEA

Go To Box “A”

After 15 minutes of ALS Care: Continue resuscitation and Transport

DEFIB at Pediatric Field Guide Recommended Joules

DEFIB at Pediatric Field Guide Recommended Joules

Use CPR feedback device “puck” for all patients with Broselow measurement of purple or greater.

A

167 January 2018

Rhythm Check

2021p Pediatric Pulseless Arrest Asystole / PEA

ROSC VF / VT

ROSC

Start chest compressions Consider circumstances of arrest:

2 minutes CPR o OPA / NPA / Capnography / BVM o Attach monitor/defibrillator

Routine medical assessment Treat reversible causes

Asystole * / PEA

2 min CPR ref. IO / IV

2 min CPR ref. Epinephrine q 4 min

Asystole / PEA

Asystole / PEA

Go To Box “A”

Ref. VF / VT

After 15 minutes of ALS Care: 1. Asystole = CONTACT BASE (AIP, Children’s TMCA, CMP, SaddleRock) for

consideration of TOR at any point if continuous asystole. 2. PEA = Continue resuscitation and Transport

Rhythm Check

VF / VT A

2 min CPR Ref. Pediatric Respiratory Failure / Arrest

Ref. PediatricROSC

Use CPR feedback device “puck” for all patients with Broselow measurement of purple or greater.

Index

* Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. The AFR incident number should be included on the strip.

168 January 2018

CPR, Ventilation and Advanced Airway: • No intubation for cardiac arrest < age 12 • i-gel O2Airway preferred for all patients < 12 years old and should be placed as soon as possible to allow for continuous chest compressions • If advanced airway (i-gel O2) in place, ventilate continuously at 10 breaths/minute • If no advanced airway (i-gel O2), alternate ventilations and compressions in 15:2 ratio • Avoid hyperventilation Shock energy for defibrillation: • 1st shock 2 J/kg, or Broselow recommendation, subsequent shocks 4 J/kg, or Pediatric Field Guide recommendation Family Members • Family presence during resuscitation is recommended, unless disruptive to resuscitation efforts

2020p Pediatric Pulseless Arrest ALS

Index

Reversible Causes: Hypovolemia Tamponade (cardiac) Hypoxia Toxins H+ (Acidosis) Thrombosis: PE,AMI Hypo/Hyperkalemia Hypothermia Tension Pneumothorax

169 January 2018

YES

2025p Pediatric Return of Spontaneous Circulation

ROSC after Cardiac Arrest

Transport patient to Children’s Hospital Colorado main campus

Recurrent dysrhythmia? Treat per protocol

Reassess ABCs Obtain baseline vitals

Continuous cardiac monitoring

Hypotension for age? Ref. Pediatric Field Guide

Signs or symptoms of poor perfusion caused by bradycardia? (altered mental status, chest pain, signs of shock)

Pull - Push 20ml/kg NS bolus IV/ IO Reassess

Repeat 20ml/kg NS boluses up to 40ml/kg until goal met of: Threshold heart rate for age Normal Systolic Blood Pressure for age

and Capillary refill < 2 seconds

Index

170 January 2018

Index

Bradycardia HR < 60 and inadequate for clinical

condition

Bradycardia HR < 60 and inadequate for clinical condition

2030p Pediatric Tachyarrhythmia

Routine Medical Assessment Identify and treat underlying cause

ref.O2

Monitor ECG: identify rhythm

Start IV / ref. IO

Search for and treat underlying cause:

e.g.: dehydration, fever,

hypoxia, hypovolemia, pain Persistent tachyarrhythmia causing:

(Any of the following) Hypotension for age, altered mental status other signs of poor

perfusion

YES

Wide QRS? > 0.09sec

CONTACT BASE Ref. Synchronized

Cardioversion Transport

Valsalva maneuver CONTACT BASE

ref. Adenosine

Probable Sinus Tachycardia

Infants: rate usually < 220

Children: rate usually < 180

CONTACT BASE: Ref. Synchronized Cardioversion

NO

NO

YES

NO YES

Signs of Poor Perfusion: -Cool, pale extremities -Prolonged Cap Refill time (>2 sec) -Lethargy/ alt mental status -Hypotension

171 January 2018

Maintain airway Assist breathing as needed Ref. Oxygen Monitor ECG: identify rhythm Start IV / Ref. IO

Maintain airway Assist breathing as needed Give oxygen Monitor ECG: identify rhythm Start IV

Monitor and Transport

Monitor and Transport

Ref. epinephrine IV/IO Ref. Atropine IV/IO For increased

vagal tone or primary AV block CONTACT BASE for transcutaneous

pacing For further considerations Contact

Base

Reminders: If pulseless arrest develops, ref. VF / VT or

Asystole / PEA algorithm Search for possible reversible causes:

“5Hs and 5 Ts” Increased Vagal Tone:

-Child has increased ICP not responsive to Oxygen -Possible toxic ingestions ie: clonidine, digoxin, blood pressure medications, nitro, lithium, nasal spray decongestants (taken orally)

Begin CPR

Persistent bradycardia?

2040p Pediatric Bradycardia

Yes

No

Adequate Perfusion Poor Perfusion

Persistent bradyarrhythmia causing: (Any of the following)

Hypotension for age altered mental status signs of Poor Perfusion

Yes No

Bradycardia HR < 60 and inadequate for

clinical condition

Bradycardia HR < 60 and inadequate for clinical condition

Yes

Index

Signs of Poor Perfusion: -Cool, pale extremities -Prolonged Cap Refill time (>2 sec) -Lethargy/ alt mental status -Hypotension

172 January 2018

2050p Pediatric Non-Traumatic Pulseless Arrest

Place patient on cardiac monitor

Dependent lividity Or

Rigor mortis Or

Decomposition

Advanced Directives indicating DNR

CONTACT BASE for consideration of field

pronouncement

Asystole* Not Asystole

Ref. VF / VT or Asystole / PEA algorithm

Cardiac arrest from the following causes should approached as a medical cardiac arrest:

Overdose Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage

Index

* Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. The AFR incident number should be included on the strip.

Yes

No

173 January 2018

Yes

Index

No

Yes

No

No

No

Yes

Yes

Yes

No

Birth

30 sec.

60 sec.

No

Yes

2200p Newborn Resuscitation (< 24 Hours Old)

Routine Care: Warm Suction airway if necessary Dry Ongoing evaluation

Breathing and crying and

good tone?

Warm, clear airway if necessary, dry, stimulate

Consider & Treat reversible causes

HR < 100, gasping or apnea

BVM 40 – 60 / min (30 seconds)

SpO2 monitoring

HR < 100 ?

HR < 60 ?

BVM 40 – 60 / min (30 seconds)

SpO2 monitoring

HR < 60 after 1 minute of CPR?

Labored breathing or persistent cyanosis?

Clear airway SpO2 monitoring

Supportive care

DO NOT USE EZ IO Drill for newborns Pink EZ IO needle should be placed by hand.

CPR (1 minute) Ratio: 3 to 1

Depth: 1/3 depth of chest Rate: 120 per minute

Full Resuscitation CPR (2 minute cycles) Ratio: 3 to 1 Depth: 1/3 depth of chest Rate: 120 per minute

Transport to Children’s Hospital Colorado

ref. Epinephrine

Neonatal Oxygen Recommendations (From 2015 NRP Guidelines)

Begin resuscitation of newborns ≥35

weeks gestation with room air. If breathing is labored, supplement with oxygen to the targets listed.

Begin resuscitation <35 weeks gestation

with supplemental oxygen titrated to the targets listed.

Targeted Preductal* (Right Arm) SpO2 After Birth (From 2015 NRP Guidelines)

1 minute: 60%-65% 3 minutes: 60%-75% 5 minutes: 80%-85%

10 minutes: 85%-95%

*preductal: indicates a patent ductus arteriosus

Consider & Treat reversible causes

174 January 2018

General Considerations (From 2015 AHA Guidelines) Newborn infants who do not require resuscitation can be identified generally based on 3 questions:

Term gestation? Crying or breathing? Good muscle tone?

If answer to all 3 questions is “yes” then baby does not require resuscitation and should be dried, placed skin-to-skin on mother, and covered to keep warm If answer to any of 3 questions is “no” then infant should receive 1 or more of following 4 categories of intervention in sequence:

Initial steps in stabilization (warm, clear airway, dry, stimulate) Ventilation Chest compression Administration of epinephrine and/or volume expansion

It should take approx. 60 seconds to complete initial steps The decision to progress beyond initial steps is based on an assessment of respirations (apnea, gasping, labored or unlabored breathing) and heart rate (>/< 100 bpm) Assisting Ventilations:

Assist ventilations at rate of 40-60 breaths per minute to maintain HR > 100 Use 2-person BVM when possible

Chest compressions:

Indicated for HR < 60 despite adequate ventilation w. supplemental O2 for 30 seconds 2 thumb – encircling hands technique preferred Allow chest recoil Coordinate with ventilations so not delivered simultaneously 3:1 ratio of compressions to ventilations

Medications:

Epinephrine is indicated if the newborn’s heart rate remains less than 60bpm after at least 30 seconds of PPV AND another 60 seconds of chest compressions coordinated with PPV using 100% Oxygen

2200p Newborn Resuscitation

Index

175 January 2018

General Considerations: A. Neonate/Newborn refers to a newly born child under the age of 30 days. While most

neonates transition to post-natal life without difficulty, 10% will require medical assistance.

Respiratory insufficiency is the most common complication observed in the newly born.

B. Neonates born precipitously may exhibit signs of stress such as apnea, grunting respirations,

lethargy or poor tone

1. Provide warmth, bulb suction mouth and then nose, and dry the infant

2. If breathing spontaneously, HR >100 and infant is vigorous, continue to monitor

3. If apneic, cyanotic, lethargic, or HR <100, provide 100% oxygen via BVM

ventilations at a rate of 40-60 bpm

4. If HR < 60, begin CPR at 3:1 compression : ventilation ratio.

C. For neonates who do not respond to initial interventions as above:

1. Obtain blood glucose level and if < 60, administer dextrose IV/IO (D10 5 mL/kg)

2. Administer epinephrine IV for persistent HR < 60

3. Consider hypovolemia and administer 10-20ml/kg NS over 5-10 minutes

D. Neonates with congenital heart disease may not be detected prior to hospital discharge after

delivery. Consider a cardiac cause of shock in the neonate who remains hypoxic or has

persistent cyanosis despite 100% oxygen. These neonates may decompensate precipitously

and fluid administration should be used judiciously (10ml/kg NS)

E. Newborns are at high risk for hypothermia. Provide early warming measures, keep covered

as much as possible (especially the head) and increase the temperature in the ambulance

F. Acrocyanosis (cyanosis of only the hands and feet) is normal in newborns and does not

require intervention

G. Prolonged apnea without bradycardia or cyanosis may indicate respiratory depression

caused by narcotics. However, naloxone should be avoided in infants of a known or

suspected narcotic-addicted mother as this may induce a withdrawal reaction. Respiratory

support alone is recommended

H. Obtain pregnancy history, gestational age of the neonate, pregnancy complications, and any

illicit drug use during pregnancy.

2200p Newborn Considerations

Index

176 January 2018

Specific Information Needed

A. History of the event: onset, duration, seizure activity, precipitating factors. Was the patient sitting, standing, or lying? Pregnant?

B. Past history: medications, diseases, prior syncope C. Associated symptoms: dizziness, nausea, chest or abdominal/back pain, headache,

palpitations

Specific Objective Findings

A. Vital signs B. Neurological status: level of consciousness, residual neurological deficit C. Signs of trauma to the head or mouth or incontinence D. Neck stiffness

Treatment

A. Place patient in position of comfort: do not sit patient up prematurely; supine or lateral positioning if not completely alert

B. Monitor vital signs and level of consciousness closely for changes or recurrence. C. Establish venous access and administer Normal Saline if indicated. D. Consider hypoglycemia. If signs of hypoglycemia are present ref. Pediatric

Hypoglycemia E. If vital signs abnormal for age

1. Ref. Oxygen.

2. Keep patient supine.

3. Establish venous access.

4. Monitor cardiac rhythm (12-lead EKG)

Specific Precautions

A. Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the patient is still unconscious, treat as coma. If the patient is confused, treat according to Pediatric Altered Mental Status.

B. Most syncope is vasovagal, with dizziness progressing to syncope over several minutes. Recumbent position should be sufficient to restore vital signs and level of consciousness to normal.

C. Syncope that occurs without warning or while in a recumbent position is potentially serious and often caused by an arrhythmia.

D. Patients with syncope, even though apparently normal, should be transported

Index

3000p Pediatric Syncope

177 January 2018

Rule out or treat ref. Ped hypoglycemia

Determine when last KNOWN to be normal and document specific time

“At 2:15 PM”, not “1 hour ago”

Obtain medical history

Document medications

Identify family or friend who may assist with history and decision-making, get contact info and strongly encourage to come to ED as they may be needed for consent for treatments

Fully monitor patient and continually reassess:

Improvement or worsening of deficit

Adequacy of ventilation and oxygenation

Cardiovascular stability

POSSIBLE STROKE (Acute onset neurological deficit not

likely due to trauma)

Start IV and draw blood

Document cardiac rhythm

Ensure full monitoring in place: cardiac, SpO2

Assess and stabilize ABCs, ref.O2

ref.O2

Start IV / ref. IO

Assess Cincinnati Prehospital Stroke Scale (Presence of single sign sufficient)

Transport to Children’s Hospital Main Campus for pts < 12 years old.

Notify receiving hospital of Stroke Alert

3010p Pediatric Stroke

Index

178 January 2018

Persistent AMS?

Assess ABCs ref. VF / VT or Asystole / PEA, respiratory distress

or obstructed airway protocol as appropriate.

Determine character of event Consider seizure, syncope

and TIA Monitor and transport with

supportive care

BGL < 60 mg/dL clinical condition suggests

hypoglycemia? BGL = “Hi”

Perform rapid neurologic assessment including LOC and Cincinnati Prehospital

Stroke Score (CPSS)

ref. Seizure protocol

No

Consider other causes of AMS: ref.

overdose, Shock, heat/cold emergency, EtOH Intoxication

No

During transport: ref.O2 Start IV / ref. IO Monitor vital signs, airway, breathing, and ECG.

Check BGL

ref. Hypoglycemia/Hypergly

cemia protocol

Seizure activity present?

Focal neuro deficit or positive CPSS?

3020p Pediatric Altered Mental Status

Yes

Yes

Yes

Yes

No

ref. Stroke protocol

Index

179 January 2018

ref. Midazolam via most readily available route (IN preferred)

Transport and monitor ABCs, vital signs, and neurological condition

Complete head to toe assessment

Support ABCs:

ref.O2

Monitor BGL and ref. hypoglycemia

Identify and treat reversible causes (see below)

Yes No

Check pulse and reassess ABCs Give supplemental oxygen

No

Yes

CONTACT BASE

Start IV / ref. IO

ref. Midazolam IV/ IM/ IN. IV preferred

If seizure < 5 min medication not necessary

If seizure > 5 min or recurrent sz, then treat as follows:

Yes

No

Actively Seizing?

Actively Seizing?

Actively Seizing?

3030p Pediatric Seizure

Index

Common Causes of Seizures

Epilepsy

Febrile seizure

Trauma/NAT

Hypoglycemia

Intracranial hemorrhage

Overdose (TCA)

Meningitis

Stimulant use (cocaine, meth)

180 January 2018

Seizure Precautions

Ensure airway patency, but do not force anything between teeth. NPA may be useful

Give oxygen

Suction as needed

Protect patient from injury

Check pulse immediately after seizure stops

Keep patient on side

Document:

Document: Seizure history: onset, time interval, previous seizures, type of seizure

Obtain medical history: head trauma, diabetes, substance abuse, medications, compliance with anticonvulsants, pregnancy

3030p Pediatric Seizure

Index

181 January 2018

A. Minors that are clinically intoxicated should be transported for evaluation. a. Parents may wish to take their children home to “sleep it off”. The clinically intoxicated

minor is at risk for adverse outcome and often benefits from evaluation of both medical and psychosocial concerns.

b. The parent or guardian must speak with the base physician if he or she is refusing transport of the minor.

3050p Pediatric Alcohol Intoxication

Index

182 January 2018

Abdominal pain and/or vomiting

Assess ABCs

ref.O2

Complete set of Vital Signs

Physical exam

Ref. Pediatric Shock as indicated

Monitor and transport

Frequent reassessment for deterioration and response to treatment

ref.Ondansetron ref. Fentanyl

4010p Pediatric Abdominal Pain / Vomiting

Index

183 January 2018

4020p Pediatric Overdose and Acute Poisoning

PPE and decontaminate when appropriate

ABCs

ref.O2

Start IV / ref. IO

monitor

ref. Naloxone

Airway adjuncts and BVM ventilations as needed

Altered Mental Status Protocol

IV / ref. IO fluid bolus ref. hypotension/shock protocol

Stimulant

Tachycardia, HTN, agitation,

sweating,

psychosis

Tricyclic antidepressant

Wide complex tachycardia,

seizure

Organophosphate or nerve agent

DUMBELS/SLUDGE

syndrome

Calcium Channel Blocker

Bradycardia, heart block, hypotension

ß-Blocker

Bradycardia, heart block, hypotension

CONTACT BASE ref. Sodium

bicarb

ref.Nerve Agent Antidote Kit

ref.Atropine

ref. Epinephrine if no response to 20cc/kg NS

bolus

20 cc/kg NS bolus

ref. Calcium and ref. Epinephrine

Ref. Epinephrine

20 cc/kg NS bolus

Yes

No

Yes

No

Yes Consider specific

ingestions

No

Need for airway management?

Hypotension?

Altered mental status?

Known Specific ingestion?

ref.Glucagon

Ref. Seizure

ref. resp.failure protocol

ref.Glucagon

Yes

No Monitor

Transport

Index

184 January 2018

Is BGL < 60?

Check blood glucose level in ANY patient with signs or symptoms consistent with hypoglycemia

Examples:

Altered MS, agitation, focal neurologic deficit, seizure, weakness, diaphoresis, decreased motor tone, pallor

ref. Oral Glucose Reassess patient

No

Monitor and transport or CONTACT

BASE for refusal

ref. Glugacon IM ref. IO

Yes

Yes

If hypoglycemia still most likely despite normal reading on

glucometer, administer sugar while considering other causes

of ref. altered mental status

Symptoms resolved?

Yes

Yes

No

Still symptomatic?

Are you able to establish IV access?

ref. dextrose IV & reassess patient

Yes

No

Recheck BGL and consider other causes of

altered mental status

No

Can the patient safely tolerate oral glucose?

intact gag reflex, follows verbal

commands

No

4025p Pediatric Hypoglycemia/Hyperglycemia

Index

Yes

No

Considerations for Hyperglycemia:

In general, treat the patient, not the glucose value.

Consider NS bolus for patients with hyperglycemia and no evidence of fluid overload

Ped patients with concern for DKA should not exceed 10-20 ml/kg of lfuids.

ref. Shock

ref. altered mental status

185 January 2018

Index

All symptomatic patients:

Check blood glucose and treat hypoglycemia, if present

Start IV / ref. IO / ref.O2

Give NS bolus IV 20 cc/kg up to 1 liter

Ref. Methylprednisolone

Patient at risk for adrenal insufficiency:

Identified by family or medical alert bracelet

Chronic steroid use

Congenital Adrenal Hyperplasia

Addison’s disease

20 cc/kg NS bolus, as needed

Continue to monitor for development of Hypoglycemia

If otherwise considering administration of corticosteroid, CONTACT BASE for consult.

Assess for signs of acute adrenal

crisis:

Pallor, weakness, lethargy

Vomiting, abdominal pain

Hypotension, shock

Congestive heart failure

Does patient have hypotension and signs of poor

perfusion?

Altered mental status

Tachycardia

Cool, clammy skin

Monitor 12 lead ECG q 5 min for signs of hyperkalemia

4031p Pediatric Adrenal Insufficiency

186 January 2018

Notes: If the patient is confirmed to have a disease (such as congenital adrenal hyperplasia or chronic use of systemic steroids) that could lead to acute adrenal insufficiency or Addisonian crisis, then the administration of steroids may be life-saving and necessary for reversing shock or preventing cardiovascular collapse. • Patients at risk for adrenal insufficiency may develop Addisonian crisis when under physiologic stress which would not lead to cardiovascular collapse in normal patients. Such triggers may include trauma, dehydration, infection, myocardial ischemia, etc. • If no corticosteroid is available during transport, notify receiving hospital of need for immediate corticosteroid upon arrival.

4031p Pediatric Adrenal Insufficiency

Index

187 January 2018

Ref. Spinal Immobilization before moving patient if trauma suspected

Monitor cardiac rhythm

Remove wet garments, dry and insulate patient

Transport, even if initial assessment normal

Monitor ABC, VS, mental status

Remove wet garments, dry and insulate patient

Heimlich maneuver NOT indicated

Consider all causes of Altered Mental Status

Suction as needed

Start IV, obtain BGL and give oxygen

Monitor ABC, VS, mental status

Remove wet garments, dry and insulate patient

Suction as needed

Start IV, ref. IO, check BGL, ref.O2

Transport

Monitor ABC, VS, mental status

ABCs

Awake and alert

Assess mental status

Awake but altered LOC Comatose or unresponsive

Yes No

Monitor cardiac rhythm

Pulse Present?

Start CPR, attach AED/monitor/defibrillator and treat per Pediatric ref. VF / VT or Asystole / PEA algorithm If suspected

hypothermia ref. Hypothermia

4040p Pediatric Drowning

Index

188 January 2018

Index

Systemic hypothermia Presumed to be primary problem

based on clinical scenario

Monitor cardiac rhythm

Remove wet garments, dry and insulate patient

Transport, even if initial assessment normal

Monitor ABC, VS, mental status

Dress injured area lightly in clean cloth to protect from further injury

Do not rub, do not break blisters

Do not allow injured part to refreeze. Repeated thaw freeze cycles are especially harmful

Monitor for signs of systemic hypothermia

Remove wet garments, dry and insulate patient

ref. Altered Mental Status

Suction as needed

Start IV, check BGL and give oxygen

Transport

Monitor ABC, VS, mental status

Remove wet garments, dry and insulate patient

Suction as needed

Start IV, ref. IO, BGL, oxygen

Transport

Monitor ABC, VS, mental status

High flow O2

ABCs

Awake but altered LOC Comatose or unresponsive

Yes No

PEA Asystole or V-fib/VT

Handle very gently

Start IV w. warm IVF

Insulate patient

ref. Resp Failure

Localized cold injury

Frostbite, frostnip

Hypothermia and Frostbite

Pulse Present?

Start CPR, attach AED/monitor/defibrillator and treat ref. VF / VT or Asystole / PEA algorithm with following changes:

Single dose ref. Epinephrine IV/IO

For Vfib/VT: single attempt defibrillation only

4050p Pediatric Hypothermia

Monitor cardiac rhythm

ref. Resp Failure

Monitor cardiac rhythm

189 January 2018

Heat Cramps

Normal or slightly elevated body temperature

Warm, moist skin

Generalized weakness

Diffuse muscle cramping

Index

Heat Exhaustion

Elevated body temperature

Cool, diaphoretic skin

Generalized weakness

Anxiety

Headache

Tachypnea

Possible syncope

Heat Stroke

Very high core body temperature

Hot, dry skin w. cessation of sweating

Hypotension

Altered mental status

Seizure

Coma

Immediate Transport indicated

Adequate airway and breathing?

No Yes

Ref. respiratory failure

Start IV. ref. IO, ref.O2, 20cc/kg bolus NS unless signs of

volume overload

Remove excess clothing

For heat stroke, consider external cooling measures if prolonged transport

ref. seizures, cardiac arrhythmias per protocol

Monitor and transport

20cc/kg bolus NS

Monitor VS and transport

Hyperthermia

Classify by clinical syndrome

Consider non-environmental causes (see below)

4060p Pediatric Hyperthermia

190 January 2018

4070p Pediatric Insect/Arachnid Bite and Stings Protocol

ref.O2

Start IV. ref. IO

Assess for localized vs. systemic signs and symptoms and depending

on animal involved

Localized Symptoms:

Pain, warmth and swelling

Systemic Symptoms:

Hives, generalized erythema, swelling, angioedema

Hypotension

Altered mental status

Other signs of shock

Initiate general care for bites and stings

ref. allergy & anaphylaxis protocol

ref. Fentanyl for black widow spider and /or

ref. diphenhydramine if needed for itching

Index

191 January 2018

Index

4080p Pediatric Snake Bite

Assess ABCs, mental status ref.O2 Start IV, ref. IO Monitor Vital signs

Remove patient from proximity to snake Remove all constricting items from bitten limb (e.g.: rings, jewelry, watch, etc.) Immobilize bitten part Initiate prompt transport

• Do NOT use ice, refrigerants, tourniquets, scalpels or suction devices • Mark margins of erythema and/or edema with pen or marker and include time measured.

Transport

Assess for localized vs. systemic signs and symptoms

Localized Symptoms: • Pain and swelling • Numbness, tingling to bitten part • Bruising/ecchymosis

Systemic Symptoms: • Metallic or peculiar taste in mouth • Hypotension • Altered mental status • Widespread bleeding • Other signs of shock

Monitor pt and ref. Respiratory Distress as indicated

ref. Fentanyl

ref. Hypotension/Shock as indicated

Immobilize bitten part

192 January 2018

DEFINITION: An infant < 1 year of age with episode frightening

to the observer characterized by apnea, choking/gagging, color change or change in muscle

tone

Obtain detailed history of event and medical history

Complete head-to-toe assessment

Support ABCs as necessary

Regardless of the infant’s appearance at the time of EMS assessment, the history of an Brief Resolved Unexplained Event (BRUE) must always result in:

A. Ambulance transport to an emergency department OR

B. Base contact to consult with ER physician to discuss leaving patient on scene Against Medical Advice.

4090p Pediatric Brief Resolved Unexplained Event (BRUE)

Index

193 January 2018

Clinical history to obtain from observer of event:

Document observer’s impression of the infant’s color, respirations and muscle tone For example, was the child apneic, or cyanotic or limp during event? Was there seizure-like activity noted? Was any resuscitation attempted or required, or did event resolve spontaneously? How long did the event last? Past Medical History:

Recent trauma, infection (e.g. fever, cough) History of GERD History of Congenital Heart Disease History of Seizures Medication history

Examination/Assessment

Head to toe exam for trauma, bruising, or skin lesions Check anterior fontanelle: is it bulging, flat or sunken? Pupillary exam Respiratory exam for rate, pattern, work of breathing and lung sounds Cardiovascular exam for murmurs and symmetry of brachial and femoral pulses Neuro exam for level of consciousness, responsiveness and any focal weakness

4090p Pediatric Brief Resolved Unexplained Event (BRUE)

Index

194 January 2018

General Guideline: A. Children with special health care needs include those with chronic physical, developmental,

behavioral or emotional health issues. These children often have complex medical needs and

may be technology-dependent. Parents or caregivers for such children can be a wealth of

knowledge about their child’s care and may carry a reference care sheet. CONTACT BASE

(AIP, Children’s TMCA, CMP, SaddleRock) for any concerns.

Feeding Tubes: A. Feedings tubes are used for administration of medications and to provide feeds to children

with an impaired ability to take oral feeds. Always ask caretaker the type of feeding tube

(does the tube end in the stomach or jejunum?) and when it was placed

B. Tubes may be placed through the nose, mouth or abdomen and end in the stomach or

jejunum (upper intestine)

C. Consider venting and/or gently aspirating the feeding tube in a child with respiratory or

abdominal distress to allow removal of gastric contents and decompression

D. Feeding tubes that have been placed less than 6 weeks ago are not well established and may

close within 1 hour of tube removal. If transport time is prolonged, place an 8 Fr suction

catheter tube 2 inches into the stoma to maintain patency. Do NOT use the tube.

Tracheostomy: A. A tracheostomy is a surgical opening between the trachea and the anterior surface of the

neck. Its purpose is to bypass the upper airway for chronically ventilated patients, upper

airway obstructions, or to facilitate secretion removal in those with ineffective gag or

swallow reflexes.

B. Use bag-valve attached to the tracheostomy to assist ventilations if needed. May also attempt

BVM with gloved finger over the tracheostomy

C. Inability to ventilate and/or signs of respiratory distress (nasal flaring, retractions, hypoxia,

etc) may indicate tracheostomy obstruction. Suction tracheostomy, passing the suction

catheter no further than 6 cm. Limit suctioning time to minimum amount of time necessary

to accomplish effective suctioning. Oxygenate between passes with the suction catheter.

D. 0.5ml of saline may be instilled into the tracheostomy to assist suctioning of thick secretions

E. If unable to ventilate through the tracheostomy tube and patient is apneic, bradycardic, or in

pulseless arrest, remove tracheostomy tube and pass an appropriately sized endotracheal

tube through the stoma approximately 1-2 inches, secure and ventilate. Appropriate depth

must be based upon breath sounds, as right mainstem intubation is likely.

F. Remember that caregivers are often the best people to change and suction a tracheostomy

tube. Use them as your resource when possible.

Central Venous Catheters (CVCs): A. Because of their size and location, a much greater risk of serious bacterial infections exist

with CVCs compared to peripheral intravenous lines. Special care must be used when

accessing such lines

B. Prior to accessing a CVC, hands should be washed and gloves worn. Vigorously scrub the CVC

hub with an alcohol swab. While alcohol possesses some antimicrobial properties, the

friction produced by scrubbing is the most effective

C. A port is an implanted venous central venous catheter (below the surface of the skin). These

devices require a non-coring (e.g. Huber) needle for accessing and should not be accessed in

the field

4095p Care Of the Child with Special Needs

Index

195 January 2018

Scene Safety A. Scene safety and provider safety are a priority. Consider police contact if scene safety is a

concern.

Specific Information Needed A. Obtain history of current event; inquire about recent crisis, toxic exposure, drugs, alcohol,

emotional trauma, and suicidal or homicidal ideation. B. Obtain past history; inquire about previous psychiatric and medical problems, medications.

Treatment

A. Attempt to establish rapport B. Assess ABCs C. Transport to closest Emergency Department. D. Be alert for possible elopement. E. Consider organic causes of abnormal behavior (trauma, overdose, intoxication, hypoglycemia) F. Check blood sugar ref. Hypoglycemia G. If altered mental status or unstable vital signs:

1. Ref. Oxygen. 2. Establish venous access. 3. Refer to Altered Mental Status Protocol.

5000p Pediatric Psychiatric / Behavioral Emergency

Index

196 January 2018

BSI Scene safety Consider mechanism Consider need for additional

resources

Give high flow oxygen ref. Resp Distress as indicated ref. Resp Failure as indicated Spinal immobilization if indicated

Control exsanguinating hemorrhage: Direct pressure ref. Tourniquet protocol if indicated Pelvic stabilization if indicated

Assess disability and limitation: Brief neuro assessment Ref. Extremity splinting if indicated

Transport to closest appropriate facility Large bore IV, 2nd if unstable. ref. IO Consider fluid bolus 20cc/kg if unstable or

suspected significant injuries. ref. Shock Monitor vital signs, ABCs, neuro status, GCS Ref. Fentanyl

General impression ABCs and LOC Rapid Trauma Assessment Ref. Traumatic Pulseless Arrest Prepare for immediate transport SAMPLE history

7000p Pediatric General Trauma Care

Index

197 January 2018

Sexual Assault Abuse/neglect

Confine history to pertinent medical needs

Respect patient’s emotional needs

Protect evidence: No washing or changing

clothes

Transport

Observe pt’s behavior around caregivers

Watch out for:

Injury inconsistent with stated mechanism

Delayed treatment

Spreading blame

Conflicting stories

Prior/ healing injuries

Don’t judge, accuse or confront victim

Don’t judge, accuse or confront victim or

suspected assailant

Transport patient if suspected abuse or

neglect, no matter how minor the injury may

appear.

ref. General Trauma Care

7010p Pediatric Special Trauma Scenarios

Index

Notify Aurora Police Department of all suspected abuse / assault

Request APD officer to respond to receiving facility if not on

scene prior to patient transport.

198 January 2018

7015p Pediatric Traumatic Pulseless Arrest

Index

Monitor cardiac rhythm

7015p Pediatric Traumatic Pulseless Arrest

Asystole*?

CONTACT BASE for consideration of Field

Pronouncement

CPR until cardiac monitor applied

Ref. bilateral needle thoracostomy on all traumatic arrests with trauma to trunk

IV. ref. IO access with NS bolus enroute

Place pt on Cardiac Monitor1

Immediate transport to closest appropriate trauma center

Control life threatening external bleeding Continue chest compressions and ventilations

as per AFR Pediatric Field Guide Ref. LMA

1Load and go is always a reasonable approach to penetrating trauma arrest.

Traumatic pulseless arrest is a unique situation.

Do not apply “combo pads” Do not defibrillate

Do not administer ACLS medications Do not treat as medical arrest

Cardiac arrest from the following causes should be approached as a medical cardiac arrest:

Overdose Respiratory arrest Airway obstruction Asphyxiation Hanging Drowning Electrocution Lightning/high voltage

Yes No

* Asystole is defined as the absence of any electrical activity and must be observed in two or more leads for > 10 seconds. A printed copy of the patient’s EKG demonstrating asystole must be sent to the EMS Operations Captain. Include the AFR incident number on the strip.

199 January 2018

Repeat Pull / Push

20 cc/kg bolus Up to a

total of 60 cc/kg administered

ref. General Trauma Care

Administer oxygen

Large bore IV

2nd IV preferred

ref. IO

Evaluate breath sounds,

respiratory effort, and consider

tension pneumothorax

ref. needle thoracostomy if arrest or impending arrest

Treat en route

Keep patient warm

Ref. Intraosseous Access

Monitor:

ABCs, VS, mental status

Rapid transport to appropriate trauma center

Pull / Push 20 cc/kg NS Bolus

Use a 60cc syringe

and 3-way

Reassess

Trauma with suspected serious injury and/or signs of shock

7020p Pediatric Traumatic Shock

Hypotension for age? Yes

No

Index

Monitor cardiac rhythm

200 January 2018

ref. General Trauma Care

Uncontrolled Bleeding

Control with direct pressure to bleeding area or vessel

Bleeding Controlled

If bleeding not controlled with direct pressure, ref. Tourniquet

Large bore IV. ref. IO

If hypotensive, ref. Shock

Document neurovascular exam

Amputated part:

Wrap in moist, sterile dressing

Place in sealed plastic bag

Place bag in ice water

Do not freeze part

Stump:

Cover with moist sterile dressing covered by dry dressing

ref. fentanyl

Cover with moist sterile dressing

Splint near-amputated part in anatomic position

Monitor and transport to appropriate Trauma Center

Treat other injuries per protocol

Complete Amputation Partial / Near-Amputation

7025p Pediatric Amputations

Index

201 January 2018

7029p Pediatric Head Trauma

ref. General Trauma Care

ref. Oxygen ref. Pediatric Spinal Immobilization as indicated ref. Pediatric Seizure as indicated

ref. Pediatric Respiratory Failure / Arrest Requiring Assisted Ventilations as indicated

Ref. Pediatric Traumatic Shock Rapid Trauma Assessment

Treat other injuries per protocol

Watch for status changes

Transport to Children’s Hospital Main Campus for pts < 12 years old.

Continue to monitor for developing hypoxemia and shock

Index

Hypotension for age and / or definite signs of shock?

No Yes

Cushing’s Triad is a sign of increased intracranial pressure and consists of:

Hypertension (often with a widening pulse pressure)

Bradycardia

Irregular respirations

GCS < 8?

Head of bed should be elevated 300 unless hypotensive for age.

Yes

No

IV Access

Monitor cardiac rhythm

202 January 2018

No

7030p Pediatric Face and Neck Trauma

ref. General Trauma Care

Clear airway

Rapid trauma assessment

ref. Spinal immobilization

ref. Resp Distress as indicated

ref. Resp Failure as indicated

Laryngeal trauma* Transport

Severe airway Bleeding?

No

Complete neuro exam

Asses for subcutaneous air

Cover/protect eyes as indicated

Do not try to block drainage from ears, nose

Save avulsed teeth in saline-soaked gauze, do not scrub clean

Transport ASAP to closest appropriate facility

IV access en route. ref. IO

Treat other injuries per protocol

Suction airway as needed

Direct pressure if appropriate

Monitor ABCs, VS, mental status, SpO2

ref. Fentanyl

Yes

Yes

Index

203 January 2018

Full spinal immobilization if suspected spine injury

Document neuro assessments before and after immobilization

Complete patient assessment

Treat other injuries per protocol

Monitor for status changes

Large bore IV and consider 2nd line ref. IO

Rapid transport to appropriate Trauma Center

ref. General Trauma Care

If vital signs abnormal for age ref. Shock

Monitor ABCs, VS, mental status, SpO2.

ref. Fentanyl

7035p Pediatric Spinal Trauma

Index

204 January 2018

Spinal Immobilization A. Context/Special Considerations:

B. 60-80% of spine injuries in children occur at the cervical level

C. Children < 8 age year are more likely to sustain high C1-C3 injuries

D. Less force is required to injure the cervical spine in children than adults

E. Children with Down Syndrome are at risk for cervical spine injury

F. Avoid strapping abdomen- children are abdominal breathers

G. Use age/size appropriate immobilization devices

H. Proper immobilization of pediatric patients should prevent:

1. Flexion/extension, rotation, lateral bending or axial loading of the neck

(car seats do not prevent axial loading and are not considered proper

immobilization technique)

2. Non-neutral alignment or alteration in normal curves of the spine for age

(consider the large occiput)

3. Twisting, sliding or bending of the body during transport or care

Spinal Immobilization criteria: A. Be conservative. Children are difficult to assess and “clinical clearance” criteria

are not well established, as in adults

B. Immobilize the following patients as well as any child you suspect clinically may

have a spine injury:

1. Mechanisms of injury that imply potential need for spinal stabilization and for whom stabilization should be considered include but are not limited to:

MVC/MCC/Bicycle/Equestrian Accident

Diving / Axial Load

Fall > 3 feet

2. Altered Mental Status (GCS < 15, AVPU < A, or intoxication)

3. Barrier to evaluate for spinal injury (e.g. language or development barrier)

4. Focal neurologic findings (paresthesias, loss of sensation, weakness)

5. Non-ambulatory patient

6. Any complaint of neck pain

7. Torticollis (limited range of motion, difficulty moving neck in history or physical)

8. Substantial torso Injury (thorax, abdomen, pelvis)

7040p Pediatric Spinal Immobilization Considerations

Index

205 January 2018

Penetrating trauma?

Vital signs abnormal for age?

Occlusive dressings for

sucking wounds

Rapid transport & stabilize in route

Large bore IV and consider 2nd line ref. IO

Flail Chest?

Are you able to oxygenate and ventilate effectively?

Airway management and assisted ventilations as

indicated

Splint with bulky dressing

ref. Resp Distress as indicated ref. Resp Failure as indicated

ref. needle thoracostomy

ref. shock enroute

Assess for need for assisted ventilations

ref. Fentanyl

Monitor ABCs, VS, mental status, SpO2.

7045p Pediatric Chest Trauma

Yes

Yes

No

No

Yes

No

Yes

No

ref. General Trauma Care

Rapid Transport to closest appropriate Trauma Center

Index

206 January 2018

ref. General Trauma Care

Rapid transport to closest appropriate Trauma Center

IV access

Consider 2nd line if MOI significant

ref. IO

Penetrating trauma?

Vital signs abnormal for age?

Cover wounds, viscera with saline moistened gauze dressing

Do not attempt to repack exposed viscera

ref. Shock

Monitor ABCs, VS, mental status, SpO2.

ref. Fentanyl

7050p Pediatric Abdominal Trauma

No

No

Yes

Yes

Index

207 January 2018

7055p Pediatric Burns

No

No

Yes

Stop burning process:

Remove clothes if not adhered to patient’s skin

Flood with water only if flames/smoldering present

Respiratory Distress?

Critical Burn?*

O2 NRB 15 lpm

ref. Resp Distress as indicated

ref. Resp Failure as indicated

Evaluate degree and body surface area involved

Start 2 large-bore IVs

20 cc/kg NS bolus

ref. IO

IV NS TKO

Remove rings, jewelry, constricting items

Dress burns with dry sterile dressings

Treat other injuries per protocol

Cover patient to keep warm

ref, Fentanyl

Monitor ABCs, VS, mental status, SpO2

ref. General Trauma Care

Transport to Trauma Center

Yes

*Critical Burn:

2º > 30% BSA 3º > 10% BSA Respiratory injury, facial burn Associated injuries, electrical or deep chemical burns, underling PMH (cardiac, DM), age < 10

Index

208 January 2018

ALBUTEROL SULFATE (PROVENTIL, VENTOLIN) Description

Albuterol is a selective ß-2 adrenergic receptor agonist. It is a bronchodilator and positive chronotrope.

Onset & Duration

Onset: 5-15 min. after inhalation

Duration: 3-4 hours after inhalation Indications

Bronchospasm secondary to asthma, COPD or allergic reaction

Contraindications

Severe tachycardia is a relative contraindication Adverse Reactions

Tachycardia

Palpitations

Dysrhythmias Drug Interactions

Sympathomimetics may exacerbate adverse cardiovascular effects.

ß-blockers may antagonize albuterol. How Supplied

Pre-diluted nebulized solution: 2.5 mg in 3 ml NS (0.083%)

Dosage and Administration Asthma Adult:

Dose Albuterol sulfate solution 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5 to 15 minutes. May be repeated twice (total of 3 doses).

Pediatric: Albuterol sulfate 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate (6-8 lpm) that will deliver the solution over 5-15 minutes. May be repeated twice during transport (total of 3 doses).

Protocol

Adult Asthma

Adult COPD

Pediatric Respiratory Distress

Adult Allergy and Anaphylaxis

Pediatric Asthma

Pediatric Allergy and Anaphylaxis Special Considerations

Consider inline nebs for patients requiring endotracheal intubation or CPAP.

May precipitate angina pectoris and dysrhythmias

Should be used with caution in patients with suspected or known coronary disease, diabetes mellitus, hyperthyroidism, prostatic hypertrophy, or seizure disorder

Wheezing associated with anaphylaxis should first be treated with epinephrine IM.

Index

209 January 2018

ADENOSINE (ADENOCARD) Description

Adenosine transiently blocks conduction through the AV node thereby terminating reentrant tachycardias involving the AV node. It is the drug of choice for AV nodal reentrant tachycardia (AVNRT, often referred to as “PSVT”). It will not terminate dysrhythmias that do not involve the AV node as a reentrant limb (e.g. atrial fibrillation).

Onset & Duration

Onset: almost immediate

Duration: 10 sec Indications

Stable, narrow-complex supraventricular tachyarrhythmia (suspected AVNRT) Contraindications

Any irregular tachycardia. Specifically never administer to an irregular wide-complex tachycardia, which may be lethal

Post cardiac transplant patients should not receive adenosine Adverse Reactions

Chest pain

Shortness of breath

Diaphoresis

Palpitations

Lightheadedness Drug Interactions

Methylxanthines (e.g. caffeine) antagonize adenosine, a higher dose may be required

Dipyridamole (persantine) potentiates the effect of adenosine; reduction of adenosine dose may be required

Carbamazepine may potentiate the AV-nodal blocking effect of adenosine Dosage and Administration

Adult: 12 mg IV bolus, rapidly, followed by a normal saline flush. May repeat x 1. Total of 2 doses. For further considerations CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock)

Pediatric: CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock)

Index

210 January 2018

ADENOSINE (ADENOCARD) cont. Protocol

Adult Tachyarrhythmia

Pediatric Tacharrhythmia

Special Considerations

Reliably causes short lived but very unpleasant chest discomfort. Always warn your patient of this before giving medication and explain that it will be a very brief sensation

May produce bronchospasm in patients with asthma

Transient asystole and AV blocks are common at the time of cardioversion

Adenosine is not effective in atrial flutter or fibrillation

Adenosine is safe in patients with a history of Wolff-Parkinson-White syndrome if the rhythm is regular and QRS complex is narrow

A 12-lead EKG should be performed and documented

Adenosine requires continuous EKG monitoring throughout administration

Print continuous EKG while administering adenosine and deliver to attending physician.

Index

211 January 2018

AMIODARONE (CORDARONE) Description

Amiodarone has multiple effects showing Class I, II, III and IV actions with a quick onset. The dominant effect is prolongation of the action potential duration and the refractory period.

Indications

Cardiac arrest in patients who continue to have VF/VT after CPR, epinephrine, and defibrillation

Stable, wide complex tachycardia BASE CONTACT REQUIRED (AIP, Children’s, TMCA, CMP, SaddleRock)

Precautions

Wide complex irregular tachycardia

Sympathomimetic toxidromes, i.e. cocaine or amphetamine overdose

NOT to be used to treat ventricular escape beats or accelerated idioventricular rhythms Contraindications

Hypotension in patients with a pulse Adverse Reactions

Severe hypotension

Bradycardia Dosage and Administration

Adult: Max dose 450mg Pulseless Cardiac arrest in patients who continue to have VF/VT after CPR, epinephrine, and defibrillation Arrest (Refractory VT/VF) Initial 300 mg IV/IO bolus. Additional 150 mg IV/IO bolus in 4 minutes if pt continues to have VF/VT Wide Complex tachycardia with adequate perfusion CONTACT BASE REQUIRED for order (AIP, Children’s, TMCA, CMP, SaddleRock) 150 mg slow push

Pediatric: Reference Pediatric Field Guide

Pulseless Arrest (Refractory VT/VF) Cardiac arrest in patients who continue to have VF/VT after CPR, epinephrine, and defibrillation 5mg/kg IV/IO slow push. For additional doses CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock).

Protocol

Adult Pulseless Arrest Algorithm VF / VT

Adult Pulseless Arrest Algorithm Asystole / PEA

Pediatric Pulseless Arrest VF / VT

Pediatric Pulseless Arrest Asystole / PEA

Adult Tachycardia

Special Considerations

A 12-lead EKG should be performed and documented.

Index

212 January 2018

ASPIRIN (ASA) Description

Aspirin inhibits platelet aggregation and blood clotting and is indicated for treatment of acute coronary syndrome in which platelet aggregation is a major component of the pathophysiology. It is also an analgesic and antipyretic

Indications

Suspected acute coronary syndrome. (chest pain, diaphoresis, dyspnea, etc) Contraindications

Active gastrointestinal bleeding

Aspirin allergy How Supplied

Chewable tablets 81mg Dosage and Administration

324mg PO Protocol

Adult Chest Pain

Special Considerations

Patients with suspected acute coronary syndrome taking warfarin (Coumadin) or clopidogrel (Plavix) may still be given aspirin

Index

213 January 2018

ATROPINE SULFATE Description

Atropine is an endogenous antimuscarinic, anticholinergic substance. It is the prototypical anticholinergic medication with the following effects:

Increased heart rate and AV node conduction

Decreased GI motility

Urinary retention

Pupillary dilation (mydriasis)

Decreased sweat, tear and saliva production (dry skin, dry eyes, dry mouth)

Indications

Adult Bradycardia with poor perfusion including: o 2nd and 3rd degree heart block

Organophosphate poisoning

Pediatric Bradycardia with Poor Perfusion associated with increased vagal tone or Primary AV Block

Precautions

Should not be used without medical control direction for stable bradycardias

Closed angle glaucoma Adverse Reactions

Anticholinergic toxidrome in overdose, think “blind as a bat, mad as a hatter, dry as a bone, red as a beet”

Dosage and Administration

Adult Bradycardia with Poor Perfusion Adult: Initial dose of 0.5mg IV / IO bolus. Additional dose of 0.5mg IV / IO bolus if needed at 4 minute intervals, May repeat q 4 min up to a total of 3mg (Stop at ventricular rate which provides adequate mentation and blood pressure)

Pediatric Bradycardia with Poor perfusion associated with increased vagal tone or primary AV Block

Reference Pediatric Field Guide 0.02mg/kg, IV/IO bolus. Minimum dose 0.1mg Maximum single dose is 0.5mg Maximum total dose 1.0mg

Poisoning/Overdose

For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) Protocol

Adult Bradycardia

Pediatric Bradycardia

Adult Overdose / Acute Poisoning

Pediatric Overdose and Acute Poisoning

Index

214 January 2018

CALCIUM GLUCONATE Description

Cardioprotective agent in hyperkalemia.

10% calcium gluconate solution contains 1 g calcium gluconate per 10 mL, which is only 90mg of elemental calcium.

Doses below refer to dose of calcium gluconate solution, not elemental calcium.

Calcium chloride contains 3 times the concentration of elemental calcium compared to calcium gluconate.

If calcium gluconate not available, calcium chloride is an acceptable substitution. Indications

Not indicated for routine treatment of pulseless arrest

Adult Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history o Calcium channel blocker overdose

Calcium channel blocker overdose with bradycardia and hypotension/shock Contraindications

Known hypercalcemia

Suspected digoxin toxicity (i.e. digoxin overdose) Precautions

Must flush IV / IO or give in separate line from Sodium bicarb to prevent precipitation/formation of calcium carbonate

Extravasation may cause tissue necrosis

In setting of digoxin toxicity, may worsen cardiovascular function Dosage and Administration

Adult:

Pulseless arrest assumed due to hyperkalemia: o To be administered before Sodium Bicarbonate

Must flush IV/IO line between meds. o 3 g slow IV / IO push

Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) o 3 grams slow IV / IO push over 2-3 minutes. Dose may be repeated every 10

minutes for total of 3 doses Pediatric: Reference Pediatric Field Guide

Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) o 60 mg/kg (0.6 mL/kg), NOT TO EXCEED 1 Gram slow IV/IO push not to

exceed 2 mL/min. o May repeat every 10 minutes for a total of (3) doses.

Index

215 January 2018

CALCIUM GLUCONATE Protocol

Adult Pulseless Arrest Algorithm VF / VT

Adult Pulseless Arrest Algorithm Asystole / PEA

Adult Overdose / Acute Poisoning

Pediatric Overdose and Acute Poisoning

Index

216 January 2018

CALCIUM CHLORIDE Description

If calcium gluconate not available, calcium chloride is an acceptable substitution. Calcium chloride has 3 times the concentration of elemental calcium as calcium gluconate, so the volume given should be decreased. Calcium chloride is more likely to cause tissue necrosis in the event of extravasation and is therefore reserved for immediately life-threatening conditions when given via peripheral line.

Cardioprotective agent in hyperkalemia. Indications

Not indicated for routine treatment of cardiac arrest

Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history o Calcium channel blocker overdose

Calcium channel blocker overdose with bradycardia and hypotension/shock Contraindications

Known hypercalcemia

Suspected digoxin toxicity (i.e. digoxin overdose) Precautions

Must flush IV / IO or give in separate line from Sodium bicarb to prevent precipitation/formation of calcium carbonate

Extravasation may cause tissue necrosis

In setting of digoxin toxicity, may worsen cardiovascular function Dosage and Administration

Adult:

Pulseless arrest assumed due to hyperkalemia: o To be administered before Sodium Bicarbonate

Must flush IV / IO line between meds. o 1 gram slow IV / IO push

Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) 1

gram slow IV / IO push over 2-3 minutes (5 mL of a 10% solution). Dose may be repeated every 10 minutes for total of 3 doses.

Pediatric: Reference Pediatric Field Guide

Calcium channel blocker overdose with bradycardia and hypotension/shock: o For order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) o 20 mg/kg (0.2 mL/kg), NOT TO EXCEED 1 gram slow IV/IO push NOT TO

EXCEED 1 mL/min o May repeat every 10 minutes for a total of (3) doses Index

217 January 2018

CALCIUM CHLORIDE (continued)

Protocol

Adult Pulseless Arrest Algorithm VF / VT

Adult Pulseless Arrest Algorithm Asystole / PEA

Adult Overdose / Acute Poisoning

Pediatric Overdose and Acute Poisoning

Index

218 January 2018

DEXTROSE Description

Glucose is the body's basic fuel and is required for cellular metabolism. A sudden drop in blood sugar level will result in disturbances of normal metabolism, manifested clinically as a decrease in mental status, sweating and tachycardia. Further decreases in blood sugar may result in coma, seizures, and cardiac arrhythmias. Serum glucose is regulated by insulin, which stimulates storage of excess glucose from the blood stream, and glucagon, which mobilizes stored glucose into the blood stream.

Indications

Hypoglycemia (BGL< 60 mg / dL)

Not indicated for routine treatment of pulseless arrest Precautions

None

Dosage and Administration

Adult:

25 grams (250mL of a 10% solution) IV / IO infusion or 25 grams (50 mL of a 50% solution) IV / IO bolus. May repeat if needed.

<50kg: Reference Pediatric Field Guide

5mL/kg of D10% up to a maximum of 250mL Do not piggy back. Straight infusion.

Protocol

Adult Hypoglycemia

Altered Mental Status

Adult Seizures

Pediatric Altered Mental Status

Pediatric Seizures

Overdose / Acute Poisoning

Psych/Behavioral

Newborn Resuscitation

Pediatric Hypoglycemia Special Considerations

Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to ensure route patency.

Dextrose can be irritable to the vein and the vein should be flushed after administration.

Dextrose should be diluted 1:10 with normal saline (to create D10W) for patients < 50kg. o 25 grams of D50 mixed into a 250mL bag of NaCl = D10W

Index

219 January 2018

DIPHENHYDRAMINE (BENADRYL) Description

Antihistamine for treating histamine-mediated symptoms of allergic reaction. Also Anticholinergic and antiparkinsonian effects used for treating dystonic reactions caused by antiphsychotic and antiemetic medications (e.g.: haloperidol, droperidol, compazine, etc).

Indications

Allergic reaction

Dystonic medication reactions or akathesia (restlessness) Precautions

Asthma or COPD, thickens bronchial secretions

Narrow-angle glaucoma Side effects

Drowsiness

Dilated pupils

Dry mouth and throat

Flushing Drug Interactions

CNS depressants and alcohol may have additive effects.

MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines. Dosage and Administration

Adults: 50 mg IV / IO / IM Pediatrics: Reference Pediatric Field Guide 1 mg/kg slow IV /IO / IM (not to exceed 50 mg)

Protocol

Adult Allergy and Anaphylaxis

Adult Insect / Arachnid Bite and Stings

Pediatric Allergy and Anaphylaxis

Pediatric Insect / Arachnid Bite and Stings

Index

220 January 2018

EPINEPHRINE (ADRENALIN) Description

Endogenous catecholamine alpha, beta-1, and beta-2 adrenergic receptor agonist. Causes dose-related increase in heart rate, myocardial contractility and oxygen demand, peripheral vasoconstriction and bronchodilation.

Indications

Pulseless Arrest

Anaphylaxis ( 2 or more of the following signs or symptoms) Hypotension Signs of poor perfusion Bronchospasm, stridor Altered mental status Urticaria

Asthma

Hypotension with poor perfusion refractory to adequate fluid resuscitation (typically 30 mL/kg crystalloid)

Bradycardia with Poor Perfusion

Adverse Reactions

Tachycardia and tachydysrhythmia

Hypertension

Anxiety

May precipitate angina pectoris Drug Interactions

Should not be added to sodium bicarbonate or other alkaloids as epinephrine will be inactivated at higher pH.

Dosage and Administration

Adult Pulseless Arrest 1 mg (10 ml of a 1:10,000 solution), IV/IO bolus. Repeat every 4 minutes. o Only a Single Dose of Epi if suspected Systemic Hypothermia in Cardiac Arrest Asthma: 0.3 mg (0.3 ml of a 1:1,000 solution) IM. Anaphylaxis: 0.3 mg (0.3 ml of a 1:1,000 solution) IM. Repeat in 5 minutes X 1. Bradycardia with hypotension and poor perfusion refractory to other interventions: ***APPLY STICKER TO BAG***

Mix: 1mg (1:1 or 1:10) into 1000mL NaCL with a MACRO (10gtt) drip set

Infuse: Start at W/O to gravity to give small aliquots of fluid. Typical volumes are <100 mL total, as typical doses are expected to be < 100mcg.

Desired effects: a) BP >90 mmHg systolic b) Improved respiratory status c) Improved perfusion/mentation

Index

221 January 2018

EPINEPHRINE (ADRENALIN) cont.

Pediatric: Reference Pediatric Field Guide

Cardiac arrest: 0.01 mg/kg IV / IO (0.1 ml/kg of 1:10,000 solution). Repeat every 4 minutes. Bradycardia with Poor Perfusion for order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) IV / IO Asthma 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM Anaphylaxis 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution) IM. May repeat in 5 minutes x 1.

Newborn (< 24 hours old): (PINK EZ IO placed by hand NOT drill)

Cardiac arrest: 0.3mL of 1:10,000 solution IO / IV Repeat every 4 minutes.

Bradycardia (heart rate < 60 bpm after adequate ppv and chest compressions) 0.3mL of 1:10,000 solution IO / IV

Protocol

Adult Pulseless Arrest Algorithm VF / VT

Adult Pulseless Arrest Algorithm Asystole / PEA

Adult Hypothermia

Pediatric Pulseless Arrest VF / VT

Pediatric Pulseless Arrest Asystole / PEA

Newborn Resuscitation

Adult Allergy and Anaphylaxis

Adult Asthma

Pediatric Respiratory Distress

Pediatric Asthma

Pediatric Croup

Pediatric Allergy and Anaphylaxis

Pediatric Bradycardia

Pediatric Hypothermia Special Considerations

May increase myocardial oxygen demand and angina pectoris. Use with caution in patients with known or suspected CAD

Only a single dose of Epi if suspected Systemic Hypothermia in Pulseless Arrest associated with Asystole, Vfib, VT

Calculating Drip Rate

1 mg = 1000 mcg = 1 mcg / 1 mL = 10 gtt = 1 mL 1000 mL 1000 mL 1 mL / 10 gtt 60 sec 60 sec 2 mcg = 2 mL = 20 gtt = 2 gtt = 1 gtt / 4 mcg = 4 mL = 40 gtt = 2 gtt 2 mL 20 gtt 60 sec 6 sec 3 sec / 4 mL 40 gtt 60 sec 3 sec

Index

222 January 2018

FENTANYL (SUBLIMAZE) Description

Potent synthetic opioid analgesic. Fentanyl is 100 times more potent than morphine. Onset & Duration

Onset: Within 2~3 minutes

Duration: 30 minutes Indications

Moderate to severe pain

The objective of pain management is not the removal of all pain. Use fentanyl to make the patient’s pain tolerable enough to allow for adequate assessment, treatment and transport

Persistent chest pain that is not relieved by 3 doses of SL Nitroglycerine in non- inferior wall MIs and without prior Nitroglycerin in inferior wall MIs.

Contraindications

Hypotension (<90mm Hg Systolic for Adult patients) (Age specific criteria for pediatrics)

The use of parenteral narcotics in the presence of parenteral benzodiazepines is not allowed

Side Effects

Respiratory depression and apnea: May occur suddenly, and is more common in children and the elderly. Capnography should be monitored in the patient if the patient has decreased consciousness or appears sedated after being given fentanyl.

Hypotension, especially when used in combination with other sedatives such as alcohol or benzodiazepines.

Can increase intracranial pressure

Chest wall rigidity has been reported with rapid administration

Pediatric patients may develop apnea without manifesting significant mental status changes

Dosage and Administration

Adult: IV route: 1-2 mcg/kg, SLOW IV bolus. Dose may be repeated after 5 minutes x 1 and titrated to clinical effect to a maximum cumulative dose of 300mcg. Consider lower dose of 0.5-1 mcg/kg in elderly pts over 65 years Any Additional dosing requires CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) IN route: 1-2 mcg/kg IN single dose. Additional dose only via IV route. May give 1 additional dose 5 minutes after initial IN dose up to a maximum cumulative dose of 300mcg. Consider lower dose of 0.5-1 mcg/kg in elderly pts over 65 years. Any Additional dosing requires CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)

Index

223 January 2018

FENTANYL (SUBLIMAZE) cont.

Pediatric (1-12 years): REFERENCE PEDIATRIC FIELD GUIDE

IV route: 1 mcg/kg SLOW IV bolus. Dose may be repeated after 5 minutes and titrated to clinical effect to a maximum cumulative dose of 3 mcg/kg

IN route: 2 mcg/kg IN single dose. Adminisiter a maximum of 1 mL of fluid per nostril Additional dose preferred via IV route. May give 1 additional dose 10 minutes after initial IN dose up to a maximum cumulative dose of 4 mcg/kg

Pediatric < 1 year: REQUIRES CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)

NOTE: IV route is preferred for more accurate titration. Continuous pulse oximetry is mandatory. Capnography should be used if the patients level of consciousness decreases after being given fentanyl to assess for respiratory depression. Frequent evaluation of the patient’s vital signs is also indicated. Emergency resuscitation equipment and naloxone must be immediately available. Protocol Adult Extremity Injuries Adult Amputation Adult Chest Pain Adult Abdominal Pain / vomiting Adult Insect / Arachnid Bite and Stings Adult Snake Bite Adult Face and Neck Trauma Adult Spinal Trauma Adult Chest Trauma Adult Abdominal Trauma Adult Burns Pediatric Abdominal Pain/Vomiting Pediatric Insect / Arachnid Bite and Stings Pediatric Snake Bite Pediatric Amputations Pediatric Face and Neck Trauma Pediatric Spinal Trauma Pediatric Chest Trauma Pediatric Abdominal Trauma Pediatric Burns

Index

224 January 2018

GLUCAGON Description

Increases blood sugar concentration by converting liver glycogen to glucose. Glucagon also causes relaxation of smooth muscle of the stomach, duodenum, small bowel, and colon.

Onset & Duration

Onset: variable Indications

Hypoglycemia BGL < 60 mg/dL and IV access is unavailable.

Hypotension, bradycardia from beta-blocker or calcium channel overdose. Side Effects

Tachycardia

Headache

Nausea and vomiting Dosage and Administration Adult:

Hypoglycemia 1.0 mg, IM Beta Blocker/Calcium Channel overdose for order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) 2.0 mg IV bolus

Pediatric: Reference Pediatric Field Guide

Hypoglycemia 0.1 mg/kg IM. Maximum dose 1.0 mg IM Beta Blocker/Calcium Channel overdose for order CONTACT BASE (AIP, Children’s, TMCA, CMP, SaddleRock) 2.0 mg IV bolus

Protocol

Adult Seizure Pediatric Seizure Adult Overdose / Acute Poisoning Adult Hypoglycemia Pediatric Overdose and Acute Poisoning Pediatric Hypoglycemia

Index

225 January 2018

IPRATROPIUM BROMIDE (ATROVENT) Description

Ipratropium is a anticholinergic antimuscarinic bronchodilator chemically related to Atropine.

Onset & Duration

Onset: 5-15 min. after inhalation

Duration: 6-8 hr. after inhalation Indications

Bronchospasm secondary to asthma and COPD Contraindications

Do not administer to children < 2 years

Soy or peanut allergy is a contraindication to use of Atrovent metered dose inhaler, not the nebulized solution, which does not have the allergen contained in propellant

Adverse Reactions

Palpitations

Tremors

Dry mouth How Supplied

Premixed Container: 0.5 mg in 2.5ml NS Dosage and Administration Not indicated for repetitive dose or continuous neb use Adult Mild- Mod- Severe Bronchospasm:

Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer. Do not repeat.

Child (2yrs – 12yrs) Mild- Mod- Severe Bronchospasm

Ipratropium (0.5 mg/2.5 ml) along with albuterol in a nebulizer. Do not repeat.

Protocol

Adult Asthma

Adult COPD

Pediatric Respiratory Distress

Pediatric Asthma

Index

226 January 2018

MAGNESIUM SULFATE Description

Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. In cardiac patients, it stabilizes the potassium pump, correcting repolarization. It also shortens the Q-T interval in the presence of ventricular arrhythmias due to drug toxicity or electrolyte imbalance. In respiratory patients, it may act as a bronchodilator in acute bronchospasm due to asthma or other bronchospastic diseases. In patients suffering from eclampsia, it controls seizures by blocking neuromuscular transmission and lowers blood pressure as well as decreases cerebral vasospasm.

Indications

Antiarrhythmic

Torsade de pointes associated with prolonged QT interval Respiratory

Severe bronchospasm secondary to asthma; unresponsive to all of the following:

albuterol and ipratropium, continuous albuterol, and IM epinephrine.

Obstetrics

Pregnancy > 20 weeks gestational age with evidence of eclampsia

Precautions

Bradycardia

Hypotension

Respiratory depression Adverse Reactions

Bradycardia

Hypotension

Respiratory depression Dosage and Administration

Torsades de Pointes suspected caused by prolonged QT interval: 2 gm, IV / IO bolus.

Refractory Severe Bronchospasm: For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 2 gm, slow IV

push. Eclampsia:

For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) 2 gm, slow IV push.

Pediatric: Reference Pediatric Field Guide

For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Asthma 25-50mg/kg IV bolus. Maximum dose 2.0 grams

Protocol

Adult Pulseless Arrest Algorithm VF / VT

Adult Asthma

Adult Eclampsia

Adult Seizure

Pediatric Asthma

Index

227 January 2018

METHYLPREDNISOLONE (SOLU-MEDROL) Description

Methylprednisolone is a synthetic steroid that suppresses acute and chronic inflammation and may alter the immune response. In addition, it potentiates vascular smooth muscle relaxation by beta-adrenergic agonists and may alter airway hyperactivity.

Indications

Anaphylaxis

Severe asthma

COPD

Shock with history of adrenal insufficiency Contraindications

Evidence of active GI bleed

Adverse Reactions

Most adverse reactions are a result of long-term therapy and include:

Gastrointestinal bleeding

Hypertension

Hyperglycemia Dosage and Administration

Anaphylaxis, Severe Asthma, COPD: After primary treatment priorities are completed Adult:

125 mg, Slow IV Push

Pediatric: Reference Pediatric Field Guide 2.0 mg/kg Slow IV Push, Maximum dose 60.0 mg Shock with history of adrenal insufficiency: Adult:

125 mg, Slow IV Push, IO slowly Pediatric: Reference Pediatric Field Guide

2.0 mg/kg Slow IV Push , IO slowly. Maximum dose 125mg Protocol

Adult Asthma

Adult COPD

Adult Allergy and Anaphylaxis

Adult Adrenal Insufficiency

Pediatric Asthma

Pediatric Allergy and Anaphylaxis

Pediatric Adrenal Insufficiency

Index

228 January 2018

METHYLPREDNISOLONE (SOLU-MEDROL) Special Considerations

Must be reconstituted and used immediately

The effect of methylprednisolone is generally delayed for several hours.

Methylprednisolone is not considered a first line drug. Be sure to attend to the patient’s primary treatment priorities (i.e. airway, ventilation, beta-agonist nebulization, fluid bolus) first. If primary treatment priorities have been completed and there is time while in route to the hospital, then methylprednisolone can be administered. Do not delay transport to administer this drug

Index

229 January 2018

MIDAZOLAM (Versed) Description

Midazolam HCl is a water-soluble short acting benzodiazepine sedative-hypnotic. It is believed that benzodiazepines exert their effect on the GABA receptor to create anxiolysis, sedation and muscle relaxation.

Indications

Seizures > 5min or multiple seizures

Eclampsia

Sedation of the combative or Excited Delirium patient

Sedation prior to Synchronized Cardioversion Contraindications

Hypotension (<90mm Hg Systolic for Adult patients) (Age specific criteria for pediatrics) Adverse Reactions

Respiratory depression, including apnea. Capnography should be applied to the patient if the patient has decreased consciousness or appears sedated after being given Versed

Hypotension

Sedative effect of midazolam may be heightened by associated use of opioids, alcohol, or other CNS depressants.

Dosage and Administration

Sedation of combative patient: Adult:

Standing order of 2mg IV or 5mg IM / IN. May repeat x 1 in 5 minutes For third dose CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) *In elderly pts over 65 years or small adults <50kg administer ½ dose.

Pediatric: Reference Pediatric Field Guide

0.1 mg/kg, IV / IM For order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)

Seizure / Eclampsia: Adult:

2mg IV may repeat x 1 in 5 minutes. Total of 2 doses. 5mg IM / IN may repeat x 1 in 5 minutes. Total of 2 doses. For additional dosing CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)

Pediatric: Reference Pediatric Field Guide

0.1 mg/kg, IV / IM may repeat x1 in 5 minutes. Maximum single dose 2 mg. 0.2 mg/kg, IN (divided into each nare may repeat x1 in 5 minutes. Maximum

single dose 5 mg. For additional dosing CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)

Index

230 January 2018

MIDAZOLAM (Versed) cont.

Excited Delirium

Adult: STANDING ORDER of: Initial dose of 2mg IV. REPEAT doses of 2mg IV in 5 minutes x 2 for a MAX of up to 6mg IV.

OR Initial dose of 10mg IM / IN. Additional doses of 5mg IM / IN x 2. For MAX of up to 20mg IM / IN. Synchronized Cardioversion:

Pacing

Adult: One time dose of 2mg IV or 5mg IM/IN

Pediatric: Contact Base

Synchronized Cardioversion

Adult: One time dose of 2mg IV or 5mg IM/IN prior to shock Pediatric: Contact Base

Protocol

Synchronized Cardioversion

Adult Tachycardia

Transcutaneous Pacing

Adult Seizure

Adult Eclampsia

Pediatric Seizure

Adult Combative Patient

Excited Delirium

Special Considerations

Provide continuous cardiac and pulse-oximetry monitoring

Capnography should be applied to the patient if the patient has decreased consciousness or appears sedated after being given Versed

Have resuscitation equipment readily at hand.

Due to increased risk of hypotension and respiratory depression, the use of parenteral benzodiazepines in the presence of parenteral narcotics is not allowed

In elderly patients > 65 years old or small adults < 50kg, administer ½ dose.

Index

231 January 2018

NALOXONE (NARCAN) Description

Naloxone is a competitive opioid receptor antagonist

Onset & Duration Onset: Within 5 minutes Duration: Approximately 1 hour

Indications

For reversal of suspected opioid-induced respiratory depression

Not Indicated for routine treatment of Pulseless arrest Adverse Reactions

Tachycardia

Nausea and vomiting

Pulmonary Edema Dosage and Administration

Adult: 0.5 mg IV / IN / IO q 3 min until patient is breathing spontaneously (10-12/min) In Adult cases where IV / IN access is not feasible, 2 mg bolus IM is appropriate

Pediatric: Reference Pediatric Field Guide

0.5 mg IV / IN / IO q 3 min until patient is breathing spontaneously Protocol

Altered Mental Status

Adult Overdose / Acute Poisoning

Pediatric Altered Mental Status

Pediatric Overdose / Acute Poisoning Special Considerations

No maximum limit

Not intended for use unless respiratory depression or impaired airway reflexes are present. Reversal of suspected mild-moderate opioid toxicity is not indicated in the field as it may greatly complicate treatment and transport as narcotic-dependent patients may experience violent withdrawal symptoms

Patients receiving EMS administered naloxone should be transported to a hospital.

In the State of Colorado, bystanders, law enforcement, and other first responders can administer naloxone if they feel a person is experiencing an opiate-related drug overdose event (Colorado Revised Statutes §12-36-117.7).

There are significant concomitant inherent risks in patients who have received naloxone, including:

o Recurrent respiratory/CNS depression given short half-life of naloxone o Co-existing intoxication from alcohol or other recreational or prescription drugs o Acetaminophen toxicity from combination opioid/acetaminophen prescriptions o Non-cardiogenic pulmonary edema associated with naloxone use o Acute psychiatric decompensation, overdose, SI/HI or psychosis requiring ED

evaluation

Index

232 January 2018

o Sudden abrupt violent withdrawal symptoms which may limit decision making capacity (continued next page)

Given the above risks, it is strongly preferred that patients who have received naloxone be transported and evaluated by a physician. However, if the patient clearly has decision-making capacity he/she does have the right to refuse transport. If adamantly refusing, patients must be warned of the multiple risks of refusing transport.

If the patient is refusing transport contact base. If any concerns or doubts about decision-making capacity exist, err on the side of transport.

Index

233 January 2018

NERVE AGENT KIT (DUODOTE) Description

A streamlined, easy-to-use replacement for the Mark I™Kit. FDA approved for Emergency Medical Services (EMS) use in the treatment of organophosphorus nerve agent and organophosphorus insecticide poisoning. Contains two antidotes in 1 auto-injector; 2.1 mg of Atropine in a 0.7-mL solution and 600 mg of pralidoxime chloride in a 2-mL solution. Delivered sequentially into separate areas of the muscle–Easy to use: only 1 injection with 1 needle

Onset & Duration

Onset: Within 5 minutes Duration: 1-4 hours

Indications

Treatment of poisoning by organophosphorus nerve agents as well as organophosphorus insecticides. Should be administered as soon as symptoms of organophosphorus poisoning appear.

Adverse Reactions

Tachycardia

Nausea and vomiting

Pulmonary Edema Dosage and Administration MILD symptoms:

Blurred vision, miosis (excessive constriction of the pupils) Excessive, unexplained teary eyes Excessive, unexplained runny nose Increased salivation such as sudden drooling Chest tightness or difficulty breathing Tremors throughout the body or muscular twitching Nausea and/or vomiting Unexplained wheezing, coughing, or increased airway secretions Acute onset of stomach cramps Tachycardia or bradycardia

Treatment for MILD Symptoms:

FIRST DOSE: In the situation of known or suspected organophosphorus poisoning, administer one DuoDote™ injection into the mid-outer thigh if the patient experiences two or more MILD symptoms of nerve gas or insecticide exposure Wait 10 to 15 minutes for DuoDote™ to take effect. If, after 10 to 15 minutes, the patient does not develop any SEVERE symptoms, no additional DuoDote™ injections are recommended, but definitive medical care should ordinarily be sought immediately. ADDITIONAL DOSES: If, at any time after the first dose, the patient develops any SEVERE symptoms, administer two additional DuoDote™ injections in rapid succession, and immediately seek definitive medical care

Index

234 January 2018

NERVE AGENT KIT (DUODOTE) cont. SEVERE Symptoms:

Strange or confused behavior Severe difficulty breathing or copious secretions from lungs/airway Severe muscular twitching and general weakness Involuntary urination and defecation Convulsions Loss of consciousness Respiratory arrest (possibly leading to death)

Treatment for SEVERE Symptoms:

Immediately administer three DuoDote™ injections into the patient’s mid-outer thigh in rapid succession, and immediately transport. No more than 3 doses of DuoDote™ should be administered unless definitive medical care is available.

Protocol

Adult Overdose / Acute Poisoning

Pediatric Overdose and Acute Poisoning Special Considerations Before injecting

Tear open plastic pouch at any of the notches, and remove the DuoDote™ Auto-Injector Place DuoDote™ in your dominant hand and firmly grasp it, with the Green Tip pointing downward With your other hand, pull off the Gray Safety Release, taking care never to touch the Green Tip Keep fingers clear of both ends of the auto-injector

You are now ready to inject Select site and inject The injection site is the mid-outer thigh area. You can inject through clothing, but make sure that pockets are empty Firmly push Green Tip straight down (at a 90ºangle) against mid-outer thigh, continuing to push firmly until you feel the auto-injector trigger After the DuoDote™ Auto-Injector triggers, hold it firmly in place against the injection site for 10 seconds

After injecting Remove the DuoDote™ Auto-Injector from thigh and inspect the Green Tip; if the needle is visible, then the injection was successful If the needle is not visible, make sure the Gray Safety Release is removed and repeat the preceding injection steps Push the exposed needle against a hard surface until it bends back, then put the used auto-injector back in the plastic pouch Keep used auto-injector(s) with the patient so other medical personnel will be aware of how many injections were administered

Index

235 January 2018

NITROGLYCERINE (NITROSTAT, etc) Description

Short-acting peripheral vasodilator decreasing cardiac preload and afterload Onset & Duration

Onset: 1-3 min. Duration: 20-30 min.

Indications

Pain or discomfort due to suspected Acute Coronary Syndrome

Pulmonary edema due to congestive heart failure

Contraindications SBP < 100 Recent use (48 hours) of erectile dysfunction (ED) medication (e.g. Viagra, Cialis) Patients with pulmonary hypertension who are taking Revatio. Inferior STEMI Pattern (ST elevation II, III, aVF)

Adverse Reactions

Hypotension

Headache

Syncope Dosage and Administration

0.4 mg (1/150 gr) sublingually or spray, every 4 minutes PRN up to a total of 3 doses

Protocol

Adult Chest Pain

Adult CHF / Pulmonary Edema

Index

236 January 2018

ONDANSETRON (ZOFRAN) Description

Ondansetron is a selective serotonin 5-HT3 receptor antagonist antiemetic. Indications

Nausea and/or vomiting Contraindications

None Dosage and Administration

Adult: 4 mg IV/IM/PO. May repeat x 1 dose as needed.

Pediatric less than 4 years old: Reference Pediatric Field Guide 2 mg IV

Pediatric greater than 4 years old: Reference Pediatric Field Guide 4 mg IV/IM/PO

Protocol

Adult Abdominal Pain/Vomiting

Pediatric Abdominal Pain/Vomiting

Index

237 January 2018

ORAL GLUCOSE (GLUTOSE, INSTA-GLUCOSE) Description

Glucose is the body's basic fuel and is required for cellular metabolism Indications

Known or suspected hypoglycemia (BGL < 60 mg/dL) and able to take PO Contraindications

Inability to swallow or protect airway Unable to take PO meds for another reason

Administration

One full tube 15 g buccal.

Protocol

Altered Mental Status

Adult Hypoglycemia

Pediatric Altered Mental Status

Pediatric Hypoglycemia

Index

238 January 2018

OXYGEN Description

Oxygen added to the inspired air increases the amount of oxygen in the blood, and thereby increases the amount delivered to the tissue. Tissue hypoxia causes cell damage and death. Breathing, in most people, is regulated by small changes in the acid-base balance and CO2 levels. It takes relatively large decreases in oxygen concentration to stimulate respiration.

Indications

Low / Moderate flow O2 for the following: o All patients unable to achieve SpO2 > 90% on room air

Titrate to goal of > 90%

High flow O2 for the following: o BVM o Hypotension/shock states from any cause o Multi-systems Trauma o Suspected carbon monoxide poisoning o Obstetrical complications, childbirth o All patients unable to achieve SpO2 > 90% with low/moderate flow oxygen

Titrate to goal of > 90%

Administration

Flow LPM Dosage Low Flow 1-2 LPM Moderate Flow 3-9 LPM High Flow 10-15 LPM

Special Notes

Do not use permanently mounted humidifiers. If the patient warrants humidified oxygen, use a single patient use device.

Adequate oxygenation is assessed clinically and with the SpO2 while adequate ventilation is assessed clinically and with Waveform Capnography.

If the patient is not breathing adequately, the treatment of choice is assisted ventilation, not just oxygen.

Do not withhold oxygen from a COPD patient out of concerns for loss of hypoxic respiratory drive. This is never a concern in the prehospital setting with short transport times

Index

239 January 2018

PHENYLEPHRINE (INTRANASAL) Description

Used for topical nasal administration, phenylephrine primarily exhibits alpha adrenergic stimulation. This stimulation can produce moderate to marked vasoconstriction and subsequent nasal decongestion.

Indications

Prior to nasotracheal intubation to induce vasoconstriction of the nasal mucosa

Nose bleed Precautions

Avoid in pts with known CAD

Avoid administration into the eyes, which will dilate pupil Dosage and Administration

Instill two drops of 1% solution in the nostril prior to attempting nasotracheal intubation

Administer 2 sprays in affected naris in patient with active nosebleed after having patient blow nose to expel clots.

Protocol

Nasotracheal intubation

Adult Epistaxis

Pediatric Epistaxis

Index

240 January 2018

RACEMIC EPINEPHRINE (VAPONEPHRINE) Description

Racemic epinephrine is an epinephrine preparation in a 1:1000 dilution for use by oral inhalation only. Inhalation causes local effects on the upper airway as well as systemic effects from absorption. Vasoconstriction may reduce swelling in the upper airway, and ß effects on bronchial smooth muscle may relieve bronchospasm.

Onset & Duration

Onset: 1-5 minutes

Duration: 1-3 hours Indications

Stridor at rest Side Effects

Tachycardia

Palpitations Dosage and Administration

0.5 ml racemic epinephrine (acceptable dose for all ages) mixed in 2 ml saline, via nebulizer at 6-8 LPM to create a fine mist

Protocol

Pediatric Respiratory Distress

Pediatric Croup Special Considerations

Racemic epi is heat and photo-sensitive

Do not confuse the side effects with respiratory failure or imminent respiratory arrest.

Index

241 January 2018

SODIUM BICARBONATE Description

Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. Acids are increased when body tissues become hypoxic due to cardiac or respiratory arrest.

Indications

Not indicated for routine treatment of pulseless arrest

Pulseless arrest associated with any of the following clinical conditions: o Known hyperkalemia o Renal failure with or without hemodialysis history o To be administered after Calcium Gluconate or Calcium Chloride

Must flush IV / IO line between meds.

Tricyclic overdose with arrhythmias, widened QRS complex, hypotension, seizures

Contraindications

Metabolic and respiratory alkalosis

Hypocalcemia

Hypokalemia Adverse Reactions

Metabolic alkalosis

Hyperosmolarity may occur, causing cerebral impairment Dosage and Administration

Adults Tricyclic OD with hypotension or prolonged QRS > 0.10 sec

1.0 mEq/kg slow IV/IO push Repeat if needed in 10 minutes.

Pediatrics (>10kg) Reference Pediatric Field Guide (purple or larger) Tricyclic OD with hypotension or prolonged QRS > 0.10 sec

1.0 mEq/kg slow IV / IO push Repeat if needed in 10 minutes.

Pediatrics (<10kg) Reference Pediatric Field Guide For Order CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock) Requires Dilution

Suspected hyperkalemia-related pulseless arrest in ADULT:

To be administered after Calcium Chloride or Calcium Gluconate

Must flush IV / IO line between meds

2 amps IV / IO Suspected hyperkalemia-related pulseless arrest in PEDIATRIC: For order CONTACT BASE (AIP, Children’s, TMCA)

Index

242 January 2018

SODIUM BICARBONATE Protocol

Adult Pulseless Arrest Algorithm VF / VT

Adult Pulseless Arrest Algorithm Asystole / PEA

Adult Overdose / Acute Poisoning

Pediatric Overdose and Acute Poisoning

Drug Interactions

May precipitate in calcium solutions.

Alkalization of urine may increase half-lives of certain drugs.

Vasopressors may be deactivated. Special Considerations

Sodium bicarbonate administration increases CO2 which rapidly enters cells, causing a paradoxical intracellular acidosis.

Sodium bicarb is no longer recommended for routine use in prolonged cardiac arrest. Its use in pulseless arrest should be limited to known or suspected hyperkalemia (e.g. dialysis patient).

Index

243 January 2018

TOPICAL OPHTHALMIC ANESTHETICS Description

Used for topical administration as a pain reliever for eye irritation. Only proparacaine and tetracaine are approved for use.

Indications

Pain secondary to eye injuries and corneal abrasions

Topical anesthetic to facilitate eye irrigation Contraindications

Known allergy to local anesthetics

Globe lacerations or rupture Precautions

Transient burning/stinging when initially applied

Dosage and Administration

Instill two drops into affected eye. For repeat dose: required to CONTACT BASE (AIP, Children’s, TMCA, CMP, Saddle Rock)

Protocol

May be used for the above listed indications as needed Special Considerations

This is single patient use. Unused portions are to be discarded and only new bottles are to be used.

Do not administer until patient consents to transport and transport has begun

Topical ophthalmic anesthetics should never be given to a patient for self-administration

Index

244 January 2018

Performance Criteria

Skills Demonstration 0-2 MINUTES (BLS Airway) Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck. Compressor uses Q-CPR information displayed on MRx to give effective compressions

At least 100 compressions per minute At least 2 inches deep Allow full recoil Once deployed, use Q-CPR for duration of the arrest

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

2-4 MINUTES (ALS Airway) New Compressor uses Q-CPR information displayed on MRx to give effective compressions

At least 100 compressions per minute At least 2 inches deep Allow full recoil

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

Core Competency

Adult Medical Arrest – Compressor

Index

245 January 2018

Performance Criteria

Skills Demonstration 0-2 MINUTES (BLS airway) Correctly size and insert an OPA Connect Waveform Capnography to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique, give the pt 1 breath every 6 seconds

First rescuer squeezes bag 1 breath every 6 seconds Second rescuer seals mask to pt’s face use “C-E” Technique

2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography Once i-gel O2 Airway is in place:

Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds

Second rescuer to set up IV/IO or other task as assigned by attending paramedic

4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography 6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography

Core Competency

Adult Medical Arrest – Ventilator

Index

246 January 2018

Performance Criteria

Skills Demonstration 0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in medical arrest Delegates a rescuer to begin chest compressions Delegates 2 rescuers to begin ventilations Turn MRx energy level to 150J. Hand CPR puck to the Compressor Apply Combo Pads – If arrest witnessed by EMS, Correctly interpret and treat rhythm Verifies appropriate compressions and ventilations At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 2-4 MINUTES (Advanced Airway) Directs resumption of compressions and ventilations if needed Delegates or places i-gel O2 Airway and inserts suction catheter Connect Waveform Capnography to the i-gel O2 Airway Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 4-6 MINUTES (IV/IO access) Directs resumption of compressions and ventilations if needed Delegates or places IV/IO Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 6-8 MINUTES (Medication Administration) Directs resumption of compressions and ventilations if needed Delegates or administers indicated medication(s) Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm

Core Competency

Adult Medical Arrest – Lead Paramedic

Index

247 January 2018

Performance Criteria

0-2 MINUTES (BLS Airway) Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck. Pumper uses Q-CPR information displayed on MRx to give effective compressions

At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest

Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

2-4 MINUTES (Advanced Airway) Continue using Q-CPR

At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest

Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

4-6 MINUTES (IV/IO access) Continue using Q-CPR

At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest

Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

6-8 MINUTES (Medication Administration) Continue using Q-CPR

At least 100 compressions per minute At least 2 inches deep Once deployed, use Q-CPR for duration of the arrest

Call out times: At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

Core Competency

Adult Traumatic Arrest – Compressor

Index

248 January 2018

Performance Criteria

0-2 MINUTES (BLS airway) Maintain manual in-line stabilization if indicated Correctly size and insert an OPA Connect Waveform Capnography to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique, give the pt 1 breath every 6 seconds

First rescuer squeezes bag 1 breath every 6 seconds Second rescuer seals mask to pt’s face use “C-E” Technique

2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography Once i-gel O2 Airway is in place:

Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds

Second rescuer to set up IV/IO or other task as assigned by attending paramedic

4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilation using Waveform Capnography

6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography

Core Competency

Adult Traumatic Arrest – Ventilator

Index

249 January 2018

Performance Criteria

0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in traumatic arrest Delegates or controls life threatening external bleeding Delegates a rescuer to begin continuous chest compressions Delegates 2 rescuers to begin ventilations ( 1 breath every 6 seconds) with inline spinal immobilization if indicated Hand CPR puck to the Compressor Place patient on MRx (interpret EKG)

Prepare for immediate transport or

Contact Base if asystole Perform physical exam Address life threatening injuries Verify continuous compressions and ventilations ( 1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 2-4 MINUTES (Advanced Airway) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Direct or places i-gel O2 Airway with suction catheter Connect Waveform Capnography to i-gel O2 Airway Verify effective ventilations ( 1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors Address life threatening injuries 4-6 MINUTES (Needle Decompression if indicated) Directs resumption of continuous compressions and ventilations ( 1 breath every 6 seconds) Perform bilateral needle thoracostomy for trunk trauma At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

6-8 MINUTES (IV/IO) (Fluid Administration) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Directs or places IV/IO Directs or administers fluid bolus(s) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

Core Competency

Adult Traumatic Arrest – Lead Paramedic

Index

250 January 2018

Performance Criteria

0-2 MINUTES (BLS Airway) Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck if indicated. Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

2-4 MINUTES (Advanced Airway) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Switch to continuous compressions after advanced airway placement 4-6 MINUTES (IV/IO access)

New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

Core Competency

Pediatric (<12years) Medical Cardiac Arrest - Compressor

Index

251 January 2018

6-8 MINUTES (Medication Administration) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth – 1 month, 3:1 compression to ventilation ration 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

Core Competency

Pediatric (<12years) Medical Cardiac Arrest - Compressor

Index

252 January 2018

Performance Criteria

0-2 MINUTES (BLS airway) Correctly size and insert an OPA Connect Waveform Capnography to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique

Pt age >1 month to 12 years First rescuer uses 15:2 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique

Pt age birth to 1 month First rescuer uses 3:1 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique

2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed Verify effective ventilations using Waveform Capnography Once i-gel O2 Airway is in place:

Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds

Second rescuer to set up IV/IO or other task as assigned by attending paramedic

4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography 6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography

Core Competency

Pediatric (<12years) Medical Cardiac Arrest - Ventilator

Index

253 January 2018

Performance Criteria

0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in medical arrest Delegates a rescuer to begin chest compressions (15:2) for pt 1month – 12 years Delegates a rescuer to begin chest compressions (3:1) for pt birth – 1 month Delegates 2 rescuers to begin ventilations (15:2)(3:1) Measure patient with Length Based Tape – Determine patient’s “color” Use AFD Pediatric Field Guide for appropriate interventions, therapies, etc Monitor turned on to appropriate energy level Hand CPR puck to the Compressor (Length Based Tape color “purple” or longer) Apply Combo Pads – Anterior / Posterior placement recommended Verifies appropriate compressions and ventilations At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 2-4 MINUTES (Advanced Airway) Directs resumption of compressions and ventilations (15:2)(3:1), if needed Delegates or places i-gel O2 Airway as indicated in AFD Pediatric Field Guide Connect Waveform Capnography to igel-O2 Airway. Verify effective ventilations Verifies switch to continuous compressions and appropriate ventilatory rate (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 4-6 MINUTES (IV/IO access) Directs resumption of compressions and ventilations, if needed Directs or places IV/IO Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm 6-8 MINUTES (Medication Administration) Directs resumption of compressions and ventilations, if needed Directs or administers indicated medication(s) Verifies appropriate compressions and ventilations (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 1 minute and 45 seconds charge monitor At 2 minutes ensures hands-off patient for rhythm check 5-10 second pre-shock pause for rhythm identification Correctly interpret and treat rhythm

Core Competency

Pediatric (<12years) Medical Cardiac Arrest – Lead Paramedic

Index

254 January 2018

Performance Criteria

Skills Demonstration 0-2 MINUTES (BLS airway) Correctly size and insert an OPA Connect Waveform Capnography to MRx and BVM Connect BMV to O2 source, set regulator to 15 lpm Using 2-rescuer Technique

Pt age >1 month to 12 years First rescuer uses 15:2 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique

Pt age birth -1 month First rescuer uses 3:1 compression to ventilation ratio Second rescuer seals mask to patients face with “C-E” Technique

2-4 MINUTES (ALS airway) Continue using 2-rescuer BVM Technique until i-gel O2 airway placed Verify effective ventilations using Waveform Capnography Once i-gel O2 Airway is in place:

Switch to 1 rescuer BVM Technique. First rescuer gives pt 1 breath every 6 seconds

Second rescuer to set up IV/IO or other task as assigned by attending paramedic

4-6 MINUTES (ALS airway) Continue with 1 rescuer BVM technique (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography 6-8 MINUTES (ALS airway) Continue with 1 rescuer BVM (1 breath every 6 seconds) Verify effective ventilations using Waveform Capnography

Core Competency Pediatric (<12years)

Pediatric Trauma Arrest – Ventilator

Index

255 January 2018

Performance Criteria Skills Demonstration 0-2 MINUTES (BLS Airway) Start Chest Compressions Paramedic will set up the MRx and hand Compressor the CPR puck if indicated (please see AFD Pediatric Field Guide). Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

2-4 MINUTES (Advanced Airway) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Switch to continuous compressions after advanced airway placement 4-6 MINUTES (Needle Decompression-if indicated) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

6-8 MINUTES (Fluid Administration) New Compressor uses Q-CPR information displayed on MRx to give effective compressions (Length Based Tape purple and longer)

Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio 2 inches deep or 1/3 the depth of the chest. Allow complete recoil

Call out times: At 1 minute and 30 seconds At 1 minute and 45 seconds At 2 minutes hands-off patient and rotate to new assigned task

Core Competency Pediatric (<12years)

Pediatric Trauma Arrest – Compressor

Index

256 January 2018

Performance Criteria

Skills Demonstration 0-2 MINUTES (BLS) Check patient’s responsiveness, breathing and pulse – verify pt is in traumatic arrest Delegates or controls life threatening external bleeding Delegates a rescuer to begin chest compressions Pt age > 1 month to 12 years, 15:2 compression to ventilation ratio Pt age birth - 1 month, 3:1 compression to ventilation ratio Delegates 2 rescuers to begin ventilations utilizing Waveform Capnography . Maintain in line spinal stabilization if indicated Measure patient with Length Based Tape – Determine patient’s “color” Use AFD Pediatric Field Guide for appropriate interventions, therapies, etc Hand CPR puck to the Compressor (Length Based Tape color “purple” or longer) Place patient on MRx (interpret EKG)

Prepare for immediate transport or

Contact Base if asystole

Perform physical exam Address life threatening injuries Verify continuous compressions and ventilations At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors 2-4 MINUTES (Advanced Airway) Directs resumption of compressions and ventilations (15:2)(3:1), if needed Delegates or places i-gel O2 Airway as indicated in AFD Pediatric Field Guide Verifies that Waveform Capnography is being utilized with the i-gel O2 Verifies switch to continuous compressions and appropriate ventilatory rate (1 breath every 6 seconds) At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors Address life threatening injuries 4-6 MINUTES (Needle Decompression if indicated) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Perform bilateral needle thoracostomy for trunk trauma At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

6-8 MINUTES (IV/IO) (Fluid Administration) Directs resumption of continuous compressions and ventilations (1 breath every 6 seconds) Directs or places IV/IO Directs or administers fluid bolus(s), bolus amount as indicated in the AFD Pediatric Field Guide. At 1 minute and 30 seconds plan rotation of personnel At 2 minutes switch compressors

Core Competency Pediatric (< 12years)

Pediatric Trauma Arrest – Lead Paramedic

Index