ALS Protocols Complete-RAPID CITY PDF

RAPID CITY PENNINGTON COUNTY ADVANCED LIFE SUPPORT PROTOCOLS
These protocols are effective as of August 2009
Pre-hospital Emergency Medical Services in the Rapid City metro and Pennington County area have evolved dramatically in the past decade. Since the first major revision of these Advanced Life Support (Paramedic) Protocols, what were once a few pages in a notebook have mushroomed into a formidable volume. The current revision of these protocols is a compilation of input from multiple sources local, national and international. Our practice of pre-hospital emergency medicine is second-to-none. In an increasingly sophisticated and technologybased environment, a special thanks goes to those dedicated individuals who take the knowledge condensed herein and provide a critical service for our community. It should always be remembered that protocols define process, people provide care. As always, these protocols are an evolving project. We invite your comments and suggestions. Sincerely, John M. Rud, M.D., F.A.C.E.P
Rapid City and Pennington County Pre-hospital Advanced Life Support Protocols
RECEIPT OF PROTOCOL ACKNOWLEDGEMENT This is to certify that the undersigned has received the Rapid City and Pennington County Pre-hospital Advanced Life Support Protocols, and accepts the responsibility for knowing and practicing in accordance with these protocols.
Name (please print)
Date
Signature
Rapid City Department of Fire and Emergency Services Paramedics
INTRODUCTION This protocol manual represents the foundation for the clinical standards of the Pre-hospital Emergency Medical Services system in Rapid City and Pennington County. The process which resulted in the construction of this set of protocols will remain in place and these protocols will continue to be edited and revised to reflect the dynamic role of Pre-hospital Emergency Medical Services within the medical care community. Section 1. contains the Patient Assessment Protocols. Section 2. contains the Medical Treatment Protocols. Section 3. contains the Trauma Treatment Protocols. Section 4. contains the Environmental Injury Treatment Protocols. The Treatment Protocols are divided into adult and pediatric sections, each with two parts: I. II. Level I. treatment is an intervention that can performed without contacting medical control. (Designated by Roman numeral I.) Level II. treatment is an intervention that requires contact with Medical Control prior to performing. (Designated by red Roman numeral II.)
Section 5. contains the Procedure Protocols. The Procedure protocols where applicable, include a description of Indications, Precautions, Techniques, and Complications for procedures approved for use in the Rapid City/Pennington County EMS System. Procedure Protocols will in some instances include Level I. and Level II. interventions. Section 6. contains the Operational Protocols required for effective clinical and tactical EMS operations in the Rapid City/Pennington County EMS system. Section 7. contains Drug Summaries. The Drug Summaries include a description of Actions, Indications, Contraindications, Side Effects, Dosages (adult and pediatric if applicable) and available forms of those drugs approved for use in the Rapid City/Pennington County EMS System. Section 8. contains a full list of tables and illustrations.
Rapid City Department of Fire and Emergency Services Paramedics
INDEX ADVANCED LIFE SUPPORT PROTOCOLS
Page
Definitions .................................................................................................................... 1-1 1. Patient Assessment Assessment-Trauma Patient, Primary Survey................................................... 1-3 Assessment-Trauma Patient, Secondary Survey.............................................. 1-5 Assessment-Medical Patient ............................................................................. 1-8 Assessment-Pediatric Patient ........................................................................... 1-9 Assessment-Neurologic .................................................................................. 1-11 Patient History................................................................................................. 1-14 Treatment Protocols - Medical Protocol 2.1: General Supportive Care............................................................ 2-1 Protocol 2.2: Abdominal Pain .......................................................................... 2-6 ACLS core protocols Protocol 2.3: Asystole .................................................................................... 2-7 Protocol 2.4: Bradycardia ............................................................................ 2-10 Protocol 2.5: Narrow-Complex Tachycardia ................................................ 2-12 Protocol 2.6: Neonatal Resuscitation .......................................................... 2-15 Protocol 2.7: Premature Ventricular Ectopy................................................. 2-17 Protocol 2.8: Pulseless Electrical Activity, (PEA) ........................................ 2-19 Protocol 2.9: Ventricular Fibrillation / Pulseless Ventricular Tachycardia .... 2-22 Protocol 2.10: Wide-Complex Tachycardia with Pulse .................................. 2-25 Protocol 2.11: Airway Obstruction ................................................................... 2-28 Protocol 2.12: Allergic Reaction / Anaphylaxis ................................................ 2-30 Protocol 2.13: Asthma ..................................................................................... 2-32 Protocol 2.14: Behavioral / Psychiatric ............................................................ 2-33 Protocol 2.15: Cardiogenic Shock ................................................................... 2-35 Protocol 2.16: Chest Pain................................................................................ 2-36 Protocol 2.17: Coma / Altered Mental Status .................................................. 2-38 Protocol 2.18: COPD....................................................................................... 2-40 Protocol 2.19: Diabetic Emergencies .............................................................. 2-42 Protocol 2.20: Drug Overdose / Ingestion / Poisoning..................................... 2-44 Protocol 2.21: Hypertensive Emergencies ...................................................... 2-49 Protocol 2.22: OB / GYN ................................................................................. 2-51 Protocol 2.23: Pulmonary Edema.................................................................... 2-55 Protocol 2.24: Seizures and Status Epilepticus ............................................... 2-56 Protocol 2.25: Sudden Infant Death Syndrome (SIDS) ................................... 2-58 Protocol 2.26: Syncopal Episode..................................................................... 2-59
2.
INDEX (CONT.) ADVANCED LIFE SUPPORT PROTOCOLS

3. Page Treatment Protocols - Trauma Protocol 3.1: Trauma and Hypovolemic Supportive Care................................. 3-1 Protocol 3.2: Abdominal / Pelvic Trauma ......................................................... 3-6 Protocol 3.3: Amputation .................................................................................. 3-8 Protocol 3.4: Burns......................................................................................... 3-10 Protocol 3.5: Chest Trauma ........................................................................... 3-17 Protocol 3.6: Extremity Injuries....................................................................... 3-20 Protocol 3.7: Eye Injuries ............................................................................... 3-22 Protocol 3.8: Head Trauma ............................................................................ 3-24 Protocol 3.9: Spinal Trauma........................................................................... 3-27 Protocol 3.10:Trauma Cardiac Arrest .............................................................. 3-29 Treatment Protocols Environmental Injury Protocol 4.1: Bites and Stings .......................................................................... 4-1 Protocol 4.2: Drowning / Near Drowning .......................................................... 4-3 Protocol 4.3: Hyperthermia............................................................................... 4-6 Protocol 4.4: Hypothermia and Frostbite .......................................................... 4-8 Procedure Protocols Protocol 5.1: Airway Management: General Principles ................................... 5-1 Protocol 5.2: Airway Management: Assisting Ventilation................................. 5-4 Protocol 5.3: Airway Management: Clearing and Suctioning the Airway ......... 5-6 Protocol 5.4: Airway Management: Obstructed Airway ................................... 5-9 Protocol 5.5: Airway Management: Opening the Airway ............................... 5-12 Protocol 5.6: Advanced Airway Management: Combitube ............................ 5-15 Protocol 5.7: Advanced Airway Management: Orotracheal Intubation .......... 5-19 Protocol 5.8: Advanced Airway Management: Nasotracheal Intubation ........ 5-24 Protocol 5.9: Advanced Airway Management: Rapid-Sequence Induction.... 5-28 Protocol 5.10: Advanced Airway Management: Needle Cricothyrotomy ......... 5-33 Protocol 5.11: Advanced Airway Management: Surgical Cricothyrotomy........ 5-37 Protocol 5.12: CPAP ....................................................................................... 5-41 Protocol 5.13: Defibrillation ............................................................................. 5-44 Protocol 5.14: Endotracheal Drug Administration............................................ 5-47 Protocol 5.15: External (Transcutaneous) Cardiac Pacing.............................. 5-49 Protocol 5.16: Glucose Level Determination ................................................... 5-53 Protocol 5.17: Intraosseous Infusion (Jamshidi & EZ-IO)................................ 5-56 Protocol 5.18: Medication Administration ........................................................ 5-64 Protocol 5.19: Nebulized Bronchodilators ....................................................... 5-68 Protocol 5.20: Pain Management .................................................................... 5-70 Protocol 5.21: Peripheral IV Line Insertion ...................................................... 5-72 Protocol 5.22: Restraint (Physical and Chemical) ........................................... 5-75 Protocol 5.23: Saline Lock Insertion ................................................................ 5-79
4.
5.

5. Page Procedure Protocols (Cont.) Protocol 5.24: Spinal Immobilization ............................................................... 5-80 Protocol 5.25: Splinting, Extremity................................................................... 5-84 Protocol 5.26: Stroke (CVA) Stroke Alert ...................................................... 5-87 Protocol 5.27: Tension Pneumothorax Decompression .................................. 5-89 Protocol 5.28: Trauma Alert ............................................................................ 5-93 Protocol 5.29: 12 Lead ECG ........................................................................... 5-95 Operational Protocols Protocol 6.1: Advanced Directives / DNR Orders............................................ 6-1 Protocol 6.2: Confidentiality............................................................................. 6-4 Protocol 6.3: Controlled Substance Documentation ........................................ 6-6 Protocol 6.4: Crime Scene Operations .......................................................... 6-13 Protocol 6.5: Field Determination of Death.................................................... 6-17 Protocol 6.6: Hazardous Materials / WMD Incidents ..................................... 6-21 Protocol 6.7: Helicopter Utilization................................................................. 6-67 Protocol 6.8: Infectious / Communicable Disease ......................................... 6-76 Protocol 6.9: Inter-facility Transport (Critical Care) ....................................... 6-83 Protocol 6.10: Multiple Casualty Incidents (MCI)............................................. 6-85 Protocol 6.11: No-Transport (Refusal, Cancel) ............................................... 6-99 Protocol 6.12: Patient Care Report (PCR) Requirements ............................. 6-106 Protocol 6.13: Public Inebriate Disposition .................................................... 6-109 Protocol 6.14: Radio Reports ........................................................................ 6-112 Protocol 6.15: Rules of Engagement............................................................. 6-115
6.
7. Drug Summaries Approved Drug List ...................................................................................................... 7-1 Adenocard (Adenosine) ............................................................................................... 7-3 Albuterol (Proventil) ..................................................................................................... 7-5 Amiodarone (Cordarone) ............................................................................................. 7-7 Aspirin (Acetylsalicylic Acid)......................................................................................... 7-9 Ativan (Lorazepam).................................................................................................... 7-10 Atropine Sulfate (as a cardiac agent)......................................................................... 7-11 Atropine Sulfate (as an antidote for poisoning) .......................................................... 7-13 Benadryl (Diphenhydramine) ..................................................................................... 7-15 Calcium Gluconate..................................................................................................... 7-17 Cyanokit ..................................................................................................................... 7-19 Dextrose 50% (D50) .................................................................................................. 7-21 Dextrose 25% (D25) .................................................................................................. 7-22 Dopamine Infusion (Intropin)...................................................................................... 7-23 Epinephrine (1:10,000) .............................................................................................. 7-25 Epinephrine (1:1000) ................................................................................................. 7-27 Etomidate (Amidate) .................................................................................................. 7-29

Page 7. Drug Summaries (Cont.) Fentanyl (Sublimaze) ................................................................................................. 7-31 Glucagon.................................................................................................................... 7-33 Haldol (Haloperidol) ................................................................................................... 7-34 Haz-Mat / WMD drugs (Mark I Kit, not stocked) Pralidoxime (2 Pam) Chloride ......................................................................... 7-36 Atropine Sulfate............................................................................................... 7-38 Inter-facility Transport drugs (not stocked) Heparin Infusion .............................................................................................. 7-40 Nitroglycerin Infusion....................................................................................... 7-42 Integrilin........................................................................................................... 7-44 Lasix (Furosemide) .................................................................................................... 7-46 Lidocaine (Xylocaine)................................................................................................. 7-48 Lidocaine 2% Viscous Gel (Xylocaine)....................................................................... 7-50 Morphine Sulfate........................................................................................................ 7-51 Narcan (Naloxone) ..................................................................................................... 7-53 Neo-Synephrine ......................................................................................................... 7-55 Nitroglycerin Spray /Tablet......................................................................................... 7-56 Procainamide (Pronestyl)........................................................................................... 7-58 Sodium Bicarbonate................................................................................................... 7-59 Succinylcholine (Anectine) ......................................................................................... 7-61 Thiamine Hydrochloride ............................................................................................. 7-63 Valium (Diazepam) .................................................................................................... 7-64 Zemuron (Rocuronium) .............................................................................................. 7-66 Zofran (Ondansetron) ................................................................................................ 7-68 Infusion Charts (Adult, Pediatric, Critical Care)............................................... 7-70 7-72 8. Tables and Illustrations
Table 1.A. Normal Vital Signs in the Pediatric Age Group ........................................ 1-10 Table 1.B. Glasgow Coma Scale Adult / Child ....................................................... 1-11 Table 1.C. Glasgow Coma Scale Infant / Small Child ............................................ 1-13 Table 2.A. APGAR Score................................................................................. 2-16, 2-52 Illustration 3.A. Rule of Nines Chart .......................................................................... 3-15 Table 3.A. Parkland Burn Formula............................................................................ 3-14 Table 3.B. Burn Classifications ................................................................................. 3-16

8. Tables and Illustrations (Cont.) Page Illustration 5.A. Combitube Placement ...................................................................... 5-16 Illustration 5.B. Combitube Anatomy......................................................................... 5-17 Illustration 5.C. Combitube Anatomy......................................................................... 5-18 Illustration 5.D. Mallampati Classification.................................................................. 5-31 Illustration 5.E. Thyromental Distance ...................................................................... 5-32 Illustration 5.F. PTLV O2 Delivery Device ................................................................ 5-36 Illustration 5.G. Laryngeal Anatomy .......................................................................... 5-40 Illustration 5.H. Intraosseous Needle Placement ...................................................... 5-59 Illustration 5.I. Cook Emergency Pneumothorax Kit................................................ 5-92 Illustration 5.J. 12-Lead Precordial Lead Placement................................................ 5-98 Table 5.A. ETT Size By Age ..................................................................................... 5-23 Illustration 6.A. Illustration 6.B. Illustration 6.C. Illustration 6.D. Illustration 6.E. Illustration 6.F. Illustration 6.G. Illustration 6.H. Table 7.A. Table 7.B. Table 7.C. Table 7.D. Table 7.E. Table 7.F. Table 7.G. RCRH Controlled Drug Administration Record................................. 6-10 Ambulance Controlled Substance Log ............................................. 6-11 Controlled Substance Usage Log..................................................... 6-12 HazMat Zones.................................................................................. 6-66 20-Minute Ground Travel Zone ........................................................ 6-75 MCI IC Flowchart.............................................................................. 6-96 START Triage .................................................................................. 6-97 METTAG Triage Tag........................................................................ 6-98
Dopamine Drip......................................................................................... 7-70 Epinephrine Drip ...................................................................................... 7-70 Lidocaine Drip.......................................................................................... 7-70 Procainamide Drip ................................................................................... 7-71 Pediatric Infusions ................................................................................... 7-71 Heparin Drip............................................................................................. 7-72 Nitroglycerin Drip..................................................................................... 7-72
Section 1 Patient Assessment
Definitions Level I Treatment: Level I treatment is denoted by a Roman numeral I. It is defined as an intervention that can be performed under standing orders and does not require contact with medical control to perform (within protocol parameters). Level II Treatment: Level II treatment is denoted by a red Roman numeral II. It is defined as an intervention that requires contact with medical control to perform. Clinical Definitions: It is necessary to make a differentiation between neonatal, infant and adult patients to select appropriate protocols. A. Neonate: The difference between neonates and infants, for the purposes of these protocols, is based on age. A neonate is in a physiological transition from mechanisms used in utero to those that are used after delivery and severance of the umbilical cord. Thus, a patient less than six weeks old will be considered as a neonate. B. Infant: Infants have functional differences from older children, which relate to their developing physiology and their poorly developed intellect. Ability to communicate and understand are limited. This is a distinction based on age, not size. A patient less than one (1) year of age will be considered as an infant. C. Pediatric and Adult: The term pediatric is used in these protocols as a collective term, including neonates, infants, children and adolescents. Any patient less than 18 years old is considered pediatric, from a legal standpoint (except emancipated or married minor). The legal standpoint must be considered in decisions about patient rights in regard to treatment refusals, choice of hospitals, etc.
Rapid City Department of Fire and Emergency Services Paramedics, PAGE 1-1
Definitions (cont.) For medical purposes, differences between neonates, infants and children may appear in protocols such as dysrhythmia and arrest protocols. Without specific notations, all these groups are treated similarly. Age in these young patients may still be an important factor in the history, influencing the probability for accidental ingestion of poisons or the occurrence of certain types of accidents. A more subtle distinction, from a medical perspective, is made between adolescents and adults. Adolescents are nearly equal physiologically to adults, aside from age and size. Most significantly, drug dosages for adults assume a body size between 50 and 200 kg (100 - 400lbs.). From a medication dosage standpoint, pediatric patients weigh less than 50 kg (100 lbs.). Reference: Thomas, CL (Ed.): Tabers Cyclopedic Medical Dictionary, F.A. Davis Co., Philadelphia, 1985. pgs. 43, 839, 1105, 1244
ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY Environmental Assessment: A. Recognize environmental hazards to rescuers, and secure area for treatment. B. Recognize hazard to patient, and protect from further injury. C. Identify number of patients. Initiate a triage system if appropriate. D. Observe position of patient, mechanism of injury, surroundings. E. Initiate communications if hospital resources require mobilization; call for backup if needed. F. Identify self. Consider TRAUMA ALERT. Primary Survey: Note initial level of responsiveness (awake, verbal, pain, unresponsive). A. Airway: 1. 2. 3. B. Observe the mouth and upper airway for air movement. Protect cervical spine from movement in trauma victims. Use assistant to provide continuous in-line cervical immobilization. Look for evidence of upper airway problems such as vomitus, bleeding, and facial trauma.
Breathing: 1. 2. 3. 4. Look for jugular venous distention and tracheal deviation. Expose chest and observe chest wall movement. Note respiratory rate (qualitative), noise, and effort. Look for life-threatening respiratory problems and briefly stabilize: a. b. c. 5. 6. Open or sucking chest wound - Seal. Large flail segment - Stabilize. Tension pneumothorax: transport rapidly and consider decompression.
Auscultate for crackles (wet sounds), wheezes, or decreased breath sounds. Palpate for tenderness, wounds, fractures, crepitus, or unequal rise of chest.
ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY (cont.) C. Circulation: 1. Palpate for radial and carotid pulses. Note pulse quality (strong, weak), and general rate (slow, fast, moderate). Where a pulse is able to be palpated can be indicative of an approximate systolic BP. The following are general guidelines, they should not be considered absolutes: a. b. c. 2. 3. 4. Radial pulse - systolic BP > 90 Femoral pulse - systolic BP > 80 Carotid pulse - systolic BP > 70
Check capillary refill time in fingertips: 2 sec is typically normal. Check skin color and condition. Control hemorrhage by direct pressure with clean dressing to wound.
D. Responsiveness: 1. 2. 3. Reassess level (awake, responsive to voice or pain, no response). Briefly note body position and extremity movement. Check movement and sensation in all four extremities prior to moving patient.
ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY Secondary survey is the systematic assessment of the entire patient. The purpose of the secondary survey is to uncover problems which are not lifethreatening but which could be injurious or could become life-threatening to the patient. It should be performed after: 1. 2. Primary survey. Stabilization and initial treatment of life-threatening airway, breathing, or circulatory difficulties.
A. Initial Vital signs. B. Additional History. C. Head and Face: 1. 2. 3. 4. 5. 6. Observe for deformities, asymmetry, bleeding. Palpate for deformities, tenderness, or crepitus. Re-check airway for potential obstruction: dentures, bleeding, loose or avulsed teeth, vomitus, abnormal tooth position from mandibular fracture, and absent gag reflex. Eyes: pupils (equal or unequal, responsiveness to light), foreign bodies, contact lenses, periorbital ecchymosis (raccoon eyes). Nose: deformity, bleeding, discharge. Ears: bleeding, discharge, bruising behind ears. (Battles sign)
D. Neck: 1. 2. 3. Re-check for deformity or tenderness if not already immobilized. Observe for penetrating wounds, neck vein distention and use of neck muscles for respiratory effort. Also note altered voice, and medical alert tags. Palpate for crepitus, tracheal shift, sub-q air.
E. Chest: 1. 2 Observe for wounds, symmetry of chest wall movement Have patient take deep breath: observe for pain, symmetry, air leak from wounds.
ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont). 3. 4. Re-auscultate for crackles (wet sounds), wheezes, and decreased or absent breath sounds. Palpate for tenderness, wounds, fractures, crepitus, or un-equal rise of chest.
F. Abdomen: 1. 2. Observe for wounds, bruising, distention. Palpate all 4 quadrants for tenderness, rigidity.
G. Pelvis: 1. Palpate and compress lateral pelvic rims and symphysis pubis for tenderness or instability.
H. Shoulders/Upper Extremities: 1. 2. 3. 4. 5. 6. I. Observe for angulation, protruding bone ends, symmetry. Palpate for tenderness, crepitus. Note distal pulses, color, medical alert tags. Check sensation. Test for weakness if no obvious fracture present (have patient squeeze your hands). If no obvious fracture, gently move arms to check overall function.
Lower Extremities: 1. 2. 3. 4. 5. 6. Observe for angulation, protruding bone ends, symmetry. Palpate for tenderness, crepitus. Note distal pulses, color. Check sensation. Test for weakness if no obvious fracture present (have patient push feet against your hands). If no obvious fracture, gently move legs to check overall function.
J.
*Back: 1. 2. If patient is stable, logroll, observe and palpate for wounds, fractures, tenderness, bruising. Recheck motor and sensory function as appropriate.
ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont). * Examination of the back may take place after the primary survey and prior to placing patient on backboard if rapid transport is indicated (see Trauma and Hypovolemic Supportive Care Protocol).
Special Notes: A. Be systematic. If you jump from one obvious injury to another, the subtle injury that is most dangerous to the patient is easily missed. B. Obtain and record two or more sets of vital signs and neurologic observations on every patient. A patient cannot be called Stable without sets of vital signs giving similar normal readings. Serial vital signs are an important parameter of the patients physiologic status. Vital signs should be repeated as necessary to document changes in abnormal findings. C. Use your judgment. Weigh benefits vs risks to patient in considering a prolonged field evaluation vs rapid transport to medical facility.
ASSESSMENT - MEDICAL PATIENT A primary survey is done on all medical and trauma patients. In the awake medical patient, this may consist only of identifying yourself and noting the patients responsiveness and general appearance. The formal secondary survey may not need to be done on patients with a specific complaint, such as chest pain. Assessment must be no less thorough, but it may be limited to the body systems that are pertinent to the presenting problem. A. Vital signs: quantitative vital signs (including oxygen saturation) usually precede the rest of the exam. B. Head/Face: 1. 2. 3. Note airway patency, oral swelling, and hydration. Eyes: note pupil symmetry, reaction to light, movement. Note symmetry of facial movements.
C. Neck: 1. Observe for neck vein distention in the upright position and use of accessory muscles for breathing.
D. Chest: 1. 2. Observe chest wall for symmetry of air movement. Auscultate: a. b. E. Abdomen: 1. 2. Observe for distention, bruising Palpate for tenderness, rigidity, masses. Breath sounds for symmetry, crackles (wet sounds), wheezing, or evidence of obstruction. Heart for regularity (if irregular, is it intermittently or consistently irregular?).
F. Extremities: 1. 2 Observe: presence of edema, color of skin. Palpate for warmth, tenderness, presence of pulses.
G. See Neurologic Assessment
ASSESSMENT - PEDIATRIC PATIENT Children can be examined easily from head to toe, but lack of understanding by the patient, poor cooperation, and fright often limit the ability to assess completely in the field. Children often cannot verbalize what is bothering them, so it is important in trauma victims to do a systematic primary and secondary survey, which covers areas that the patient may not be able to tell you about. Any observations about spontaneous movements of the patient and areas that the child protects are very important. In the patient with a medical problem, the more limited set of observations listed below should pick up potentially serious problems. A. General: 1. 2. 3. Level of alertness, eye contact, attention to surroundings. Muscle tone: Normal, increased or weak and flaccid. Responsiveness to parents, caregivers; is the patient playful or inconsolable?
B. Head: 1. 2. Signs of trauma. Fontanelle, if open: abnormal depression or bulging.
C. Face: 1. 2. Pupils: size, symmetry, reaction to light. Hydration: brightness of eyes, is child making tears, are the mouth and lips moist or dry?
D. Neck: note stiffness. E. Chest: 1. 2. 3. Note presence of stridor, retractions (depressions between ribs on inspiration), grunting, increased respiratory effort, or rapid/overly slow respiratory rate. Breath sounds: symmetrical, wet, wheezing. Heart rate, obvious murmur?
F. Abdomen: distention, rigidity, bruising, tenderness.
ASSESSMENT - PEDIATRIC PATIENT (cont.) G. Extremities: 1. 2. 3. 4. Brachial pulse. Signs of trauma. Muscle tone, symmetry of movement. Areas of tenderness, guarding or limited movement.
H. Skin: 1. 2. 3. I. Skin temperature and color, capillary refill. Unusual rashes, i.e., petechia, urticaria. Skin turgor.
See Neurologic Assessment
TABLE 1.A. NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP AGE PULSE beats/min. (mean) 144 140 130 130 100 100 90 RESPIRATIONS rate/min. BLOOD PRESSURE Systolic + or - 20
Premature Newborn 6 months 1 year 3 years 5 years 8 years
20-38 20-38 20-30 20-24 20-24 20-24 12-20
N/A N/A 80 palp 90 palp 95 palp 95 palp 100 palp
ASSESSMENT - NEUROLOGIC Management of patients with head injury or neurologic illness depends on careful assessment of neurologic function. Changes are particularly important. The first observations of neurologic status in the field provide the basis for monitoring sequential changes. It is therefore important that the first responder accurately observe and record neurologic assessment using measures which will be followed throughout the patients hospital course. A. Vital Signs: Observe particularly for adequacy of ventilation, also depth, frequency, and regularity of respirations. B. Level of consciousness: Use Glasgow Come scale. TABLE 1.B. GLASGOW COMA SCALE ADULT / CHILD EYE OPENING: None To pain To speech Spontaneously BEST VERBAL RESPONSE: None Garbled sounds Inappropriate words Disoriented sentences Oriented BEST MOTOR RESPONSES: None Abnormal extension Abnormal flexion Withdrawal to pain Localizes pain Obeys commands Score = Sum of scores in 3 categories: (15 points possible) 1 2 3 4 5 6 1 2 3 4 5 1 2 3 4
ASSESSMENT - NEUROLOGIC (cont.) C. Eyes: 1. 2. Direction of gaze. Size and reactivity of pupils.
D. Movement: Observe whether all four extremities move equally well. E. Sensation (if patient awake): Observe for absent, abnormal, or normal sensation at different levels if cord injury is suspected. Special Notes: A. The Glasgow Coma Scale (GCS) used above has gained acceptance as one method of scoring and monitoring patients with head injury. It is readily learned, has little observer-to-observer variability, and accurately reflects cerebral function. Always record specific responses rather than just the score (sum of observations). Remember that a patient who is totally without response will have score of 3, not 0. B. Use a flow sheet to follow and identify changes rapidly. C. Sensory and motor exam must be documented before moving patient with suspected spinal injury. D. Note what stimulus is being used when recording responses. Applied noxious stimuli must be adequate to the task but not excessive. Initial mild stimuli can include light pinch, dull pinprick - if these are unsuccessful at eliciting a pain response, pressure with a dull object to base of nailbed, stronger pinch (particularly in axilla) may be necessary to demonstrate the patients best motor response. Note: The sternal rub shall not be used to test pain response. E. When responses are not symmetrical, use motor response of the best side for scoring GCS and note asymmetry as part of neurologic evaluation. F. Use of restraints or intubation of patient will obviously make some observations less accurate. Be sure to note on chart if circumstances do not permit full verbal or motor evaluation.
ASSESSMENT - NEUROLOGIC (cont.) Special Notes (cont.): G. Glasgow Coma Scale of 13 or less-observe closely for deterioration. Glasgow Coma Scale of 8 or less will probably require airway intervention at some point. H. In infants and small children, the GCS may be difficult to evaluate. Children who are alert and appropriate should focus their eyes and follow your actions, respond to parents or caregivers, and use language and behavior appropriate to their age level. In addition, they should have normal muscle tone and a normal cry. Several observers should attempt to elicit a best verbal response, to avoid over or underestimation of level of consciousness. TABLE 1.C. GLASGOW COMA SCALE INFANT / SMALL CHILD EYE OPENING: None To pain To speech Spontaneously BEST VERBAL RESPONSE: None Moans, grunts Cries to pain Irritable cries Coos, babbles BEST MOTOR RESPONSES: None Abnormal extension Abnormal flexion Withdrawal to pain Localizes pain Spontaneous movement Score = Sum of scores in 3 categories: (15 points possible) 1 2 3 4 5 6 1 2 3 4 5 1 2 3 4
PATIENT HISTORY Medical: A. Chief complaint: 1. 2. 3. 4. 5. 6. 7. When did it start? How long has it been going on? Is it changing? How intense is the problem? Very severe, mild? What caused or brought on the condition? Does anything make it better or worse? For pain: describe the location, type of pain, severity, radiation. What caused the patient or family to seek help at this time? Has the patient experienced or been treated before for this problem? When? Are there any other symptom bothering the
B. Associated complaints: patient at this time?
C. Pertinent past medical history. D. Allergies. E. Medications and drugs. F. Survey of surroundings for evidence of drug abuse, mental function, family, problems. Trauma: A. Chief complaints: areas of tenderness, pain. B. Associated complaints. C. Mechanism of injury: 1. 2. 3. 4. What were the implements involved-weapons, autos, etc? How did the injury happen: cause, precipitating factors? What trajectories were involved. Bullets, cars, people? How forceful was the mechanism: speed of vehicles, force of the blow, etc.?
PATIENT HISTORY (cont.) Trauma (cont.): 4. With a vehicle: What is the condition of windshield, steering wheel, and vehicle body? Was there significant intrusion into the passenger compartment? Were the passengers wearing seatbelts? Was the patient ejected from the vehicle? Type: rollover, head-on, rear-end, T-bone?
D. Mental status and pertinent findings since accident according to witnesses or bystanders. Patient getting worse? Better? E. Treatment since accident: movement of patient by bystanders, etc. Patient ambulatory at scene? Special Notes: A. Do not let the gathering of information distract from management of lifethreatening problems. B. Appropriate questioning can provide valuable information while establishing authority, competence, and rapport with patient. C. In medical situations, history is commonly obtained before or during physical assessment. In trauma cases it may be simultaneous or following the primary survey. An assistant is often used for gathering information from family or bystanders. D. USE BYSTANDERS to confirm information obtained from the patient and to provide facts when the patient cannot. History from the scene is invaluable. E. Over-the counter medications (including aspirin and birth control pills) are frequently overlooked by patient and EMS, but may be important to emergency problems.
Section 2 Treatment Protocols - Medical
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE Note: This protocol provides guidelines for the initial care and packaging of medical patients. Because patients with hypovolemia and/or traumatic complaints may require different treatment and transport priorities, a separate Trauma and Hypovolemia Supportive Care Protocol has been created. The General Supportive Care Protocol is meant to be the foundation of care for all medical patients, and may be the only protocol invoked for any particular patient. If there is a question as to whether a patient requires a particular intervention, contact with Medical Control is advised. Medical Control contact is not required if only this protocol is implemented. Contact may be required if other protocols need to be implemented. ADULT CARE I.1. I.2. Patient assessment and history-taking. Include charting of at least two sets of vital signs. Airway management: A. Initial management includes patient maneuvers to assure a patent airway. positioning and manual
B. Patients with obvious signs and symptoms of hypoxia (e.g. tachypnea, cyanosis, tachycardia, altered mental status,) should initially be treated with 10-15 L/min via non-rebreather mask (Exception: Patients with COPD may initially be started on 2-4L/min via nasal cannula See 2.18: COPD Protocol) Respiratory suppression from oxygen administration should be closely monitored and managed by assisted ventilation. C. If the patient has continued difficulty with oxygenation and ventilation after simple airway maneuvers, airway adjuncts and/or advanced airway procedures may be used. D. Endotracheal tube placement must be verified by three (3) different methods immediately following intubation (see 5.7-9: Advanced Airway Management Protocols). Tube placement must also be re-verified after securing tube, after moving the patient, and at any other time of concern or change in the patients condition (including the movement of the patient from the ambulance cot to the hospital bed).
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE- (cont.) ADULT CARE-(cont.) If there is any question regarding the position of the endotracheal tube, the endotracheal tube should be withdrawn and the patient reintubated. E. When in the ambulance, the patient on O2 should be connected to the on-board oxygen supply and the portable O2 tank securely stowed. This is to avoid the possibility of the O2 tank becoming a potentially lethal missile during sudden stops or accidents. All patients receiving O2 during transport must continue to receive O2 from the vehicle to the ED. I.3 ECG monitoring should be done in all patients with previous cardiac history, potential for, or signs of instability. All patients monitored during transport shall continue to be monitored during transfer from the vehicle to the receiving ED. Venous access: A. Paramedic discretion should be used in determining which route of access, if any should be established. General guidelines follow. B. Establish intravenous access with NS or saline lock, and preferably, an 18 gauge, or larger catheter in any patient with abnormal vital signs or in whom the possibility of development of instability exists. Examples include patients with hypertension, SOB, or chest pain. C. Medical patients with systolic BP < 90 mm/Hg associated with signs and symptoms of shock should have an IV of NS established. D. Cardiac arrests, all significant trauma patients, and diabetics with low or elevated glucose levels should have a large-bore IV of NS established unless contraindicated. I.5 Follow additional protocols as needed, establishing Medical Control contact as dictated by protocol. If Medical Control is not needed, contact the destination facility to give patient report, following the 6.14: Radio Report Protocol.
I.4
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE- (cont.) ADULT CARE- (cont) I.6 Transport red lights and sirens (Code 3, HOT) if patients condition is critical. Critical is defined by a medical or traumatic condition requiring immediate medical intervention by physician and nursing personnel upon arrival at the Emergency Department. Critical may further be defined as any patient whose deteriorating medical condition cannot be controlled by the Paramedic. NOTE: The exception to this is the chest pain patient; the alert chest pain patients condition may be worsened by a red lights and siren transport due to the elevated anxiety factor. The attending Paramedic should weigh risk vs benefit when deciding how to transport these patients. All other patients will be transported non-red lights and sirens (Code 2, COLD).
PEDIATRIC CARE I.1. I.2. Patient assessment and history-taking. Will include charting of at least two sets of vital signs, including blood pressure. Airway Management: A. Initial management includes patient maneuvers to assure a patent airway. positioning and manual
B. Patients with signs and symptoms of hypoxia (e.g. tachypnea, cyanosis, tachycardia, altered mental status,) should initially be treated with O2 by non-rebreather mask. Respiratory suppression from oxygen administration should be closely monitored and managed by assisted ventilation. C. If the patient has continued difficulty with oxygenation and ventilation after simple airway maneuvers, airway adjuncts and advanced airway procedures may be used. Authorized airway access methods include oral and nasal airways and endotracheal intubation. Nasotracheal intubation is not recommended in children of less than 8 years of age because anatomical relationships make it especially difficult. D. Endotracheal tube placement must be verified by three different methods immediately following intubation (see 5.7-9: Advanced Airway Management Protocols). Tube placement must also be
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE - (cont.) PEDIATRIC CARE-(cont.) re-verified after securing tube, after moving the patient, and at any other time of concern or change in the patients condition (including the movement of the patient from the ambulance cot to the hospital bed). If there is any question regarding the position of the endotracheal tube, the endotracheal tube should be withdrawn and the patient re-intubated. E. When in the ambulance, the patient on O2 should be connected to the on-board oxygen supply and the portable O2 tank securely stowed. This is to avoid the possibility of the O2 tank becoming a potentially lethal missile during sudden stops or accidents. All patients receiving O2 during transport must continue to receive O2 from the vehicle to the ED. I.3 ECG monitoring should be done in all patients with previous cardiac history, potential for, or signs of instability. All patients monitored during transport must continue to be monitored during transfer from the vehicle to the receiving ED. Venous access: A. Paramedic discretion should be used in determining whether venous access is needed and which route of access is most appropriate. (NOTE: intraosseous infusion is typically (not EZ-IO) a Level II intervention and requires Medical Control authorization except in cases of cardiac arrest.) The need for a prophylactic IV is rare in the pediatric patient. If there is a question as to the necessity of establishing an IV, contact Medical Control. B. When needed, establish intravenous access with NS TKO or saline lock. In children less than 50 kg, use a 250 ml or 500 ml bag with a Buretrol micro drip and the largest size catheter possible. Averagesized teenage children (weighing more than 50kg) may be treated the same as adults in determining type of IV access. If a pediatric patient requires a significant fluid bolus administration for any reason, contact with Medical Control is strongly encouraged, though not necessarily before the volume infusion. I.5. Follow additional protocols as needed, establishing Medical Control contact as dictated by protocol. If Medical Control contact is not needed, contact the destination facility to give patient report, following the 6.14: Radio Report Protocol.
I.4
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE - (cont.) PEDIATRIC CARE-(cont.) I.6 Transport red lights and sirens (Code 3, HOT) if patients condition is critical. Critical is defined by a medical or traumatic condition requiring immediate medical intervention by physician and nursing personnel upon arrival at the Emergency Department. Critical may further be defined as any patient whose deteriorating medical condition cannot be controlled by the Paramedic. All other patients will be transported nonred lights and sirens (Code 2, COLD).
Note: Infants of less than six months of age can be obligate nose-breathers, therefore nasal congestion can present with apparently severe respiratory distress. This may be easily remedied by suctioning of mucous from the nose with a bulb syringe or suction catheter. Children often naturally assume a position which maintains their airway adequately. Attempts to force the patient out of this position, away from comforting family members, or to administer O2 may result in agitation which may produce further airway compromise. Oxygen may be better tolerated if administered via blow-by from a mask held by the patient or parent. Transport of small children without need of cervical/spinal immobilization may best be accomplished with the child restrained in a car seat, a pediatric restraint device made expressly for the ambulance cot, or less optimally, held by the caretaker and both securely restrained to the stretcher or seat in the ambulance. No pediatric patient will be transported without being restrained in some manner. A parent or caretaker can be allowed to travel with the child unless that persons presence may be detrimental to the childs treatment. Cardiac dysfunction in children is more likely to respond to effective oxygenation and ventilation than fluid administration and medications. Defibrillation alone is rarely successful.
PROTOCOL 2.2: ABDOMINAL PAIN ADULT CARE I.1. I.2. I.3. I.4. General Supportive Care. Position of comfort. Nothing by mouth. If systolic BP < 90 (check for orthostatic changes in vital signs) and signs of shock: a) b) O2, 10-15 L/min, non-rebreather mask. IV NS, 500 cc fluid challenge, consider contact with Medical Control prior to further fluids being infused. Upper abdomen and lower chest pain may reflect thoracic pathology such as myocardial infarction, etc. and massive fluid resuscitation may be contraindicated. Consider second line if fluid resuscitation not contraindicated.
c) II.1.
None.
PEDIATRIC CARE I.1. I.2. I.3. I.4. General Supportive Care. Position of Comfort. Nothing by mouth. If hypotensive (based on age) and signs of shock are present: a) b) II.1. O2 via non-rebreather mask. IV NS 20 cc/kg initial fluid challenge.
Contact Medical Control prior to further fluids being infused.
PROTOCOL 2.3: ASYSTOLE ADULT CARE I.1 I.2 Identify asystole in two leads. If asystole is due to blunt trauma and criteria from 6.5: Field Determination of Death Protocol are met, contact Medical Control for termination of efforts. If asystole is due to penetrating trauma, resuscitation will not terminated in the field unless signs of irreversible death are present (decapitation, significant dependent lividity, rigor mortis, etc.). See 6.5: Field Determination of Death Protocol. CPR. Intubate and large-bore IV, IO NS, TKO Epinephrine, 1 mg 1:10,000 solution IV/IO every 3-5 minutes for duration of pulselessness (ET dose 2-2.5 mg if IV/IO access delayed or unavailable). Atropine, 1 mg IV/IO every 3-5 minutes to maximum dose of 3 mg. ET dose 2-2.5 mg if IV/IO access delayed or unavailable. Maximum dose also doubled if ET). Glucagon, 1-2 mg IV/IO if patient known to be taking or has beta-blocker medications prescribed. (Tenormin, Monocor, Lopressor, Inderal, etc.) Search for and treat possible reversible cause: a) b) c) d) e) Hypoxia Secure airway and ventilate Hyperkalemia (renal failure, dialysis patient, potassium ingestion) Consider Sodium Bicarbonate / Calcium Gluconate Hypothermia Limit ALS, handle gently Hyperthermia Move from heat, resuscitate in cool environment Hypovolemia History any suspicions give fluid boluses
I.3
I.4 I.5. I.6.
I.7.
I.8. I.9.
PROTOCOL 2.3: ASYSTOLE- (cont.) f) Acidosis Secure airway, ventilate, consider Sodium Bicarbonate
g) Tension pneumothorax Chest decompression (needle thoracostomy) h) Drug overdose Obtain history treat accordingly I.10. II.1. II.2. II.3. Consider fine V-Fib Consider Sodium Bicarbonate, 1.0 mEq/kg, IV, (hyperkalemia, metabolic acidosis). Consider Calcium Gluconate 2.3 - 3.7 mEq IV injected over 10-20 seconds, repeated at 10 minute intervals if necessary (hyperkalemia). Contact Medical Control for possible termination of efforts if steps I.1 to I.9 are completed and patient remains asystolic. (See 6.5: Field Determination of Death Protocol).
PEDIATRIC CARE I.1. I.2. I.3. I.4. I.5. I.6. Use Broselow Tape! Identify asystole in two leads. CPR. Intubate and IV NS, TKO. If peripheral IV access not possible, establish intraosseous line NS, TKO. Epinephrine, 0.01 mg/kg, IV/IO 1:10,000 solution every 3-5 minutes for duration of pulselessness. (If IV/IO access delayed or not available, 0.1 mg/kg ET 1:1000 solution. Check glucose level. If blood glucose < 60 in child or < 40 in newborn a) b) c) d) > 2 years: D50 at 1 ml/kg < 2 years: D25 at 2 ml/kg < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20 kg, 0.5 mg IM.
I.7.
PROTOCOL 2.3: ASYSTOLE- (cont.) PEDIATRIC CARE- (cont.) I.8. Search for and treat possible reversible cause: a) b) c) d) e) Hypoxia Secure airway and ventilate Hyperkalemia (renal failure, potassium ingestion) Consider Sodium Bicarbonate Hypothermia Limit ALS, handle gently Hyperthermia Move from heat, resuscitate in cool environment Hypovolemia History any suspicions give fluid boluses (20 ml/kg NS over 30 minutes) Acidosis Secure airway, ventilate, consider Sodium Bicarbonate Tension pneumothorax Chest decompression (needle thoracostomy) Drug overdose Obtain history treat accordingly
f) g)
h)
II.1
Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (hyperkalemia, metabolic acidosis)
PROTOCOL 2.4: BRADYCARDIA ADULT CARE I.1. I.2 General Supportive Care. The asymptomatic patient that presents with a bradycardia (< 60 BPM) should have an IV started, but drug therapy should be withheld if the patient seems to tolerate the rate well. Contact Medical Control if in doubt. If systolic BP < 90, PVCs, altered mental status, signs or symptoms of ischemia: Atropine, 0.5 mg IV or ET, repeated every 3-5 min up to 3 mg total. (Note: Atropine may not be effective on high degree block / wide QRS Bradycardia. One 0.5 dose may be attempted, but if completely ineffective or patient in extremis, pacing should become primary treatment). Obtain 12-lead ECG (when it can be done without delaying needed treatment). Strongly consider pacing (see 5.15: External Cardiac Pacing Protocol) if: a) b) c) II.1. II.2. Patient does not respond to Atropine. IV access unsuccessful. Symptoms so severe that waiting for a maximal response to Atropine would be detrimental.
I.3.
1.4. 1.5.
Consider Dopamine infusion 2-10 mcg/kg/min. (See Drug Summaries Infusion Charts, Page 7-71). Consider Epinephrine infusion containing 1 mg in 250 ml D5W given at a rate of 2-10 mcg, / min. IV (30-150 micro drops/min), titrate to pulse 60. (See Drug Summaries - Infusion Charts, Page 7-71).
PEDIATRIC CARE I.1. I.2. Use Broselow Tape! General Supportive Care.
PROTOCOL 2.4: BRADYCARDIA PEDIATRIC CARE- (cont.) I.3. Establish airway and assure ventilation - cardiac arrest or significant rhythm disturbance in children is almost always due to respiratory insufficiency first. Establish IV access and consider a bolus with 20 ml/kg of NS over 30 minutes. Check glucose level. If blood glucose < 60 in child or < 40 in newborn a) b) c) d) I.6. > 2 years: D50 at 1 ml/kg < 2 years: D25 at 2 ml/kg < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20 kg, 0.5 mg IM.
I.4. I.5.
If hypotension (age dependent) present, PVCS, altered mental status, or signs and symptoms of ischemia and poor perfusion: a) Epinephrine, 0.01 mg/kg IV/IO 1: 10,000 repeated every 3-5 minutes at same dose. If no IV or IV delayed and patient intubated: ET 0.1 mg/kg (0.1ml/kg) 1:1000. Consider Atropine, 0.02 mg/kg IV/IO; may repeat once. Atropine may be used first if suspected increased vagal tone or AV block. 1. 2. 3. 0.1 mg minimum dose Maximum single dose 0.5 mg in child; I mg in adolescent Maximum total dose 1 mg in child; 2mg in adolescent
b)
II.1 II.2
Consider pacing see 5.15: External Cardiac Pacing Protocol. Consider Epinephrine or Dopamine infusions, (See Drug Summaries Pediatric Infusion Charts, Page 7-72)
PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA Note: A narrow QRS is less than .12 milliseconds in duration. Rate must be > 150; tachycardia is most likely a secondary problem when the heart rate is less than 150. Treat hypoxia, hypovolemia, pain and other problems first. The field treatment of this rhythm will depend on what the rhythm is, and whether the patient is stable or unstable. Unstable is defined as: A. B. C. D. Systolic BP < 90 mm/Hg OR Decreased level of consciousness OR Signs and symptoms of pulmonary edema OR Severe chest pain and shortness of breath.
ADULT CARE I.1. I.2. General Supportive Care. Record rhythm strip before, during, and after intervention. Obtain 12-lead ECG (when it can be done without delaying needed treatment).
CONSCIOUS, STABLE: I.1. I.2. I.3. I.4. II.1. Vagal maneuvers. If rhythm is Atrial fibrillation (irregular) or Atrial flutter, Adenosine is ineffective. Contact Medical Control to discuss treatment options. Adenosine, 6 mg rapid IV push followed by 20 ml NS IV flush. If rhythm persists 1-2 min after initial dose, repeat Adenosine, 12 mg rapid IV push. Follow all doses immediately with 20 ml NS IV flush. Repeat Adenosine, 12 mg dose may be considered in 1-2 min. if rhythm persists.
PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA (cont.) ADULT CARE (cont.) UNSTABLE: (all rhythms) II.1. Consider sedation with Etomidate, .1 mg/kg or Valium, 5 mg IV prior to cardioversion. Note: Patients with drastically decreased mentation should not receive sedation. II.2. II.3. II.4. II.5. * Synchronized biphasic cardioversion, 30J** Synchronized biphasic cardioversion, 50J** Synchronized biphasic cardioversion, 75J** Synchronized biphasic cardioversion, 120J** If rhythm is not Atrial Fibrillation or Atrial flutter, prior to cardioversion, pharmacologic conversion with Adenosine may be attempted at the discretion of Medical Control. In the presence of severe hypotension, pulmonary edema or unconsciousness, administer immediate unsynchronized shocks to avoid delays.
PEDIATRIC CARE Note: Pediatric SVT rate is generally greater than 230 bpm. Unstable in the pediatric patient is defined as: A. B. C. D. STABLE: I.1. General Supportive Care if patient is stable. Age dependent hypotension (despite oxygenation and ventilation) OR Decreased level of responsiveness OR Abnormal skin color OR Capillary refill > 2 seconds.
PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA (cont.) PEDIATRIC CARE (cont.) UNSTABLE: I.1. I.1. II.1. II.2. Use Broselow Tape! Establish IV NS, TKO. If peripheral IV access not possible and patient severely obtunded, establish intraosseous line NS, TKO. Consider vagal maneuvers if child is old enough, but do not delay pharmacologic therapy or cardioversion if patient is obtunded. Vagal maneuvers should not be attempted without discussion with Medical Control. If IV access is immediately available, consider Adenosine, 0.1 mg/kg IV or IO rapid IV push followed by 10 ml NS IV flush. Second dose if necessary and possible may be doubled (0.2 mg/kg). Maximum first dose: 6 mg; maximum second dose: 12 mg. Consider sedation with Valium, 0.2 mg/kg IV, (not to exceed 10 mg/dose) in preparation for cardioversion, but do not delay cardioversion. Synchronized biphasic cardioversion at 0.5 - 1.0 joules/kg. Synchronized biphasic cardioversion at 2.0 joules/kg if initial energy ineffective.
II.3.
II.5. II.3. II.4.
PROTOCOL 2.6: NEONATAL RESUSCITATION Note: The level of resuscitation the neonate will require will be dependent on the infants clinical presentation. The APGAR score can be used as a tool to help determine this, but resuscitation of a newborn child should not be delayed to obtain an APGAR score if the infant is in obvious distress. See APGAR Score Chart, Table 2.A, at the end of this protocol and 2.22: OB / GYN Protocol. APGAR scoring guidelines: 0 to 3 indicates severe distress 4 to 6 indicates moderate distress 7 to 10 indicates mild or no distress
If the APGAR score at 5 minutes is less than 7, obtain additional scores (if possible) every 5 minutes until the score reaches 7 or more. The primary enemy of newborns is hypothermia, which can occur within minutes due to increased evaporative heat loss due to the infants large body surface area and the presence of amniotic fluid. I.1. I.2. I.3. I.4. I.5. I.6. I.7. Dry immediately and warm! Tactile stimulation, rub with towel. Position airway and suction mouth, oropharynx and then nose. If normal respiratory rate, HR > 100 and core color pink, provide supportive care only. If apnea/gasping respirations, HR < 100 or central cyanosis, administer 100% oxygen and assist ventilations with BVM at a rate of 40-60. If HR < 60 and no improvement after 30 seconds of BVM assisted ventilation, intubate. If HR < 60 and no improvement after 30 seconds of BVM assisted ventilation, begin chest compressions at a rate of 120/min. A. Compression/ventilation ratio 3:1. B. One third to one half chest depth.
PROTOCOL 2.6: NEONATAL RESUSCITATION (cont.) C. Perform compressions with both thumbs (with hands encircling the back) at mid-sternum. I.8. I.9. II.1. If meconium present, perform deep tracheal suctioning through ETT with proper suction adapter. Check glucose level, if < 40, administer D10, 5 ml/kg. Consider intraosseous IV if infant severely obtunded, but do not delay transport for IV access; utilize ETT for Epinephrine administration if needed and vascular access is difficult. Consider Epinephrine, 0.01 mg/kg IV/IO/ET (0.1 ml/kg) 1: 10,000 repeated every 3-5 minutes. Use Broselow Tape!
II.2.
TABLE 2.A. APGAR Score

APGAR Score
0 Points Absent Absent Flaccid No response Blue, pale 1 Point <100 Slow, irregular Some flexion Some Blue & pink 2 Points >100 Strong cry Active motion Vigorous Fully pink TOTAL: 1 Minute 5 Minutes
Heart Rate Respiratory Effort Muscle Tone Irritability Color
* Infants with scores of 7-10 usually require supportive care only. * A score of 4-6 indicates moderate depression. * Infants with scores of 3 or less will require aggressive resuscitation.
PROTOCOL 2.7: PREMATURE VENTRICULAR ECTOPY Indications: Treatment of PVCs should be limited to those patients with probable cardiac complaints, e.g. chest pain, syncope, SOB, etc. Patients who have PVCs and are asymptomatic generally do not require intervention. Use this protocol if the ventricular complexes meet any of these criteria and the underlying heart rate is greater than 60: 1. With frequency 6/min and symptomatic. 2. Multifocal at any frequency. 3. R on T pattern at any frequency. 4. Coupling (bigeminy or trigeminy) at any frequency (This protocol is for isolated coupling and bursts (see 2.10: Wide-Complex Tachycardia With Pulse Protocol for rapid sustained patterns of ventricular complexes). Note: Underlying heart rate should be closely monitored, if PVCs are perfusing and underlying heart rate is very low, suppressing the PVCs may leave the patient unable to perfuse at all. Ventricular escape beats can sustain a patient temporarily. Medication dosage should be reduced by 50% if patient age > 70, presence of CHF, shock or liver disease. If patient is borderline as to whether and how to treat, contact Medical Control to discuss treatment options. Cardiac monitor strip recordings must document premature complexes prior to pharmacologic intervention. ADULT CARE I.1. I.2. I.3. General Supportive Care. Lidocaine, 1mg - 1.5mg/kg IV or ET. If PVCs not suppressed with first bolus, Lidocaine, 0.5 - 0.75 mg/kg IV or ET, repeated as necessary at 10 minute intervals to suppress ventricular ectopy. Total bolus dose not to exceed 3 mg/kg.
PROTOCOL 2.7: PREMATURE VENTRICULAR ECTOPY (cont.) ADULT CARE(cont.) I.4. II.1. If PVCs suppressed, Lidocaine infusion at a rate of 2-4 mg/min. (30-60 microdrops/min. (See Drug Summaries - Infusion Charts, Page 7-71). Consider Amiodarone 150 mg over 10 minutes. If Lidocaine ineffective.
PEDIATRIC CARE I.1. II.1. II.2. General Supportive Care. Treat ectopy with pharmacologic intervention only if child is symptomatic. Lidocaine, 1 mg/kg IV or ET bolus. If PVCs not suppressed with first bolus, Lidocaine, 0.5 mg/kg IV or ET, repeated as necessary at 10 minute intervals to suppress ventricular ectopy. Total bolus dose not to exceed 3 mg/kg. If PVCs suppressed, Lidocaine infusion containing 300 mg Lidocaine in 250 mg D5W given at a rate of 20-50 mcg/kg/min. (1- 2.5 microdrops/kg/min. (See Drug Summaries - Pediatric Infusion Charts, Page 7-72).
II.3.
PROTOCOL 2.8: PULSELESS ELECTRICAL ACTIVITY, (PEA) ADULT CARE I.1. I.2. I.3. I.4. CPR. Intubate and large-bore IV or IO NS, TKO (Consider fluid bolus if hypovolemia suspected). Epinephrine, 1 mg 1:10,000 solution IV every 3-5 minutes for duration of pulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable. Atropine, 1 mg IV every 3-5 minutes to maximum dose of 2.5 mg (0.04 mg/kg) IF heart rate < 60/min. (ET dose 2-2.5 mg if IV access delayed or unavailable. Maximum dose also doubled if ET). Glucagon, 1-2 mg IV/IO if patient known to be taking or has beta-blocker medications prescribed. (Tenormin, Monocor, Lopressor, Inderal, etc.) Search for and treat possible reversible cause: a) b) c) d) e) f) g) h) Hypoxia Secure airway and ventilate Hyperkalemia (renal failure, dialysis patient, potassium ingestion) Consider Sodium Bicarbonate / Calcium Gluconate Hypothermia Limit ALS, handle gently Hyperthermia Move from heat, resuscitate in cool environment Hypovolemia History any suspicions give fluid boluses Acidosis Secure airway, ventilate, consider Sodium Bicarbonate Tension pneumothorax Chest decompression (needle thoracostomy) Drug overdose Obtain history treat accordingly
I.5. I.6.
PROTOCOL 2.8: PULSESLESS ELECTRICAL ACTIVITY, (PEA) (cont.) ADULT CARE (cont.) II.1. II.2. Consider Sodium Bicarbonate 1.0 meq/kg, IV. (Hyperkalemia, metabolic acidosis) Consider Calcium Gluconate 2.3 - 3.7 mEq IV injected over 10-20 seconds, repeated at 10 minute intervals if necessary (hyperkalemia).
PEDIATRIC CARE I.1. I.2. I.3. I.4. I.5. Use Broselow Tape! CPR. Intubate and IV NS, TKO. If peripheral IV access not possible, establish intraosseous line NS, TKO. Check glucose level. If blood glucose < 60 in child or < 40 in newborn a) b) c) d) I.6. > 2 years: D50 at 1 ml/kg < 2 years: D25 at 2 ml/kg < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20 kg, 0.5 mg IM.
Epinephrine, 0.01 mg/kg, IV or IO 1:10,000 solution every 3-5 minutes for duration of pulselessness. (If IV access delayed or not available, 0.1 mg/kg ET 1:1000 solution. Search for and treat possible reversible cause a) b) c) d) Hypoxia Secure airway and ventilate Hyperkalemia (renal failure, potassium ingestion) Consider Sodium Bicarbonate Hypothermia Limit ALS, handle gently Hyperthermia Move from heat, resuscitate in cool environment
I.7.
PROTOCOL 2.8: PULSESLESS ELECTRICAL ACTIVITY, (PEA) (cont.) PEDIATRIC CARE (cont.) e) Hypovolemia History any suspicions give fluid boluses (20 ml/kg NS over 30 minutes) Acidosis Secure airway, ventilate, consider Sodium Bicarbonate Tension pneumothorax Chest decompression (needle thoracostomy) Drug overdose Obtain history treat accordingly
f) g)
h)
II.1
Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (Hyperkalemia, metabolic acidosis).
PROTOCOL 2.9: VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA: Note: This protocol assumes refractory V-Fib/pulseless V-Tach, or a successful conversion to a perfusing rhythm from those rhythms. If at any time, rhythm converts to another pulseless rhythm (PEA, Asystole), continue treatment from that protocol. If interfacing with 1st responder AED, it is always wise to let 1st responders continue with AED defibrillation sequences if the situation is progressing correctly, this allows ALS personnel time to set up for airway and other procedures. If 1st responder defibrillation is not progressing correctly, disconnect AED, hook up manual cardiac monitor-defibrillator and continue or begin defibrillation sequence. Chest compressions are very important and interruptions to chest compressions should be minimized wherever possible. Compressions should continue while drugs are being administered and defibrillator is charging. It is not important whether a drug is administered before or after a shock. Countershocks should be administered and drug sequences continued as long as VF/VT persists. ADULT CARE I.1. I.2. I.3. I.4. I.5. I.6. I.7. I.8. I.9. I.10. Biphasic countershock, 150 J*. CPR (5 cycles or minimum of 2 minutes). Intubate and large-bore IV, IO NS, TKO whenever possible. Epinephrine, 1 mg 1:10,000 solution IV/IO every 3-5 minutes for duration of pulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable. Continue CPR (5 cycles or minimum of 2 minutes), rhythm check. Biphasic countershock 150-200 J*. Amiodarone, 300 mg IV/IO, consider repeat dose of 150 mg IV/IO in 3-5 minutes. Continue CPR (5 cycles or minimum of 2 minutes), rhythm check. Biphasic countershock 150-200 J*. Glucagon, 1-2 mg IV/IO if patient known to be taking or has beta-blocker medications prescribed. (Tenormin, Monocor, Lopressor, Inderal, etc.)
PROTOCOL 2.9: VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA-(cont.): ADULT CARE (cont.): I.11. I.12. II.1. II.2. * Consider Lidocaine, 1.5 mg/kg IV/IO for max dose of 3 mg/kg. If rhythm converts and then patient re-fibrillates, countershock immediately using the same energy as the last successful shock. Consider Sodium Bicarbonate, 1.0 meq/kg, IV,(Hyperkalemia, metabolic acidosis) Consider Calcium Gluconate 2.3 - 3.7 mEq IV injected over 10-20 seconds, repeated at 10 minute intervals if necessary (hyperkalemia). If countershock restores a perfusing rhythm, treat heart rate, blood pressure and cardiac rhythm as required by pertinent protocol.
PEDIATRIC CARE I.1. I.2. I.3. I.4. I.5. I.6. Use Broselow Tape! Biphasic countershock, 2 joules/kg*. CPR (5 cycles or minimum of 2 minutes). Intubate and IV, NS, TKO whenever possible If peripheral IV access not possible, establish intraosseous line NS, TKO. Epinephrine, 0.01 mg/kg, ET, IV or IO 1:10,000 solution every 3-5 minutes for duration of pulselessness. (If IV access delayed or not available, 0.1 mg/kg ET 1:1000 solution. Continue CPR (5 cycles or minimum of 2 minutes), rhythm check. Biphasic countershock 4 joules/kg*. Amiodarone, 5 mg/kg IV or IO, (can repeat once in 3-5 minutes). Continue CPR (5 cycles or minimum of 2 minutes), rhythm check. Biphasic countershock 4 joules/kg *.
I.7. I.8. I.9. I.10. I.11.
PROTOCOL 2.9: VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA-(cont.) PEDIATRIC CARE (cont.): I.12. I.13. I.14. Consider Lidocaine, 1 mg/kg IV or IO (can repeat twice). Contact Medical Control at earliest opportunity to discuss treatment options and transport as soon as possible. Search for and treat possible reversible cause a) b) c) d) e) Hypoxia Secure airway and ventilate Hyperkalemia (renal failure, potassium ingestion) Consider Sodium Bicarbonate Hypothermia Limit ALS, handle gently Hyperthermia Move from heat, resuscitate in cool environment Hypovolemia History any suspicions give fluid boluses (20 ml/kg NS over 30 minutes) Acidosis Secure airway, ventilate, consider Sodium Bicarbonate Tension pneumothorax Chest decompression (needle thoracostomy) Drug overdose Obtain history treat accordingly
f) g)
h) I.15. II.1. *
If rhythm converts and then patient re-fibrillates, countershock immediately using the same energy as the last successful shock. Consider Sodium Bicarbonate, 1.0 meq/kg, IV, (Hyperkalemia, metabolic acidosis) If countershock restores a perfusing rhythm, treat heart rate, blood pressure and cardiac rhythm as required by pertinent protocol.
PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE Note: A wide QRS is more than .11 milliseconds in duration. The field treatment of this rhythm will depend on whether the patient is stable or unstable. Unstable is defined as: A. B. C. D. Systolic BP < 90 mm/Hg OR Decreased level of consciousness OR Signs and symptoms of pulmonary edema OR Severe chest pain and shortness of breath.
ADULT CARE I.1. I.2. General Supportive Care. Record rhythm strip before, during, and after intervention. Obtain 12-lead ECG to verify rhythm (when it can be done without delaying needed treatment).
CONSCIOUS, STABLE I.1. I.2. Amiodarone, 150 mg IV over 10 minutes. May repeat once in 10 minutes if needed. Consider trial of Adenosine (see Protocol 2.5. Narrow Complex Tachycardia) if rhythm is possibly SVT with aberrancy. If unsure of rhythm, contact Medical Control and send 12-lead to hospital for interpretation (do not delay transport). Consider Procainamide, 100 mg IV over 5 min. (20mg/min.). Maximum total dose 17 mg/kg. If chemical conversion successful, maintenance infusion at 1 to 4 mg/min. (See Drug Summaries - Infusion Charts, Page 7-72). If pharmacologic intervention is unsuccessful, contact Medical Control to discuss treatment options. The conscious, stable patient in V-Tach seldom needs cardioversion in the field, but if transport times will be prolonged, synchronized cardioversion may be attempted at the discretion of Medical Control (see UNSTABLE treatment). If at any point the conscious, stable patient begins to deteriorate, prepare for synchronized cardioversion (see UNSTABLE treatment).
II.1.
II.2.
II.3.
PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE (cont.): ADULT CARE (cont.): UNSTABLE: Note: If patient in extremis and deteriorating rapidly, and contacting Medical Control will be time consuming, do not delay cardioversion! proceed and contact Medical Control at earliest opportunity. II.1. Consider sedation with Etomidate, .1 mg/kg or Valium 5 mg IV prior to cardioversion. Note: Patients with drastically decreased mentation should not receive sedation. II.2. II.3. II.4. II.5. II.6. * Synchronized biphasic cardioversion, 75 joules*. Synchronized biphasic cardioversion, 120 joules*. Synchronized biphasic cardioversion, 150 joules*. Synchronized biphasic cardioversion, 200 joules*. If wide-complex rhythm re-curs, synchronized cardioversion, at level previously successful. In the presence of severe hypotension, pulmonary edema or unconsciousness, administer immediate unsynchronized shocks to avoid delays.
PEDIATRIC CARE Note: A wide QRS in the pediatric patient is generally considered to be anything .08 milliseconds or more in duration. Unstable in the pediatric patient is defined as: A. B. C. D. Age dependent hypotension (despite oxygenation and ventilation) OR Decreased level of responsiveness OR Abnormal skin color OR Capillary refill > 2 seconds.
PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE (cont.) PEDIATRIC CARE-(cont.) STABLE: I.1. I.2. I.3. I.4. General Supportive Care if patient is stable. Use Broselow Tape! Establish IV NS, TKO. Consider trial of Adenosine (see Protocol 2.5. Narrow Complex Tachycardia) if rhythm is possibly SVT with aberrancy. If unsure of rhythm, contact Medical Control for consult.
UNSTABLE: Note: If patient in extremis and deteriorating rapidly, and contacting Medical Control will be time consuming, do not delay cardioversion! proceed and contact Medical Control at earliest opportunity. II.1. II.2. If peripheral IV access not possible and patient severely obtunded, establish intraosseous line NS, TKO. Consider sedation with Valium, 0.2 mg/kg IV, (not to exceed 10 mg/dose) in preparation for cardioversion, but do not delay cardioversion if patient in extremis. Synchronized Cardioversion at 0.5 - 1.0 joules/kg.* Synchronized Cardioversion at 2.0 joules/kg* if initial energy ineffective. If a second shock (2.0 joules/kg) is unsuccessful or if the tachycardia recurs quickly, consider Amiodarone 5 mg/kg over 20 minutes before a third shock at 2.0 joules/kg.* If delays in synchronization occur and patient is severely obtunded, administer immediate unsynchronized shocks.
II.3. II.4. II.5.
PROTOCOL 2.11: AIRWAY OBSTRUCTION Indications: 1. 2. All patients who cannot phonate and are suspected of foreign body airway obstruction. Suspect patients in cardiac arrest that occurred in a restaurant or during a meal.
ADULT CARE I.1. I.2. I.3. General Supportive Care. If air exchange is adequate, do not provide specific treatment. If air exchange is inadequate and there is a reasonable suspicion of foreign body obstruction, perform Heimlich maneuver to try and relieve obstruction. If unable to relieve obstruction with Heimlich maneuver, visualize with laryngoscope and extract foreign body with McGill forceps. If obstruction cannot be relieved by direct laryngoscopy and patient remains unable to ventilate and continues to deteriorate, contact Medical Control for possible Surgical Cricothyrotomy intervention (see 5.11: Advanced Airway Management: Surgical Cricothyrotomy Protocol).
I.4. II.1.
PEDIATRIC CARE I.1. I.2. I.3. General Supportive Care. If air exchange is adequate, do not provide specific treatment. If air exchange is inadequate and there is a reasonable suspicion of foreign body obstruction, perform age-correct Heimlich maneuver to try and relieve obstruction. If unable to relieve obstruction with Heimlich maneuver, visualize with laryngoscope and extract foreign body with McGill forceps.
I.4.
PROTOCOL 2.11: AIRWAY OBSTRUCTION (cont.) PEDIATRIC CARE (cont.) II.1. If obstruction cannot be relieved by direct laryngoscopy and patient remains unable to ventilate and continues to deteriorate, contact Medical Control for possible Needle Cricothyrotomy intervention (see 5.10: Advanced Airway Management: Needle Cricothyrotomy Protocol).
PROTOCOL 2.12: ALLERGIC REACTION - ANAPHYLAXIS Indications: 1. 2. 3. 4. Note: All patients with dyspnea, hoarseness, dysphonia or strider following an allergic reaction OR Patients with wheezing and other signs of bronchospasm associated with above OR Hypotension and/or decreased level of consciousness associated with above OR Hives, swelling and flushing of skin associated with above. The patient with only hives, rash and or itching that is not getting worse may need no intervention other than observation and transport. Patient should be monitored closely, and if symptoms are getting worse, more aggressive treatment will be warranted. Ensure airway, early endotracheal intubation may be advisable before swelling becomes severe. Suction as needed and prepare to assist ventilations. ADULT CARE I.1. I.2. I.3. I.4. I.5. General Supportive Care. Epinephrine, 1: 1000, 0.3 mg IM. Benadryl, 25-50 mg, IV or IM. If systolic blood pressure < 90 mm/Hg with mild signs of shock, fluid bolus 250 to 500 ml IV Normal Saline. If shortness of breath and wheezing present: Albuterol, unit dose vial of 2.5 mg . Contents of vial is nebulized and administered until dose complete, may be repeated once if necessary. If patient in extremis and systolic blood pressure < 90 mm/Hg with obvious signs of shock and decreased level of consciousness, Epinephrine, 1:10,000, 1 ml, slow IV over 3-5 min.
II.1.
PROTOCOL 2.12: ALLERGIC REACTION - ANAPHYLAXIS (cont.) PEDIATRIC CARE I.1. I.2. I.3. General Supportive Care. If hypotension present (based on age) with signs of shock, fluid bolus, 20 ml/kg IV. If shortness of breath and wheezing present, and patient age less than 2 years old, Albuterol, 1.25 mg (half of unit dose vial). Medication is nebulized and administered until distress relieved or dose complete. If more than 2 years old, use adult dosage. If patient normotensive, Epinephrine, 1:1,000 0.01 ml/kg (0.01 mg/kg), not to exceed 0.3 mg, IM. Benadryl, 1 mg/kg IM or IV. If hypotension present (based on age) with obvious signs of shock, Epinephrine, 1:10,000, 0.01 mg/kg slow IV over 3-5 min. (not to exceed 1 ml dose). If peripheral IV access not possible and patient severely obtunded, establish intraosseous line NS, TKO.
I.4. I.5. II.3.
II.4.
PROTOCOL 2.13: ASTHMA Indications: 1. Patients with respiratory distress and : A. B. C. History of asthma AND Wheezing on auscultation and/or prolonged expiration AND No evidence of pulmonary edema or congestive heart failure.
ADULT CARE I.1. I.2. I.3. General Supportive Care. Position of comfort. Albuterol, unit dose vial of 2.5 mg. Contents of vial is nebulized and administered until dose complete. Repeat twice if necessary. If more than three treatments required, contact medical control. Consider CPAP if patient in extremis. If Albuterol ineffective and patient in severe distress, consider Epinephrine, 1:1000, 0.3 mg IM. Use with caution in patients 50 years old, heart rate > 100, hypertensive, or history of CAD/HTN, Monitor ECG!
I.4. II.1.
PEDIATRIC CARE I.1. I.2. I.3. General Supportive Care. Position of comfort. If patient age more than 2 years old, Albuterol, unit dose vial of 2.5 mg . Contents of vial is nebulized and administered until dose complete. Repeat once if necessary. If more than two treatments required, contact medical control. If patient age less than 2 years old, Albuterol, 1.25 mg ( half of unit dose vial). Medication is nebulized and administered until dose completed. In children unable to use mouthpiece, administer by nebulizer mask. If unable to cooperate with nebulization and patient getting worse, consider Epinephrine, 1:1000, 0.01 mg/kg IM (not to exceed 0.3 ml). Do not use Epinephrine if Albuterol has been effective.
I.4.
II.1.
PROTOCOL 2.14: BEHAVIORAL / PSYCHIATRIC ADULT CARE I.1. I.2. I.3. I.4. I.5. General Supportive Care. Have Law Enforcement remove those individuals who aggravate the situation. Establish a calm, quiet atmosphere, and attempt to establish rapport with patient. Do not be judgmental or question the patients motives. Be aware of weapons! Remove any weapons (or potential weapons) from the patient. Use Law Enforcement assistance if necessary. Obtain patient history, this includes a history of the current event as well as previous psychiatric and medical problems, medications. Inquire about recent crisis, toxic exposure, drugs, alcohol, emotional trauma or suicidal thoughts. If suicidal or threatening behavior is suspected do not leave the patient alone, obtain Law Enforcement assistance if not already present. Obtain vital signs and perform physical exam as indicated. Treat any medical problem according to appropriate protocol. If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Try not to violate the patients personal space. Psychiatric patients may have another reason for mental disturbances. Be aware of hypoglycemia, hypoxia, head injury, intoxication or toxic ingestion. If the situation appears threatening, consider a show of force involving Law Enforcement before attempting to restrain. If physical restraint of the patient becomes necessary, refer to 5.22: Restraint (Physical and Chemical) Protocol. If when physically restrained, patient continues to pose a threat to self and others, consider chemical restraint (see 5.22: Restraint (Physical and Chemical) Protocol).
I.6. I.7.
I.8.
I.9. I.8. II.1.
PROTOCOL 2.14: BEHAVIORAL / PSYCHIATRIC (cont.) PEDIATRIC CARE I.1. I.2. I.3. I.4. General Supportive Care. Have Law Enforcement remove those individuals who aggravate the situation. Establish a calm, quiet atmosphere, and attempt to establish rapport with patient. Do not be judgmental or question the patients motives. Obtain patient history, this includes a history of the current event as well as previous psychiatric and medical problems, medications. Inquire about recent crisis, toxic exposure, drugs, alcohol, emotional trauma or suicidal thoughts. If suicidal or threatening behavior is suspected do not leave the patient alone, obtain Law Enforcement assistance if not already present. Obtain vital signs and perform physical exam as indicated. Treat any medical problem according to appropriate protocol. If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Try not to violate the patients personal space. Psychiatric patients may have another reason for mental disturbances. Be aware of hypoglycemia, hypoxia, head injury, intoxication or toxic ingestion. Truly violent and threatening behavior in the pediatric patient is less frequent and somewhat easier to manage than it is in the adult patient, but the threat still exists. The same cautions about weapons and violent behavior apply as with the adult patient, and Law Enforcement should always be involved in questionable situations. If physical restraint of the patient becomes necessary, refer to 5.22: Restraint (Physical and Chemical) Protocol. If when physically restrained, patient continues to pose a threat to self and others, consider chemical restraint (see 5.22: Restraint (Physical and Chemical) Protocol).
I.5. I.6.
I.7.
I.8.
I.1. II.1.
PROTOCOL 2.15: CARDIOGENIC SHOCK Indications: 1. Patients with chest pain or dyspnea, who have not suffered trauma and have: A. B. C. Systolic BP < 80 mm Hg. Obvious signs and symptoms of shock. No rate problem, if heart rate unacceptably high or low, normalize rate before using this protocol.
ADULT CARE I.1. I.2 I.3. I.4. I.5. II.2 General Supportive Care. IV, NS. If lungs clear, consider fluid bolus of 250-500 ml NS to ensure adequate ventricular filling pressure before considering vasopressor administration. If crackles (rales) present, maintain IV at TKO. Consider CPAP. Obtain 12-lead ECG (when it can be done without delaying needed treatment). Dopamine infusion, 5-20 mcg/kg/min IV. Infusion should be started at 5 mcq/kg/min. and titrated to systolic BP 90 mm/Hg. (See Drug Summaries - Infusion Charts, Page 7-1).
PEDIATRIC CARE I.1 II.1 II.2 General Supportive Care. IV, NS. If lungs clear, consider fluid bolus 20/ml/kg IV. Consider Dopamine infusion (See Drug Summaries - Pediatric Infusion Charts, Page 7-2).
PROTOCOL 2.16: CHEST PAIN Indications: 1. Patients of either gender age 25 or over complaining of non-pleuritic pain in the anterior chest, described as CRUSHING, TIGHT, DULL, CONSTRICTING, BAND-LIKE, HEAVY, ETC. Patients of either gender age 25 or over with non-pleuritic chest, jaw, back or arm pain associated with nausea, vomiting, pallor, diaphoresis, or dyspnea.
2.
ADULT CARE I.1. I.2. I.3. I.4. General Supportive Care. IV, NS. Position of comfort - Semi-fowlers is usually best. Treatment of any arrhythmia per specific protocol. Nitroglycerin, one metered dose, SL spray, if systolic BP > 90 mm/Hg. May be repeated twice Q 5 min. if systolic BP remains > 90 mm/Hg (consider patient administered Nitroglycerin within last 15 minutes). Note: If patient becomes hypotensive after administration of Nitroglycerin, lie flat temporarily and administer fluid. When patient becomes normotensive again, return to Semi-fowlers Note: Ask if patient is taking erectile dysfunction drugs (Viagra, Levitra), patients taking these drugs should not be given nitroglycerin. Note: Contact Medical Control prior to the administration of Nitroglycerin to the patient with a suspected right ventricular infarct. These patients are pre-load dependent and can decompensate quickly. I.5. Suspected MIs shall have a 12-lead ECG acquired. If the 12-lead ECG substantiates the suspicion of an MI, notify the base hospital at the earliest opportunity and transmit an ECG for base station physician review. Patient must be constantly monitored, including during the move from the ambulance to the ED. A significant number of patients who develop ventricular fibrillation may have no warning arrhythmias.
I.6.
PROTOCOL 2.16: CHEST PAIN (cont.) ADULT CARE (cont.) I.7. Aspirin, Have the patient chew and swallow four (4) baby aspirins (324 mg) if the patient meets the following requirements: a) b) c) d) e) f) g) h) i) I.8. Pain of probable cardiac origin persisting for at least 15 minutes. No aspirin allergy. Age over 30. Systolic blood pressure less than 180. Diastolic blood pressure less than 110. No surgery or major trauma within the last two weeks. No stroke or serious neurological problems within the last 6 months. No bleeding disorders (ulcers, esophageal varices, etc.) Not pregnant. May repeat
Fentanyl 50-100 mcg (1 mcg/kg) slow (over 1-2 min.) IV. as necessary to a total of 150 mcg.
If allergic to Fentanyl, consider Morphine Sulfate, 2 mg incremental doses, IV, repeated at 5 minute intervals to a total of 4mg, titrated for pain relief. Do not administer morphine if systolic BP < 90 mm/Hg. Note: If patient develops depressed respirations following Morphine or Fentanyl administration, be prepared to actively support airway and ventilation and possibly administer Narcan. Note: If patient becomes hypotensive after administration of Morphine or Fentanyl, lie flat temporarily and administer fluid. When patient becomes normotensive again, return to Semi-fowlers. II.1. For doses of Morphine Sulfate or Fentanyl over maximum total dose, contact Medical Control.
PEDIATRIC CARE I.1. I.2. II.1. General Supportive Care. Treatment of any arrhythmia per specific protocol. None.
PROTOCOL 2.17: COMA / ALTERED MENTAL STATUS Note: Although alcohol is a common cause of altered mental status, it is not commonly a cause of frank coma (i.e., total unresponsiveness to pain). No judgment in the field should be made concerning the importance of the presence of alcohol on any patients breath who presents totally unresponsive to pain.
ADULT CARE I.1. I.2. Strongly consider possible need for cervical spine immobilization. Carefully monitor for any neurological deficits. Be aware of Medical Alert tags, breath odor, signs of drug abuse, sources of gases or potential toxins. General Supportive Care. IV, NS. Check glucose level, if blood glucose 70, administer D50, 50ml (25 GM) IV. Consider Glucagon 1 mg IM if unable to obtain IV. Administer Thiamine 100 mg IV if alcohol abuse is suspected/apparent. Note: If both D50 and Thiamine are to be administered and patient is poorly nourished with alcohol abuse strongly suspected/apparent, administer Thiamine before D50. I.6. If blood glucose > 70, administer Narcan 0.4-2 mg, IV, ET, or IM. Use the larger dose of Narcan if overdose with synthetic narcotic compounds suspected (Darvocet, Fentanyl, etc.). Opiate overdose should not be ruled out based just on the patients age or appearance, opiates can be a commonly prescribed drug for all ages and types of patients. Be particularly attentive to airway, protect as needed (positioning, NP, OP airways, suctioning, elective intubation) the truly unconscious, unresponsive patient can not control their own airway. Use appropriate discretion regarding immediate intubation of patients who may quickly regain gag reflexes/consciousness, such as the hypoglycemic diabetic after IV Glucose, opiate overdose patients after Narcan, and the seizure patient after the seizure is over. None.
I.3. I.4. I.5.
I.7.
I.8.
II.1.
PROTOCOL 2.17: COMA / ALTERED MENTAL STATUS (cont.) PEDIATRIC CARE I.1. I.2. Strongly consider need for cervical spine immobilization. Carefully monitor for any neurological deficits. Be aware of Medical Alert tags, breath odor, signs of drug abuse, sources of gases, potential toxins or ingestions. General Supportive Care. IV, NS. Check glucose level. If blood glucose < 60 in child or < 40 in newborn a) b) c) d) I.5. I.6. > 2 years: D50 at 1 ml/kg < 2 years: D25 at 2 ml/kg < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20 kg, 0.5 mg IM.
I.3. I.4.
If blood glucose within normal values, consider Narcan 0.1 mg/kg IV, ET, or IM( not to exceed 2 mg). Be particularly attentive to airway, protect as needed (positioning, NP, OP airways, suctioning, elective intubation) the truly unconscious, unresponsive patient can not control their own airway. Use appropriate discretion regarding immediate intubation of patients who may quickly regain gag reflexes/consciousness, such as the hypoglycemic diabetic after IV Glucose, opiate overdose cases after Narcan, and the seizure patient after the seizure is over. None.
I.7.
II.1.
PROTOCOL 2.18: COPD Indications: 1. Patients with respiratory distress and: A. B. C. History of COPD AND Wheezing on auscultation, diminished breath sounds bilaterally, prolonged expiration AND No evidence of pulmonary edema or congestive heart failure.
ADULT CARE I.1. I.2. General Supportive Care, Position of comfort - the short of breath COPD patient will usually find the position themselves that allows them to breathe the easiest, Fowlers position is usually the best, the COPD patient that is lying flat or that allow you to lie them flat is typically in dire straits. O2 starting at 2L/min. If signs and symptoms of hypoxia persist, then increase O2 as needed.* Observe for changes in mental status or respiratory depression, assist ventilation as necessary. Albuterol unit dose vial of 2.5 mg. nebulized and administered until dose complete. Repeat twice if necessary. If more than three treatments required, contact Medical Control. When administering Albuterol nebulizer treatments to the COPD patient, an IV of NS should be started and a cardiac monitor attached.
I.3.
I.4.
* Note: It is common to find protocols that caution against the use of high concentrations of supplemental oxygen for patients with COPD (emphysema, chronic bronchitis). Such protocols may restrict supplemental oxygen for a spontaneously breathing COPD patient at 2 liters/minute by nasal cannula. The intent is to avoid inhibition of their spontaneous respiratory efforts. However, it is desirable to minimize the length of time that any patient, including one with COPD, suffers from hypoxia. Hypoxia is life threatening. All hypoxic patients should receive supplemental oxygen as quickly and as in as high a concentration as their respiratory drive will tolerate. The clinical problem in the field is determining how much supplementary oxygen a COPD patient can safely tolerate.
PROTOCOL 2.18: COPD (cont.) The COPD patient regulates his spontaneous ventilation by internal measurement of the oxygen content in their blood. This is different from normal patients who use CO2 content to drive ventilation. When a COPD patient is hypoxic, ventilation is over-stimulated. If the COPD patient has a large surplus of oxygen, as may occur with inappropriate use of high concentrations of supplemental oxygen, spontaneous ventilation decreases. An understanding of this simple physiologic control mechanism can be used to safely titrate oxygen administration with COPD patients. When COPD patients have acute respiratory distress, oxygen may be given in high concentrations until the rapid respiratory rate begins to slow down towards normal. This shows that hypoxia is becoming less severe and respiratory drive is starting to return to normal. The supplemental oxygen dosage may then be reduced in a titrated manner as the respiratory rate returns to normal. This simple approach allows oxygenation to be restored as quickly as possible and reduces the potential harm of extended hypoxia. I.5. II.1 Consider CPAP if patient in extremis. None
PROTOCOL 2.19: DIABETIC EMERGENCIES Note: Hypoglycemia may present as focal neurologic deficit or coma (could be mistaken for stroke). All patients with altered mentation should have glucose checked. Unconsciousness in the diabetic may be due to hypoglycemia or hyperglycemia, check glucose before administering D50. The hypoglycemic diabetic contacted by EMS in the field will many times try to refuse transport if D50 is administered prior to the patient being loaded into the ambulance and transport begun. The Paramedic should exercise careful discretion with these refusal situations, and transport to a medical facility should always be strongly encouraged and offered. If the conscious and fully alert patient ultimately refuses, make it very clear to them that a good meal must be consumed in a short time frame as the D50 will not last, refer to 6.11: No Transport (Refusal, Cancel) Protocol. Statistically, the insulin-dependent diabetic tends to do reasonably well if left at home after being treated with D50 in the field following a profound hypoglycemic episode. The same cannot be said of the diabetic that controls their disease only with an oral medication or diet. These patients tend to have poorer outcomes and every possible means must be utilized to encourage this sub-set of patients to accept transport. The best way to treat these patients is to administer any required D50 after the patient is in the ambulance and enroute to the hospital. ADULT CARE I.1. I.2. I.3. General Supportive Care. Do finger stick and check glucose regardless of potential need for IV. If glucose to 70 and patient is alert (able to hold glass in hand and drink from it), give oral self-administered sugar solution (Glutose, soda or orange juice with sugar). If patient is stuporous or unconscious and glucose to 70, administer D50 (25 gm) 50ml, IV (start large-bore NS IV in good vein and run NS in liberally as D50 is injected). Do not delay transport to determine response to D50. If unable to start IV, administer Glucagon, 1 mg., IM.
I.4.
I.5. I.6.
PROTOCOL 2.19: DIABETIC EMERGENCIES (cont.) ADULT CARE (cont.) I.7. I.8. II.1. If patient does not return to normal LOC or if patient condition deteriorates, repeat glucose check. If glucose remains < 70, repeat D50 IV. None.
PEDIATRIC CARE I.1. I.2. I.3. General Supportive Care, Do finger stick and check glucose regardless of potential need for IV. If glucose less than threshold values noted below* and patient is alert, (able to hold glass in hand and drink from it), give oral self-administered sugar solution (Glutose, soda or orange juice with sugar). *If blood glucose < 60 in child or < 40 in newborn a) b) c) d) I.5. I.6. I.7. II.1. > 2 years: D50 at 1 ml/kg < 2 years: D25 at 2 ml/kg < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20 kg, 0.5 mg IM.
I.4.
Do not delay transport to determine response to D25/D50. If patient does not return to normal LOC or if patient condition deteriorates, repeat glucose check. If remains below threshold values, repeat D50 or D25 IV. None.
PROTOCOL 2.20: DRUG OVERDOSE / INGESTION / POISONING Note: The intentional overdose or suicide gesture patient is to be considered potentially dangerous. Additionally, certain types of ingestions such methamphetamines (Crank, Crystal, Speed. Meth) and drugs such as PCP (Phencyclidine, Angel Dust) can cause a patient to be particularly violent and uncooperative, utilize Law Enforcement assistance to manage these patients as necessary. During response to these incidents EMS will be required to stage in the area until Law Enforcement arrives and determines the scene is secure. The suicide gesture and illicit drug overdose patient that is alert will frequently resist the suggestion that they be transported to a medical facility, If it is determined that a true intentional overdose did occur, the patient must be transported. Law Enforcement assistance should be sought to accomplish this if necessary. The use of certain types of Designer or Club drugs such as Ecstasy (MDMA) in the Rave Party setting can result in the patient becoming hyperthermic and profoundly dehydrated, be aware and treat as necessary. The over-all goal of treatment of the overdose/ingestion/poisoning patient should be general supportive care and support of the ABCs. Treatment of specific problems should be guided by the pertinent protocol. ADULT CARE I.1. I.2. I.3. General Supportive Care. (Special attention provided to airway protection up to and including elective intubation. IV NS. Check blood glucose level, if 70 administer D50, 25 gm IV, see 2.19: Diabetic Emergencies Protocol. If suspected narcotic involvement or with a change in level of consciousness due to an unknown agent, Narcan, 0.4-2 mg IV, ET, or IM. Use the larger dose if overdose with synthetic narcotic compounds suspected (Darvocet, Fentanyl, etc.). Opiate overdose should not be ruled out based just on the patients age or appearance, opiates can be a commonly prescribed drug for all ages and types of patients.
PROTOCOL 2.20: DRUG OVERDOSE / INGESTION / POISONING (cont.) ADULT CARE (cont.) Consider titrating Narcan to achieve adequate respiratory effort and avoid a withdrawl reaction or combativeness. I.4. Consider repeating Narcan, 0.4-2 mg via IV, ET, or IM for patient with pinpoint pupils, depressed respiratory effort or LOC but no response to initial dose. In suspected narcotic overdoses, withhold decision to intubate until after the patient has received Narcan. If suspected Tricyclic Antidepressant (TCA) (Doxepin, Amitriptyline, etc.) overdose and tachycardia, QRS widening present, Sodium Bicarbonate 1.0 meq,kg IV. Contact Medical Control for potential additional doses. Note: Statistically, intentional overdose with TCAs is quite common. In the absence of direct evidence of TCA overdose (inappropriately empty pill bottles, etc.), the ECG is an essential part of the diagnosis and treatment (tachycardia, QRS widening). Patient should also be observed for anticholinergic effects, (dry mouth/mucosa, vasodilation, hypotension, decreased sweating, lethargy/altered mentation). Patient may also experience seizures. Control airway aggressively, patient may become severely obtunded very quickly. Treat cardiotoxic effects with Sodium Bicarbonate, hypotension with fluids, and seizures with benzodiazepines (see 2.24: Seizures and Status Epilepticus Protocol). I.7. I.8. I.9. Contact Medical Control or Poison Control* for information on the suspected poison(s) or drugs if needed. Observe any emesis for possible pill fragments. Gather all medications, over-the-counter drugs, or other possible safe to transport toxins accessible to the patient and transport with the patient to the ED. Utilize Law Enforcement assistance as needed in managing the violent, uncooperative or suicide gesture patient. If necessary to restrain patient, refer to 5.22: Restraint (Physical and Chemical) Protocol.
I.5. I.6.
I.10.
PROTOCOL 2.20: DRUG OVERDOSE / INGESTION / POISONING (cont.) ADULT CARE (cont.) I.11. Situations involving inhaled and cutaneous exposure to toxins can pose significant risks to rescuers. Be aware of Hazardous Materials implications and do not enter an environment where such an exposure has taken place until it has been determined to be safe to do so (Dont needlessly make more patients, seek Haz-Mat team assistance when in doubt). For specific treatment of medical problems caused by Hazardous Materials, see 6.6: Hazardous Materials/WMD Incidents Protocol. Where no Haz-Mat problem exists, inhaled toxins should be treated with 100% O2 via NRB mask (unless specifically contraindicated). Where no Haz-Mat problem exists, cutaneous exposure patients should be removed from environment and decontaminated with copious amounts of water. All clothes should be removed and care should be taken not to contaminate rescuers. If overdose is suspected with antipsychotic drugs (Thorazine, Compazine, Haldol, Lithium, Risperdal, etc.) and patient is awake and experiencing extrapyramidal reaction symptoms, Benadryl 50 mg IV or IM repeat as needed. Do not administer Benadryl if patient is not alert or unconscious.
I.12. I.13.
I.14.
PEDIATRIC CARE I.1. General Supportive Care. (Special attention provided to airway protection up to and including elective intubation. IV NS if patient obtunded or significant altered mentation. Check blood glucose level, if < 60 in child or < 40 in newborn, administer IV glucose or Glucagon, see 2.19: Diabetic Emergencies Protocol. If suspected narcotic involvement or with a change in level of consciousness due to an unknown agent, Narcan, 0.1m/kg IV, ET, IO or IM (not to exceed 2 mg). Suspicion of opiate overdose in the pediatric patient should be based on a history gathered relative to the patients possible access to the drug. In suspected narcotic overdoses, withhold decision to intubate until after the patient has received Narcan.
I.2. I.3.
I.4.
PROTOCOL 2.20: DRUG OVERDOSE / INGESTION / POISONING (cont.) PEDIATRIC CARE-(cont.) I.5. I.6. I.7. Contact Medical Control or Poison Control* for information on the suspected poison(s) or drugs if needed. Observe any emesis for possible pill fragments. Gather all medications, over-the-counter drugs, or other possible safe to transport toxins accessible to the patient and transport with the patient to the ED. Utilize Law Enforcement assistance as needed in managing the violent, uncooperative or suicide gesture patient. If necessary to restrain patient, refer to 5.22: Restraint (Physical and Chemical) Protocol. Situations involving inhaled and cutaneous exposure to toxins can pose significant risks to rescuers and when children are involved, rescuers may be prone to take risks they would not otherwise take. Be aware of Hazardous Materials implications and do not enter an environment where such an exposure has taken place until it has been determined to be safe to do so (Dont needlessly make more patients, seek Haz-Mat team assistance when in doubt). For specific treatment of medical problems caused by Hazardous Materials, see 6.6: Hazardous Materials/WMD Incidents Protocol. Where no Haz-Mat problem exists, inhaled toxins should be treated with 100% O2 via NRB mask (unless specifically contraindicated). Where no Haz-Mat problem exists, cutaneous exposure patients should be removed from environment and decontaminated with copious amounts of water. All clothes should be removed and care should be taken not to contaminate rescuers. If suspected Tricyclic Antidepressant (TCA) (Doxepin, Amitriptyline, etc.) overdose and tachycardia, QRS widening present, Sodium Bicarbonate 1.0 meq,kg IV. Additional information above (Note) for adult TCA overdose also applies to pediatric patient. Consider repeating Narcan, 0.1 mg/kg/via IV, ET, IO, or IM (not to exceed 2 mg) for patient with pinpoint pupils, depressed respiratory effort or LOC but no response to initial dose.
I.8.
I.9.
I.10. I.11.
II.1
II.2.
PROTOCOL 2.20: DRUG OVERDOSE / INGESTION / POISONING (cont.) PEDIATRIC CARE-(cont.) II.3. If overdose is suspected with antipsychotic drugs (Thorazine, Compazine, Haldol, Lithium, Resperidal, etc.) and patient is experiencing extrapyramidal reaction symptoms, Benadryl 1 mg/kg IV or IM repeat as needed.
* Poison Control 1-800-764-7661
PROTOCOL 2.21: HYPERTENSIVE EMERGENCIES Note: Hypertension in itself is not the primary concern or focus, the problems resulting from the hypertension are the most concerning aspect. In the presence of neurologic findings, pre-hospital treatment of hypertension may be contraindicated because a rapid or precipitous drop in BP may compromise cerebral blood flow and cause further neurological complications. Secondary hypertension (high BP in response to stress or pain) is commonly seen in the field. It does not require field treatment, and may not even mean the patient has chronic hypertension requiring ongoing treatment. Hypertension is seen in severe head injury and intracranial bleeding and may be a protective response which increases perfusion to the brain. Treatment should be directed at lowering the intracranial pressure, not the blood pressure. ADULT CARE I.1 I.2 I.3. General Supportive Care, IV NS. Cardiac monitor, Obtain 12-lead ECG (when it can be done without delaying needed treatment). Recheck BP with special attention to correct cuff size and placement. Falsely elevated BP readings can result from a cuff which is too small for the patient. The cuff should cover to of the upper arm, and the bladder should completely encircle the arm. If unconscious, support airway and hyperventilate. Consider intubation using Lidocaine 1mg/kg IV to reduce increased intracranial pressure. If the patient is seizing, in congestive heart failure or having chest pain, treat per appropriate protocol. Consider elevation of head 45 degrees if not contraindicated.
I.4. I.5. I.6.
PROTOCOL 2.21: HYPERTENSIVE EMERGENCIES PEDIATRIC CARE I.1. I.2. General Supportive Care. Recheck BP with special attention to correct cuff size and placement. Falsely elevated BP readings can result from a cuff which is too small for the patient. The cuff should cover to of the upper arm, and the bladder should completely encircle the arm. If unconscious, support airway and hyperventilate. None.
I.3. II.1.
PROTOCOL 2.22: OB / GYN Definitions: Imminent Delivery: 1. 2. 3. 4. Amniotic sac has broken AND Contractions are 2-3 minutes apart or less (constant). There is crowning of the fetal head or bulging in the perineum that suggests the fetus is about to exit the birth canal. Mother has urge to bear down or have bowel movement.
Delayed Delivery: 1. 2. 3. Determine: 1. 2. 3. 4. 5. The number of previous pregnancies the mother has had. The frequency and duration of contractions. The condition of the amniotic sac (broken, unbroken). The presence or absence of vaginal bleeding. Approximate gestational age of the fetus. Contractions are 5 or more minutes apart. Amniotic sac is not broken. First pregnancy for the mother and both of the above are present.
ADULT CARE I.1. I.2. I.3. General Supportive Care, O2, IV NS. If vaginal bleeding, check for orthostatic changes in vital signs. hypotensive, give fluid bolus and consider second line. If
If vaginal bleeding, attempt estimate of blood loss (number of pads saturated in past 6 hours). Ask about clots or tissue fragments (bring tissue to hospital if possible). Position patient with advanced pregnancy on left side. backboard for trauma, tilt board to left and block up.. If on long
I.4. I.5.
If patient pregnant and indications of delayed delivery, begin transport and establish Medical Control contact as soon as possible so Labor and Delivery can prepare for patient arrival..
PROTOCOL 2.22: OB/GYN (cont.) ADULT CARE (cont.) I.6. If there is indication of Imminent Delivery, make decision to deliver on scene or transport immediately. Be prepared to stop ambulance if delivery occurs enroute.
Delivery I.1. I.2. I.3. I.4. I.5. I.6. I.7. Use clean or sterile technique. Guide and control, but do not retard or hurry delivery. Once the fetuss head has emerged, check for nuchal cord, suction the mouth, then nose with bulb syringe. Suction again after delivery. Stimulate by drying (this should be enough to start infant crying). Protect infant from fall and temperature loss; dry and wrap for warmth (especially head, use beanie). Note time of delivery. Assess infants status using APGAR score. Neonatal Resuscitation Protocol. If less than 7, see 2.6:
TABLE 2.A. APGAR Score

APGAR Score
0 Points Absent Absent Flaccid No response Blue, pale 1 Point <100 Slow, irregular Some flexion Some Blue & pink 2 Points >100 Strong cry Active motion Vigorous Fully pink TOTAL: 1 Minute 5 Minutes
Heart Rate Respiratory Effort Muscle Tone Irritability Color
* Infants with scores of 7-10 usually require supportive care only. * A score of 4-6 indicates moderate depression. * Infants with scores of 3 or less will require aggressive resuscitation.
PROTOCOL 2.22: OB/GYN (cont.) ADULT CARE (cont.) I.8. Clamp the cord in two places approximately 6-8 inches from the infant. (keep the infant at or below the level of the mother until the cord is clamped. Cut the cord between the clamps. If excessive bleeding occurs postpartum, massage the top of the uterus gently. Assess infants status again at 5 minutes using APGAR score. Do not delay transport for or attempt to deliver placenta. If placenta delivers spontaneously, take to the hospital in plastic bag.
I.9. I.10. I.11. I.12
Prolapsed Cord I.1. I.2. Place the mother in left lateral Trendelenburg position, elevate hips if possible or knee-chest position. Insert gloved hand for counter-pressure against infants head to allow blood flow through cord. Elevation of the buttocks may also help to alleviate pressure on the cord. Transport Code 3 (HOT) to the nearest appropriate facility.
I.3.
Breech Position I.1. I.2. I.3. If the presenting part of the fetus is not the head, coach the mother and attempt to assist a controlled delivery. If unable to deliver, place the mother in left lateral Trendelenburg position. Transport Code 3 (HOT) to the nearest appropriate facility.
Nuchal Cord I.1 If the fetus presents at the perineum with the umbilical cord wrapped around its neck, try to slip the cord gently over the babys head. If cord too tight to do so, place two clamps about 2 inches apart on the cord and cut cord in between. Unwind, then deliver infant quickly.
PROTOCOL 2.22: OB/GYN (cont.) II.1 None
PEDIATRIC CARE (Childbearing minor treated medically same as adult)
PROTOCOL 2.23: PULMONARY EDEMA Indications: 1. Patients presenting with dyspnea, having a history of CHF, MI, HTN or coronary artery disease with three or more of the following: A. B. C. D. E. F. 2. cyanosis rales (crackles) peripheral edema frothy pink sputum respiratory rate > 25 or <10 neck vein distension
Systolic blood pressure must be 90 mm Hg and pulse < 150 (otherwise see 2.15: Cardiogenic Shock Protocol or pertinent arrhythmia protocol).
ADULT CARE I.1. I.2. I.3. I.4. General Supportive Care, IV saline lock or NS TKO. High Fowlers position, assist with ventilation and intubate as needed. Consider CPAP. If normotensive or hypertensive, Nitroglycerin, up to (3) SL sprays or 0.4 mg SL tabs Q 5 min. (watch BP). Nitro therapy should be directed toward relieving the worst of the patients respiratory distress so relatively comfortable transport is possible. If normotensive or hypertensive, Lasix, 40 mg, IV.
II.1.
PEDIATRIC CARE I.1. I.2 II.1. General Supportive Care, IV saline lock or NS TKO. High Fowlers position, assist with ventilation and intubate as needed. If normotensive or hypertensive for patient age, Lasix, 1 mg/kg, IV.
PROTOCOL 2.24: SEIZURES AND STATUS EPILEPTICUS Note: The pharmacologic interventions in this protocol should be used when patient is having continuous seizures or repeating episodes of seizure activity without regaining consciousness. Pharmacologic intervention is not absolutely required in every case, but should be used whenever the attending Paramedic deems it necessary. Consider underlying etiology, such as hypoglycemia, cardiac arrhythmias, overdose, head injury or fever. The patient with a seizure disorder that seizes, but clears completely and has no outstanding problem may need little or no intervention and may even wish to refuse transport. This should only be allowed if the patient proves they are able to care for themselves and transport to a medical facility should be strongly encouraged. ADULT CARE I.1 I.2. I.3. Move hazardous objects away from seizing patient and protect their head. When (if) patient stops seizing, place in left lateral recumbent position( if no c-spine injury is suspected) and clear airway, suction if needed. The seizure patient that regains consciousness may be extremely disoriented upon awakening. Do not allow patient to wander around or even get up until they are fully alert. General Supportive Care. IV NS if status seizures or prolonged significantly altered mentation. Check blood glucose level, if 70 administer D50, 25 gm IV,, see 2.19: Diabetic Emergencies Protocol. If not hypoglycemic, administer Ativan, 1 mg IV repeated once to a total of 2 mg, dose to effect. Consider Valium, 5 mg, slow IV repeated once to a total of 10 mg, dose to effect. If unable to obtain venous access, then Valium 5-10 mg IM route, (acceptable but slower acting and less predictable). If above total doses of Ativan and Valium are ineffective in controlling status seizures, contact Medical Control to discuss treatment options.
I.4. I.5 I.6. I.7. I.8. II.1.
PROTOCOL 2.24: SEIZURES AND STATUS EPILEPTICUS PEDIATRIC CARE I.1 I.2. I.3. Move hazardous objects away from seizing patient and protect their head. When (if) patient stops seizing, place in left lateral recumbent position ( if no c-spine injury is suspected) and clear airway, suction if needed. The seizure patient that regains consciousness may be extremely disoriented upon awakening. Do not allow patient to wander around or even get up until they are fully alert. The febrile seizure patient may need little in the way of intervention if the seizure is over, but absolutely should be transported. Parents that try to refuse service for such a patient should be strongly encouraged to accept transport. Attempts at cooling the febrile seizure patient are usually of little value and may actually make things worse. It should just be assured that the patient is not overheated by excessive layers of blankets, etc. The issue that needs to be addressed and treated is the cause of the fever. General Supportive Care. IV NS if status seizures or prolonged significantly altered mentation. Check blood glucose level, if < 60 in child or < 40 in newborn, administer IV glucose or Glucagon, see 2.19: Diabetic Emergencies Protocol. If not hypoglycemic, administer Ativan 0.05 - 0.2 mg/kg slow IV, IO or IM until seizures begin to diminish. (for IV or IO use, dilute 1:1 in NS) Consider Valium 0.25 mg/kg slow diminish. IV or IO until seizures begin to
I.4.
I.5. I.6 II.1. II.2. II.3.
If unable to obtain venous access, Valium may also be administered rectally at 0.5 mg/kg using a tuberculin syringe (without needle) inserted rectally 4-5 cm.
PROTOCOL 2.25: SUDDEN INFANT DEATH SYNDROME (SIDS) Note: This protocol should be used if it is determined after a careful examination that an infant that has suffered a cardiac arrest is nonresuscitatable by Advanced Life Support standards, refer to 6.5: Field Determination of Death Protocol for criteria. If patient does not meet criteria for field determination of death, immediately begin resuscitation using pertinent protocol based on patients presenting cardiac rhythm. SIDS cause is unknown, cases typically occur between one month and one year of age. I.1. Deliver death message in a gentle manner to parents or caregivers. A resuscitation should not be begun on a infant that has advanced rigor mortis and post mortem lividity for the family. Doing so only creates a false illusion of a potential positive outcome. Contact Law Enforcement for coroner involvement. Support family, assist with activating any available support structure (clergy, family members, etc.). Gather and document as complete a history as is possible: a) b) c) d) e) f) I.5. Position in which child was found Condition of bed Last time child seen well Seizure activity, trauma, possible ingestion Associated S/S, fever, respiratory problems, infection, vomiting, etc. Past medical history, prematurity, development, nutrition
I.2. I.3. I.4.
Note and completely document physical findings relative to both patient and environment: a) b) c) d) Presence of rigor mortis and or post mortem dependent lividity Presence of froth or blood tinged sputum at mouth or nose Signs of trauma Living conditions in residence
I.6.
Avoid premature assessments, statistically, most SIDS cases are not child abuse or homicides. However they do occur, so thorough assessment and documentation is essential.
PROTOCOL 2.26: SYNCOPAL EPISODE Note: Syncope is by definition a transient state of unconsciousness from which the patient has recovered. If the patient is still unconscious, see 2.17: Coma/Altered Mental Status Protocol. Emphasis should be placed on underlying cause of syncope and its treatment. Statistically, the most common cause of unconsciousness in the elderly patient in the pre-hospital setting is CVA/stroke problems. In the younger patient it is seizures. ADULT CARE I.1. I.2. I.3. I.4. General Supportive Care. ECG. IV NS if patient remains not alert. Consider possible need for cervical spine immobilization if patient sustained fall during syncope. Carefully monitor for any neurological deficits. Be aware of Medical Alert tags, breath odor, signs of drug abuse, sources of gases, potential toxins or ingestions. Consider past medical history and possibility of transient dysrhythmia, hypovolemia (check for orthostatic changes in vital signs), medication side effects, glucose level abnormalities, inner ear disorders, CVA/TIA. The patient that has passed out and then regained consciousness will frequently want to refuse service. Make sure patient has received full assessment (vitals, ECG, glucose check) and remind them that passing out is not normal before processing such a refusal, refer to 6.11: No Transport (Refusal, Cancel) Protocol. None.
I.5.
I.6.
II.1.
PEDIATRIC CARE I.1. I.2. General Supportive Care. ECG. IV NS if patient remains not alert.
PROTOCOL 2.26: SYNCOPAL EPISODE (cont.) PEDIATRIC CARE (cont.) I.3. I.4. Consider possible need for cervical spine immobilization if patient sustained hard fall during syncope. Carefully monitor for any neurological deficits. Be aware of Medical Alert tags, breath odor, signs of drug abuse, sources of gases, potential toxins or ingestions. Consider past medical history and possibility of transient dysrhythmia, hypovolemia (check for orthostatic changes in vital signs), medication side effects, glucose level abnormalities, inner ear disorders, CVA/TIA. The parents of a pediatric patient that has passed out and then regained consciousness may want to refuse service. Make sure patient has received full assessment (vitals, ECG, glucose check) and remind them that passing out is not normal before processing such a refusal, refer to 6.11: No Transport (Refusal, Cancel) Protocol. None.
I.5.
I.6.
II.1.
Section 3 Treatment Protocols - Trauma
PROTOCOL 3.1: TRAUMA AND HYPOVOLEMIC SUPPORTIVE CARE NOTE: This protocol presents the basic components of patient packaging for trauma patients. Due to the significant differences in priorities and packaging in the pre-hospital care of medical cases, a separate General Supportive Care Protocol has been developed. This Trauma and Hypovolemic Supportive Care Protocol may be the only protocol used in trauma or hypovolemia situations where a specific diagnostic impression and choice of protocol(s) cannot be made. If there is a question as to whether a patient requires a particular intervention, contact with Medical Control is advised. This protocol is frequently referred to by other protocols which may override it in recommending more specific therapy. Although the following protocol is oriented toward the treatment of the trauma patient, the principles of rapid evaluation, treatment, and transport of patients with hypovolemia secondary to other problems parallel those listed below. Fluid resuscitation may be required in large volumes or in smaller incremental boluses. Careful monitoring for signs of volume overload is essential. Medical Control contact may be useful for patients requiring fluid resuscitation. ADULT CARE I.1. I.2. I.3. Assessment of scene. Primary survey. Airway access with cervical spine control, initial management includes patient positioning and manual maneuvers to assure a patent airway. Patients with signs and symptoms of hypoxia should initially be treated with O2 12-15 L/min via non-rebreather mask. Assist ventilation (24 breaths/min) in patients with respiratory rate<12/min, shallow respirations with inadequate tidal volume, or a decreased level of consciousness. (GCS 8 or less). If the patient has continued difficulty with oxygenation and ventilation after simple airway maneuvers, airway adjuncts and advanced airway procedures may be used. Endotracheal tube placement must be verified by three (3) different methods immediately following intubation (see 5.7-9: Advanced Airway Management Protocols). Tube placement must also be re-verified after securing tube, after moving the patient, and at any other time of
I.4.
I.5.
PROTOCOL 3.1: TRAUMA AND HYPOVOLEMIC SUPPORTIVE CARE (cont.) ADULT CARE (cont.) concern or change in the patients condition (including the movement of the patient from the ambulance cot to the hospital bed). If there is any question regarding the placement of the endotracheal tube, the endotracheal tube should be withdrawn and the patient reintubated. In line cervical spine stabilization must be maintained during attempts at oral intubation. If cervical spine injury is strongly suspected and/or obvious, and field intubation is necessary, strongly consider nasal intubation if there is spontaneous respiratory effort present (see 5.8: Advanced Airway Management: Nasotracheal Intubation Protocol). I.6 I.7. Hemorrhage control as necessary. Immobilization on long backboard with cervical collar, CID, and straps (minimum of 4). In the event of significant localized facial injury and patient insists on sitting forward to maintain own airway, do not force patient onto backboard, manage c-spine as best as is possible with ccollar and KED only. If patient meets Trauma Alert criteria (see 5.28: Trauma Alert Protocol) Facilitate immediate transport and early as possible notification of receiving hospital (before leaving scene if possible). Goal with Trauma Alert and other significant trauma cases is maximum of ten minutes on scene. If injuries are minor in nature, the Paramedic may elect to complete the secondary survey at the scene. Immediately stabilize any life threatening respiratory problems: a) Sucking chest wound b) Tension pneumothorax (see 5.27: Tension Pneumothorax Decompression Protocol) c) Flail chest NOTE: The following steps should not delay transport. I.11. IV NS using two large bore lines using at least one blood tubing set.
I.8.
I.9. I.10.
PROTOCOL 3.1: TRAUMA AND HYPOVOLEMIC SUPPORTIVE CARE (cont.) ADULT CARE (cont.) Note: Fluid administration in the field should be geared toward raising the patients systolic BP to no more than 90 100 mm/Hg. Any more could potentially worsen internal bleeding. I.12. I.13. I.14. ECG monitoring. Complete bandaging, splinting and packaging. Follow additional protocols as needed, establishing Medical Control contact as dictated by protocol. If Medical Control is not needed, contact the destination facility to give patient report, following the 6.14: Radio Report Protocol. Transport red lights and sirens (Code 3, HOT) if patients condition is critical. Critical is defined by a medical or traumatic condition requiring immediate medical intervention by physician and nursing personnel upon arrival at the Emergency Department. Critical may further be defined as any patient whose deteriorating medical condition cannot be controlled by the Paramedic. All other patients will be transported nonred lights and sirens (Code 2, COLD).
I.15.
PEDIATRIC CARE I.1 I.2. I.3. Assessment of scene. Primary survey. Airway access with cervical spine control, initial management includes patient positioning and manual maneuvers to assure a patent airway. Patients with signs and symptoms of hypoxia should initially be treated with O2 via non-rebreather mask at 10-12 LPM. Assist ventilation (24 breaths/min) in patient with respiratory rate<12/min, shallow respirations with inadequate tidal volume, or decreased level of consciousness. (GCS 8 or less). If the patient has continued difficulty with oxygenation and ventilation after simple airway maneuvers, airway adjuncts and advanced airway procedures may be used.
I.4.
PROTOCOL 3.1: TRAUMA AND HYPOVOLEMIC SUPPORTIVE CARE (cont.) PEDIATRIC CARE (cont.) I.5. Endotracheal tube placement must be verified by three (3) different methods immediately following intubation (see 5.7-9: Advanced Airway Management Protocols). Tube placement must also be re-verified after securing tube, after moving the patient, and at any other time of concern or change in the patients condition (including the movement of the patient from the ambulance cot to the hospital bed). If there is any question regarding the placement of the endotracheal tube, the endotracheal tube should be withdrawn and the patient reintubated. In line cervical spine stabilization must be maintained during attempts at oral intubation. If cervical spine injury is strongly suspected and/or obvious, and field intubation is necessary, strongly consider nasal intubation (if more than 8 y/o) if there is spontaneous respiratory effort present (see 5.8: Advanced Airway Management: Nasotracheal Intubation Protocol). I.6. I.7. Hemorrhage control as necessary. Immobilization on long backboard with cervical collar, CID, and straps (minimum of 4). Use pediatric immobilization device if patient size appropriate. In the event of significant localized facial injury and patient insists on sitting forward to maintain own airway, do not force patient onto backboard, manage c-spine as best as is possible with c-collar and KED only. If patient meets Trauma Alert criteria (see 5.28: Trauma Alert Protocol) Facilitate immediate transport and early as possible notification of receiving hospital (before leaving scene if possible). Goal with Trauma Alert and other significant trauma cases is maximum of ten minutes on scene. If injuries are minor in nature, the Paramedic may elect to complete the secondary survey at the scene. Immediately stabilize any life threatening respiratory problems: a) Sucking chest wound b) Tension pneumothorax (see 5.27: Tension Pneumothorax Decompression Protocol) c) Flail chest
I.8.
I.9. I.10.
PROTOCOL 3.1: TRAUMA AND HYPOVOLEMIC SUPPORTIVE CARE (cont.) PEDIATRIC CARE (cont.) NOTE: The following steps should not delay transport. I.11. I.12. I.13. I.14. IV NS - initial fluid bolus should be 2O ml/kg. (Keep in mind that normal BP and heart rate varies with childs age). ECG monitoring. Complete bandaging, splinting and packaging. Follow additional protocols as needed, establishing Medical Control contact as dictated by protocol. If Medical Control is not needed, contact the destination facility to give patient report, following the 6.14: Radio Report Protocol. Transport red lights and sirens (Code 3, HOT) if patients condition is critical. Critical is defined by a medical or traumatic condition requiring immediate medical intervention by physician and nursing personnel upon arrival at the Emergency Department. Critical may further be defined as any patient whose deteriorating medical condition cannot be controlled by the Paramedic. All other patients will be transported nonred lights and sirens (Code 2, COLD). Intraosseous venous access may be attempted during transport if: a) Full Arrest II.1. Intraosseous venous access may be attempted during transport with authorization from Medical Control if: a) Child 3 years old AND b) unconscious, AND c) signs and symptoms of shock
I.15.
I.16.
PROTOCOL 3.2: ABDOMINAL / PELVIC TRAUMA NOTE: The extent of abdominal injury is difficult to assess in the field. Be very suspicious; with significant blunt trauma, injuries to multiple organs are the rule. Patients with spinal cord injury or altered mentation due to drugs, alcohol or head injury may not complain of pain and may lack guarding in the face of significant intra-abdominal injury. Significant intra-abdominal injury may occur without any external signs of injury, particularly in children. Strongly consider the mechanism of injury, the forces involved and be highly suspicious of occult trauma. ADULT CARE I.1. I.2. I.3. I.4. Trauma and Hypovolemic Supportive Care. High flow O2 via NRB mask. Large-bore IV NS, consider second line. Always place second line if signs of shock. Cover eviscerated tissue with moist saline dressing, then dry sterile dressing. Do not attempt to replace eviscerated contents back into abdominal cavity. Immobilize impaled objects in place to prevent further movement. None.
I.5. II.1.
PEDIATRIC CARE I.1. I.2. I.3. Trauma and Hypovolemic Supportive Care. High flow O2 via NRB mask. Large-bore IV NS, consider second line.
PROTOCOL 3.2: ABDOMINAL/PELVIC TRAUMA (cont.) PEDIATRIC CARE (cont.) I.4. Cover eviscerated tissue with moist saline dressing, then dry sterile dressing. Do not attempt to replace eviscerated contents back into abdominal cavity. Immobilize impaled objects in place to prevent further movement. None.
I.5. II.1.
PROTOCOL 3.3: AMPUTATION ADULT CARE I.1. I.2. I.3. I.4. Trauma and Hypovolemic Supportive Care. High flow O2 via NRB mask. Large-bore IV NS at appropriate rate maintain systolic BP 90-100 mm/Hg only. Gently rinse stump with saline, cover with moistened sterile gauze, and cover with dry dressing. Elevate. Dress and use direct pressure to control hemorrhage as needed. If partial amputation, dress and splint in anatomical position to facilitate optimum vascular status. Wrap with bulky dressings. Avoid torsion in handling and splinting. Consider pain control with Morphine, see 5.20: Pain Management Protocol. If pain control requires medication dosages above those set by the Pain Management protocol, contact Medical Control.
I.5.
I.6. II.1.
Amputated part care I.1. I.2. I.3. Irrigate amputated part thoroughly and gently in NS to remove loose debris do not scrub. Wrap amputated part in moistened sterile gauze (several layers). (If possible) Place amputated part in sealed plastic bag and if ice and sufficient size cooler is available, float bag in cooler filled with ice water. If plastic bag, ice and cooler not immediately available, transport in moistened gauze only affording part all protection possible. Handle gently. Transport part with patient as quickly as possible, do not delay transport of amputated part for care. Do not freeze part by placing it directly on ice or by adding any other coolant (never use dry ice).
I.4. I.5.
PROTOCOL 3.3: AMPUTATION (cont.) Amputated part care (cont.) I.6. I.7. Do not float part in container of any solution. Do not use any antiseptic or other solution.
PEDIATRIC CARE I.1. I.2. I.3. I.4. Trauma and Hypovolemic Supportive Care. High flow O2 via NRB mask. Large-bore IV NS. Gently rinse stump with saline, cover with moistened sterile gauze, and cover with dry dressing. Elevate. Dress and use direct pressure to control hemorrhage as needed. If partial amputation, dress and splint in anatomical position to facilitate optimum vascular status. Wrap with bulky dressings. Avoid torsion in handling and splinting. Amputated part care as above for adult. Contact Medical Control for pain control in the pediatric patient.
I.5.
I.6. II.1
PROTOCOL 3.4: BURNS A. Thermal Burns 1. Hot toxic gases, including carbon monoxide are given off. It is important to note if the burn occurred inside an enclosed space. The patient that has been trapped in an enclosed space with hot gases, steam or smoke is the one most likely to suffer burn inhalation injury or toxic inhalation. It is prudent to assume carbon monoxide poisoning and airway involvement in all closed space burns evaluate airway constantly. 2. Assess and treat for associated trauma (blast or fall). 3. Two percent or greater burns should be seen by a physician. B. Chemical Burns 1. Situations involving inhaled and cutaneous exposure to chemicals can pose significant risks to rescuers. Be aware of Hazardous Materials implications and do not enter an environment where such an exposure has taken place until it has been determined to be safe to do so (Dont needlessly make more patients, seek Haz-Mat team assistance when in doubt). When unknown or potential Hazardous Materials are involved, see 6.6: Hazardous Materials/WMD Incidents Protocol. 2. Usually more localized than thermal burns. 3. Noxious gases will often affect the lungs to produce pulmonary insult. Laryngeal and bronchial edema may cause subsequent significant airway obstruction. 4. If safe to do so, remove or brush off any dry particles or powder, then irrigate with copious amounts of saline or water (including eyes). a) Do not perform decontamination yourself if Hazardous or unknown chemicals are involved. Seek Haz-Mat team assistance. Do not transport contaminated patients, de-con first, notify medical facility early. Watch for hypothermia! The wet, burned patient will become hypothermic easily. Protect from weather.
b)
5. Evaluate for systemic effects of chemical contamination.
PROTOCOL 3.4: BURNS (cont.) 6. C. Assess and treat for associated trauma (blast or fall).
Electrical Burns (including lightning) 1. Be sure the patient is no longer in contact with the electrical source, obtain engine company and power company assistance if necessary. Dont become a victim yourself! 2. Closely evaluate airway and cardiac status. Prolonged respiratory support may be needed, lightning injuries can cause prolonged respiratory arrest. Prompt, continuous respiratory support (sometimes for hours) can result in full recovery. 3. Patients often suffer from traumatic injuries as well. These can be from fall, blast, or extreme muscle contractions. Immobilize cervical spine. 4. Even though the surface area of the burn may be small, involvement of internal organ systems can be extensive. 5. All electrical burns should be evaluated by a physician.
D.
Assess burns by the following criteria: 1. Percent of body burned: a) Rule of Nines (see Table 3.B., Rule of Nines Chart below). 2. Extent of burn based on depth: b) Superficial, partial-thickness, full-thickness (see Table 3.C., Burn Classification Chart below) 3. Age of the patient. 4. Site of burns: c) Face, extremities, etc.
E.
American Burn Association Burn Severity Grading System: Note: Burn = partial-thickness or full-thickness burn unless specified. TBSA = total percentage of body surface area affected by injury. Young = patient younger than 10 years of age. Adult = patient 10 to 50 years of age. Old = patient older than 50 years of age.
PROTOCOL 3.4: BURNS (cont.) 1. Minor Burn (Potential outpatient management) a) b) c) < 10 % TBSA burn in adult < 5 % TBSA burn in young or old < 2 % full-thickness burn
2. Moderate Burn (Hospital admission) a) b) c) d) e) f) g) 10 to 20 % TBSA burn in an adult 5 to 10 % TBSA burn in young or old 2 to 5 % full-thickness burn High-voltage injury (visible external burns may be minor or not evident) Suspected inhalation injury Circumferential burn Concomitant medical problem predisposing patient to infection (diabetes, sickle cell disease, etc.)
3. Major Burn (Referral to Burn Center) a) b) c) d) e) f) g) ADULT CARE I.1. I.2. . I.3. Trauma and Hypovolemic Supportive Care. Remove clothing that is hot, smoldering, wet, contaminated with chemicals or which is not adhered to the patient. (Prevent hypothermia). Obtain information regarding possibility of smoke/toxic fume inhalation. Treat with 100% O2 via NRB mask. If patient known to have been in enclosed space, be prepared to manage airway aggressively and possibly intubate early. Assess and treat for associated trauma (blast, fall). > 20 % TBSA burn in an adult > 10 % TBSA burn in young or old > 5 % full-thickness burn High-voltage burn Known inhalation injury Any significant burn to face, eyes, ears, genitalia or joints Significant associated trauma (fractures, other major trauma)
I.4.
PROTOCOL 3.4: BURNS (cont.) ADULT CARE (cont.) I.5. I.6. I.7. I.8. I.9. Remove rings, bracelets and other constricting items. If burns are < 10% TBSA (Minor Burn), cover with sterile, moist burn dressings (do not use ice) If burns are > 10% TBSA (Moderate to Major Burn), cover with dry, sterile burn dressings or sheets to avoid hypothermia. Large-bore IV access (2 lines if possible). If necessary IVs may be started through area of burn, but try to avoid. If Moderate to Major burn, consider fluid infusion 250-500 ml NS titrated to maintain adequate BP (SBP 100) and perfusion. For additional fluids contact Medical Control. Note: Be aware that the severely burned patient may need significant fluid infusions (see Table 3.A., Parkland Burn Formula below), but they may not need it right away. Lines should be in place irregardless of immediate need for fluid. Morphine, 2-4 mg repeated q 5 min. to a total of 10 mg for pain control (see 5.20: Pain Management Protocol) as long as patient remains hemodynamically stable. Contact receiving hospital at earliest opportunity. Trauma Alert if patient meets criteria, see 5.28: Trauma Alert Protocol. When giving report to receiving hospital reference the burn patient, avoid giving complicated percentages and descriptions. Just clearly describe extent (partial, fullthickness) and where on the body the burns are. For analgesic dosages above those referenced by the Pain Management Protocol or fluid resuscitation above that listed above, contact medical Control.
I.10.
I.11.
II.1.
PEDIATRIC CARE I.1. I.2. . Trauma and Hypovolemic Supportive Care. Remove clothing that is hot, smoldering, wet, contaminated with chemicals or which is not adhered to the patient. (Prevent hypothermia).
PROTOCOL 3.4: BURNS (cont.) PEDIATRIC CARE (cont.) I.3. Obtain information regarding possibility of smoke/toxic fume inhalation. Treat with 100% O2 via NRB mask. If patient known to have been in enclosed space, be prepared to manage airway aggressively and possibly intubate early. Assess and treat for associated trauma (blast, fall). Remove rings, bracelets and other constricting items. With the pediatric patient only use sterile, moist burn dressings on very minor or small burns (burn that you can cover with your hand), the pediatric patient is more susceptible to hypothermia than the adult patient. On all other burns, cover only with dry, sterile burn dressings or sheets. (do not use ice) Large-bore (for patient size) IV access. If necessary IVs may be started through area of burn, but try to avoid. If Moderate to Major burn, consider fluid infusion 20 ml/kg NS. If in doubt or for additional fluids contact Medical Control. Contact receiving hospital at earliest opportunity. Trauma Alert if patient meets criteria, see 5.28: Trauma Alert Protocol. When giving report to receiving hospital reference the burn patient, avoid giving complicated percentages and descriptions. Just clearly describe extent (partial, fullthickness) and where on the body the burns are. Consider Morphine, 0.1 mg/kg slow IV TABLE 3.A. Parkland Burn Formula Parkland Burn Formula (24 Hr.) 4ml. x patient kg. x % of TBSA burn (partial and full-thickness together) = total fluids in 24 hrs. 1st 50% admin. in 1st 8 hrs. 2nd 50% over following 16 hrs.
I.4. I.5. I.6.
I.7. I.9. I.10.
II.1.
PROTOCOL 3.4: BURNS (cont.) ILLUSTRATION 3.A. Rule of Nines Chart
TABLE 3.B. Burn Classifications
CHARACTERISTICS Classification Superficial burn Cause Ultraviolet light, very short flash (flame exposure) Scald (spill or splash), short flash Appearance Dry and red; blanches with pressure Blisters; moist, red and weeping; blanches with pressure Blisters (easily unroofed); wet or waxy dry; variable color (patchy to cheesy white to red); does not blanch with pressure Waxy white to leathery gray to charred and black; dry and inelastic; does not blanch with pressure
Superficial partialthickness burn
Deep partial-thickness burn
Scald (spill), direct flame, oil, grease
Full-thickness burn
Scald (immersion), direct flame, steam, oil, grease, chemical, highvoltage electricity
PROTOCOL 3.5: CHEST TRAUMA NOTE: Chest trauma is not able to be definitively treated in the field and prolonged treatment prior to transport is not indicated if significant injury is suspected. If patient is critical, transport rapidly and avoid treatment of non-emergent problems at the scene. The depth and severity of penetrating chest trauma is impossible to determine in the field, and all penetrating chest trauma patients should receive rapid transport with Trauma Alert notification regardless of how stable they may seem. Chest injuries sufficient to cause respiratory distress are frequently associated with significant internal blood loss. Look for hypovolemia. Significant intrathoracic injuries can exist without any external signs of injury. Note mechanism of injury carefully and maintain a high index of suspicion. ADULT CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Assess chest and back (including axillary region and base of neck) for wounds, bruising, paradoxical chest wall movement, rib cage/ sternal instability or crepitus, and areas of tenderness. Note if neck veins flat or distended. Auscultate lung sounds as soon as possible and re-assess frequently. Consider Trauma Alert if patient meets criteria, see 5.28: Trauma Alert Protocol. Make notification early and transport rapidly if patient meets criteria. High flow O2 via NRB mask. If patient deteriorating rapidly, intubate early! If significant trauma, IV NS using two large bore lines and at least one blood tubing set. Remember, Trauma fluid administration in the field should be geared toward raising the patients systolic BP to no more than 90 100 mm/Hg. Any more could potentially worsen internal bleeding.
I.3. I.4.
I.5. I.6. I.7.
PROTOCOL 3.5: CHEST TRAUMA (cont.) ADULT CARE (cont.) I.8. I.9. Stabilize any flail chest segments. Cover any open chest wound (sucking chest wound) with Vaseline gauze taped on three sides to vent air out. If sealed completely, may convert injury to tension pneumothorax. Do not attempt to remove any impaled objects; stabilize these in place with bulky dressings and tape or by any means necessary. Needle decompression if suspected tension pneumothorax, see 5.27 Tension Pneumothorax Decompression Protocol. Remember, needle decompression in the field is only for the patient with a suspected tension pneumothorax, not a simple pneumothorax. The distinction must be made between the two. If covered sucking chest wound is present, remove the seal and allow chest pressures to equilibrate, no further treatment may be necessary.
I.10. II.1.
PEDIATRIC CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Assess chest and back (including axillary region and base of neck) for wounds, bruising, paradoxical chest wall movement, rib cage/ sternal instability or crepitus, and areas of tenderness. Note if neck veins flat or distended. Auscultate lung sounds as soon as possible and re-assess frequently. Consider Trauma Alert if patient meets criteria, see 5.28: Trauma Alert Protocol. Make notification early and transport rapidly if patient meets criteria. High flow O2 via NRB mask. If patient deteriorating rapidly, intubate early! If significant trauma, IV NS, consider 20 ml/kg fluid bolus if patient hypotensive. Contact Medical Control for further fluids.
I.3. I.4.
I.5. I.6. I.7.
PROTOCOL 3.5: CHEST TRAUMA (cont.) PEDIATRIC CARE (cont.) I.8. I.9. Stabilize any flail chest segments. Cover any open chest wound (sucking chest wound) with Vaseline gauze taped on three sides to vent air out. If sealed completely, may convert injury to tension pneumothorax. Do not attempt to remove any impaled objects; stabilize these in place with bulky dressings and tape or by any means necessary. Needle decompression if suspected tension pneumothorax, see 5.27 Tension Pneumothorax Decompression Protocol. Remember, needle decompression in the field is only for the patient with a suspected tension pneumothorax, not a simple pneumothorax. The distinction must be made between the two. If covered sucking chest wound is present, remove the seal and allow chest pressures to equilibrate, no further treatment may be necessary. Contact Medical Control if the need is seen for fluids above the initial 20 ml/kg. fluid bolus for the hypotensive pediatric patient.
I.10. II.1.
II.2.
PROTOCOL 3.6: EXTREMITY INJURIES ADULT CARE I.1. I.2. I.3. I.4. I.5. Trauma and hypovolemic supportive care. Avoid IV on injured extremity. Assess distal pulses and sensation prior to immobilization of injured extremity. Apply sterile dressing to open fractures. Note carefully wounds that appear to communicate with bone, and initial position of bone in wound. Splint areas of tenderness or deformity; immobilize the joint above and below the injury in the splint. Grossly angulated fractures may be re-aligned by applying gentle axial traction and returning to anatomical position if indicated: a) b) To restore distal circulation To immobilize adequately (i.e., realign femur fracture)
Make one attempt, if resistance is met or extreme increased pain is caused, stabilize the limb in the position of most comfort with the best circulation. I.6. I.7. I.8. I.9. II.1. Assess distal pulses and sensation after splinting. Elevate simple extremity injuries. Apply padded cold pack (do not place directly on skin) if time and extent of injuries allow. Monitor circulation (pulse and skin temperature), sensation, and motor function distal to site of injury during transport. Consider pain management, see 5.20: Pain Management Protocol. None.
PEDIATRIC CARE I.1. I.2. Trauma and hypovolemic supportive care. Avoid IV on injured extremity. Assess distal pulses and sensation prior to immobilization of injured extremity.
PROTOCOL 3.6: EXTREMITY INJURIES (cont.) PEDIATRIC CARE (cont.) I.3. I.4. I.5. Apply sterile dressing to open fractures. Note carefully wounds that appear to communicate with bone, and initial position of bone in wound. Splint areas of tenderness or deformity; immobilize the joint above and below the injury in the splint. Grossly angulated fractures may be re-aligned by applying gentle axial traction and returning to anatomical position if indicated: a) b) To restore distal circulation To immobilize adequately (i.e., realign femur fracture)
Make one attempt, if resistance is met or extreme increased pain is caused, stabilize the limb in the position of most comfort with the best circulation. I.6. I.7. I.8. II.1. Assess distal pulses and sensation after splinting. Elevate simple extremity injuries. Apply padded cold pack (do not place directly on skin) if time and extent of injuries allow. Monitor circulation (pulse and skin temperature), sensation, and motor function distal to site of injury during transport. Contact Medical Control for pain management.
PROTOCOL 3.7: EYE INJURIES ADULT CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Be alert for associated head and cervical spine injury. If chemicals in eyes, irrigate eyes with copious normal saline or clean water (if only one eye is affected, flush with affected eye down so chemical is not flushed into unaffected eye). Do not irrigate if globe disruption is suspected. Do not attempt to remove foreign bodies by other means. If suspected or obvious laceration or disruption of the globe is present, do not place any pressure on the globe or orbit. Place dressings over both eyes, but only if they do not contact any impaled foreign bodies or put pressure on eyes. If hyphema is present, do not put pressure on the orbit or globe. Transport patient in sitting position or with head elevated unless c-spine immobilization is required (block up head end of backboard). Place dressings over both eyes, but only if they do not contact any impaled foreign bodies or put pressure on eyes. Dont be concerned with contact lens removal in the field. None.
I.3.
I.4.
I.5. II.1.
PEDIATRIC CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Be alert for associated head and cervical spine injury. If chemicals in eyes, irrigate eyes with copious normal saline or clean water (if only one eye is affected, flush with affected eye down so chemical is not flushed into unaffected eye). Do not irrigate if globe disruption is suspected. Do not attempt to remove foreign bodies by other means. If suspected or obvious laceration or disruption of the globe is present, do not place any pressure on the globe or orbit. Place dressings over both eyes, but only if they do not contact any impaled foreign bodies or put pressure on eyes.
I.3.
PROTOCOL 3.7: EYE INJURIES PEDIATRIC CARE (cont.) I.4. If hyphema is present, do not put pressure on the orbit or globe. Transport patient in sitting position or with head elevated unless c-spine immobilization is required (block up head end of backboard). Place dressings over both eyes, but only if they do not contact any impaled foreign bodies or put pressure on eyes. Dont be concerned with contact lens removal in the field. None.
I.5. II.1.
PROTOCOL 3.8: HEAD TRAUMA NOTE: When head injury patients deteriorate, check first for airway, oxygenation and blood pressure problems in that order! If the patient is tachycardic or hypotensive, evaluate for hypovolemia from other injuries. The most important information you can provide for the base physician is the level of consciousness and its changes. Is the patient stable, deteriorating or improving? Restlessness can be a sign of hypoxia. Cerebral anoxia is the most frequent cause of death in head injury. Control airway and ventilate, hypoventilation aggravates cerebral edema. ADULT CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Cervical spine immobilization. The patient with significant head trauma will always need to be immobilized. Secure patient to LBB in a manner that will allow it to be safely turned to the side if patient vomits. High flow O2 via NRB mask. If unconscious, control airway and ventilate at 24 breaths/min. Use BLS methods initially to control airway: NP/OP airways, suction, BVM, etc. Many times a patients airway can initially be adequately managed this way before having to intubate. If patient deteriorating rapidly, intubate early! If time allows, administer Lidocaine 1-1.5 mg/kg IV I minute prior to intubation. Consider nasotracheal intubation if patients mid-face is intact, (see 5.8: Advanced Airway Management: Nasotracheal Intubation Protocol). Consider Trauma Alert if patient meets criteria, see 5.28: Trauma Alert Protocol. Make notification early and transport rapidly if patient meets criteria. Large-bore IVs NS X 2, run fluids at TKO rate unless hypotensive. Control scalp hemorrhage with direct pressure, this can be difficult hemorrhage to control, continued pressure may be needed. If underlying skull is instable, pressure should be applied to the periphery of the laceration over intact bone.
I.3.
I.4. I.5. I.6.
I.7. I.8.
PROTOCOL 3.8: HEAD TRAUMA (cont.) ADULT CARE (cont.) I.9. II.1. II.2. Constantly reassess level of consciousness and any changes, use Glasgow Coma Scale, see Assessment-Neurologic, Table 1.B. Consider Rapid Sequence Induction for intubation, see 5.9: Advanced Airway Management: Rapid Sequence Induction Protocol. Contact Medical Control for sedation of the combative patient that is already intubated.
PEDIATRIC CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Cervical spine immobilization. The patient with significant head trauma will always need to be immobilized. Secure patient to LBB in a manner that will allow it to be safely turned to the side if patient vomits. High flow O2 via NRB mask. If unconscious, control airway and ventilate at 24 breaths/min. Use BLS methods initially to control airway: NP/OP airways, suction, BVM, etc. Many times a patients airway can initially be adequately managed this way before having to intubate. If patient deteriorating rapidly, intubate early! If time allows, administer Lidocaine 1-1.5 mg/kg IV I minute prior to intubation. If patient 8 years of age, consider nasotracheal intubation if patients mid-face is intact, (see 5.8: Advanced Airway Management: Nasotracheal Intubation Protocol). Consider Trauma Alert if patient meets criteria, see 5.28: Trauma Alert Protocol. Make notification early and transport rapidly if patient meets criteria. IV NS, consider 20 ml/kg fluid bolus if patient hypotensive. Medical Control for further fluids. Contact
I.3.
I.4. I.5.
I.6.
I.7. I.8.
Control scalp hemorrhage with direct pressure, this can be difficult hemorrhage to control, continued pressure may be needed. If underlying skull is instable, pressure should be applied to the periphery of the laceration over intact bone.
PROTOCOL 3.8: HEAD TRAUMA (cont.) PEDIATRIC CARE (cont.) I.9. II.1. II.2. II.3. Constantly reassess level of consciousness and any changes, use Glasgow Coma Scale, see Assessment-Neurologic, Table 1.B-C. Consider Rapid Sequence Induction for intubation, see 5.9: Advanced Airway Management: Rapid Sequence Induction Protocol. Contact Medical Control for sedation of the combative patient that is already intubated. Contact Medical Control if the need is seen for fluids above the initial 20 ml/kg. fluid bolus for the hypotensive pediatric patient.
PROTOCOL 3.9: SPINAL TRAUMA NOTE: In the spine injured patient that has hypotension that is unresponsive to simple measures, it is likely due to other injuries. Neurologic deficits make these other injuries hard to evaluate. Cord injury above the level of T-8 removes tenderness, rigidity and guarding as clues to abdominal injury. Full spinal immobilization should be accomplished in all patients that have penetrating trauma to the neck or torso irregardless of the lack of complaints of pain or presence of neurologic deficits. ADULT CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Cervical spine immobilization. a) b) c) I.3. I.4. I.5. Secure patient to LBB in a manner that will allow it to be safely turned to the side if patient vomits. Check patients back before logrolling onto LBB. Assess neurologic function before and after moving to LBB.
High flow O2 via NRB mask. Large-bore IV NS, fluid bolus only if hypotensive. Reassess neurologic function frequently during transport with special attention to evidence of neurologic function below level of injury and any limbs which may not have sensation. None.
II.1
PEDIATRIC CARE I.1. I.2. Trauma and Hypovolemic Supportive Care. Cervical spine immobilization. a) b) Secure patient to LBB in a manner that will allow it to be safely turned to the side if patient vomits. Check patients back before logrolling onto LBB.
PROTOCOL 3.9: SPINAL TRAUMA (cont.) PEDIATRIC CARE (cont.) c) d) I.3. I.4. I.5. Assess neurologic function before and after moving to LBB Use appropriate pediatric immobilization device.
High flow O2 via NRB mask. IV NS, consider 20 ml/kg fluid bolus if patient hypotensive. Medical Control for further fluids. Contact
Reassess neurologic function frequently during transport with special attention to evidence of neurologic function below level of injury and any limbs which may not have sensation. None.
II.1
PROTOCOL 3.10: TRAUMA CARDIAC ARREST NOTE: Victims of blunt trauma cardiac arrest without vital signs (pulse, respirations) at the scene have a mortality rate of essentially 100%. Trauma cardiac arrests secondary to penetrating injuries can be successfully resuscitated. There is a higher rate of survival in patients with low velocity penetrating injuries (knife, etc.) versus patients with high velocity injuries (gunshot. etc.). Carefully assess and compare the patients pulseless, apneic state with the mechanism of injury present. Consider if there may have been a medical cause for the cardiac arrest or the patient may just have had an occluded airway secondary to being knocked unconscious during an MVA, etc. If there is any doubt as to whether the cardiac arrest was caused by the trauma, a resuscitation should be begun in the absence of signs of irreversible death (decapitation, significant dependent lividity, rigor mortis, etc.). A. Blunt Trauma Arrest 1. Assess patient for spontaneous respirations and or pulse. 2. Assess mechanism carefully. 3. Assess for signs of massive external blood loss and or, massive blunt head, torso or abdominal trauma. 4. If patient has no spontaneous respirations and no pulse and mechanism of injury or other signs at the scene indicate that arrest was caused by the blunt trauma, consider field determination of death. See 6.5: Field Determination of Death Protocol. 5. If a resuscitation is started on a blunt trauma patient that still has vital signs and a cardiac arrest occurs, continue resuscitation and contact Medical Control to determine the viability of continuing the resuscitation to the hospital. B. Penetrating Trauma Arrest 1. Initiate BLS and immobilize C-spine.
PROTOCOL 3.10: TRAUMA CARDIAC ARREST (cont.) Penetrating Trauma Arrest (cont.) 2. Intubate and rapid transport (Code 3, HOT) 3. Large bore IV NS X2 using at least one blood tubing set, fluid bolus 20 ml/kg. 4. If cardiac activity returns with above treatment, treat any arrhythmias per pertinent protocol. 5. Consider field determination of death if signs of irreversible death are present (decapitation, significant dependent lividity, rigor mortis, etc.). See 6.5: Field Determination of Death Protocol.
Section 4 Treatment Protocols Environmental Injury
PROTOCOL 4.1: BITES AND STINGS NOTE: For all types of bites and stings, the goal of pre-hospital care is to prevent further inoculation and to treat any possible allergic reaction. Time since envenomation is important, as anaphylaxis rarely occurs more than 60 minutes after inoculation. Roughly 60% of patients who have experienced a generalized reaction to a bite or sting in the past will have a similar or more severe reaction upon reinoculation. It is possible to have a severe reaction with a first inoculation. If possible and the offending insect, snake, etc. is dead and or contained, try to have it transported to the hospital for positive identification. Be careful: a dead snake may reflexively bite and envenomate. All human bites, dog or cat bites, and snake bites, should be further evaluated at a medical facility for proper cleansing and potential antibiotic therapy. ADULT CARE I.1. I.2. I.3. I.4. I.5. I.6. II.1. Trauma and Hypovolemic Supportive Care. Any suspected poisonous bite should receive a large-bore IV of NS. If allergic reaction suspected, see 2.12: Allergic Reaction/Anaphylaxis Protocol. Immobilize affected area, keep patient quiet to reduce venom absorption Do not use ice. Remove rings, bracelets, constrictive clothing, etc. immediately from bitten extremities, swelling may make them difficult to remove later. If bee or wasp sting, and stinger mechanism is visible, try to remove without breaking venom sac by scraping out with a straight edge. None.
PROTOCOL 4.1: BITES AND STINGS (cont.) PEDIATRIC CARE I.1. I.2. I.3. I.4. I.5. I.6. II.1. Trauma and Hypovolemic Supportive Care. Any suspected poisonous bite should receive a large-bore IV of NS. If allergic reaction suspected, see 2.12: Allergic Reaction/Anaphylaxis Protocol. Immobilize affected area, keep patient quiet to reduce venom absorption Do not use ice. Remove rings, bracelets, constrictive clothing, etc. immediately from bitten extremities, swelling may make them difficult to remove later. If bee or wasp sting, and stinger mechanism is visible, try to remove without breaking venom sac by scraping out with a straight edge None.
PROTOCOL 4.2: DROWNING / NEAR DROWNING NOTE: All near drowning patients or submersions should be transported. Even if patient initially appears fine, they can deteriorate rapidly. Monitor closely, pulmonary edema frequently occurs due to aspiration, hypoxia and other factors. It may not be evident until several hours after a near drowning episode. Beware of cervical spine injuries they often go unrecognized in the drowning/near drowning patient. C-spine immobilization can be accomplished while the patient is still in the water. If the patient is hypothermic, defibrillation and pharmacologic therapy may be unsuccessful until the patient is re-warmed. Prolonged CPR may be needed, see 4.4: Hypothermia and Frostbite Protocol.
. ADULT CARE I.1. I.2. I.3.
General Supportive Care - strongly consider need for cervical immobilization. Assess the need for trauma supportive care that may be interrelated. Large-bore IV NS, TKO. Administer O2 on all patients. Suction if needed and support airway as indicated. In the patient that needs to be intubated, try to refrain from bagging the patient before intubating, it may precipitate significant vomiting. Go immediately to intubation when needed. Consider CPAP if patient in extremis. Monitor cardiac rhythm during transport; treat any arrhythmia per pertinent protocol. With the submerged patient, assess rescue vs. body recovery. Contact Medical Control for guidance in determining rescue vs. recovery. The following parameters will need to be considered: a) How long was patient submerged? Generally speaking, a rescue will turn into a body recovery after the patient has been submerged for 1 - 2 hours (remember, submersion times can be approximate, try to obtain as accurate information as possible.
I.4. I.5. I.6.
PROTOCOL 4.2: DROWNING / NEAR DROWNING (cont.) ADULT CARE (cont.) b) Temperature of water. Medical literature supports the possibility of survival with little or no neurological sequelae after being submerged as long as an hour or more in cold water ( 68 F). In the Black Hills, even in the summer, many natural bodies of water will still qualify as cold water. If patient submerged in cold water, see 4.4: Hypothermia and Frostbite Protocol. c) Degree of contamination of water. II.1. None.
PEDIATRIC CARE I.1. I.2. I.3. General Supportive Care - strongly consider need for cervical immobilization. Assess the need for trauma supportive care that may be interrelated. IV NS, TKO. Administer O2 on all patients. Suction if needed and support airway as indicated. In the patient that needs to be intubated, try to refrain from bagging the patient before intubating, it may precipitate significant vomiting. Go immediately to intubation when needed. Monitor cardiac rhythm during transport; treat any arrhythmia per pertinent protocol. With the submerged patient, assess rescue vs. body recovery. Contact Medical Control for guidance in determining rescue vs. recovery. The following parameters will need to be considered: a) How long was patient submerged? Generally speaking, a rescue will turn into a body recovery after the patient has been submerged for 1 - 2 hours (remember, submersion times can be approximate, try to obtain as accurate information as possible.
I.4. I.5.
PROTOCOL 4.2: DROWNING / NEAR DROWNING (cont.) PEDIATRIC CARE (cont.) b) Temperature of water. Medical literature supports the possibility of survival with little or no neurological sequelae after being submerged as long as an hour or more in cold water ( 68 F). In the Black Hills, even in the summer, most natural bodies of water will still qualify as cold water. If patient submerged in cold water, see 4.4: Hypothermia and Frostbite Protocol. c) Degree of contamination of water. II.1. None.
PROTOCOL 4.3: HYPERTHERMIA NOTE: Heat stroke is a life-threatening medical emergency, It is distinguished by an altered level of consciousness. Sweating may still be present, especially in exercise-induced heat stroke. The other persons at risk for heat stroke are the elderly and persons on medications which impair the bodys ability to regulate heat. Differentiate heat stroke from heat exhaustion (hypovolemia of more gradual onset) and heat cramps (abdominal or leg cramps). Be aware that heat exhaustion can lead to heat stroke. Do not let cooling in the field delay transport. Cool patient as is possible enroute. Do not use ice water or very cold water to cool patients, these may induce vasoconstriction. Use only slightly cool or even tepid water. ADULT CARE I.1. I.2. I.3. I.4. General Supportive Care. Remove from hot environment immediately, remove excess clothing. If patient alert and heat cramps or mild heat exhaustion, give small amounts cool liquids PO as tolerated (be alert for potential vomiting). Cool with water or saline, including head. Direct the patient compartment fan over the patient to promote evaporation. Note: do not put water on a patient without air from some source blowing over them, you may make the problem worse. If patient with heat stroke or severe heat exhaustion, continue cooling measures enroute to medical facility. For heat stroke/exhaustion, large-bore IV NS, TKO if vital signs within normal parameters. If hypotensive, fluid bolus 250-500 ml. Assess need for further fluids. Monitor cardiac rhythm. Assess temperature if possible (may be 104 F or greater). Treat any seizure activity per 2.24: Seizures and Status Epilepticus Protocol. None.
I.5.
I.6. I.7. I.8. II.1.
PROTOCOL 4.3: HYPERTHERMIA (cont.) PEDIATRIC CARE I.1. I.2. I.3. I.4. General Supportive Care. Remove from hot environment immediately, remove excess clothing. If patient alert and heat cramps or mild heat exhaustion, give small amounts cool liquids PO as tolerated (be alert for potential vomiting). Cool with water or saline, including head. Direct the patient compartment fan over the patient to promote evaporation. Note: do not put water on a patient without air from some source blowing over them, you may make the problem worse. If patient with heat stroke or severe heat exhaustion, continue cooling measures enroute to medical facility. For heat stroke/exhaustion, IV NS, TKO if vital signs within normal parameters. If hypotensive for age, fluid bolus 20 ml/kg. Assess need for further fluids. Monitor cardiac rhythm. Assess temperature if possible (may be 104 F or greater). Treat any seizure activity per 2.24: Seizures and Status Epilepticus Protocol. None.
I.5.
I.6. I.7. I.8. II.1.
PROTOCOL 4.4: HYPOTHERMIA AND FROSTBITE NOTE: Generalized Hypothermia: The profoundly hypothermic patient may need prolonged palpation/observation to detect any pulse, respiratory effort or organized cardiac rhythm. Hypothermic patients (cold air or water) should not be determined dead until re-warmed or determined dead by other criteria. Bradycardia is normal and should not be treated. Even very slow rates may be sufficient for metabolic demands. CPR is only indicated for asystole and ventricular fibrillation, if patient has any organized cardiac rhythm, CPR is currently felt to be unnecessary. When CPR is done, it should be done gently. Excessive movement of the patient and intubation attempts have been known to precipitate ventricular fibrillation, therefore, patients with any organized cardiac rhythm should not be intubated if airway can be supported by alternative measures. The profoundly hypothermic patients metabolic demand for O2 will be diminished anyway. The heart is most likely to fibrillate below 85-88 F. Defibrillation should be attempted one time, but prolonged CPR may be necessary until core temperature is above this level. ALS drugs should be used sparingly, one round can be attempted, but peripheral vasoconstriction may prevent entry into central circulation until temperature is restored. At that time, a large bolus of unwanted drugs may be circulated into the heart. Shivering typically does not occur below 90 F. Below this, patient may not even feel cold, and occasionally will even undress and appear vasodilated. Re-warming should be accomplished with careful monitoring in a hospital setting, field re-warming is not indicated. The goal should be to prevent further heat loss and maintain warm environment. Local (frostbite): Thawing is extremely painful and should be done under controlled conditions in the hospital. Careful monitoring, pain medications, prolonged re-warming and sterile handling are required.
PROTOCOL 4.4: HYPOTHERMIA AND FROSTBITE (cont.) Local (frostbite) (cont.): Do not re-warm prematurely, this includes warm water soaking and applying heat packs in the field. It is clear that partial re-warming or re-warming followed by re-freezing is far more injurious to tissue than any delay in re-warming. Indications for field re-warming are almost non-existent. ADULT CARE Generalized Hypothermia: I.1. I.2. General Supportive Care, handle patient gently. Prolonged gentle CPR may be required. No CPR if any organized electrical cardiac activity is present. Attempt defibrillation once if ventricular fibrillation present. One round of ALS drugs may be attempted if indicated. Avoid unnecessary suctioning or airway manipulation. Indications for intubation are the patient in asystole and ventricular fibrillation. If the patient has an organized cardiac rhythm, manage airway and oxygenate by alternative means if possible. Remove all clothing (especially if wet or constrictive) from patient. Wrap in blankets and protect from wind exposure. Increase ambient air temperature in ambulance. The goal is not field re-warming, it is to prevent further heat loss and maintain warm environment. Large-bore IV with warmed NS, TKO. Do not start IV until patient is moved to transport vehicle. Consider reason patient in cold environment and also alternative reasons for altered mental status (ETOH, medical cause stroke, hypoglycemia, drug overdose, etc.). Treat as indicated. Assess core temperature if possible. None.
I.3.
I.4.
I.5. I.6.
I.7. II.1.
PROTOCOL 4.4: HYPOTHERMIA AND FROSTBITE (cont.) Local (frostbite): I.1. I.2. I.3. I.4. I.5. II.1. Remove wet or constricting clothing. Keep skin dry and protected from wind. Do not attempt to re-warm the affected areas, prevent further heat loss and maintain warm environment. Avoid thaw and re-freeze at all costs. Dress affected areas lightly in clean dressings to protect from pressure, trauma or friction. Do not rub, do not break blisters. Maintain core temperature by keeping patient warm with blankets, warm IV fluids, etc. Transport with frostbitten areas supported and elevated, if feasible. None.
PEDIATRIC CARE Generalized Hypothermia: I.1. I.2. General Supportive Care, handle patient gently. Prolonged gentle CPR may be required. No CPR if any organized electrical cardiac activity present. Attempt defibrillation once if ventricular fibrillation present. One round of ALS drugs may be attempted if indicated. Avoid unnecessary suctioning or airway manipulation. Indications for intubation are the patient in asystole and ventricular fibrillation. If the patient has an organized cardiac rhythm, manage airway and oxygenate by alternative means if possible. Remove all clothing (especially if wet or constrictive) from patient. Wrap in blankets and protect from wind exposure. Increase ambient air temperature in ambulance. The goal is not field re-warming, it is to prevent further heat loss and maintain warm environment. IV with warmed NS, TKO. transport vehicle. Do not start IV until patient is moved to
I.3.
I.4.
I.5.
PROTOCOL 4.4: HYPOTHERMIA AND FROSTBITE (cont.) PEDIATRIC CARE (cont.) Generalized Hypothermia (cont.): I.6. Consider reason patient in cold environment and also alternative reasons for altered mental status (ETOH, medical cause - hypoglycemia, drug overdose, etc.). Treat as indicated. Assess core temperature if possible. None.
I.7. II.1.
Local (frostbite): I.1. I.2. I.3. I.4. I.5. II.1. Remove wet or constricting clothing. Keep skin dry and protected from wind. Do not attempt to re-warm the affected areas, prevent further heat loss and maintain warm environment. Avoid thaw and re-freeze at all costs. Dress affected areas lightly in clean dressings to protect from pressure, trauma or friction. Do not rub, do not break blisters. Maintain core temperature by keeping patient warm with blankets, warm IV fluids, etc. Transport with frostbitten areas supported and elevated, if feasible. None.
Section 5 Procedure Protocols
PROTOCOL 5.1: Airway Management - General Principles The following principles should be remembered in the heat of battle to allow optimum care of the airway without unnecessary intervention. 1. Use the simplest method of airway management appropriate to the patient. BLS procedures should generally be used first, progressing to more invasive ALS procedures. BLS procedures by themselves may be all that are needed to efficiently manage the patients airway. 2. Use a method with which you, as a responder, are comfortable. 3. Use meticulous suctioning to keep the airway clear of debris always being aware of oxygenation. 4. Monitor continuously to be sure that your treatment is still effective. 5. The following must always be considered: A. Patency: how open and clear is the airway, free of foreign substances, blood, vomitus, and tongue. B. Ventilation: the amount of air the patient is able to inhale and exhale in a given time. C. Oxygenation: the amount of oxygen the patient is carrying to their tissues. 6. Gloves, mask and eye protection should be used for all airway procedures. The following protocols are recommended as a guide for approaching both simple and difficult medical and trauma airway problems. They assume that the responder is proficient in the various procedures, and will need to be modified according to training level. Advanced procedures should only be attempted if simpler ones fail and if the technician is qualified. Individual cases may require modification of these protocols. Medical Respiratory Arrest: 1. Open airway using head tilt-chin lift or head tilt-neck lift. 2. Use BVM with supplemental oxygen to ventilate.
PROTOCOL 5.1: Airway Management-General Principles (cont.) Medical Respiratory Arrest: (cont.) 3. Insert nasopharyngeal airway or oropharyngeal airway if patency difficult to maintain. 4. Suction as needed. 5. Perform orotracheal intubation after initial airway management if respiratory arrest continues. Medical Respiratory Insufficiency: 1. Open the airway using most efficient method. 2. Insert nasopharyngeal airway if patient will tolerate. 3. Suction as needed, being aware of oxygenation. 4. Apply supplemental oxygen by mask as needed. 5. Assist ventilations with BVM if needed. 6. Perform nasotracheal or orotracheal intubation if prolonged support is needed, or if airway requires continued protection from aspiration. Traumatic Respiratory Arrest 1. Open airway using jaw thrust maneuver, protecting neck. 2. Clear the airway, suction as needed. 3. Have assistant perform manual in-line stabilization to head and neck. 4. Use hand to draw tongue and mandible forward if needed in patients with facial injuries. 5. Use BVM for initial control of ventilation. 6. Perform orotracheal intubation with in-line stabilization. Cricoid pressure may make intubation easier. (Sellick maneuver)
PROTOCOL 5.1: Airway Management-General Principles (cont.) Traumatic Respiratory Arrest (cont.) 7. If intubation cannot be performed due to severe facial injury, and patient cannot be ventilated with BVM and adjuncts, consider surgical or needle cricothyrotomy only after contact with Medical Control. Traumatic Respiratory Insufficiency: 1. Open airway using jaw thrust maneuver, protecting neck. 2. Clear the airway, suction as needed. 3. Have assistant apply continued manual in-line stabilization to head and neck. 4. Use hand to draw tongue and mandible forward (if needed) with facial injuries. 5. Insert nasopharyngeal airway. 6. Administer high flow 02 and assist ventilations with BVM if necessary. 7. If midface intact, attempt nasotracheal intubation to secure airway if needed. 8. If patient deteriorates, and cannot be supported by less invasive means: a. Attempt orotracheal intubation with in-line stabilization, or b. Consider surgical cricothyrotomy only after contact with Medical Control.
PROTOCOL 5.2: Airway Management: Assisting Ventilation Indications: A. Inadequate patient ventilation due to fatigue, coma, or other causes of respiratory depression. B. To apply positive pressure ventilation in patients with pulmonary edema and severe fatigue. C. To ventilate patients in respiratory arrest. D. For use in conjunction with ETT or Combitube to ventilate. E. To break laryngospasm. Technique: A. Open the airway. B. Check for ventilation. C. If patient is not breathing, perform 2 quick breaths, and check pulse. Begin CPR as needed. D. If pulse is present but patient is not breathing, ventilate with adjuncts (OPA, NPA) and BVM. E. Assure high-flow oxygen is connected to BVM. F. Position yourself above patients head, continue to hold airway position, seat mask firmly on face, and begin assisted ventilation. G. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust mask fit as needed. H. If patient resumes spontaneous respirations, switch to high-flow oxygen via NRB mask. Intermittent assistance with BVM may still be needed. Complications: A. Inadequate ventilations due to poor seal between patients mouth and ventilatory device.
PROTOCOL 5.2: Airway Management: Assisting Ventilation (cont.) B. Gastric distention, possibly causing vomiting, may require placement of a nasogastric or orogastric tube. C. Pneumothorax in children. Special Notes: A. 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 ventilations, even in patients who do not require or will not tolerate intubation.
PROTOCOL 5.3: Airway Management: Clearing and Suctioning the Airway Indications: A. Trauma to the upper airway, with blood, teeth, or other material causing partial obstruction. B. Vomitus, food or other foreign material in airway. C. Excess secretions or pulmonary edema fluid in upper airway or lungs (with endotracheal tube in place). D. Meconium or amniotic fluid in mouth, nose and oropharynx of newborn. Precautions: A. Suctioning, particularly through endotracheal tubes, always risks suctioning away the available oxygen as well as the fluid from the airway. Limit the suction time to a few seconds while the catheter is being withdrawn. B. The above precaution should NOT be followed when significant vomitus or other material continues to well up and completely obstruct the airway. In that instance, suctioning must be continued until an airway is re-established. C. Use equipment large enough for the job at hand. Large amounts of particulate matter require large-bore suction tips using connecting tubing. D. The catheter and tubing will require frequent rinsing with water or saline solution to permit continued suction. Have a bottle of water or saline at hand before you begin. Use gauze to remove large material from the end of the catheter. E. Do not insert a suction catheter with the suction functioning. Suction only on withdrawal of the catheter. Technique: A. Open airway and inspect for visible foreign material. B. Turn patient on side, if spinal trauma is not a concern, to facilitate clearance. C. Remove large or obvious foreign matter with gloved hands. Sweep finger ACROSS posterior pharynx and clear material out of mouth.
PROTOCOL 5.3: Airway Management: Clearing and Suctioning the Airway (cont.) Technique (cont.): E. Suction of oropharynx: 1. Attach tonsil tip (or use open end of tubing for large amounts of debris). 2. Ventilate and oxygenate the patient prior to the procedure as needed. 3. Insert tip into oropharynx under direct vision, with sweeping motion. 4. Continue intermittent suction interspersed with active oxygenation by mask or positive pressure ventilation with BVM if needed. 5. If suction becomes clogged, dilute by suctioning sterile water or saline solution to clean tubing. If suction clogs repeatedly, use connecting tubing alone, or manually remove large debris. F. Catheter suction of endotracheal tube: 1. Attach appropriate size suction catheter to tubing of suction device (leaving suction end in sterile container). 2. Hyperventilate patient 4-5 times rapidly. 3. Detach bag from endotracheal tube and insert sterile tip of suction catheter without suction. 4. When catheter tip has been gently advanced as far as possible, apply suction in a circular motion and withdraw catheter slowly. 5. Rinse catheter tip in sterile water or saline solution. 6. Hyperventilate patient before each suction attempt. Complications: A. Hypoxia due to excessive suctioning time without adequate ventilation between attempts. B. Persistent obstruction due to inadequate tubing size for removal of debris.
PROTOCOL 5.3: Airway Management: Clearing and Suctioning the Airway (cont.) Complications (cont.): C. Lung injury from aspiration of stomach contents due to inadequate suctioning. D. Asphyxia due to recurrent obstruction if airway is not monitored after initial suctioning. E. Trauma to the posterior pharynx from forced use of equipment. F. Vomiting and aspiration from stimulation of gag reflex. G. Induction of cardiac arrest from vagal simulation. Special Notes: A. Bulb suction should be used on the newborn. Consider intubation and/or use of a meconium suction device if meconium is present and a depressed newborn is delivered. B. Patients with pulmonary edema may have endless frothy secretions. Be sure to also oxygenate and assist ventilations even though you might be tempted to suction continuously. C. You will note that complications may be caused both by inadequate and overly vigorous suctioning. Technique and choice of equipment are very important. Choose equipment with enough power to suction large amounts rapidly to allow time for ventilation. D. Proper airway clearance can make the difference between a patient who survives and one who dies. Airway obstruction is one of the most common treatable cause of pre-hospital death.
PROTOCOL 5.4: Airway Management: Obstructed Airway Indications: A. Complete or partial obstruction of the airway due to a foreign body. B. Complete or partial obstruction due to airway swelling from anaphylaxis, croup or epiglottis. C. Patient with unknown injury or illness who cannot be ventilated after airway opening procedures. Precautions: A. Perform chest thrusts only in visibly pregnant patients, obese patients and in infants. B. Patients with a partial airway obstruction can be extremely uncomfortable and hard to manage. Abdominal or chest thrusts will not be effective and may injure the patient who is still ventilating on their own. Resist the temptation to attempt relief of obstruction if it is not complete, but be ready to intervene promptly if full obstruction occurs. C. Hypoxia from airway obstruction can cause seizures. Chest or abdominal thrusts may not be effective until the patient relaxes when the seizure terminates. Technique: Complete Airway Obstruction: A. Open airway using head tilt-chin lift or jaw thrust. B. Attempt to ventilate using BVM. C. If unable to ventilate, reposition the airway and reattempt ventilations. D. If airway remains obstructed, visualize with laryngoscope and remove any obvious foreign body with Magill forceps. E. Reposition the airway and attempt to ventilate. F. If unable to ventilate, administer 5 subdiaphragmatic thrusts. G. Reposition the airway and reattempt to ventilate.
PROTOCOL 5.4: Airway Management: Obstructed Airway (cont.) Technique: Complete Airway Obstruction (cont.): H. Consider surgical or needle cricothyrotomy if obstruction above the cords is unrelieved or unable to ventilate adequately with BVM. (Remember; surgical cricothyrotomy is a difficult and hazardous technique that is to be used only in extraordinary circumstances and after contact with Medical Control). I. When obstruction relieved: 1. Transport patient on side if necessary, keeping airway clear of debris and oral secretions. 2. Apply high-flow oxygen via NRB mask. 3. Constantly reassess adequacy of ventilations and support as needed. 4. Suction aggressively as needed, being aware of oxygenation. 5. Restrain if combative. Partial Airway Obstruction: A. Have patient assume most comfortable position. B. Apply high-flow oxygen via NRB mask. C. Suction upper airway if needed. D. If patient unable to move air, confused or otherwise deteriorating, visualize airway and remove foreign body or perform abdominal thrusts as noted above. Complications: A. Hypoxic brain damage and death from unrecognized or unrelieved obstruction. B. Trauma to ribs, lungs, liver and spleen from chest or abdominal thrusts (particularly when forces are not evenly distributed). C. Vomiting and aspiration after relief of obstruction.
PROTOCOL 5.4: Airway Management: Obstructed Airway (cont.) Complications (cont.): D. Creation of complete obstruction after incorrect blind finger probing in airway. E. Tonsillar or pharyngeal laceration from over-vigorous finger sweep or laryngoscope insertion.
PROTOCOL 5.5: Airway Management: Opening the Airway Indications: A. Inadequate air exchange in the lungs due to jaw or facial fracture causing narrowing of air passage. B. Lax jaw or tongue muscles causing airway narrowing in the unconscious patient. C. Noisy breathing or excessive respiratory effort, which could be due to partial obstruction. D. In preparation for suctioning, management maneuvers. Precautions: A. For trauma patients, keep neck in midline and avoid flexion or hyperextension. B. For medical patients, neck extension may be difficult in an elderly person with extensive arthritis and little neck motion. Do not use excessive force or movement, a jaw thrust or chin lift without head tilt will be more successful. C. All airway maneuvers should be followed by an evaluation of their success; if breathing is still labored, a different method or more time for recovery may be needed. D. Childrens airways have less supporting cartilage; overextension can kink the airway and increase the obstruction. Watch chest movement to determine the best head angle. E. Dentures should usually be left in place since they provide a framework for the lips and cheeks and allow more effective BVM ventilation. Technique: A. To open the airway initially, choose method most suitable for patient, head tilt-chin lift or jaw thrust (see below). B. Assess ventilations. C. Relieve partial or complete obstruction, if present assisted ventilation or other airway
PROTOCOL 5.5: Airway Management: Opening the Airway (cont.) Technique (cont.): D. Assess oxygenation; use supplemental oxygen as needed. E. Choose method to maintain airway patency during transport. 1. Position patient on side if needed (if medical problem). 2. Oropharyngeal (OP) airway; a. b. c. d. Choose size by measuring from corner of mouth to ear margin. Depress tongue with tongue blade, or insert gently following the curvature of the pharynx. Insert gently with curve pointing upward. Advance to back of tongue, then turn to follow curve of airway. Move gently to be the tip is free in back of pharynx.
3. Nasopharyngeal (NP) airway. a. b. Lubricate tube with water soluble lubricant Insert in right nostril first with tube at 90 degrees to face, along floor of nose until flange is seated at nostril. Keep curve in line with normal airway curve. If you meet resistance or passage appears too narrow, try left side.
G. Assess breathing to be sure maneuver has resolved problem. H. Consider intubation. I. Resume ventilatory assistance and oxygenation as appropriate.
Complications: A. Cervical spinal cord injury from neck hyperextension in trauma victim with cervical fracture. B. Neck fracture in older patients with rigid neck due to forced extension during airway maneuvers. C. Death due to inadequate ventilation or hypoxia. D. Nasal or posterior pharyngeal bleeding due to trauma from tubes.
PROTOCOL 5.5: Airway Management: Opening the Airway (cont.) Complications (cont.): E. Increased airway obstruction from tongue following improper oropharyngeal airway placement. F. Aspiration of blood or vomitus from inadequate suctioning and continued contamination of lungs from upper airway. Special Notes: A. During transport, medical patients can be placed in a stable position on their sides for effective airway control, use a flexed leg, arms, or pillows for support. B. Nasopharyngeal airways are very useful for airway maintenance, and are underused. The nasal insertion provides more stability, the airway is better tolerated in partially awake patients, and it does not carry the risk of blocking the airway further like the stiff oropharyngeal airway. METHODS OF OPENING THE AIRWAY: HEAD TILT-CHIN LIFT: Technique: From beside head, place one hand on forehead. Grasp lower edge of chin with fingers of other hand and lift chin forward. Teeth may come together. Indications: Trauma or medical patient. JAW THRUST: Technique Position yourself above patient. Place fingers of each hand under angle of jaw, just below ears, using forearms to maintain head alignment. Gently thrust angle of jaw forward. Indications: Trauma or medical patient where neck extension is not possible.
PROTOCOL 5.6: Advanced Airway Management: Combitube Indication: Patient requiring advanced airway and attempts at oro/nasotracheal intubation have been unsuccessful. Contraindications: A. Patients under 5 feet tall. B. Responsive patients with an intact gag reflex. C. Patients with known esophageal disease. D. Patients who have ingested caustic substances. Technique: A. Begin ventilation or CPR, taking usual precautions to verify an open airway. B. Prepare Combitube for insertion by testing cuff integrity and lubricating with water soluble lubricant. C In the supine patient, lift the tongue and lower jaw upward with one hand.
CAUTION: When facial trauma has resulted in sharp, broken teeth or dentures, remove dentures and exercise extreme caution when passing the Combitube into the mouth to prevent the cuff from tearing. D With the other hand, hold the Combitube so that it curves in the same direction as the natural curvature of the pharynx. Insert the tip into the mouth and advance gently until the black printed ring is aligned with the teeth or alveolar ridges (see illustration 5.A. Combitube placement below).
CAUTION: DO NOT FORCE THE COMBITUBE If the tube does not advance easily, redirect it or withdraw and reinsert. E Inflate the blue pilot balloon leading to the pharyngeal cuff, with 100 ml of air using the 140 ml (cc) syringe. Note that this may cause the Combitube to move slightly from the patients mouth. (see illustration 5.B. Combitube Anatomy below). Inflate the white pilot balloon leading to the distal cuff, with approximately 15 ml of air using the 20 ml (cc) syringe. (see illustration 5.B.)
PROTOCOL 5.6: Advanced Airway Management: Combitube (cont.) Technique (cont.): G. Begin ventilation through the longer blue Pharyngeal Lumen (#1). (see illustration 5.C. Combitube Anatomy below). If auscultation of breath sounds is positive and auscultation of gastric insufflation is negative, continue ventilation. Confirm with end-tidal CO2 detector. H. IF NECESSARY, if auscultation of breath sounds is negative, and gastric insufflation is positive, immediately begin ventilation through the shorter clear Tracheal Lumen (#2) (see illustration 5.C.). Assess tracheal ventilation by auscultation of breath sounds and absence of gastric insufflation. Confirm with end-tidal CO2 detector. I. If a Combitube is placed and is functioning correctly, it should be left in place until the patient is brought to the Emergency Department.
ILLUSTRATION 5.A. COMBITUBE PLACEMENT
PROTOCOL 5.6: Advanced Airway Management: Combitube (cont.) Technique (cont.): ILLUSTRATION 5.B. COMBITUBE ANATOMY
Distal Tracheal Cuff
Pilot Balloon for Small Distal Tracheal Cuff (#2)
Pilot Ballon for Large Pharyngeal Cuff (#1)
Large Proximal Pharyngeal Cuff
PROTOCOL 5.6: Advanced Airway Management: Combitube (cont.) Technique (cont.): ILLUSTRATION 5.C. COMBITUBE ANATOMY
Pharyngeal Lumen (#1)
Tracheal Lumen (#2)
Black Teeth Rings
PROTOCOL 5.7: Advanced Airway Management: Orotracheal Intubation Indications: A. Patient with persistent hypoxia and hypoventilation despite initial simple airway interventions and adjuncts. B. Patient requiring airway protection to: 1. Prevent aspiration of gastric contents, upper airway secretions, or bleeding. 2. Suction secretions and maintain airway patency. C. To administer drugs during resuscitation for absorption through the lungs when an IV or IO cannot be obtained immediately. Precautions: A. Do not use intubation as the initial method of managing the airway in a cardiac/respiratory arrest, oxygenate prior to intubation. (accomplish with BVM and adjuncts as needed). B. Nasotracheal intubation may be the preferred technique in the breathing patient. Oral intubation with in-line stabilization of the cervical spine is the best alternative in the non-breathing or inadequately breathing trauma patient. Careful visualization with the laryngoscope is needed, and Magill forceps may be useful in guiding the ET tube. Surgical or needle cricothyrotomy may be indicated in a traumatic respiratory arrest if intubation is not successful. C. Never lever the laryngoscope against the teeth. The jaw should be lifted with direct upward and outward traction by the laryngoscope. D. Prepare suction beforehand. esophagus is intubated. Vomiting is particularly common when the
E. Intubation should take no more than 15-20 sec to complete: do not lose track of time. If visualization is difficult, stop and re-ventilate before trying again.
PROTOCOL 5.7: Advanced Airway Management: Orotracheal Intubation (cont.) Technique: A. Assemble equipment while continuing ventilation: 1. Choose tube size (see Table 5.A. ETT Size by Age). Use as large a tube as possible. 2. Introduce the stylette into the tube and be sure it stops 1/2 short of the tubes end. 3. Assemble laryngoscope and check light. 4. Connect and check suction. 5. Test cuff integrity (in cuffed tube) by inflating with 10 ml syringe then deflate. Syringe may be left connected. B. Position patient: neck flexed forward, head extended back. Back of head should be level with or higher than back of shoulders. C. Give a minimum of 4 good ventilations before starting procedure. D. Insert laryngoscope to right of midline. Move it to midline, pushing tongue to left and out of view. E. Lift straight up on blade and out (no levering) to expose posterior pharynx. F. Identity epiglottis: tip of curved blade should sit in vallecula (in front of epiglottis), straight blade should slip over epiglottis. Sellick maneuver (cricoid pressure) by assistant may improve cord visualization and reduce risk of aspiration. G. With additional gentle pressure to straighten the airway, identify trachea from arytenoid cartilages and vocal cords. H. Insert tube from right side of mouth, along blade into trachea under DIRECT VISION. I. Advance tube so cuff is 1-1.5 beyond cords. Ventilate and watch for chest rise. Listen for sounds over stomach (should not be heard) and lungs and axillae.
PROTOCOL 5.7: Advanced Airway Management: Orotracheal Intubation (cont.) Technique (cont.): J. Inflate cuff with 7-8 ml air.
K. To avoid accidental extubation ALWAYS maintain control of tube with one hand until secured. L. If the medical patient needs to be moved excessively, it is also a wise practice to put a c-collar on the patient and immobilize their head and neck with a cervical immobilization device (CID) to further avoid the possibility of accidental extubation. The trauma patient will be routinely immobilized. M. In the patient who is still somewhat awake, or who may reawaken during transport. If not using a commercial tube holder, before securing tube consider a bite block made from a cut off OP airway to prevent patients teeth from damaging tube. N. Re-auscultate over stomach, both sides of chest and axillae. O. Note proper tube position (21 cm at teeth for females, 23 cm at teeth for males) and secure tube with tape, ties or commercial tube holder. P. In all cases where an ET tube has been placed, Three different methods will be used to confirm tube placement. 1. Direct auscultation over the stomach and bilateral chest wall. 2. The use of an esophageal intubation detector (EID). 3. The use of an end-tidal CO2 detector of either the color metric type or the constant-monitoring type (constant-monitoring type preferred). Familiarization with the end-tidal CO2 detector will be maintained reference pediatric vs adult sizes, fluids down tube, length of usage, etc. Fogging of the ET tube, while it is helpful in assessing placement, is not 100% reliable and should not be used as one of the primary methods of confirming tube placement. Q. Tube placement must also be re-verified after securing tube, after moving the patient, and at any other time of concern or change in the patients condition (including the movement of the patient from the ambulance cot to the hospital bed).
PROTOCOL 5.7: Advanced Airway Management: Orotracheal Intubation (cont.) Technique (cont.): R. If there is any doubt about the placement of the tube, it should be withdrawn and the patient re-intubated. Complications: A. Esophageal intubation: particularly common when tube not visualized as it passes through cords. The greatest danger is in not recognizing the error. Auscultation over stomach during trial ventilations should reveal air gurgling through gastric contents with esophageal placement. Also, make sure your patients color improves, as it should when ventilating. B. Intubation of right mainstem bronchus: be sure to listen to chest bilaterally. C. Upper airway trauma due to excess force with laryngoscope or to traumatic tube placement. D. Vomiting and aspiration during traumatic intubation or intubation of patient with intact gag reflex. E. Cervical spine fracture in patients with arthritis and poor cervical mobility. F. Hypoxia due to prolonged intubation attempt. G. Cervical cord damage in trauma victims with unrecognized spine injury. H. Ventricular arrhythmias or fibrillation in hypothermia patients from stimulation of airway. I. Induction of pneumothorax, either from traumatic insertion, forceful bagging, or aggravation of underlying pneumothorax.
Special Notes: A. REMEMBER: Endotracheal intubation is NOT the procedure of choice in the first seconds of a resuscitation. It is secondary procedure only. Most patients can be adequately ventilated with a BVM with oropharyngeal or nasopharyngeal airway.
PROTOCOL 5.7: Advanced Airway Management: Orotracheal Intubation (cont.) Special Notes (cont.): B. Difficult intubations can frequently be made easier by continuous pressure placed over the thyroid and cricoid cartilages moving the vocal cords posteriorly into view (Sellick Maneuver). C. Do not be overly aggressive and quick to intubate in trauma patients with upper airway trauma. If you are able to manage secretions and ventilate, intubation is often not required and the complications may outweigh the advantages if your hand is not forced. TABLE 5.A. ETT SIZE BY AGE
AGE Premature Newborn 6 Months 18 Months 3 Years 5 Years 8 Years 10-15 Years Adult
OROTRACHEAL TUBE SIZE 2.5 - 3.0 3.0 - 3.5 3.5 4.0 4.5 5.0 Cuffed 6.0 Cuffed 6.5 - 7.0 Cuffed 7.0 - 9.0 Cuffed
PROTOCOL 5.8: Advanced Airway Management: Nasotracheal Intubation Indications: A. Same function as orotracheal intubation. B. Most useful in breathing, comatose patients requiring intubation. May be better tolerated in partly conscious patients than oral intubation. C. Asthma, pulmonary edema, certain cases of facial trauma and epiglottitis with respiratory failure, where intubation may need to be achieved in a sitting position. Precautions: A. Head must be exactly in midline for successful intubation. B. Have suction ready. Vomiting can occur, as with any stimulation of the airway. C. Nasotracheal intubation can be more time-consuming than orotracheal intubation. D. Often nares are asymmetrical and one side is much easier to intubate. Avoid inducing bilateral nasal hemorrhage by forcing a nasotracheal tube on multiple attempts. E. Do not use in patients with an obviously fractured and mis-aligned nose. Craniofacial trauma is not a contraindication to nasotracheal intubation if midface is intact. If mid-face is not intact, nasotracheal intubation is contraindicated. F. Be sure adapter on distal end of tube is firmly in place. G. Nasotracheal intubation is not recommended in children less than 8 years of age. Technique: A. Choose correct ET tube size (usually 7.0-7.5 mm tube in adult or 1/2 size smaller than orotracheal size, limitation is nasal canal diameter. The size of the patients little finger can be used as an approximate guide to tube size, the two will be very similar in size. B. Position patient with head in midline, neutral position (cervical collar may be in place, or assistant may hold in-line stabilization in trauma patients).
PROTOCOL 5.8: Advanced Airway Management: Nasotracheal Intubation (cont.) Technique (cont.): C. Assist ventilations prior to procedure if spontaneous respirations are inadequate. Pre-dilatation of the chosen nostril with a lubricated (2% viscous Lidocaine) nasal airway slightly larger than selected ET tube will facilitate passage and decrease epistaxis. D. Connect BAAM to tube adapter and orient adapter to curvature of tube (this will help you know the direction the eye of the tube is going once it disappears into the patients nose). E. Test cuff integrity by inflating with 10 ml syringe then deflate. Syringe may be left connected. F. Lubricate ET tube with 2% viscous Lidocaine. Synephrine in each nostril. Give 2 sprays of Neo-
G. With gentle steady pressure, and the tube at right angles to the patients face, introduce the tube through the nose towards the posterior pharynx. Use the right nostril if possible. The whistling noise made through the BAAM by the patients respirations will help you guide the tube toward the tracheal opening. If the whistling stops (and the patient is still breathing) the tube needs to be re-directed so the whistling is heard again. H. There will be a slight resistance just before entering trachea. Wait for an inspiratory effort before final advance into trachea. Patient may also cough or buck just as tube passes through vocal cords.. I. J. Laryngospasm may be encountered during nasotracheal intubation. Continue advancing until air is exchanging through the tube, this will be noted by constant whistling through the BAAM.
K. Advance about 1-1.5 inch further, then inflate cuff. L. Coughing after intubation can be reduced by instilling 5ml of 2% Lidocaine down the tube. M. Ventilate and check for breath sounds bilaterally and abdominal (stomach) sounds.
PROTOCOL 5.8: Advanced Airway Management: Nasotracheal Intubation (cont.) Technique (cont.): N. If there is any doubt about the placement of the tube, it should be withdrawn and the patient re-intubated. O. Note proper tube position and secure. P. In all cases where an ET tube has been placed, Three different methods will be used to confirm tube placement. 1. Direct auscultation over the stomach and bilateral chest wall. 2. The use of an esophageal intubation detector (EID). 3. The use of an end-tidal CO2 detector of either the color metric type or the constant-monitoring type (constant-monitoring type preferred). Familiarization with the end-tidal CO2 detector will be maintained reference pediatric vs adult sizes, fluids down tube, length of usage, etc. Fogging of the ET tube, while it is helpful in assessing placement, is not 100% reliable and should not be used as one of the primary methods of confirming tube placement. Q. Tube placement must also be re-verified after securing tube, after moving the patient, and at any other time of concern or change in the patients condition (including the movement of the patient from the ambulance cot to the hospital bed). Complications: A. Same as orotracheal intubation. In addition: B. Further craniofacial injury particularly in patients presenting with facial trauma and mid-face instability. C. Upper airway bleeding caused by tube trauma. C. Vomiting and aspiration in the patient with intact gag reflex. Special Notes: A. In the field, the secret of blind nasotracheal intubation is perfect positioning and gentle patience.
PROTOCOL 5.8: Advanced Airway Management: Nasotracheal Intubation (cont.) Special Notes (cont.): B. After accomplishing nasotracheal intubation, avoid flexion or extension of the patients head as this may result in extubation or advancement of the tube down the right main stem bronchus (C-collar and CID are very useful for this). C. In head trauma, 1 mg/kg of Lidocaine should be given IV prior to intubation to decrease any rise in intracranial pressure associated with the intubation. D. Difficult nasotracheal intubations can frequently be made easier by continuous pressure placed over the thyroid and cricoid cartilages moving the vocal cords posteriorly (Sellick Maneuver). The tube can frequently be felt going through (or not going through) the cords while this is being done.
PROTOCOL 5.9: Advanced Airway Management: Rapid-Sequence Induction For Endotracheal Intubation Rapid-sequence induction for intubation may be performed by Paramedics who have completed both a Surgical Airway course approved by the Medical Director and a Rapid-Sequence Induction course, and who have demonstrated evidence of skill competency to the Medical Director at least 3 times per year. Indications: A. Patients with potential or actual airway compromise due to depressed sensorium (GCS of 8 or less) or whose combativeness threatens the airway or spinal cord stability. B. Patients who demonstrate a high probability of airway compromise during transport (i.e. smoke inhalation, severe head injury). C. Patients who need ventilatory assistance or airway protection. Precautions: A. May produce initial muscle fasciculations. B. May cause vomiting during muscle fasciculations. C. Cardiac dysrhythmias; bradycardia, PVCs and V-fib may be induced. D. Malignant hyperthermia is a rare metabolic process of the skeletal muscles that may be triggered by Succinylcholine. E. Succinylcholine is associated with increased intraocular pressure. Equipment: 1. 2. 3. 4. 5. 6. Endotracheal tube of appropriate size w/stylet 10 cc syringe Laryngoscope handle and appropriate blade Commercial tube holder or tape BVM and O2 RSI medications (Lidocaine, Atropine (if Peds), Etomidate, Succinylcholine) 7. Suction equipment 8. Combitube 9. Surgical cricothyrotomy equipment (#10 scalpel, endotracheal tube of appropriate size).
PROTOCOL 5.9: Advanced Airway Management: Rapid-Sequence Induction For Endotracheal Intubation (cont.) Technique: A. NOTE: THIS IS A LEVEL II INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED! Be prepared to give Medical Control an airway assessment consisting of: 1. Mallampati Classification (if possible). (see illustration 5.D. below) 2. Thyromental distance. (see illustration 5.E. below) 3. Assessment of mouth opening (should be at least two finger widths). 4. Assessment of cervical mobility and any other problems. B. Ensure all equipment is set up for intubation, Combitube placement and surgical cricothyrotomy. C. Connect the patient to the cardiac monitor and pulse oximeter. D. Pre-oxygenate with high-flow oxygen by mask. Do not manually ventilate the patient unless respiratory effort is ineffective, as this may result in gastric distention with vomiting and aspiration,. E. Premedicate the patient with Lidocaine 1 mg/kg IV. (head injury) F. Premedicate child less than 5 years of age with Atropine .01 mg/kg IV. G. Sedate (induce) the patient with Etomidate .3 mg/kg IV. Note: The administration of the sedation drug alone may be enough to facilitate intubation, always check. H. Consider opening the cervical collar while providing in-line manual immobilization of the head and neck. Apply cricoid pressure to occlude the esophagus until intubation is successfully completed and the ETT cuff is inflated. If the patient actively vomits, cricoid pressure must be released. I. Administer Succinylcholine 2.0 mg/kg IV over 30 seconds, wait until muscle fasciculations stop and perform intubation. If unable to intubate during the first 20 seconds, stop and ventilate the patient with BVM for 30-60 seconds and reattempt to intubate. If endotracheal intubation fails and you are unable to adequately ventilate the patient with the BVM, consider Combitube placement or cricothyrotomy.
PROTOCOL 5.9: Advanced Airway Management: Rapid-Sequence Induction For Endotracheal Intubation (cont.) Technique I. (cont.): Note: per physician request only Zemuron (Rocuronium) .6 mg/kg IV/IO may be used as an initial paralyzing agent as an alternative to Succinylcholine. Keep in mind that Zemuron is contraindicated in the patient that presents as difficult to orally intubate, due to its relatively long duration and the possibility of the need for prolonged airway support. J. Once intubation is completed, confirm tube placement by three different methods and secure the tube.
K. Treat bradycardia during intubation by temporarily halting intubation attempt and hyperventilating the patient with BVM and 100% oxygen. If the patient remains bradycardic, consider Atropine 0.5 mg IV (adult), 0.01 mg/kg (ped). L. Re-secure the cervical collar and complete any unfinished spinal precautions for transport. M. Consider the use of Zemuron (Rocuronium) 0.6 mg/kg IV/IO for prolonged paralysis during longer transports. Note: Do not administer Zemuron to the patient who is already starting to awaken from the administration of Succinylcholine. Sedate first with Morphine, Valium or Etomidate, then administer Zemuron. If patient has not started to reawaken, then Zemuron only is acceptable. Contraindications: A. Penetrating eye injury. B. Neurological disease (i.e. multiple sclerosis). C. Severe burn or trauma greater than 48 hours old. D. Malignant hyperthermia or known history of malignant hyperthermia. E. Anatomical considerations that would make orotracheal intubation very difficult. Documentation: The following items must be documented in the Patient Care Report:
PROTOCOL 5.9: Advanced Airway Management: Rapid-Sequence Induction For Endotracheal Intubation (cont.) Documentation (cont.): 1. 2. 3. 4. 5. Indication for intubation. Tube size. Pre-oxygenation prior to intubation and oxygen saturation. Classification and condition of airway; (clear, emesis, blood, etc.). Confirmations of tube placement, including auscultating breath sounds over both lung fields, as well as absence of sounds over epigastric region. Use of EID and end-tidal CO2 device (pleth and readout) as additional adjunct for confirmation. Difficulty with the procedure, including number of attempts. Depth of insertion and how the tube is secured. Who performed the procedure. Cricoid pressure. Manual in-line immobilization of c-spine for trauma patients. Means by which patient was ventilated after intubation and oxygen delivered. Cardiac rhythm. Status of ETT after each movement of patient. Status of tube at receiving facility; breath sounds, oxygen saturation, endtidal CO2 reading, clinical improvement/stability. Document MD who confirms tube placement.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
ILLUSTRATION 5.D. MALLAMPATI CLASSIFICATION
Class I
Class II
Class III
Class IV
PROTOCOL 5.9: Advanced Airway Management: Rapid-Sequence Induction For Endotracheal Intubation (cont.) ILLUSTRATION 5.E. THYROMENTAL DISTANCE
The Thyromental Distance is the distance of the lower mandible in the midline from the chin to the thyroid notch. This measurement is performed with the adult patients neck fully extended. It helps one determine how anterior the patient may be and how much room there is for the tongue to be displaced during laryngoscopy.
PROTOCOL 5.10: Advanced Airway Management: Needle Cricothyrotomy (PTLV) An emergent needle cricothyrotomy (Percutaneous Translaryngeal Ventilation or PTLV) may be performed by the Paramedic who has completed a surgical airway course approved by the Medical Director, and who has proven evidence of skill competency to the Medical Director at least two (2) times per year. Evidence will be documented and signed by the Medical Director annually. Criteria: A patient of less than 8 years of age with a life-threatening airway obstruction. Indications: A. A patient in whom a patent airway cannot be secured with intubation. B. Situations in which standard endotracheal intubation cannot be performed due to: 1. Severe laryngeal edema. 2. Massive traumatic facial/oropharyngeal injury. 3. Massive congenital deformities. 4. Complete airway obstruction by a foreign body that cannot be extricated with direct laryngoscopy techniques. C. A minimum of three (3) attempts at intubation have been made, and all Paramedics present have attempted to visualize the cords. Precautions: A. This procedure is not without considerable hazards. The cricothyroid membrane must be correctly identified to prevent uncontrollable bleeding and possible damage to surrounding structures when the puncture is made. B. Maintain manual cervical spine alignment during procedure. C. The needle cricothyrotomy provides minimal oxygenation and ventilation, short scene times and expedited transport are essential.
PROTOCOL 5.10: Advanced Airway Management: Needle Cricothyrotomy (PTLV) (cont.) Equipment: (In PTLV Kit) 1. 14 gauge X 1.25 inch IV catheter (unprotected) 2. 10 cc syringe (remove stopper from IV catheter and attach 10 cc syringe) 3. Povidone-iodine or alcohol swabs 4. O2 delivery (ventilation) device (see illustration 5.F. below) 5. Tape and 4x4 gauze pads Technique: A. Assess need to perform needle cricothyrotomy. NOTE: THIS IS A LEVEL II INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED! B. Gather all needed equipment and hook patient to cardiac monitor, capnography and pulse oximeter. C. Place the patient in a supine position. If no cervical spinal injury exists, slightly hyperextend the neck to identify the cricoid and thyroid cartilage. If possibility of cervical spine injury, maintain neck in neutral position. D. Palpate and locate the cricothyroid membrane between the thyroid and cricoid cartilages (see illustration 5.G. below). E. Stabilize the thyroid cartilage with non-dominant hand between thumb and index finger. Prep the area by swabbing with Povidone-iodine or alcohol swabs. F. With the dominant hand, puncture the skin midline directly over the cricothyroid membrane with the catheter/syringe assembly. Advance the needle through the membrane caudally (towards the feet) at a 45 degree angle aspirating with the syringe as the needle is advanced. Be careful to avoid the posterior tracheal wall. G. Aspiration of air signifies entry into the trachea. H. Once in the trachea, advance the catheter over the needle and withdraw the needle and syringe. I. Remove blue cap from PTLV O2 delivery device and attach to hub of IV catheter, turn petcock to ON, attach O2 tubing end to O2 tank regulator and open to 25 LPM.
PROTOCOL 5.10: Advanced Airway Management: Needle Cricothyrotomy (PTLV) (cont.) Technique (cont.): J. Ventilate/oxygenate for 1 second by placing thumb over suction catheter opening in PTLV O2 delivery device, then remove thumb for 4 seconds to allow for passive exhalation. Continue to ventilate at a ratio of 1 to 4.
K. Observe for any lung inflations and auscultate for ventilation. Monitor ECG, O2 saturation and end-tidal CO2. L. Secure catheter and device to neck with tape and 4X4s. M. Document procedure and responses completely. Complications: A. Air escaping out of the trachea through the hole created by the catheter could cause subcutaneous or mediastinal emphysema to develop. B. Exsanguinating hematoma. C. False passage into tissue. D. Perforation of the posterior trachea/esophagus. E. Non-sealed trachea wont permit adequate ventilation. F. Aspiration. G. Patient will retain high CO2 and low O2 sats even if procedure is done properly. H. Inadequate ventilations resulting in hypoxia and death. Special Notes: A. Remember this is a temporizing measure for a desperate situation, ventilation and oxygenation will be minimal. B. Allow for passive exhalation, the air is coming out of a very small hole. C. Any attempt at hyperventilation is contraindicated.
PROTOCOL 5.10: Advanced Airway Management: Needle Cricothyrotomy (PTLV) (cont.) ILLUSTRATION 5.F. PTLV O2 DELIVERY DEVICE
PROTOCOL 5.11: SURGICAL CRICOTHYROTOMY An emergent surgical cricothyrotomy may be performed by the Paramedic who has completed a surgical airway course approved by the Medical Director, and who has proven evidence of skill competency to the Medical Director at least two (2) times per year. Evidence will be documented and signed by the Medical Director annually. Criteria: Adults or children greater than 40 kg or more than 8 years of age with a life-threatening airway obstruction. Indications: A. A patient in whom a patent airway cannot be secured with intubation. B. Situations in which standard naso/orotracheal intubation cannot be performed due to: 1. Severe laryngeal edema. 2. Massive traumatic facial/oropharyngeal injury. 3. Massive congenital deformities. 4. Complete airway obstruction by a foreign body that cannot be extricated with direct laryngoscopy techniques. C. A minimum of three (3) attempts at intubation have been made, and all Paramedics present have attempted to visualize the cords. Precautions: A. This procedure is not without considerable hazards. The cricothyroid membrane must be correctly identified to prevent uncontrollable bleeding and possible damage to surrounding structures when the incision is made. B. This is an emergent, invasive procedure that should only be undertaken after all other means to establish a secure airway have been considered, i.e. Combitube, etc. C. Maintain manual cervical spine alignment during procedure.
PROTOCOL 5.11: SURGICAL CRICOTHYROTOMY (cont.) Equipment: 1. 2. 3. 4. 5. 6. 7. 8. 9. 5.0-6.5 cuffed ET tube or Shiley (use size appropriate tube for age of patient) Scalpel, #10 or 11 blade Trach hook 10 cc syringe Povidone-iodine or alcohol swabs Tape or tube tie 4x4 gauze pads BVM with oxygen Suction
Technique: A. Assess need to perform surgical cricothyrotomy. NOTE: THIS IS A LEVEL II INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED! B. Gather all needed equipment and hook patient to cardiac monitor and pulse oximeter. C. Place the patient in a supine position. If no cervical spinal injury exists, slightly hyperextend the neck to identify the cricoid and thyroid cartilage. If possibility of cervical spine injury, maintain neck in neutral position. D. Palpate and locate the cricothyroid membrane between the thyroid and cricoid cartilages (see illustration 5.G. below). E. Stabilize the thyroid cartilage with non-dominant hand between thumb and index finger. Prep the area by swabbing with Povidone-iodine or alcohol swabs. F. With the dominant hand, make an 1 inch incision vertically through the skin only directly over the cricothyroid membrane and bluntly dissect to expose the cricothyroid membrane. G. Then, make a horizontal stab incision through the cricothyroid membrane. Air should move freely through the incision if there is spontaneous respiratory effort. Be careful to hold the scalpel so as to limit the depth it can penetrate to prevent posterior trachea/esophageal perforation.
PROTOCOL 5.11: SURGICAL CRICOTHYROTOMY (cont.) Technique (cont.): H. Invert the scalpel and insert the scalpel handle through the cricothyroid membrane incision and rotate 90 to the incision to widen it and maintain a pathway. Use Trach hook to lift the trachea and expose the incision and pathway into the trachea. The scalpel handle may be removed if the pathway is clear and stable. If the pathway is not clear and stable, leave the scalpel handle in place. If there is adequate stabilization, proceed. I. If the scalpel handle is left in place, insert the endotracheal tube or Shiley past it into the cricothyrotomy, directing the tube distally into the trachea. If an ET tube is used, the tube should only be inserted 1 to 2 centimeters above the superior border of the cuff to avoid a right mainstem intubation. After the tube is in place, remove the scalpel handle if it was left in place. Inflate the cuff and ventilate the patient.
J.
K. Evaluate the effectiveness of the airway per Advanced Airway Management protocol. Check for subcutaneous emphysema, air leaking from the incision, or bleeding. L. Bleeding from superficial neck vessels is very common. Use direct pressure and dress wound after tube in place and ventilating. M. Secure the tube and watch carefully. oxygen via BVM, and monitor. Continue to ventilate with 100%
N. Suction trachea as needed using sterile technique. Even with inflated balloon, some blood will get into trachea, causing irritation and hypoxia. O. Document procedure and responses completely. Complications: A. Hemorrhage by laceration of a major vessel (e.g. jugular or carotid). B. Laceration of the thyroid gland. C. Damage to the larynx and/or laryngeal nerve. D. Posterior perforation of the posterior trachea/esophagus.
PROTOCOL 5.11: SURGICAL CRICOTHYROTOMY (cont.) Complications (cont.): F. False passage into tissue. G. Subcutaneous emphysema. H. Aspiration. I. Inadequate ventilations resulting in hypoxia and death.
Special Notes: A. Evaluate the neck for any expanding hematomas, anterior expanding hematomas in the neck may be a relative contraindication to the procedure. B. Existing massive subcutaneous emphysema in the neck may distort landmarks and may be a relative contraindication to the procedure. C. Direct the scalpel posteriorly at a 90 degree angle to the cricothyroid membrane to avoid injury to the vocal cords. D. Placement of an oversized tube can lead to a fractured larynx. ILLUSTRATION 5.G. LARYNGEAL ANATOMY
The laryngeal framework is made up of the thyroid cartilage and cricoid cartilage. The shield-like thyroid cartilage is the prominent Adams apple that is often seen in men. At the superior aspect of the shield is a prominent notch that is easily palpable through the skin. This notch is the only reliable landmark in the neck when attempting to find the thyroid cartilage in women or in people with short, fat necks. It is difficult if this notch is not sought, because the hyoid bone or the cricoid cartilage may be easily misidentified as the thyroid cartilage with disastrous surgical results. Once the thyroid cartilage is identified, the airway is followed caudally by palpation until the first complete ring is found. This is the cricoid ring, the only circumferential ring in the airway. This cartilage is shaped like a high school class ring with the shield located posteriorly. The membrane connecting the cartilages is the cricothyroid membrane.
PROTOCOL 5.12: CPAP General Principles: CPAP (Continuous Positive Airway Pressure) has been shown to rapidly improve vitals signs and gas exchange in a subset of extremely dyspneic patients. It can also reduce the work of breathing, decrease the sense of dyspnea and decrease the need for endotracheal intubation in many of these patients. In patients with CHF, CPAP improves hemodynamics by reducing left ventricular preload and afterload. Criteria: A. Patient must be awake and able to follow commands. B. Patient must be 12 y/o and able to fit the CPAP mask. C. Patient must have the ability to maintain their own open airway. D. AND exhibit two or more of the following: 1. Respiratory rate greater than 25 breaths per minute 2 O2 saturation of less than 94% on high-flow oxygen
3. Use of accessory muscles during respirations Indications: A. Acute respiratory distress secondary to: 1. Congestive heart failure (CHF) 2. Acute cardiogenic pulmonary edema 3. Near drowning 4. Pneumonia 5. COPD (Emphysema, chronic bronchitis, asthma) Contraindications: A. Circumstances in which ET intubation is preferred or necessary to maintain patent airway.
PROTOCOL 5.12: CPAP (cont.): Contraindications (cont.): B. Patient does not improve at all or continues to deteriorate despite CPAP administration. C. Patient in respiratory arrest/apneic. D. Patient suspect of having a pneumothorax or has suffered chest trauma. E. Patient with tracheostomy. F. Patient is actively vomiting or has upper GI bleed. Technique: A. Assure patent airway and deliver 100% O2 via appropriate delivery system. B. EXPLAIN THE PROCEDURE TO THE PATIENT. When you are extremely short of breath, having a tight-fitting mask placed over your mouth and face can be terrifying. Explaining the procedure and coaching the patient through it can many times dictate the success or failure of the procedure. C. Ensure adequate oxygen supply to the device. D. Place patient on cardiac monitor and continuous pulse oximetry. (monitor end-tidal CO2 if possible). E. Large-bore IV NS (TKO unless otherwise indicated). F. Place the delivery device over the mouth and nose and secure with provided straps. G. Start with 5 cm H2O of PEEP, use 10 cm H2O of PEEP maximum. H. Check for air leaks. I. Continue to coach patient to keep mask in place and readjust as needed.
K. Monitor and document the patients respiratory response to the treatment. L. Check and document vitals signs every 5 minutes due to changes in preload and afterload of the heart during CPAP therapy.
PROTOCOL 5.12: CPAP (cont.): M. Consider and use medications as indicated (Albuterol, nitroglycerine, etc.). If used, Nitroglycerine should be administered in tablet form during CPAP therapy. CPAP mask may have a side port for administering nebulized medications during CPAP therapy. Special Notes: A. Watch patient closely for gastric distention, which can result in vomiting. B. Close observation of patients on CPAP is critical. At a minimum, continuous pulse oximetry coupled with close observation of respiration should be done and will signify a better or worsening condition. Dont ignore the pulse component of pulse oximetry, bradycardia often announces missed respiratory insufficiency, and can rapidly progress to full cardiac arrest. In any situation in which status of breathing becomes questionable or patient significantly deteriorates, CPAP should be removed and ventilations assisted with a BVM and/or advanced airway procedures instituted. C. Assure that receiving hospital knows CPAP therapy is being performed.
PROTOCOL 5.13: Defibrillation Application: A. Place patient in a safe environment, away from pooled water and metal surfaces under either the patient or the operator. B. Remove clothing from patients upper torso. C. Always remove excessive hair with 3M clippers. Excessive hair will create an unacceptable space between the electrodes and the patients skin. D. Wipe chest dry, electrodes will adhere best when applied to a dry chest. NOTE: do not use alcohol preps. E. Attach patient therapy cable to patient therapy electrodes and confirm cable connection to the MRX. F. Remove protective liner and place the sternum electrode (RA) to the right of the upper sternum just below the right clavicle. G. Remove protective liner and place the apex electrode (LL) to the left of the left nipple in the mid-axillary line over the lower ribs. H. The anterior-posterior position is also acceptable. I. J. Do not place electrodes over pacemakers, ICD generators or nitroglycerin paste. Remove medication patches before defibrillation. Apply firm pressure to both electrodes smoothing from the center out to the edges to assure maximal contact.
Techniques: A. Defibrillation 1. Turn MRX power ON. 2. Rotate Therapy Knob to desired energy level. 3. Press the CHARGE button, when the defibrillator is fully charged to the proper energy level, the tone will change and the correct energy level appears on the screen. 4. Call for and check to make sure everyone, including the operator, is clear of the patient and any equipment attached to the patient.
PROTOCOL 5.13: Defibrillation (cont.) Techniques (cont.): 5. Confirm rhythm, confirm available energy. 6. Press flashing SHOCK button to discharge energy to the patient. Note: If the SHOCK button is not pressed within 30 seconds, the stored energy is internally removed. Note: Selected energy may be increased or decreased anytime after charging has started or is complete. Simply rotate Therapy Knob to desired energy. B. Synchronized Cardioversion. 1. Turn MRX power ON. 2. Attach patient therapy cables and electrodes as previously described. 3. Select Lead II or the lead with a clear signal and the greatest QRS amplitude (positive or negative). 4. With the Therapy Knob in the Monitor position, press the SYNC button, confirm the Sync message appears in the upper right corner of Wave Sector 1. 5. Observe the ECG rhythm and confirm that a Sync marker appears near the middle of each R wave. If the sense markers do not appear or are outside the R waves, adjust ECG SIZE (or select another lead) until they do. 6. Turn the Therapy Knob to the desired energy level. 7. Press the CHARGE button, when the defibrillator is fully charged to the proper energy level, the tone will change and the correct energy level appears on the screen. 8. Call for and check to make sure everyone, including the operator, is clear of the patient and any equipment attached to the patient. 9. Confirm rhythm, confirm available energy.
PROTOCOL 5.13: Defibrillation (cont.) Techniques (cont.): 10. Press and hold the SHOCK button until discharge of energy occurs to patient with next detected QRS complex. Release SHOCK button. Note: If the SHOCK button is not pressed within 30 seconds, the stored energy is internally removed. Note: Selected energy may be increased or decreased anytime after charging has started or is complete. Simply rotate Therapy Knob to desired energy. Special Notes: A. Defibrillation electrodes may be used to monitor patients who you believe to have a high probability of life threatening arrhythmias. To monitor through the therapy electrodes, attach patient therapy cables and electrodes as previously described and select PADDLES lead. B. Anterior-Posterior placement: The apex electrode (LL) is placed anterior just to the left of the lower sternal border, the sternal electrode (RA) is positioned posterior behind the heart. C. A patient can be defibrillated in wet conditions, such as near water or in rain or snowy weather. The patients chest should be kept dry between the defibrillation electrodes and care should be taken to keep the patient, the operator and the equipment out of pooled water. In a rainstorm, it is best to bring the patient inside. D. If interfacing with 1st responder AED, begin 1st shock at appropriate shock level. It is always wise to let 1st responders continue with AED defibrillation sequences if the situation is progressing correctly, this allows ALS personnel time to set up for other procedures. If 1st responder defibrillation is not progressing correctly, hook up MRX, disconnect AED, and continue or begin defibrillation sequence.
PROTOCOL 5.14: Endotracheal Drug Administration Indications: In critical situations requiring pharmacologic intervention, intravenous access may be difficult to achieve. Endotracheal administration of certain drugs provides adequate systemic absorption to achieve the desired effects. This is made possible by the large absorptive surface of the distal bronchial tree and the proximity of capillary beds to that area. Absorption is not as effective in the proximal bronchial tree; therefore, consideration must be given to methods, which deliver the drug most distally. Because endotracheal intubation is one of the first interventions in many critically ill patients, the endotracheal route of drug delivery may be available before venous access is obtained. Drugs available for Endotracheal use: 1. 2. 3. 4. 5. Narcan Atropine Valium Epinephrine Lidocaine
Drug Dosages: Refer to drug summaries and protocols for individual drug doses. Endotracheal dose is typically 2 - 2.5 times the IV dose. Method of Administration: A. Volume of Solution: Dilute desired drug dose in the following quantity of normal saline. ADULT: 10 ml CHILD: 5 ml INFANT: 1 to 2 ml B. Inject above solution into ET tube as deeply as possible. progress, stop chest compressions during injection. If CPR is in
C. Follow injection with 3 to 5 bagged breaths to further disperse drug distally.
PROTOCOL 5.14: Endotracheal Drug Administration (cont.) Contraindications: None: Precautions: A. Only the drugs listed above should be given via the endotracheal route. Other medications may either not be absorbed adequately, may not be effective or may actually damage the pulmonary mucosa. B. Blood, emesis, or secretions in the airway may impair delivery and absorption of the drug. The patient should be suctioned prior to drug administration if needed. C. Care should be taken, especially in pediatric patients, not to bag the patients overly vigorously to disperse the medication. Such bagging may create barotrauma.
PROTOCOL 5.15: External (Transcutaneous) Cardiac Pacing Indications: A. Symptomatic bradycardia with pulse unresponsive to pharmacologic therapy. Note: In patients with symptoms (significant hypotension, altered mentation, chest pain) due to any form of bradycardia, treatment should include supplemental oxygen, ventilatory support as needed, establishment of IV access, and administration of Atropine (0.5 mg to 1.0 mg every 5 minutes until desired response or total of 3.0 mg given). Pacing should be considered if the patient does not respond to Atropine, if IV access cannot be obtained, or if symptoms are so severe that waiting for a maximal response to Atropine would be dangerous. In patients with severe bradycardia but no symptoms, the external pacer can be put in place, but not turned on unless the patients status deteriorates. Contraindications: A. Bradycardia in the setting of profound hypothermia. Technique: The following steps are needed to initiate pacing with the Philps MRX: The MRX can pace in either demand or fixed mode. Default is demand mode. In demand mode the pacer only delivers paced pulses when the patients heart rate is below the selected pacing rate. Default pacing rate is 70 bpm. In fixed mode the pacer delivers paced pulses at the selected rate. Default rate is again 70 bpm. Note: Use demand mode whenever possible. Use fixed mode when motion artifact or other ECG noise makes R-Wave detection unreliable. Demand Mode: A. If patient is awake, consider sedation. B. Attach patient monitoring and therapy electrodes and cable as described in Defibrillation Protocol 5.12. Anterior-lateral or anterior-posterior positioning is acceptable.
PROTOCOL 5.15: External (Transcutaneous) Cardiac Pacing (cont.) Technique (cont.): C. Turn the Therapy Knob to the Pacer position. Message Pacing Paused will appear indicating pacing function is enabled, but pace pulses are not yet being delivered. D. Select the lead with the most easily detectable R-wave and observe the ECG rhythm. Verify that a white R-wave marker appears on or above the ECG wave form. A single marker should be associated with each R-wave. If the markers do not appear or are displayed in the wrong location (for example on the T wave), adjust ECG SIZE or select another lead until they do (it is normal for the sense marker location to vary slightly on each QRS complex). E. Default pre-set Pacer Rate is 70 beats per minute. If a change in this rate is desired, use the NAVIGATION and MENU SELECT buttons to change. F. Press START PACING button, the message Pacing will appear. Verify that white pacing markers appear on the ECG waveform. G. Press the PACER OUTPUT button and use the NAVIGATION and MENU SELECT buttons to increase current slowly until electrical capture is achieved. Default pre-set starting current is 30 mA. Current can be increased in 5 mA increments H. Electrical capture will typically be evidenced by a wide QRS and broad T waves after each pacing marker. In some patients capture is less obvious, may be indicated only as a change in the shape of the QRS. I. J. Energy requirements for capture may vary widely, but most adults will capture between 50 and 100 mA. Evaluate for mechanical capture, verify presence of pulses. 1. Assess pulses on the patients right side. Check for a right carotid, right femoral or brachial pulse. The pacer will make chest and back muscles twitch at the same rate as the heart, so palpation of pulses at the left carotid or left femoral artery can be misleading. 2. Assess for improved LOC and blood pressure.
PROTOCOL 5.15: External (Transcutaneous) Cardiac Pacing (cont.) Technique (cont.): 3. Spontaneous beats may be present that are not associated with the delivery of paced pulses. Note: If the patients heart rate is above the pacer rate, paced pulses are not delivered and pacing markers will not appear. K. Continuously monitor patients BP, level of consciousness and record ECG rhythm. L. Documentation will include time pacing was initiated, current required to obtain capture, pacing rate, patient responses, any medications administered during the procedure and baseline and paced rhythm strips. Note: To stop delivery of paced pulses, press PAUSE PACING button, press RESUME PACING to continue delivery of paced pulses. Delivery of paced pulses may also be stopped by turning Therapy Knob off the Pacer position. Fixed Mode: A. To pace in the Demand mode, after the Therapy Knob is turned to the Pacer position, go into the Main Menu and use the Navigation and Menu Select buttons to change the Pacer Mode from Demand to Fixed (default is demand). The rest of the procedure for Fixed Mode pacing is the same as Demand Mode. Complications: A. Coughing. B. Skin burns. C. Interference with sensing because of patient agitation or muscle contractions. D. Pain from skin and muscle stimulation. E. Failure to recognize pacer is not capturing. F. Failure to recognize the presence of underlying treatable VF.
PROTOCOL 5.15: External (Transcutaneous) Cardiac Pacing (cont.) Special Notes: A. If electrical capture is achieved without mechanical capture, treat per PEA (pulseless electrical activity) Protocol 2.8. B. If defibrillation becomes necessary while pacing, move Therapy Knob from Pacer position to the desired Manual Defib energy position. Once the Therapy Knob is moved from the Pacer position, pacing automatically stops. Proceed with defibrillation. C. To resume pacing after defibrillation, repeat the pacing procedure as described above. When pacing is resumed, pacing settings selected prior to defibrillation (mode, rate and output) are retained.
PROTOCOL 5.16: Glucose Level Determination Indications: Any patient with altered mental status should have their glucose level checked as part of their assessment regardless of the suspicion of hypoglycemia or hyperglycemia. Glucose level determination will always precede any administration of Dextrose. Technique: Note: This protocol is for the One Touch Ultra blood glucose monitor and test strips. A. Assemble items needed for testing: Blood glucose monitor, test strips, disposable lancets, alcohol preps, 4X4s, band-aids. B. This procedure is not without infection control concerns, always wear gloves and possibly eye protection. C. Clean the puncture site with an alcohol prep, allow to dry. D. Insert a test strip into the monitor with the contact bars end first and facing up into the port, push it in until it stops. The monitor will turn on automatically and the display check will appear briefly. Note: The code number will appear on the monitor, followed by the blood drop symbol. Be sure the code number that is displayed on the meter matches the test strip code, if they do not, the meter code must be reset before you continue (see below). E. When the blood drop symbol appears, the monitor is ready for test blood. Prick the side of a fingertip using a clean sterile lancet. Touch and hold the drop of blood to the narrow test channel in the top edge of the test strip, try not to smear the blood or push the finger against the test strip. If further stimulation is needed to obtain blood, massage the forearm down the wrist and palm and/or allow the hand to hang at patients side. Avoid squeezing excessively. F. Hold the blood drop to the top edge of the test strip until the confirmation window is full before the monitor begins to count down. If the confirmation window does not fill completely before the monitor begins to count down, do not add more blood, discard the test strip and re-test.
PROTOCOL 5.16: Glucose Level Determination (cont.) Technique (cont.): Note: If you do not apply a blood sample within two minutes after the blood symbol appears, the monitor will turn itself off. You must remove the test strip and insert it back into the monitor to re-start the test procedure. G. The display will show the numerical blood glucose value when the monitor counts down from 5 to 1 (5 seconds). The following messages may also be displayed: 1. LO - This may indicate a blood glucose level below 20 mg/dl 2. HI This may indicate a blood glucose level above 600 mg/dl 3. Er5 This typically indicates not enough blood on the test strip or an inaccurate test result. G. The monitor will turn off by removing the test strip. Special Notes: A. At the start of each shift, the kit containing the blood glucose monitor and the vial of test strips will be checked. It is checked to make sure the code number on the monitor display matches the code number on the test strip vial. Failure to code the monitor correctly will cause inaccurate test results. B. The blood glucose monitor coding must be checked with each new vial of test strips as follows: 1. Insert a test strip to turn on the meter. Compare the code number on the monitor display with the code number on the test strip vial. If the two code numbers match, monitor is coded correctly. 2. If the two numbers do not match, code the monitor by pressing the C button to select the correct code number. Every time the C button is pressed, the number will increase by one. To move more quickly, press and hold the C button. 3. After selecting the correct code number, it will flash for 3 seconds, then appear solid for 3 seconds. The blood drop symbol will then appear, indicating the monitor is ready for testing.
PROTOCOL 5.16: Glucose Level Determination (cont.) Special Notes (cont.): C. A control solution test should be done on the monitor under the following circumstances: 1. Every time a new vial of strips is opened. 2. Whenever the monitor is dropped or seems to be damaged. 3. Whenever test results seem to be inconsistent with the patients clinical presentation. D. Control solution test should be done per the instructions found in the One Touch Ultra owners booklet available in each station.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) JAMSHIDI: Rationale: In children, the bone marrow is a very vascular space, with rapid drainage into the central circulation. In children less than 3 years of age, it is quickly accessible with the appropriate equipment and does not collapse during shock as does the venous system. Crystalloids, blood, antibiotics, and the classic resuscitative drugs can all be delivered successfully via this route. To date, no drug has been specifically contraindicated for use by intraosseous infusion. Because it is a painful technique, it should be used only in unconscious patients. Intraosseous infusion should only be used where other methods of venous access are exhausted or not immediately available. Cardiopulmonary arrest and severe shock are the most frequently encountered indications for use of I/O. Indications: A. Child less than 3 years of age AND B. Child unconscious AND C. There is an urgent need to administer IV fluids or drugs that cannot be given effectively by another route AND D. Peripheral venous access is not obtainable Contraindications: A. Intraosseous lines should not be started through obviously infected or burned skin or underlying tissues. B. Intraosseous lines should not be started in extremities with bone or crush injuries because of fluid and /or drug infiltration through disrupted bone or venous circulation. C. Jamshidi intraosseous lines are never to be attempted in a responsive child. D. Insertion of an intraosseous line should not delay transport in an emergent situation. Sites for Insertion: A. Proximal Tibia:
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi &EZ-IO) (cont.) Sites for Insertion (cont.): 1. First choice site 2. Anterior medial surface of the tibia 2 cm below the tibial tuberosity. B. Distal Tibia: 1. Second choice site 2. Approximately 0.5 to 1 cm proximal to the medial malleolus. C. NOTE: if the bony cortex has been penetrated during a failed insertion attempt, no further attempts should be made on that bone. Technique: A. NOTE: THIS IS A LEVEL II INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED EXCEPT IN SITUATIONS OF CARDIAC ARREST. B. Assemble the following materials: 1. Intraosseous Needle a. b. Size 18 G. for infants up to 6 months of age. Size 15 G. for children from 6 months to 3 years of age.
2. Alcohol and/or Betadine prep. 3. Sterile gauze and tape for dressing. 4. Splint for stabilization of extremity. 5. 5 or 10 ml syringe containing 5 ml of NS flush solution. 6. 60 drop (mini) IV set and IV solution (NS). C. Record neurovascular status of the limb before and after the procedure. D. Clean the insertion site with alcohol and/or Betadine. E. Immobilize the extremity.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) (cont.) Technique (cont.): F. Set the flange on the needle to the estimated depth of penetration to marrow (generally between 1/4 and 1/2 inch or 1 cm). The distance from the skin through the cortex is rarely more than I cm in an infant or a small child and penetration to this depth is usually adequate. G. Insert the needle and obturator into the bone at the selected site, using a rotary motion with downward pressure. If using the proximal tibia site, angle the needle slightly inferiorly, away from the knee. If using the distal tibial site, angle the needle slightly superiorly, away from the ankle. When the needle reaches the marrow space, a pop with a decrease in resistance is usually felt. DO NOT ROCK THE NEEDLE. H. When the pop, or at least a decrease in resistance is felt, remove the obturator. Attempt to aspirate marrow through the needle with the syringe containing the flush solution. If unable to aspirate marrow, the needle may be plugged or malpositioned. Try rotating the needle to reorient the bevel and aspirate again. If unsuccessful, flush needle with at least 5 cc of NS. If line flushes easily without signs of significant subcutaneous infiltration, attach IV line. If line flushes with difficulty, try repeating aspiration to clear out possible clots, rotating the needle bevel, or repositioning the needle. The properly placed needle will stand upright without support. I. Secure the needle with gauze and tape but maintain surveillance of the site for signs of infiltration. Should significant infiltration occur, remove the needle and place pressure on the puncture site. Drug boluses should be flushed into circulation with 1 to 2 cc of NS flush for ages less than 1 year, 5 cc for ages greater than 1 year. Hypertonic solutions such as dextrose and sodium bicarb should be diluted and pushed slowly, as with peripheral IV administration.
J.
Complications: A. Localized bleeding and infiltration of fluid and drugs into surrounding tissues. B. Osteomyelitis or sepsis. C. Injury to the growth plate of the bone if placed incorrectly. D. Tibial fracture in small newborns.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) (cont.) Complications (cont.): E. Fat embolus. (Much less fat is present in a childs marrow than in an adults). F. Extravasation of fluid and drugs into popliteal space if needle tip perforates through posterior cortex of tibia, causing compression of popliteal vessels or tibial nerve. G. Fluid overload if volume administered and patient is not carefully monitored. ILLUSTRATION 5.H. INTRAOSSEOUS NEEDLE PLACEMENT
EZ-IO: Rationale: The rationale for the use of the EZ-IO is the same as the rationale for the use of the Jamshidi style bone marrow needle. The primary difference is the EZ-IO may be used on both the adult and the pediatric patient. The EZ-IO placement is much less painful then the Jamshidi, so it may be placed in the patient that is still awake, as opposed to the Jamshidi requiring a patient that is either in cardiac arrest or fully unconscious.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) (cont.) EZ-IO (cont.): Indications: A. EZ-IO AD (Adult) patient weight 40 kg and over. B. EZ-IO PD (Pediatric) patient weight 3 39 kg. C. IV fluids or medications are needed and a peripheral IV cannot be established after 3 attempts AND the patient exhibits one or more of the following: 1. Significantly altered mental status (GCS of 8 or less) 2. Respiratory compromise (O2 saturation 80% or less after appropriate oxygen therapy, respiratory rate < 10 or > than 40) 3. Hemodynamic instability (Systolic BP of < 90) Contraindications: A. Fractures or crush injuries of the bone selected for IO infusion (consider alternative site). B. Excessive tissue at the insertion site with the absence of anatomical landmarks (consider alternative site). C. Obvious, previous significant orthopedic procedures on the bone selected for IO infusion (consider alternative site). D. Obvious infection at the insertion site (consider alternative site).
E.
Insertion of an intraosseous line should not delay transport in an emergent situation.
Site for Insertion: A. Proximal Tibia: 1. Anterior medial surface of the tibia 1 cm (I finger width) medial to the tibial tuberosity on the flat, broad portion of the tibia.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) (cont.) EZ-IO (cont.): Technique: A. Assemble the following materials: 1. EZ-IO driver 2. EZ-IO needle set, AD for adults, PD for pediatric 3. Alcohol or Betadine swabs 4. EZ-Connect extension set 5. 10 ml syringe containing 10 ml of NS flush solution 6. 60 drop IV set and NS IV solution 7. Pressure bag or infusion pump 8. 2% Lidocaine (preservative free) 9. EZ-IO yellow wristband B. Record neurovascular status of the limb before and after the procedure. C. Locate landmarks and identify insertion site. D. Prepare driver and needle set, using AD needle set for adult, PD needle set for pediatric patients. Assure that needle set is securely seated on the driver. Prime extension set with NS. E. Clean the insertion site with alcohol or Betadine and stabilize leg. F. Position the driver at the insertion site with the needle set at a 90-degree angle to the bone. Gently power the needle set until the needle set tip touches the bone. G. Check to ensure that at least 5mm of the needle set is visible as indicated by the black 5 mm line on the shaft, if the black 5 mm line is not visible, the patient has too much soft tissue at the insertion site and that site will not be able to be used. Consider an alternative location or abort the procedure completely.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) (cont.) EZ-IO (cont.): Technique (cont.): H. Penetrate the bone cortex by squeezing the trigger and applying gentle, steady, downward pressure, DO NOT FORCE, allow the driver to do the work. When performing the procedure on a pediatric patient, the weight of the driver alone should generally provide enough force for successful insertion. I. Release the trigger and stop when the needle flange touches the patients skin or a sudden give or pop is felt upon entry into the medullary space. A properly placed catheter will stand up straight at a 90-degree angle and will be firmly seated in the tibial bone. While supporting the needle set with one hand, remove the driver by pulling straight up and away.
J.
K. Remove the stylet from the catheter by grasping the hub firmly with one hand and unscrewing the stylet from the catheter by turning it counter clockwise. Place the stylet in a sharps container, do not attempt to re-cap it. L. Connect the primed connection set to the catheter hubs Luer lock and rapidly flush with 10 ml NS in an adult patient and 5 ml NS in a pediatric patient. No Flush = No Flow. Failure to appropriately flush the catheter may result in a limited or no flow situation. Do not use a syringe directly on the catheter hub, use the extension set at all times. Note: In the conscious patient, slowly administer (20-50 mg adult, .5 mg/kg pediatric) 2% Lidocaine into the port (through the extension set) prior to the initial flush. This may cause transient pain but will make subsequent infusions much less painful. While the insertion procedure itself is known to be only minimally to moderately painful, infusion of fluid (which causes intramedullary pressure) can be quite painful in the conscious patient without the Lidocaine. M. Initiate infusions or medications as needed. A pressure infuser bag or pump will typically have to be used to maintain adequate flow rates. N. Apply a yellow EZ-IO wristband to the patient (the wristband is necessary as a reminder of EZ-IO placement and the need for timely removal) and dress and secure the catheter and tubing as needed to protect it. Assure that any dressings do not interfere with your ability to observe the site for problems.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) (cont.) EZ-IO (cont.): Complications: A. The complications with the EZ-IO intraosseous placement and infusion are the same as the Jamshidi placement noted above. Considerations: A. If the insertion site fails the tests, appears obstructed and cannot be flushed, extravasates or the needle set bends or breaks, the needle set must be removed and disposed of in a sharps container. If the procedure must be repeated, do it the other leg with a new needle set, DO NOT attempt a second placement on the same leg. B. To remove the EZ-IO catheter, support the patients leg with one hand, grasp the hub itself firmly (or attach a sterile syringe to the hub for a larger handle) and rotate the catheter clockwise while applying gentle upward traction. The site may be dressed with a band-aid. C. The EZ-IO catheter must be removed within 24 hours of placement.
PROTOCOL 5.18: Medication Administration Indications: Illness or injury which requires medication to improve or maintain the patients condition. Precautions: A. Certain medications can be administered via only one route, others via several. If you are uncertain about the drug you are giving, check with Medical Control. B. Make certain that the medication you want to give is the one in your hand. Always double check medication, dose, and expiration date before administration. Technique: A. Use syringe just large enough to hold appropriate quantity of medication (or use pre-filled syringe). B. Use larger gauge needle (18-21 gauge) on syringe to draw up medication. C. Break top from ampule by grasping it with 4X4s to avoid being cut by glass. D. Cleanse top of multi-dose vial with alcohol prep before drawing from it. E. Using sterile technique, draw medication into syringe. F. Change needles to smaller gauge (21 gauge or smaller) for IM or SQ administration. G. Needleless supplies will use essentially the same techniques as the needle supplies except the needles will be replaced by blunt cannulas, filter straws and Luer lock connections. Intravenous (IV) Injection Technique: A. Use size needle appropriate for viscosity of fluid injected. Glucose requires larger gauge needle (18 gauge), for most other medications 20 gauge or smaller is appropriate. B. Cleanse IV tubing injection site with alcohol prep.
PROTOCOL 5.18: Medication Administration (cont.) Intravenous (IV) Injection Technique (cont.): C. Check medication in hand - confirm medication, dose, and amount. D. Eject air from syringe. E. Insert needle into injection site. F. Pinch IV tubing closed between bottle and needle. G. Inject at rate slow enough to stop if any untoward effects develop (except with medications that require a rapid push) . H. Withdraw needle and release tubing to restore flow. I. Record medication given, dose, amount, and time.
Endotracheal (ET) Injection Technique: A. Prepare medication to be given. Dilute with NS so that the drug administered is in a total volume consistent with Endotracheal Drug Administration Protocol 5.14. B. Ventilate fully 4-5 times prior to disconnecting the bag from the endotracheal tube. C. Check medication in hand. Confirm medication, dose, and amount. D. Administer the appropriate dose into the endotracheal tube. E. Connect the bag and ventilate fully an additional 4-5 times. F. Record medication given, dose, amount, and time. Intramuscular (IM) Injection Technique: A. Use long 21-22 gauge needle (1 - 1.5). B. Check medication in hand - confirm medication, dose and amount. C. Select injection site (usually deltoid, but may be upper outer quadrant of gluteus if more convenient).
PROTOCOL 5.18: Medication Administration (cont.) Intramuscular (IM) Injection Technique (cont.) D. Cleanse site with alcohol prep. E. Eject air from syringe. F. Stretch skin over injection site. G. Insert needle through skin into muscle, aspirate and if no blood returns, inject medication. H. Remove needle and put pressure over injection site with sterile gauze. I. Record medication given, dose, amount, time.
Subcutaneous (SQ) Injection Technique: A. Use 25 gauge needle 5/8 length for most subcutaneous injections. B. Check medication in hand - confirm medication, dose, and amount. C. Select injection site (usually just distal and posterior to deltoid). D. Cleanse site with alcohol prep. E. Eject air from syringe. F. Insert needle tangentially, just underneath the skin. G. Aspirate and, if no blood returns, inject medication. H. Remove needle and put pressure over injection site with sterile gauze. I. Record medication given, dose, amount, and time.
Complications: A. Local extravasation during IV medication injection, particularly with calcium or dextrose, can cause tissue necrosis. Watch carefully and be ready to stop injection immediately. B. Allergic and anaphylactic reactions occur more rapidly with IV injections, but may occur with medication administered by any route.
PROTOCOL 5.18: Medication Administration (cont.) Complications (cont.): C. Too rapid IV injection of some drugs can cause untoward side effects; for example, Valium can cause apnea, and Epinephrine can cause severe hypertension and malignant arrhythmias. D. IM or SQ injection can cause uncertain medication levels over time. Later treatment may be jeopardized because of slow release and late effects of medication given hours before. Special Notes: A. Several medications are carried in different concentrations in a Paramedics drug box. Be sure you are using the correct concentration! B. Carry pediatric drugs in separate areas of the drug box or in a completely separate box. C. Endotracheal medication administration may provide onset of drug effect almost as rapid as with IV administration.
PROTOCOL 5.19: Nebulized Bronchodilators Indications: A. Nebulized bronchodilators are indicated for relief of bronchospasm in patients with reversible obstructive airway disease, including asthma. B. Indicated in the treatment of bronchospasm related to anaphylactic reaction. Note: Albuterol is the only bronchodilator currently in use in the Rapid City Pennington County EMS system. Contraindications and Precautions for the use of nebulized bronchodilators are those found in the Drug Summary for Albuterol. Technique: A. Twist open the top of one unit dose of Albuterol Sulfate and pour contents into the nebulizer reservoir. B. Assemble the unit including the mouth piece, and oxygen supply tubing. C. Insure that the unit is held upright to facilitate proper updraft and nebulization of the medication. D. Connect to oxygen source and set flow at 7-8 liters per minute until vapor is coming out of the unit. E. Have the patient sit upright and close their lips around the mouth piece. Have them breathe the medication in and out as slowly and as deeply as possible. Encourage the patient to keep their lips closed around the mouth piece. F. To assist in effectively administering the drug, the patient should be coached deep, smooth, slow breaths. G. In children unable to use mouthpiece, administer by mask (mask can be made by removing reservoir from non-rebreather mask and attaching tee without mouthpiece to mask) or by removing mouthpiece from tubing. H. Nebulized bronchodilators may be given via an endotracheal tube with the proper ET Neb set-up.
PROTOCOL 5.19: Nebulized Bronchodilators (cont.) Technique (cont.): I. Nebulized Bronchodilator treatments may be administered to a total of three if the Paramedic believes the patients clinical condition warrants it. If the Paramedic believes successive treatments are warranted, Medical Control must be contacted.
Special Notes: A. Proper technique in the administration of Nebulized Bronchodilators is crucial to its successful delivery into the lower airways. B. Patients ECG should be monitored if the patient has a cardiac history, is elderly or the Paramedic believes the patient may possibly have an undesirable cardiac effect from the administration of the drug. (cardiac monitoring should be done on these patients more often then it is not done). C. An IV line should be placed if clinically indicated.
PROTOCOL 5.20: Pain Management Indications: A. The patient that presents with severe pain/discomfort from an isolated orthopedic injury. These may include but are not limited to, fractured or possibly fractured extremities, joint injuries and dislocations. B. The patient that presents with severe pain/discomfort from thermal, chemical or electrical burns that are more extensive then can be considered minor (a minor burn is one that can be covered with the hand). Contraindications: A. Carefully evaluate and examine the patient and consider the mechanism of injury. Pain management will be contraindicated in the following patients: 1. Any patient with trauma to the head, chest or abdomen. 2. Any patient with an altered level of consciousness. 3. Any patient that is not hemodynamically stable (systolic BP < 90). B. Other contraindications and precautions are those found in the Drug Summaries for Morphine and Fentanyl. Technique: A. Administer Fentanyl slow IV 50-100 mcg (1 mcg/kg) slow (over 1-2 min.) IV/IO. May repeat as necessary to a total of 150 mcg. If IV route not available, may give single IM dose of 100 mcg. Dose to effect. OR: B. Administer Morphine Sulfate slow IVP in 2-4 mg increments to a total of 10 mg. Dose to effect. C. If using Morphine, also administer 4 mg Zofran (Ondansetron) IV to control nausea and vomiting. D. Use caution with narcotic analgesics in any patient > age 65.
PROTOCOL 5.20: Pain Management (cont.) Special Notes: A. Contact Medical Control if patient requires more than the maximum allowable dose of either Morphine Sulfate or Fentanyl. B. Contact Medical Control for pain management in the pediatric patient.
PROTOCOL 5.21: Peripheral IV line Insertion Indications: 1. Administer fluids for volume expansion. 2. Administer medications. Precautions: A. Do not start IVs distal to a fracture site or through skin damaged with more than erythema or superficial abrasion. B. Make certain the IV solution in hand is correct and the expiration date has not passed. Technique: A. Extremity: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Explain the procedure to the patient when possible. Connect tubing to IV solution bag. Fill drip chamber one-hall full by squeezing. Use 10 gtt set for trauma or any volume expansion. Use 60 gtt set for most medical situations and pediatric patients. Tear sufficient tape to anchor IV in place. Apply tourniquet proximal to proposed site. Alternatively, use blood pressure cuff blown up to 40 mm Hg. Scrub insertion site with alcohol prep. Hold vein in place by applying gentle traction on vein distal to point of entry. Puncture the skin with the bevel of the needle upward about 0.5 to 1 cm from the vein and enter the vein from the side or from above. Note blood return and advance the catheter either over the needle into the vein. Remove needle assembly and connect tubing. Release tourniquet (most frequent cause of IV not flowing). Open IV tubing clamp full to check flow and placement, then slow rate to TKO or desired rate. Secure tubing with tape, making sure of at least one 180 degree turn in the taped tubing to be sure any traction on the tubing is not transmitted to the catheter itself (alternatively, use commercial IV site device). Anchor with arm board or splint if needed to minimize chance of losing line with movement. Recheck to be sure IV rate is as desired and monitor.
PROTOCOL 5.21: Peripheral IV line Insertion (cont.) B. External Jugular Vein: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 13. Explain the procedure to the patient when possible. Connect tubing to IV solution bag. Fill drip chamber one-half full by squeezing. Use 10 gtt set for trauma or any volume expansion. Use 60 gtt set for most medical situations and pediatric patients. Tear sufficient tape to anchor IV in place. Position the patient: supine, head down if possible (this may not be necessary or desirable if congestive heart failure or respiratory distress present). Turn patients head to opposite side from procedure. In trauma patient, open C-Collar, keep head and neck in neutral position. Do not move patients head. . If not contraindicated, expose vein by having patient bear down. Tourniquet vein with finger pressure just above clavicle. Scrub insertion site with alcohol prep. Align the catheter in the direction of the vein, with the point aimed toward the shoulder on the same side (it may be useful to bend the catheter slightly to facilitate alignment). Puncture skin over vein first, then puncture vein itself. Use other hand to traction vein near clavicle to prevent rolling. Advance catheter well into vein once it is penetrated. Attach IV tubing. Open IV tubing clamp full to check flow and placement, then slow rate to TKO or rate desired. Secure tubing with tape, making sure of at least one 180 degree turn in the taped tubing to be sure any traction on the tubing is not transmitted to the cannula itself. Recheck to be sure IV rate is as desired and monitor.
Complications: A. Pyrogenic reactions due to contaminated fluids become evident in about 30 minutes after starting the IV. Patient will develop fever, chills, nausea, vomiting, headache, backache, or general malaise. If observed, stop and remove IV immediately. Save the solution so it may be cultured. B. Local: Hematoma formation, infection, thrombosis, phlebitis. Note: The incidence of phlebitis is particularly high in the leg. Avoid use of lower extremity if possible. C. Systemic: Sepsis, catheter fragment embolus, fiber embolus from solution in IV.
PROTOCOL 5.21: Peripheral IV line Insertion (cont.) Special Notes: A. Always use the biggest vein that is accessible. Antecubital veins are useful access sites, but if possible, avoid areas near joints (or splint well). Given the choice between a big vein near a joint and a smaller vein elsewhere that may be harder to access, use the bigger vein and splint. B. The point between the junction of two veins (bifurcation) is more stable and often easier to use. C. Start distally and if successive attempts are necessary, you will be able to make more proximal attempts on the same vein without extravasating IV fluid. D. Venipuncture itself is seldom morbid. The excess fluids inadvertently run in when nobody is watching can be fatal! E. One of the most difficult problem with IV insertion is to know when to try and when to stop trying. IV solutions in the proper setting may buy time, but in the field they may frequently lose time instead. Generally, one attempt at the scene is worthwhile if there is a delay in loading the patient. Successive attempts should always be done enroute (especially if the patient is critical). F. When starting external jugular IVs, if pressure in vein not sufficient to give flash-back, attach syringe to catheter assembly and aspirate to confirm entry into the vein.
Protocol 5.22: Restraint (Physical and Chemical) Indications: Use of physical and or chemical restraint on patients is permissible if the patient poses a danger to himself or others. Only reasonable force is allowable, i.e., the minimum amount of force necessary to control the patient and prevent harm to the patient or others. Contact Medical Control for physician direction if there is uncertainty as to whether or not the use of restraints is warranted to transport the unwilling or uncooperative patient. Restraints are to be applied to patients only in limited circumstances: A. A patient whose medical or mental condition warrants immediate ambulance transport and who is exhibiting behavior that the pre-hospital provider feels does or will endanger the patient or others. B. The pre-hospital provider reasonably believes that the patients life or health is in danger and that delay in treatment and transport would further endanger the patients life or health, and there is no reasonable opportunity to obtain the necessary consent to provide treatment or obtain informed refusal. C. The patient is being transported under the direction of a mental health hold, security hold, or police custody. Precautions: A. Restraints shall be used only when necessary to prevent a patient from seriously injuring himself or others (including the ambulance crew), and only if safe transportation and treatment of the patient cannot be done without restraints. They may not be used as punishment, or for the convenience of the crew. B. Any attempt to restrain a patient will involve risk to the patient and the prehospital provider. Efforts to restrain the patient should only be done with adequate assistance present. Obtain law enforcement assistance. C. Be sure to evaluate the patient adequately to determine the medical condition, mental status and decision-making capacity of the patient. The hostile, angry, unwilling patient who is alert, oriented, aware of his condition and capable of understanding the consequences of his refusal is entitled to refuse treatment. D. Be sure that the restraints are in good condition (will not break and will not injure the patient).
Protocol 5.22: Restraint (Physical and Chemical) (cont.) Precautions (cont.): E. Do not transport patients in the prone position or use hobble restraints. F. Ensure that the patient has been searched for weapons. Technique: Physical Restraint A. Determine that the patients medical or mental condition warrants ambulance transport to the hospital and that the patient lacks decision-making capacity, or there is basis for police custody or a mental health hold to be instituted. B. Treat the patient with respect. Efforts to verbally calm the patient may avoid the need for restraints. To the extent possible, explain what is being done and why. C. Have all equipment and personnel ready (restraints, suction, a means to promptly remove restraints, and adequate number of personnel). D. Use sufficient assistance so that, if possible, one rescuer handles each limb and one manages the head or supervises the application of restraints. E. Consider the patients strength and range of motion in the need for and method of applying restraints. F. Apply restraints to the extent necessary to subdue the patient. Do not use restraints to punish the patient. G. After application of restraints, check all limbs for circulation. During the time that a patient is in restraints, an assessment of the patients condition and vital signs shall be made at least every five minutes, but more frequently if conditions warrant. H. During transport and pending the arrival at the hospital, the patient shall be kept under constant supervision.
Protocol 5.22: Restraint (Physical and Chemical) (cont.) Technique (cont.): I. The Patient Care Report will include: a complete description of the facts justifying the use of restraints; the type of restraints; a description of the steps taken to assure that the patients needs, comfort and safety; the condition of the patient during restraint, including re-evaluations during transport; and the condition of the patient on arrival at the hospital. Removal of restraints should be done with sufficient manpower and caution to assure protection of the patient and healthcare providers. Utilize law enforcement assistance if necessary and if possible.
J.
K. Handcuffs or other hard restraints are not to be applied by pre-hospital providers. If police apply handcuffs the officer should be requested to stay with the patient and ride in the ambulance during transport. A handcuff key may be needed if patient deteriorates suddenly. L. The patient that spits or attempts to bite will have an infection control mask or a non-rebreather mask at 8-10 lpm placed. Do not gag such a patient or put a covering such as a sheet or towel over their face. It may interfere with an already compromised respiratory effort. M. The use of chemical restraints should be considered if the patient continues to struggle against physical restraint and remains uncooperative, violent or combative. Chemical Restraint A. NOTE: CHEMICAL RESTRAINT IS A LEVEL II INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED. B. Chemical restraint will be used in conjunction with physical restraint for the purpose of additional control of agitation, violence or combativeness during treatment and transport. C. Continuous monitoring will be done of the patients respiratory rate, O2 saturation and ECG. That monitoring will continue on arrival at the hospital during the transfer of the patient from the ambulance to the hospital bed.
Protocol 5.22: Restraint (Physical and Chemical) (cont.) Technique / Chemical Restraint (cont.): D. Administer: 1. Haldol: Adult 2.5 mg IM or IV, up to 5 mg Pediatric 0.1 mg IM or IV 2. Ativan (Lorazepam) 0.5 2 mg IM or IV Special Notes: A. Aspiration can occur, particularly if the patient is supine. It is the responsibility of the Paramedic to continually monitor the patients airway. If the patients condition does not contraindicate it, a low semi-fowlers position or lateral position may be the best for transport. B. Nerve injury can result from hard restraints (handcuffs). C. Do not overlook the medical causes for combativeness, such as hypoxia, hypoglycemia, stroke, hyperthermia, hypothermia, or drug ingestion. D. Contraindications, precautions, and special considerations regarding the use of chemical restraints are those found in the Drug Summary for Haldol.
PROTOCOL 5.23: SALINE LOCK INSERTION Indications: A. To administer medications. B. Precautionary IV access. Precautions: A. Do not start IV s distal to fracture site or through skin damaged with more than erythema or superficial abrasion. B. Do not use saline locks on trauma patients or any hypotensive patient that may require fluid replacement, use a regular peripheral IV with a bag of NS. Technique: A. Explain procedure to the patient whenever possible. B. Prepare extension set by flushing with normal saline. C. Perform venipuncture as stated in Peripheral IV Line Insertion Protocol 5.20. D. Attach extension set cap to IV catheter. E. Flush with approximately 3 ml normal saline. As the plunger is still moving forward and the last ml is being injected, withdraw the needle (or blunt cannula from the extension set. Maintaining a positive pressure in the catheter will prevent backflow of blood. F. Tape in place (alternatively, use commercial IV site device). G. Administering medications: 1. 2. 3. 4. Wipe extension set site with alcohol prep. Flush with 3 ml normal saline. Administer medication. Flush with 3 ml normal saline. Maintain positive pressure on syringe while last ml is injected and needle is withdrawn from cap.
PROTOCOL 5.24: Spinal Immobilization Indications: A. Cervical or upper one-third thoracic spinal tenderness, pain on palpation, pain with movement, or neurological deficit (associated distal weakness, numbness, tingling, or paralysis). B. Swelling or deformity of the spine which may be due to fracture, dislocation, or ligamentous instability. C. All trauma patients who are unconscious or present with an altered level of consciousness due to traumatic head injury or drug and/or alcohol ingestion. D. Patients with significant head trauma or who have experienced a significant mechanism of injury that cannot be ruled out by an accurate exam or history that present with the potential for unrecognized co-existent spinal trauma. Note: Perform and document a complete neurologic exam prior to and after movement of the patient. Re-document a complete exam after splinting and upon delivery to the hospital. Technique: A. Use assistant to apply neutral in-line stabilization while completing primary survey. B. Assess and document neurologic findings. C. Advise the patient of the procedure and purpose before and during application. D. Apply a rigid cervical collar to immobilize the cervical spine. E. Prepare to move the patient to a long back board or to apply a KED as the situation dictates. Note: Because a patient has been ambulatory prior to the arrival of EMS does not preclude the need for spinal immobilization. If a patient that has been ambulatory needs to be immobilized, it should be performed as the patient is found (sitting, standing, lying). Under no circumstances will a patient be allowed to walk to a backboard and lay down on it.
PROTOCOL 5.24: Spinal Immobilization (cont.) Technique (cont.): F. Use the KED for seated patients provided they are stable and rapid extrication is not required. 1. Slide the KED behind the patient and position chest panels up into the armpits. 2. Apply chest straps. 3. Apply leg straps. 4. Secure the head using padding where necessary to ensure a neutral inline position. G. Prepare to move the patient to a long spine board ensuring that adequate manpower, straps and a cervical immobilization device (CID) are at hand. 1. Logroll or lift the patient to the board as a unit. 2. Release the leg straps if a KED was used. 3. Use appropriate padding behind the neck, back, or knees in order to ensure proper in-line immobilization. 4. Apply straps to secure the chest, thighs and lower legs to the board (minimum of 3 straps, 4 are preferred) 5. Secure the head using a cervical immobilization device (CID) and tape. H. Helmets: 1. Remove helmets only when they prevent proper in- line immobilization and or airway control a. Football helmets: Leave football helmets in place if the patient is also wearing shoulder pads, that will provide neutral in-line immobilization. Removal of the facemask portion of the helmet will in most cases allow for airway control (can be done with Phillips screwdriver or trainers tool). If required, complete removal of the helmet will also necessitate removal of shoulder pads and other protective equipment. b. Motorcycle/and other sporting helmets: In most cases these helmets will need to be removed to provide for airway control and in-line immobilization unless other auxiliary protective equipment (Motocross pads) are in place or appropriate padding can be applied to ensure a neutral in-line position. When removing a helmet always use an approved BTLS / PHTLS technique.
PROTOCOL 5.24: Spinal Immobilization (cont.) Technique (cont.): I. J. When immobilizing the pediatric patient, use pediatric specific equipment, dont try to make adult equipment fit. Re-assess and re-document neurologic findings.
Spinal Immobilization Exclusion Criteria: A. Assess and document neurologic findings. B. Spinal immobilization may not be required in all situations and may be deferred in the patient who meets the following criteria: 1. Is able to present a complete and reliable history. 2. Is without cervical or thoracic pain and/or tenderness and deformity on palpation. 3. Is able to exhibit, upon a complete spinal assessment, a full range of motion without pain, and/or associated distal weakness, numbness, tingling, or paralysis. 4. Is without an event related altered mental status or loss of consciousness. 5 Is not under the influence of intoxicating medications, alcohol, or drugs.
6. Does not have a distracting injury (is not distracted by another painful injury or emotional condition that may mask the potential for injury to the spine). 7. Does not present with a language or other communication barrier that inhibits a reliable exam and history. C. Re-assess and re-document neurologic findings. Complications: A. Spinal immobilization is not a benign procedure. Be aware of the possibility of increasing chronic lower back injuries and pain and the potential for decubitus ulcers in patients with spinal compromise.
PROTOCOL 5.24: Spinal Immobilization (cont.) Complications (cont.): B. Complete airway control is assumed and immobilization must be secure enough to allow rolling and other movement of the patient. C. Injuries below the level of cord damage will be difficult to diagnose and special care must be taken in your primary and continued assessment. Special Notes: A. Application of a cervical collar by itself does not constitute adequate spinal immobilization. Cervical collars are to be used in conjunction with long back boards and cervical immobilization devices; with the addition of the KED when appropriate. B. When fitting a cervical collar to a patient, take care to see that you have the right size collar, it is adjusted and applied properly. A poorly fit, poorly applied cervical collar can be worse than none at all. C. When immobilizing a patient on a long backboard, take care that the patient is straight and even on the board, both lengthwise and side to side. Assure that the patients head and neck are fixed in the cervical immobilization device in a neutral, straight manner as well and not pulled to one side or the other. Again, poor immobilization can be worse than none at all.
PROTOCOL 5.25: Splinting, Extremity Indications: A. Pain, swelling or deformity in an extremity which may be due to fracture or dislocation. B. In an unstable extremity injury: to reduce pain, limit bleeding at the site of injury, and prevent further injury to soft tissues, blood vessels or nerves. Precautions: A. Transport of critically injured trauma patients should not be delayed by lengthy evaluation of possible non-critical extremity injuries. Prevention of further damage is accomplished by securing the patient to a long back board when other injures demand prompt treatment. B. The patient with an altered level of consciousness from head injury or drug ingestion should be carefully examined and conservatively treated, because their ability to recognize pain and injury is impaired. C. Check to make sure the obvious injury is also the only one. It is very easy to miss fractures proximal to the most visible one. D. In a stable patient in which no environmental hazard exists, splinting should be done prior to moving the patient. E. Never deliberately test for crepitus or instability. Technique: A. Assess pulse, movement, and sensation distally prior to splinting or movement. B. Remove bracelets, watches, or other constricting bands prior to splint application. C. Identify and dress open wounds. Note wounds which contain exposed bone or lie near fracture sites. D. Avoid sudden or unnecessary movement of fracture site to minimize pain and soft tissue damage. E. Choose splint to immobilize joint above and below injury. Rigid cardboard splints are best for long bones, pillow splint can be used for wrists, ankles, etc. Pad rigid splints to prevent pressure injury to extremity.
PROTOCOL 5.25: Splinting, Extremity (cont.) Technique (cont.): F. Apply gentle continuous traction to extremity and support to fracture site during splinting operation. G. Re-assess distal pulses, movement and sensation after splinting. Traction Splinting Technique (for suspected femur fractures): A. Use two persons for splint application procedure. B. Immobilize the affected extremity. Remove sock and shoe and check for distal pulse and sensation. C. Identify and dress open wounds, note exposed bone or wounds overlying fracture sites. D. Measure and adjust splint length prior to application for the Hare. If using Sager, make sure it is not too long. Use pediatric models where necessary. E. Hare application: 1. Apply ankle hitch and pull gentle traction, reducing angulation or open fractures. Support calf and thigh throughout the application of the Hare. 2. Position ischial pad under buttocks, up against bony prominence (ischial tuberosity) for the Hare. Empty pockets if needed. 3. Secure groin strap. 4. Maintain continuous traction for the Hare, and support to fracture site throughout procedure. 5. Apply traction to the Hare without losing the traction the assistant is holding with the ankle hitch. Adjust the traction until the assistant no longer needs to hold the ankle hitch and the patient experiences an improvement in comfort (movement at the fracture site will cause some pain, but increased traction continues to cause increased pain, do not proceed. Splint and support leg in position of most comfort). 6. Adjust support straps to appropriate positions under leg. 7. Secure support straps after traction properly adjusted
PROTOCOL 5.25: Splinting, Extremity (cont.) Traction Splinting Technique (cont.): F. Sager application: 1. Position the ischial pad into the groin avoiding the genitals. 2. Apply the ankle hitch for the Sager. 3. Maintain continuous stabilization and support to fracture site throughout procedure. 4. Apply traction by extending the Sager to achieve a force of 10% of body weight utilizing the same principles as the Hare for comfort. 5. Place and adjust support straps to appropriate positions under leg. 6. Secure support straps after traction properly adjusted. G. Re-assess distal pulses and sensation after splinting with both devices. H. Do not apply Hare or Sager traction devices if pelvic, knee or lower extremity fractures exist or are suspected.
PROTOCOL 5.26: Stroke (CVA) Stroke Alert Rationale: In the past, there was not much available in the way of acute care for the stroke patient. All that was really able to be accomplished was supportive care and to make attempts to prevent recurrence. More aggressive stroke treatment programs are starting to be seen. These include more advanced assessment, diagnostic and treatment modalities, to include consideration of the use of thrombolytic therapy. EMS providers can help reduce the morbidity and mortality of the stroke patient by identifying those stroke patients who may benefit from newer treatment modalities, and making early notification to the receiving medical facility so they can prepare to implement treatment. Technique: A. If patient meets stroke alert criteria, treat with the same urgency as AMI or head trauma. B. Treat patient using the treatment protocol that best addresses the signs and symptoms they present with. If unconscious, hyperventilate and consider intubation using Lidocaine 1mg/kg to reduce increased intracranial pressure. C. Obtain as thorough and complete a history as is possible of both the present event and past medical history. The patient that falls within a 3 hour time frame from first onset of symptoms initially meets stroke alert criteria. Complete the Stroke Exclusionary Criteria for Thrombolytics Survey (below) as completely as possible without delaying transport.. D. Maintain head/neck in neutral alignment, do not use pillows. E. Bradycardia may be present due to increased intracranial pressure. Atropine is not to be given if the systolic BP is above 90. F. If altered mental status, seizure activity, or focal neurological deficit: obtain and record blood glucose level. If glucose <70, administer D50 IVP. Note response. G. If seizure occurs: Valium or Ativan as needed per Seizure Protocol 2.24. H. If patient does not have any criteria that would exclude them from the use of thrombolytics per the Stroke Exclusionary Criteria Survey, notify receiving hospital and advise that you have a patient that meets stroke alert criteria. Transport patient red lights and siren (hot) to hospital.
PROTOCOL 5.26: Stroke (CVA) Stroke Alert (cont.) Stroke Exclusionary Criteria for Thrombolytics Survey Greater than three (3) hours from symptom onset. (KEY QUESTION) 1. Stroke symptoms that are improving rapidly. 2. On repeated measurement, BP systolic greater than 185 or BP diastolic greater than 110. 3. Isolated minor neurological deficits (i.e. ataxia alone, sensory loss alone, minimal weakness). 4. Within 3 months of intracranial surgery, serious head trauma, or previous stroke. 5. Within 14 days of major surgery or serious trauma. 6. History of prior intracranial hemorrhage, aneurysm or arteriovenous malformation. 7. Recent AMI. 8. GI or urinary tract bleeding within last 3 weeks. 9. Known bleeding diathesis, including but not limited to low platelet counts, Heparin use within the last 48 hours or recent use of anticoagulants such as Coumadin. 10. Witnessed seizure at stroke onset or known active seizure disorder. 11. Recent arterial puncture at a non-compressible site or a lumbar puncture within the last 7 days. 12. Blood glucose less than 70 or greater than 400. 13. Severe neurological deficits such as coma, severe obtundation. 14. Any other seriously advanced illness or terminal condition.
PROTOCOL 5.27: Tension Pneumothorax Decompression Indications: A. Increasing respiratory insufficiency in a susceptible patient: 1. Neglected spontaneous pneumothorax. 2. Cardiac arrest with CPR in progress and appearance of PEA with increased difficulty ventilating patient. 3. Sucking chest wound which has been covered completely. 4. Chest trauma with suspected pneumothorax. B. Patient must also have three or more of the below (signs of tension): 1. Systolic blood pressure less than 90 mm Hg 2. Cyanosis and progressively more severe respiratory distress 3. Decreased or absent breath sounds with hyper-expanded chest 4. Jugular venous distension 5. Tracheal shift 6. Subcutaneous emphysema Precautions: A. Be sure to understand the difference between the two types of pneumothorax. A SIMPLE pneumothorax causes some degree of respiratory difficulty and possibly chest pain. It MAY be associated with a decrease or absent breath sounds on the side of the collapse (not necessarily!!) and subcutaneous air if the cause is traumatic. Most patients will tolerate a simple pneumothorax rather well in the short term and it should not be treated in the field. TENSION pneumothorax is associated with progressive respiratory difficulty, dropping blood pressure, a drum-like hyper-expanded chest, distended neck veins, and general patient deterioration. Tracheal shift may or may not be present. Signs of pneumothorax as well as signs of tension must be present before treatment is undertaken. Accurate diagnosis is critical!
PROTOCOL 5.27: Tension Pneumothorax Decompression (cont.) Precautions (cont.): B. Pneumothorax rarely presents with tension on initial assessment. Be particularly suspicious with deterioration during transport and with patients requiring assisted ventilation. Technique: A. NOTE: CHEST DECOMPRESSION IS A LEVEL II INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED BEFORE BEING ATTEMPTED B. If covered sucking chest wound is present, remove the seal and allow chest pressures to equilibrate. No further treatment may be necessary. C. Needle decompression (Cook Pneumothorax Kit): 1. Expose the entire chest. 2. Clean area for insertion vigorously: alcohol or iodine/Betadine. 3. Attach 20 ml syringe to catheter/introducer needle. 4. Attach blue Molnar disc to catheter/introducer needle and slide up to hub of catheter (Molnar disc is used to adjust depth of catheter). 5. Insert catheter/introducer needle into the pleural space by entering the chest in the second intercostal space in the mid-clavicular line. The catheter should be inserted on the top of the rib so as to avoid the intercostal vessels and nerve. If rib is struck, slid over top of rib. 5. When tension is present, plunger will blow back out of the syringe, or an immediate hiss of air escaping will be heard. 6. If no hiss or evidence of tension is seen, remove catheter/introducer needle and reassess reason for patient deterioration. 7. If air under pressure is demonstrated, remove the introducer needle (trocar) and advance the catheter. Fix catheter at the desired depth with the Molnar disc and the enclosed pull-tie.
PROTOCOL 5.27: Tension Pneumothorax Decompression (cont.) Technique (cont.): 8. Attach one-way stopcock, clear connecting tube and Heimlich flutter valve to catheter hub. (see Illustration 5.I below). Orient to direction of airflow and tape assembly securely to patients chest. Leave one-way petcock OPEN. D. If pediatric or small adult patient, 14 - 18 gauge unprotected angiocath may be used. Attach syringe or leave angiocath open and follow above procedure. Flutter valve and 1-way stopcock from Cook kit may be used if desired. A second catheter may be needed for severe air leak. E. If patient deteriorates after needle decompression, be prepared to assist ventilation (if not already doing so) and continue hyper-oxygenating. Complications: A. Creation of pneumothorax if none existed previously. B. Pulmonary edema from release of collapsed lung, particularly in spontaneous pneumothorax. C. Laceration of the lung. D. Laceration of blood vessels: slide above rib (intercostal vessels run in the groove under each rib). E. Infection: clean rapidly but vigorously; use sterile gloves if available. Special Notes: A. Sudden onset of chest pain and shortness of breath in a normal individual may be caused by a pneumothorax (particularly in patients with chronic lung disease or asthmatics). These rarely do, but can also progress to a tension state.
ILLUSTRATION 5.I. COOK EMERGENCY PNEUMOTHORAX KIT

Unassembled
CATHETER W / INTRODUCER NEEDLE
HEIMLICH FLUTTER VALVE
CONNECTING TUBE
ONE-WAY STOPCOCK
20 ML SYRINGE
MOLNAR DISC WITH PULL-TIE
Assembled
PROTOCOL 5.28: TRAUMA ALERT Indications: The morbidity and mortality of the seriously injured trauma patient can be reduced by decreasing the amount of time between the time the patient is injured, and the time the patient receives definitive, in-hospital evaluation and treatment. The purpose of the Trauma Alert system is to bring together in a timely manner, the necessary trauma services resources to quickly and definitively evaluate and treat the seriously injured trauma patient. Technique: A. Trauma Alerts are not called in the field. When a patient is encountered that meets Trauma Alert criteria, as soon as is possible, (preferably before transport) the Paramedic (or the Paramedics designee) either by phone or radio, will contact the RCRH ED and advise that you have a patient that meets Trauma Alert criteria. This should be followed by a short report detailing the patients condition and the nature of their injuries. Trauma Alert criteria found should specifically be included in this short report. A more detailed report should be given later enroute to the hospital as time allows. B. A Trauma Alert notification will be made to RCRH for a patient who demonstrates any of the following: 1. Respiratory compromise (persistent manifestation of respiratory rate less than 10/min. or more than 29/min). 2. Glasgow Coma Scale at or below 12, attributable to trauma. 3. Systolic blood pressure below 90. 4. Penetrating injury to any of the following: a. head b. neck c. chest
d. abdomen
PROTOCOL 5.28: TRAUMA ALERT (cont.) Technique (cont.): 5. Severe burns a. Total body surface area > 20% b. Face/airway involvement 6. Spinal cord injury with hypotension 7. Physician discretion C. All patients that meet Trauma Alert criteria will be transported red lights and siren (hot) to the hospital. Special Notes: A. All patients that meet Trauma Alert criteria should receive rapid transport to the hospital; with as short scene times as are possible and most definitive pre-hospital treatment performed enroute.
PROTOCOL 5.29: 12 LEAD ECG Indications: A. A 12-lead ECG should be obtained whenever possible on the patient that exhibits signs and symptoms of an acute coronary syndrome (ACS). These syndromes include ST elevation, Acute Myocardial Infarction and unstable angina. This will typically be patients who are suffering from chest pain of probable cardiac origin. B. Patients who have a significant cardiac arrhythmia, but not the usual presentation of an acute coronary syndrome may be good candidates as well. Examples are patients with A-Fib vs SVT, those with wide complex tachycardia of uncertain origin and those with symptoms of congestive heart failure. C. Other patients with an atypical presentation of an ACS, such as a syncopal episode, unexplained diaphoresis and weakness may be candidates for a 12lead ECG as well. Precautions: A. While the acquisition of a 12-lead ECG can prove to be a valuable diagnostic tool, excessive time should not be spent in the field obtaining one if the patient is gravely ill. If necessary, try to obtain and send (if necessary) the 12-lead while the patient is being packaged for transport or enroute to the hospital. Technique: A. Explain the procedure to the patient whenever possible. B. Preparation of the skin to remove oils and dead skin cells and the elimination of muscle tension are important in obtaining a noise-free 12-lead. 1. Cleanse the skin at the electrode sites with alcohol preps and rub with a towel or gauze. Shave excessive hair. 2. Position the patients arms and legs in a comfortable position in which the extremities are resting on a supportive surface. Any self-support of the limbs by the patient may introduce fine muscle artifact even though the patient does not appear to be moving. C. Any patient that is going to have a 12-lead done should have had a standard 3, 4 or 5-lead ECG reading done first.
PROTOCOL 5.29: 12 LEAD ECG (cont.) Technique (cont.): D. If the Paramedic believes the patient may require a 12-lead to be obtained, the limb lead electrodes from the 3-lead reading should NOT be placed on the torso, they should be placed on the limbs (or replaced to the limbs if originally on the torso). Typical placement is on the inside of the wrists and the inner aspects of the legs near the ankles, but they may also be placed more proximally on the deltoids and upper legs. Proximal placement rather than distal placement of limb leads may result in a more noise-free ECG. Placement of limb leads on the torso may result in a non-standard 12-lead. E. Attach the MRX precordial lead attachment cable to the patient monitoring cable . F. Precordial lead placement: (see Illustration 5.J. below) 1. V1 2. V2 3. V3 4. V4 5. V5 6. V6 Fourth intercostal space to the right of the sternum. Fourth intercostal space to the left of the sternum. Directly between leads V2 and V4. Fifth intercostal space a midclavicular line. Level with V4 at left anterior axillary line. Level with V5 at left midaxillary line.
G. Assure that all limb leads and precordial leads are firmly attached to the proper electrodes. H. Turn Therapy Knob to Monitor (if not already on). I. J. Encourage the patient to remain as still as possible during to reduce artifact. Press the 12 LEAD button. The 12-lead preview screen will be displayed, check the signal quality on each lead and if necessary, make adjustments to improve signal quality.
K. Press the START ACQUIRE button. The message Acquiring 12-Lead will be displayed while the MRX acquires 10 seconds of ECG data. Encourage the patient to remain still while the Acquiring 12-Lead message is displayed.
PROTOCOL 5.29: 12 LEAD ECG (cont.) Technique (cont.): L. If patient age and sex were not previously entered, you are prompted to enter the information. Use the NAVIGATION and MENU SELECT buttons to enter the information. Pre-entered default is 55 y/o male. M. Once ECG acquisition is complete, ECG analysis begins automatically and is accompanied by the message Analyzing 12-Lead. The patient does not need to remain still during this time. N. Following analysis, a 12-lead ECG report is displayed, automatically printed and stored internally. Note: Do not depend on the MRXs printed interpretive statements to diagnose the presence or absence of AMI. Interpret yourself and or send 12Lead to hospital for interpretation. O. To acquire another 12-Lead, press the NEW 12-LEAD button. To exit the 12-Lead function, press the EXIT 12-LEAD button. P. A 12-lead should be transmitted to the hospital when any of the following conditions exist: 1. Medical Control requests. 2. An ST elevation MI is suspected. 3. When a cardiac rhythm is unclear and physician interpretation may help facilitate needed treatment in the field or enroute to the hospital. 4. Anytime transmitting the patients 12-Lead ECG to the hospital will help expedite the patients treatment once they arrive. This list should not be considered all inclusive, there may be other situations under which it may be appropriate to transmit a 12-lead to the hospital. Q. To transmit a 12-lead to the hospital printer: 1. Acquire 12-Lead (12-Lead Report View will be displayed).
2. Press the MENU SELECT button and using the NAVIGATION buttons, select SEND from the menu. Press MENU SELECT again.
PROTOCOL 5.29: 12 LEAD ECG (cont.) Technique (cont.): 3. Destination site will come up next, RCRH will be pre-configured (highlighted). Press MENU SELECT button. 4. Transmission device will come up next, MOTOROLA PHONE will be preconfigured (highlighted). Press MENU SELECT button. 5. Transmission will start, on screen displays will advise of the progress
ILLUSTRATION 5.J. 12-LEAD PRECORDIAL LEAD PLACEMENT

V1 Fourth intercostal space to the right of the sternum V2 Fourth intercostal space to the left of the sternum V3 Directly between leads V2 and V4 V4 Fifth intercostal space at left midclavicular line V5 Level with lead V4 at left anterior axillary line V6 Level with lead V5 at left midaxillary line
Section 6 Operational Protocols
Protocol 6.1: Advanced Directives / DNR Orders General Principles: A. This protocol is for the pre-hospital management of the statutory Advanced Directive/Do Not Resuscitate (DNR) document. This document expresses the patients legally recognized right to have CPR and or certain types of advanced care withheld in the event they are dying. This document is a specifically identifiable form that is signed by the patient or the patients authorized agent and is also signed by the patients physician. B. In addition to the written Advanced Directive/DNR document, the patient or authorized agent may have an Advanced Directive/DNR (Comfort One) necklace or bracelet. This necklace or bracelet carries the same legal weight as the document. C. CPR and or certain types of advanced care shall be withheld or terminated if the Advanced Directive/DNR document is readily accessible or if the necklace or bracelet is worn by the patient. D. An Advanced Directive/DNR order does not only apply to patients in full cardiac arrest, but should also be honored in patients who are gravely ill and near death. Procedures: A. Perform initial patient assessment. B. Verify that the Advanced Directive/DNR order is a signed copy and is unaltered (not defaced or altered physically in some manner). C. Verify that the information on the document or, if present, on the back of the necklace or bracelet reasonably appears to match the patient (name, age, sex, etc.). If possible, try to verify the patients identity from a readily available additional source such as a family member, drivers license, etc. D. Upon verification of the patients identity, withhold CPR and or certain types of advanced care (as noted below). If CPR or the noted advanced care has already been started, it should be stopped. E. If there is any question as to the validity of the Advanced Directive/DNR order or the identity of the patient, initiate full resuscitative measures and contact Medical Control for guidance.
Protocol 6.1: Advanced Directives / DNR Orders (cont.) Procedures (cont.): F. If the death occurs outside of a health care facility and the patient is not under Hospice care, the coroner shall be contacted immediately, (see Protocol 6.5: Field Determination of Death). G. Provide appropriate emotional and customer service support to the family wherever possible. H. The following resuscitative measures are to be withheld or withdrawn from a patient who has a valid Advanced Directive/DNR order: 1. CPR. 2. Endotracheal intubation or other advanced airway management. 3. Artificial ventilation. 4. Defibrillation. 5. Cardiac resuscitation medications and measures. I. The following interventions may be administered or provided: 1. Assist in maintenance of the airway (non-advanced airway management such as positioning). 2. Suctioning. 3. Oxygen. 4. Pain medication. 5. Control bleeding. J. In addition to the standard patient care documentation, the following information will be documented in the Patient Care Report: 1. Patients status when found. 2. Type of Advanced Directive/DNR order (document, bracelet, or necklace).
Protocol 6.1: Advanced Directives / DNR Orders (cont.) Procedures (cont.): 3. Any identifying number that appears on the document necklace or bracelet. 4. Name of patients physician, if known. 5. Any special circumstances which justify initiating resuscitation, if this was done despite the presence of the Advanced Directive/DNR order. 6. Cardiac monitor strips in at least two leads. Additional Considerations: A. The patient may revoke the Advanced Directive/DNR order at any time by oral expression of revocation or by destruction of the Advanced Directive/DNR order document, bracelet, or necklace. If the Advanced Directive/DNR order was executed by a guardian, agent or proxy decisionmaker, then the Advanced Directive/DNR order may be revoked by the guardian, agent, or proxy decision-maker. B. CPR and or advanced measures are to be initiated if the Advanced Directive/DNR order document, bracelet, or necklace is not readily available (bedside with or being worn by the patient). The bracelet or necklace is only available to the patient after the Advanced Directive/DNR order document has been properly executed. Removal of the bracelet or necklace may be construed as revocation. Therefore, if the necklace or bracelet is readily accessible but not on the patient, any question as to whether the order has been revoked should result in resuscitation until the situation is clarified. Consult with Medical Control if there are questions about terminating care and or transport. C. If not in full cardiac arrest, patients with Advanced Directive/DNR orders may still be transported to provide comfort measures. D. In the absence of an Advanced Directive/DNR order, patients consent to CPR/advanced care will typically be presumed. However, the statutorily authorized Advanced Directive/DNR order is only one manner for a patient to demonstrate resuscitation preferences. If no Advanced Directive/DNR order is present and responsible family members present do not wish to have a resuscitation performed on an adult patient, BLS measures shall be initiated and Medical Control shall be contacted to discuss options. See Protocol 6.5: Field Determination of Death for further guidance.
Protocol 6.2: Confidentiality General Principles: A. EMS agencies are direct providers of health care to patients and generate what is known as Protected Health Information (PHI). B. PHI consists of records that contain information that identifies an individual (such as name, social security number and address), as well as medical information about that individual such as injury or illnesses and treatments provided. PHI can exist electronically or in hard copy. C. Personal medical or identifying information known to an EMS provider about a patient that does not yet exist in electronic or hard copy form is also considered PHI. D. Federal law and City of Rapid City policy stipulate that EMS providers shall make reasonable efforts to see that PHI be kept private and confidential and not be disclosed outside the context of necessary and proper workplace operations. Procedures: A. EMS providers can use PHI for treatment, billing, clinical review and training/education purposes. B. EMS providers can also share and disclose PHI with other entities that are directly involved in the patients care, such as receiving hospitals and other pre-hospital providers in a tiered response system as long as it is for legitimate treatment, payment or health care operation purposes. C. Generally, EMS providers must limit the PHI used or disclosed to only that which is necessary to accomplish the intended purpose for which the information is needed. For example, in QI review of cases (health care operations), there would typically be no need to disclose the patients name or other identifying information. D. EMS providers shall not discuss or disclose any patients PHI with persons outside the context of necessary and proper workplace operations. E. EMS providers shall assure that both electronic and hard copy Patient Care Reports are kept secure. Printed copies of reports shall not be left unattended on counters, vehicles or other places where they may be improperly viewed.
Protocol 6.2: Confidentiality (cont.) Procedures (cont.): F. Computers with Patient Care Reports in process shall not be left unattended, if the EMS provider has to leave before completing the report it should be closed. G. Copies of Patient Care Reports will be generated only for Patient Billing Services and the receiving hospital. Other requests for copies of Patient Care Reports will be forwarded to the EMS Chief or Patient Billing Services. H. When students/observers are riding with EMS providers, the attending Paramedic will assure that the proper confidentiality documents are signed by the rider and they are thoroughly aware of patient confidentiality practices and policy. I. Radio communications shall not include disclosure of patients names.
Protocol 6.3: Controlled Substance Documentation General Principles: A. The complex legalities of narcotic distribution and storage require strict enforcement concerning the use of these types of medications. Narcotics have an ever-present risk of abuse and misuse that can and will be minimized by constant administrative and field personnel oversight and proper documentation of their use. The Medical Director is legally responsible for the storage, disbursement and subsequent record keeping for all narcotics associated with the systems provision of EMS. It is our responsibility to document all activity associated with narcotic medications to minimize any legal risks. Descriptions: A. Each narcotic kit is labeled in 4 black numbering with its own individual container number. This number will match the Medic unit number to which it is assigned. B. There are 2 narcotic kits for every unit that is assigned narcotics, one orange and one yellow. One full audited set (either orange or yellow) of all the narcotic kits is kept at the RCRH pharmacy. C. Each narcotic kit contains a single RCRH Controlled Drug Administration Record (see Illustration 6.A. below) for all narcotics stored within the kit. D. The narcotics kits contain the following narcotics in the noted quantities. 1. (2) Morphine Sulfate, 10 mg each. 2. (2) Fentanyl, 100 mcg each. 3. (2) Valium, 10 mg each. 4. (2) Ativan, 2 mg each. Procedures: Daily Narcotic Audit and Exchange Procedure A. At every shift change, the oncoming and outgoing Paramedic will facilitate a proper exchange of narcotics.
Protocol 6.3: Controlled Substance Documentation (cont.) Procedures (cont.): Daily Narcotic Audit and Exchange Procedure (cont.) B. The oncoming Paramedic will visually inspect the narcotic kit and verify that the lock number matches the previous lock number documented in the Ambulance Controlled Substance Log (see Illustration 6.B. below). Any lock change during the previous shift should be noted in the comments section of the Ambulance Controlled Substance Log and in the Usage and Disbursement Log. If there is an undocumented change in lock numbers, the outgoing Paramedic will not leave until the discrepancy is accounted for. C. After visual inspection of the lock and the container, the outgoing Paramedic will document the following in the Ambulance Controlled Substance Log. 1. 2. 3. 4. 5. 6. 7. Date Time From (printed name of the outgoing Paramedic) To (printed name of the oncoming Paramedic) Container # (narcotic kit number) Then each Paramedic will sign to verify the exchange Any other comments that are pertinent to the exchange should be noted in the comments section (lock changes, etc.) 8. Lock # D. If during the daily audit (or at any time) an undocumented lock number change or an unexplained broken lock is encountered, the narcotic kit will be opened and checked to assure that all the narcotics are present in the proper quantities and the seals are intact. If narcotics are missing or all seals are not intact, the EMS Chief, Operations Chief and the on-duty Battalion Chief will be notified immediately. Usage and replacement of a narcotic A. Any time that a patient is given a narcotic, after arrival at the hospital the RCRH Controlled Drug Administration Record (found in the narcotics kit) will be completed with all of the following information: 1. 2. 3. 4. Date Time (of administration) Patient Name Who the drug was administered by
Protocol 6.3: Controlled Substance Documentation (cont.) Procedures (cont.): Usage and replacement of a narcotic (cont.) 5. Amount Administered 6. Amount Wasted 7. If an amount is wasted, it must be witnessed, and then documented, with signature by the person who witnessed the wasting B. Double check to make sure the information filled in on the RCRH Controlled Drug Administration Record corresponds to the type of drug given. C. Make a copy of the RCRH Controlled Drug Administration Record (to turn in with daily paperwork). D. Take the entire narcotic kit and the filled out RCRH Controlled Drug Administration Record to the pharmacy located on 1st floor just off elevators. E. The pharmacy staff will take the narcotic kit and the filled out RCRH Controlled Drug Administration Record and give you a completely stocked, audited and locked narcotic kit with the proper unit number of the opposite color (yellow if you gave them orange and vice versa). F. Document usage and replacement in the proper Controlled Substance Usage Log (there is a separate sheet for each of the different drugs) in the back of the Narcotics Log book in the medic unit. The Usage Log is selfexplanatory and ALL sections must be filled out. The new lock number must also be noted in the Controlled Substance Usage Log (see Illustration 6.C. below). G. It is a legal requirement (DEA) that there be a separate file kept of all narcotics dispensed. To meet this requirement, make sure your copy of the RCRH Controlled Drug Administration Record is included with the daily paperwork for filing. This, along with the documentation in the Usage Log will meet that requirement. Narcotics Storage A. Narcotics will be stored in the built-in refrigerators in the 4 primary duty medic units and the peak-load unit. B. Nothing other than drugs will be kept in medic unit refrigerators.
Protocol 6.3: Controlled Substance Documentation (cont.) Procedures (cont.): Narcotics Storage (cont.) C. Narcotics kits are available for all medic units, those narcotic kits not stored in the primary duty medic units and the peak-load unit will be kept in a locked refrigerator in the EMS Chiefs office. In the event a transfer or similar duty requires a set of narcotics for one of the other medic units, they can be checked out from the Operations Chief, the EMS Chief, the on-duty Battalion Chief or the Paramedic in charge of medical supply. When that duty is concluded, the narcotics kit must be checked back in with one of the above mentioned personnel. Documentation will be the same as noted above. Narcotics Log books for the other medic units are in the EMS Chiefs office.
Protocol 6.3: Controlled Substance Documentation (cont.) ILLUSTRATION 6.A. RCRH CONTROLLED DRUG ADMINISTRATION RECORD
Protocol 6.3: Controlled Substance Documentation (cont.) ILLUSTRATION 6.B. AMBULANCE CONTROLLED SUBSTANCE LOG
Protocol 6.3: Controlled Substance Documentation (cont.) ILLUSTRATION 6.C. CONTROLLED SUBSTANCE USAGE LOG
Protocol 6.4: Crime Scene Operations General Principles: A. Response by EMS providers to a known or suspected crime scene, including a crime scene that is not discovered until after arrival will require specific procedures to be followed. These procedures are designed to minimize possible threats to EMS providers and to avoid unnecessary contamination of a crime scene. These crime scene situations may include but are not limited to: 1. Assaults including domestic violence situations and sexual assault 2. Reported gunshot wounds 3. Stabbings 4. Hangings 5. Suicide gestures or completed suicides 6. Homicides 7. Unexplained explosions, WMD/terrorist acts 8. Fatality or serious injury MVA 9. Any situation where an unattended death has occurred Procedures: A. Dispatched response to a known or suspected crime of violence or suicide will typically be a cold response to stage in the area until Law Enforcement has secured the scene. This response will always be followed in the absence of compelling reasons to the contrary. In the absence of being notified, do not assume a scene is secure and take precautions as necessary to assure personnel safety. B. If a crime scene is not discovered until after responding to an incident, and Law Enforcement is not present, Law Enforcement shall be called to the scene immediately. An assessment will be made of the possible threat to responders and if a threat exists, personnel will exit the scene immediately to a safe distance and wait for Law Enforcement assistance. If there is no immediate threat, necessary patient treatment may begin, being mindful of potential returning threats.
Protocol 6.4: Crime Scene Operations (cont.) Procedures (cont.): C. When responding to a known crime scene, entry to the scene should be made with the minimum number of personnel necessary to provide effective patient evaluation and treatment. Other personnel not required for treatment shall remain outside the scene. This reduces the possibility that evidence will be disturbed or contaminated. D. When responding to a crime scene where an alleged violent death has occurred and Law Enforcement is already present, the senior EMS provider present shall confer with Law Enforcement to determine the need for an evaluation of life status. If the Law Enforcement officer is able to offer a clear description of Obvious Death Criteria, then EMS units shall leave the scene without entry and document the exchange completely with names in the Patient Care report and or a Fire Report. Note: It should be noted that the Obvious Death Criteria that Law Enforcement will be using is somewhat different than what EMS providers use in Protocol 6.5: Field Determination of Death. LE Obvious Death Criteria 1. Rigor Mortis (cold and stiff in a warm environment) with extensive post mortem dependent lividity (does not apply to hypothermic patients or cold water drowning patients 2. Decapitation 3. Decomposition of the body 4. Incineration of the body If Law Enforcement is unable to offer a clear description of Obvious Death Criteria or is unsure, one (1) EMS provider shall be allowed access to the victim to evaluate life status (see Protocol 6.5: Field Determination of Death for further procedures). Check with the officer in charge for entry and any special circumstances. If Law Enforcement will not allow access in the absence of Obvious Death Criteria, explain politely to the officer in charge that it is local Law Enforcement policy that in the absence of Obvious death Criteria an evaluation of life status by medical providers be made. If access is still not allowed, leave the scene and document the exchange completely, including names of all persons involved.
Protocol 6.4: Crime Scene Operations (cont.) Procedures (cont.): E. While performing patient evaluation and treatment, precautions should be taken not to remove, move or otherwise disturb anything in the crime scene environment except as is absolutely necessary to perform effective patient evaluation and care activities. If it becomes necessary to move anything (weapons, furniture, etc.), it should carefully be moved out of the way, using caution to avoid unnecessary handling of the object. (when weapons have to be moved, try to get Law Enforcement assistance).The original position of the object should be mentally noted so investigators can reconstruct the scene as accurately as possible. F. Personnel shall avoid moving about a structure or crime scene unnecessarily or touching any object at the scene unnecessarily. Remaining in close as possible proximity to the patient will avoid the risk of contaminating other areas within the crime scene. If medications must be looked for to assist in providing treatment, it should be done by one person, exercising care to note their original locations and to try to avoid handling or touching other objects not associated with the medications. G. When removing clothing from patients that have sustained gunshot wounds, stab wounds or other assaults, avoid cutting through garments at or near bullet or stab wound holes. The bullet/stab wound hole, powder residue or powder smudges around a hole can have considerable investigative value as evidence and should not be modified if at all possible. H. If the patient has ligature or binding items around the neck, arms, feet or any other part of the body, do not remove them unless necessary to provide treatment. If the item must be removed, do not untie, but cut off taking care not to cut through any knot that may have been tied in the item. The original position and placement of the item should be mentally noted. I. If the patient is wearing jewelry, do not remove unless necessary to provide treatment. If items must be removed, the original position and placement of the item should be mentally noted. The clothing the patient was wearing should always be kept track of. Give removed clothing directly to Law Enforcement whenever possible and leave at scene. Where clothing is bloody, if possible try to avoid having blood or debris on one area or garment transfer to another area or garment (do not wad up into a ball). Do not put wet or bloody garments in plastic (red) bags. Handle clothing as little and as carefully as possible.
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K. Avoid stepping in pools of blood or other fluids. If there is blood/fluid spatter on walls, furniture or other objects, try to avoid smearing the spatter.
Protocol 6.4: Crime Scene Operations (cont.) Procedures (cont.): L. In the instance of a crime scene involving a motor vehicle accident, check with Law Enforcement before any clean up of vehicle fluids on the roadway, they may have investigative value as evidence. The only exception to this would be if the fluids (gasoline, HazMat) present an immediate significant hazard. Even then, confer with Law Enforcement about what you feel is necessary to do. Diking may be sufficient in the short term to prevent fluids from entering waterways, sewer, etc. M. When IVs need to be established, try to start them above the hands if there is a possibility the patient fired or may have fired a weapon. Law Enforcement may wish to bag a patients hands, this should be allowed if it will not interfere with treatment or delay treatment and transport. N. Disposable medical supplies and their wrappers/boxes used at a crime scene should not be cleaned up as is typically done. They should be left in place where they were used to avoid cleaning up any possible evidence. O. If a cricothyrotomy or chest decompression must be performed, do not place needles or tubes through pre-existing gunshot or stab wound holes. P. Anytime the physical environment in and around a crime scene must be disturbed by EMS providers, it should be documented completely and fully in the Patient Care Report and or Fire Report. Q EMS providers may become custodians of verbal evidence while operating at a crime scene. An excited utterance or a statement made in the heat of the moment is often times valuable and many times overlooked. Throughout contact with a patient involved in a crime, keep in mind that such statements can be key evidence in the event the patient is not able to repeat them in the future. These statements should be noted and included in the Patient Care Report and or Fire Report. When charting these statements use exact quotes, do not add or change wording.
R. EMS providers should be prepared to give their names to Law Enforcement before departing a crime scene whenever possible.
Protocol 6.5: Field Determination of Death General principles: A. Situations will arise in which EMS personnel will encounter a patient in whom resuscitative efforts should be withheld or in some cases terminated after a trial course of treatment. This protocol is designed to provide guidelines under which the PARAMEDIC may choose to discontinue or not initiate resuscitative efforts. Indications: A. The obviously deceased patient (cause trauma OR medical) that meets specific criteria. B. The cardiac arrest patient in whom resuscitation has begun, but remains without cardiac electrical activity (asystole) after a full regiment of first-line ACLS procedures. Procedures: A. In all cases where ALS resuscitation has already begun, Medical Control will be contacted for permission to cease resuscitative efforts. The Paramedic should be prepared to provide the following information for Medical Control: 1. Brief history of event 2. Patients presenting clinical condition and cardiac rhythm. 3. Procedures preformed and drugs administered. 4. Patients total elapsed down time. 5. Patients present clinical condition and cardiac rhythm. B. The PARAMEDIC may withhold or terminate resuscitative efforts in the patient that meets the following criteria: Initial Criteria: 1. No spontaneous respirations AND 2. No palpable pulse AND 3. No evidence of cardiac electrical activity (asystole) AND
Protocol 6.5: Field Determination of Death (cont.) Procedures (cont.): Initial Criteria (cont.): 4. Pupils fixed and dilated AND One or more of the following additional criteria: 1. Rigor Mortis (cold and stiff in a warm environment) 2. Extensive post-mortem dependent lividity 3. Decapitation 4. Decomposition of the body 5. Blunt trauma cardiac arrest 6. Incineration of the body 7. Legal Advanced Directive/DNR order in place (see Protocol 6.1: Advanced Directives/DNR orders) C. Apneic and pulseless penetrating trauma patients will have resuscitative efforts begun and be rapidly transported unless signs of prolonged, obvious death as noted above (1-4, additional criteria) are present. See Protocol 3.10: Trauma Cardiac Arrest for further information. D. Resuscitation should not be withheld or terminated on hypothermic patients or cold water drowning patients. If drowning patient has more than one and a half hours submersion time, contact Medical Control for direction. E. Resuscitation should not be withheld or terminated on electrocution or lightning strike patients unless signs of prolonged, obvious death as noted above (1-4, additional criteria) are present. F. All patients in whom a resuscitation is either withheld or terminated will have a cardiac rhythm strip run whenever possible and attached to the Patient Care Report. If it is not possible to obtain a rhythm strip, the reason will be documented in the Patient Care report. G. In all cases where resuscitation has either been withheld or terminated outside of a medical facility, these are considered by law to be unattended deaths and law enforcement will be called to the scene immediately. Law enforcement will call the coroner when appropriate.
Protocol 6.5: Field Determination of Death (cont.) Procedures (cont.): If transport has already begun to a facility when the resuscitation is terminated, law enforcement may choose not to respond, and in that case the coroner will typically be the investigating authority at the receiving facility. In these cases, ask Dispatch to contact law enforcement and let them decide who will respond to the receiving facility (LE or the coroner). Note: in some of these cases where a resuscitation is terminated outside of a facility, the physician may wish to see the patient and then ultimately sign the death certificate (making the situation NOT an unattended death). In some cases, they may not wish to see the patient and request the patient be taken directly to the morgue (IS an unattended death). Regardless of which of those circumstances occur, ask Dispatch to contact law enforcement for consultation so either their personnel or the coroner can meet with you at the facility and determine what will be done. The Medical Control physician shall be included in that decision making process about what will be done and who will sign the death certificate. Also be aware that where the resuscitation is stopped (city vs county / other counties) may affect who responds as an investigating authority and if they respond at all. For above situations (G) not covered by this protocol or if questions, contact the local law enforcement authority, or Medical Control and or the EMS Chief. H. Patient Care Report documentation on these cases will always include the following information: 1. Complete history of event 2. Complete description of patients presenting clinical condition (pupils, color, rigor, lividity, decomposition, etc.) and cardiac rhythm with accurate times. 3. Any procedures preformed and drugs administered with accurate times. 4. Conversations with Medical Control to include names, orders given or denied and accurate times. 5. Patients total elapsed down time as is best obtainable. 6. Complete description of patients clinical condition and cardiac rhythm when resuscitation terminated.
Protocol 6.5: Field Determination of Death (cont.) 7. Document any Law Enforcement involvement, including names if possible and accurate times. 8. Cardiac rhythm strips. I. If situations arise outside the scope of this protocol, or the Paramedic is unsure whether resuscitative measures are warranted or should be terminated, contact Medical Control for direction. If the situation appears to be a crime scene, see Protocol 6.4: Crime Scene Operations for further information.
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Additional Considerations: A. Mass Casualty Incidents involving death are not covered in detail by this protocol and have somewhat different guidelines, see Protocol 6.10: Mass Casualty Incidents for further information. B. There may be situations where the EMS provider feels compelled to begin or continue a resuscitation when it normally otherwise might not be done (hostile scene environment, family members adamant that everything be done, or other highly emotional or volatile situations). In such circumstances, the EMS provider should attempt to contact Medical Control for direction. If that is not possible, the EMS provider should use his or her best judgment in deciding what is reasonable and appropriate for the situation, including possibly starting basic resuscitative measures and transport. Medical Control should be contacted as soon as is possible.
Protocol 6.6: Hazardous Materials / WMD Incidents Indications: A. Response to reported and or known chemical/biological Hazardous Materials or Weapon of Mass Destruction (WMD) incident. B. Response to situations including but not limited to vapor/gas clouds, leaking substances, numbers of sick or deceased people or animals and noxious odors present on or near scene. Definitions: A. For adequate and uniform scene control, a system of zones is established. There are 3 control zones: the Hot (Exclusion) Zone, the Warm (Contamination Reduction) Zone, and the Cold (Support) Zone. See Illustration 6.D: HazMat Zones below. 1. Hot Zone: An area immediately surrounding an incident that is the primary area of contamination. May also include areas that are not immediately contaminated, but that HazMat Operations/IC believes the contamination will predictably spread. 2. Warm Zone: Immediately outside the Hot Zone and acts as a buffer area between the Cold and Hot Zones. It contains the Decontamination area (Contamination Reduction Corridor), which is the pathway to and from the Hot Zone. 3. Cold Zone: A clean or non-contaminated zone where support and control functions are operating or staged. General Principles: A. If you are first on scene and a HazMat/WMD situation is suspected, request a HazMat Team and engine company response. Keep yourself and your unit at a safe distance. This may require you to leave the scene for some distance, leaving patients and bystanders in a hazardous situation. This is necessary, your safety comes first. Seek a location uphill and upwind from the incident. Relay pertinent observations to in-bound units and Dispatch. B. If the HazMat Team/engine companies are already on scene, on arrival report in where/as requested (Command Post, HazMat Operations, Staging, etc.). Initial EMS operations should be established in the Cold Zone.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) General Principles (cont.): C. Initial assessment, treatment and decontamination will be performed by HazMat Team/engine company personnel in the proper level of Personal Protective Equipment (PPE). Decontaminated patients will typically then be brought to EMS personnel in the Cold Zone (outer limit of Warm Zone) for definitive treatment and transport. EMS personnel will not participate in Hot/Warm Zone operations or patient decontamination unless trained and equipped to do so. HazMat Operations/IC and the nature and scope of the contamination will dictate the level and location of EMS operations in all zones. D. EMS personnel may be required to drape the interior of ambulances with plastic and don some level of PPE to transport patients even after they have been decontaminated. Decontamination may not be complete. This will be done or not done based on recommendations from HazMat Operations/IC. Consider the potential need for secondary decontamination at the receiving facility E. Once the situation has been assessed, notify the receiving hospital(s) of the following information: 1. Location of the incident. 2. Name of the chemicals/materials involved (if known). If not known, description of signs/symptoms common to patients. 3. Number of injured/contaminated. 4. Extent of injuries/contamination. 5. Extent that patients will be decontaminated in the field. 6. Estimated time of arrival of first patients. 7. Any other pertinent information that is available. F. This protocol is designed for rendering the maximum appropriate care to each patient affected by these situations. In Mass Casualty Incident situations, not all of these assessments and treatments may be able to be performed on each patient. EMS providers should follow established MCI procedures and attempt to do the greatest good for the greatest number of patients. See Protocol 6.10: Mass Casualty Incidents for further information.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) General Principles (cont.): G. Remember that patients in potential HazMat/WMD incidents may also have non-poison related problems such as head trauma, hypoglycemia, asthma exacerbation, etc. Refer to pertinent protocol for assessment and treatment strategies related to these complaints if time and situation allows. Procedures: A. The first priority for patients in a Hot Zone will typically be evacuation to a decontamination area. Any assessment of a patient in the Hot Zone will have to be provided by personnel in the appropriate complete PPE. This will make complete exposure of the patient and utilization of assessment tools such as a stethoscope impossible. Hot Zone assessments are limited to those that can be conducted rapidly through PPE. These may include: 1. Observation of the patients mental status. 2. Observation of the patients skin signs. 3. Observation/testing of neurologic response, including GCS and pupils. 4. Observation of the patients airway, secretions, and any vomiting or other bodily fluids. 5. Pulse check. B. Patients should be removed from the contaminated environment as soon as is practical to prevent further contamination. C. The order of assessment and supportive care may be affected by incidentspecific considerations, e.g., primary survey may be followed by evacuation and decontamination, or in the case of entrapped live patients, supportive care performed by personnel in PPE may be followed by decontamination in place. In all cases, decontamination of contaminated patients should be considered a vital part of their treatment. D. The removal of contaminating materials, such as clothing, from the patient is at the discretion of HazMat Operations/IC. This should be done as rapidly as is practically feasible and should include full patient decontamination where indicated.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Procedures (cont.): E. Assessments and treatments in the Warm/Cold Zone will typically include those that need patient exposure, such as stethoscope exam or initiation of IV therapy. F. Identification of the material released for the receiving hospital may be difficult. Utilize all resources at your disposal, These include (but are not limited to) Hazmat Databases, Poison Control Center, and Base Station Physician consultation. G. These protocols include Fact Sheets on some common Biologic and Chemical agents and Radiation injury. Fact Sheet for the Biologic agents and Radiation is generic, for Chemical agents it is specific to the agent. For the listed Biologic agents there are Summary Charts and treatment information for both field and hospital treatment. Hospital treatment information is included for additional background information for the EMS provider. It should be noted that field treatment of Biologic agent affected patients is usually supportive care only and is not typically specific. Infection control and decontamination information is included where necessary. For the listed Chemical agents and Radiation injury there is an Information Needed section reference history and exposure, an Objective Findings section on physical signs, a Treatment section divided into BLS and First Responder actions, ALS provider actions in the Hot Zone, or contaminated area (if properly equipped and trained), ALS provider actions in the Warm/Cold Zone or decontamination area, as well as hospital treatment information for additional background information.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Table Of Contents BIOLOGICAL AGENTS Fact Sheet (Generic).................................................................................................. 6-26 Summary Chart of Biologic Agents ............................................................................ 6-27 Treatment Protocols for Biologic Agents.................................................................... 6-30 Anthrax ................................................................................................................ 6-30 Botulism............................................................................................................... 6-32 Brucellosis ........................................................................................................... 6-33 Cholera................................................................................................................ 6-34 Encephalitis (Venezuelan, Eastern, Western) ..................................................... 6-35 Plague ................................................................................................................. 6-36 Q Fever ............................................................................................................... 6-38 Ricin .................................................................................................................... 6-39 Smallpox.............................................................................................................. 6-40 Staphylococcal Enterotoxin B.............................................................................. 6-41 Tricothecene Mycotoxins..................................................................................... 6-41 Tularemia ............................................................................................................ 6-42 Viral Hemorrhagic Fevers.................................................................................... 6-44 References ................................................................................................................ 6-45 CHEMICAL AGENTS Chlorine ............................................................................................................... 6-46 Hydrogen Cyanide and Cyanogen Chloride ........................................................ 6-49 Methylene Diphenyl Isocyanate (MDI), Methylene Diisocyanate and Methyl Isocyanate (MIC) ................................................................................................. 6-52 Mustard (Sulfur Mustard)..................................................................................... 6-55 Nerve Agents....................................................................................................... 6-58 RADIATION INJURY ................................................................................................. 6-62 DRUG SUMMARIES Drug Summaries for all drugs referenced in this section can be found in Section 7 with other standard protocol drug summaries.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) BIOLOGICAL AGENTS Fact Sheet (Generic) 1. Military Designation: None 2. Description: There are many potential biological agents that can be used as Weapons of Mass Destruction. Ideal properties of such agents include rapid dispersion, high rate of infectivity, high degree of virulence, short incubation time, low resistance among the population, and high rate of morbidity and morality. Examples are listed in the charts below along with their health effects. 3. Non-military Uses: Biological agents are used in a wide variety of medical research and some types are easily available from biological supply warehouses. Other biologic agents occur endemically (in normally small numbers in certain patient populations), making the early detection of biologic agent use as a weapon potentially difficult. 4. Military Use: Biologic agents were allegedly used during the Gulf War by the Iraqis against the Kurdish population. While no country currently admits to the use or storage of biologic agents, defensive research occurs at the US Army Medical Research Institute at Fort Detrick, Maryland. 5. Health Effect: see chart. 6. Environmental Fate: Varies by nature of agent. Most are not persistent outside of their natural reservoirs. Refer to source document for further information.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Summary Chart of Biologic Agents
AGENT Anthrax (Inhalational) Agent Type/ Incubation Period
Bacteria/ 1-60 days
Primary Signs and Symptoms

Biphasic illness: Influenza-like illness (ILI) then abrupt onset of fever, chest pain, respiratory distress, cyanosis, occasional stridor, occasional meningismus, progression to shock and death within 24-36 hours. Acute bilateral descending flaccid paralysis beginning with cranial nerve palsies: ptosis, dry mouth, blurry vision, diplopia, dysarthria, dysphagia. (Do not confuse with nerve agent poisoning, which has copious secretions and miotic pupils or atropine overdose, which has CNS excitation with dry mucous membranes & mydriasis). Fever, sweats, malaise, anorexia, headache and back pain; sometimes undulant fever, sometimes focal complications. Vomiting, watery rice water diarrhea, dehydration and shock; abdominal cramps and anxiety in proportion to dehydration. Encephalopathy with fever and seizures and/or focal neurologic deficits.
Likely Mode of Acquisition

Inhalation
Botulism
Toxin from bacteria/ 24-36 hours
Inhalation or ingestion
Brucellosis
Bacteria/ 2-8 weeks
Inhalation, oral ingestion
Cholera
Bacteria/ 24-48 hours
Oral ingestion
Encephalitis Virus/
(Venezuelan, Eastern, Western)
1-14 days
Inhalation
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Summary Chart of Biologic Agents (cont.)
Agent Type/ Incubation Period
Bacteria/ 1-6 days
AGENT Plague

Fever, cough, dyspnea, hemoptysis, cyanosis, often prominent GI symptoms, rapid deterioration to shock and death. Fever, headache, myalgias, possibly cough, pleuritic chest pain Immediate nausea/vomiting, aphthous-like oral lesions. Then, acute onset of fever, chest pain and cough, progressing to respiratory distress and hypoxemia (1836 hours); not improved with antibiotics; hepatic and renal failure (24-48 hours); death in 36-72 hours. ILI then continued fever and popular rash that begins on the face and extremities and uniformly progresses to vesicles and pustules; headache, vomiting, back pain and delirium are common. Fever, chills, headache, myalgia, non-productive cough, dyspnea, chest pain ILI, can progress to shock.

Inhalation
(Pneumonic)
Q Fever
Bacteria/ 14-29 days
Inhalation
Ricin
Biologic toxin/ Dependent on dose: some immediate symptoms, then 18-36 hours
Inhalation, ingestion
Smallpox
Virus 12-14 days
Inhalation
Staphylococcal Toxin from bacteria/ 3-12 hours Enterotoxin B
Inhalation or ingestion
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Summary Chart of Biologic Agents (cont.)
Agent Type/ Incubation Period
Biologic toxin/ minutes
AGENT T-2 Mycotoxins

Abrupt onset of mucocutaneous and airway irritation including skin (pain, blistering, sloughing), eye (pain and tearing), gastrointestinal (bleeding, vomiting and diarrhea), and airway (dyspnea and cough), can progress to shock. Fever, chills, headache, malaise, sore throat, cough, chest pain, abdominal pain, anorexia, vomiting, diarrhea, often a pulse-temperature deficit. Fever with mucous membrane bleeding, petechiae, and hypotension in a patient without underlying malignancy

Inhalation, ingestion, skin exposure
Tularemia
Bacteria/ 1-21 days
Inhalation
Viral Hemorrhagic Fever

(e.g., Ebola)
Virus/ 2-19 days
Inhalation and ingestion (fomites)
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents
Anthrax
FIELD: Supportive care (for shock and hypoxia) HOSPITAL: IV Ciprofloxacin IV Doxycycline IV Penicillin G *Adult: 400 mg q 12 hrs 100 mg q 12 hrs 4 million Uq 4 hrs Pediatric: 10-15 mg/kg q 12 hrs Not recommended in children < 12 yrs: 50,000 U/kg q 6 hrs > 12 yrs: 4 million U q 4 hrs
MASS CASUALTY and PROPHYLAXIS: *Adult: PO Ciprofloxacin PO Doxycycline PO Amoxicillin Vaccine: Therapy should be continued for 60 days. Oral therapy should be substituted for IV when patient condition improves. Ideally post-exposure prophylaxis will include vaccine. In this case, antibiotics should be given for 30 days concurrent with vaccination. If no vaccine is available, antibiotic therapy should continue for 60 days for post-exposure prophylaxis. *Immunosuppressed persons receive the same as non-immunosuppressed persons. The appropriate regimens for pregnant women should be determined at the time using the consensus recommendations published in JAMA 1999; 281(18):1735-1745. (Ciprofloxacin is the only drug with an FDA indication for prophylaxis against aerosol Anthrax. It has been studied in animals but little experience in humans exists; other fluoroquinolones are also assumed to be effective.) 500 mg q 12 hrs 100 mg q 12 hrs 500 mg q 8 hrs Pediatric: 10-15 mg/kg q 12 hrs Not recommended in children < 20 kg: 13 mg/kg q 8 hrs > 20 kg: 500 mg q 8 hrs
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Anthrax (cont.) INFECTION CONTROL: Transmission via direct contact is possible; however, there is no data to suggest patient-to-patient transmission occurs. Observe standard barrier precautions. Measures for airborne protection are not indicated. Use standard disinfectants to clean surfaces. Notify laboratory of suspicion of anthrax so safe specimen handling can occur under Bio-Safety Level 2 conditions. Cremate bodies if possible. DECONTAMINATION: With announced threats, any person coming in direct physical contact with a substance alleged to be Anthrax should perform thorough washing of the exposed skin and articles of clothing with soap and water. Further decontamination of directly exposed persons or of others is not necessary.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Botulism FIELD: Supportive care HOSPITAL: Supportive care Polyvalent antitoxin, 10 ml over 20 minutes after skin testing. If wound botulism: dbride wound Administer appropriate antibiotics (e.g., Penicillin) PROPHYLAXIS: Consider antitoxin for those who have been exposed to toxin. INFECTION CONTROL: Observe standard barrier precautions. Wash hands after handling soiled clothes/diapers.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Brucellosis FIELD: Supportive Care HOSPITAL: Adult:
Doxycycline 200 mg q day Tetracycline 500 mg QID Rifampin 600-900 mg q day Streptomycin 1 gm q day Gentamicin 3-5 mg/kg in 3 doses q day Trimethoprim/ Sulfamethoxazole (TMX) Combination therapy is recommended (e.g., Doxycycline + Rifampin). Therapy should be continued for 6 weeks. The appropriate therapy for pediatric, Immunosuppressed and pregnant patients should be determined at the time using current references. Consider TMX + Rifampin for children < 8 years of age. PROPHYLAXIS: None recommended at present. INFECTION CONTROL: Transmission via direct contact is possible. Observe standard barrier precautions, drainage and secretion precautions for open lesions. Clean or decontaminate rooms with standard disinfectants. Launder clothing and linens as per hospital protocol. Notify laboratory of suspected infection so safe specimen handling can occur.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Cholera FIELD: Supportive care, oral hydration (electrolyte replacement drink if possible) HOSPITAL: Continue hydration (oral or IV) and Adult*: Ciprofloxacin Doxycycline Tetracycline 1 gm or 250 mg QD 300 mg x 1 day 500 mg QID Pediatric: Not recommended for children Not evaluated 500 mg/kg in 4 doses QD
Therapy should be continued for 3 days unless indicated otherwise. * Immunosuppressed persons receive the same as non-immunosuppressed persons. The appropriate regimens for pregnant women should be determined at the time. PROPHYLAXIS: Possibly oral vaccination INFECTION CONTROL: Transmission via direct or indirect contact with feces. Identify cases and implement proper enteric precautions. Disseminate information about enteric precautions (especially proper hand washing) to the public. Identify and assess contacts of cases. Provide prophylaxis (similar to treatment but use current references) to contacts if there is a high likelihood of transmission. Implement contact surveillance.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Encephalitis (Venezuelan, Eastern, Western) FIELD: Supportive care HOSPITAL: Supportive Care PROPHYLAXIS: None INFECTION CONTROL: Observe standard barrier precautions. Clean or decontaminate with standard disinfectants. Launder clothing and linens as per hospital protocol.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Plague FIELD: Supportive care (strict respiratory isolation) HOSPITAL: Adult*: IM Streptomycin IM or IV Gentamicin IV Ciprofloxacin IV Doxycycline IV Chloramphenicol Pediatric:
1 gm q 12 hrs 5 mg/kg q 12 hrs (max = 2 g) 5 mg/kg QD or 2 mg/kg then 1.7 mg/kg q 8 hrs 400 mg q 12 hrs 15 mg/kg q 12 hrs 200 mg IV QD or < 45 kg: 2.2 mg/kg q 12 hrs 100 mg q 12 hrs >45 kg: give adult dosage 25 mg/kg q 6 hrs 25 mg/kg q 6 hrs
Therapy should be continued for 10 days. Oral therapy should be substituted for IV when patient condition improves. MASS CASUALTY or PROPHYLAXIS: *Adult: PO Doxycycline PO Ciprofloxacin PO Chloramphenicol 100 mg q 12 hrs 500 mg q 12 hrs 25 mg/kg q 6 hrs Pediatric < 45 kg: 2.2 mg/kg q 12 hrs > 45 kg: give adult dosage 20 mg/kg q 12 hrs 25 mg/kg q 6 hrs
Therapy for mass casualty should be continued for 10 days; for post-exposure prophylaxis therapy should be continued for 7 days. * Immunosuppressed persons receive the same as non-immunosuppressed persons. The appropriate regimens for pregnant women should be determined at the time using the consensus recommendations published in JAMA 2000; 283(17):22812290.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Plague (cont.) INFECTION CONTROL: Transmission via respiratory droplets is possible. Identify and isolate all cases in whom pneumonic plague is suspected. Identify contacts of cases and provide prophylactic antibiotics and contact surveillance (especially those refusing antibiotics). Provide antibiotic prophylaxis to all health care workers and all other essential disaster response personnel (police, firefighters, transit workers, public health, medical examiner and mortuary staff) that might encounter close contact (< 2 meters) with patients with confirmed pneumonic plague. Personnel with close contact to cases should observe strict respiratory droplet precautions (gown, gloves, mask (surgical or HEPA mask), and eye protection). Patients should be in isolation rooms with negative pressure and high-efficiency particulate air filtration during the first 48 hours of therapy. If patient isolation is not possible, cohort patients to contain respiratory droplets. Clean or decontaminate with standard disinfectants. Launder clothing and linens as per hospital protocol. Notify laboratory of suspected plague so safe specimen handling can occur. Cremate bodies if possible. DECONTAMINATION: With announced threats, any person coming in direct physical contact with a substance alleged to be plague should perform thorough washing of the exposed skin and articles of clothing with soap and water. Further decontamination of directly exposed persons or of others is not necessary. The plague bacillus is sensitive to sunlight and heating does not survive long outside the host. In a World Health Organization analysis, a plague aerosol was estimated to be effective and infectious for as long as 1 hour.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Q Fever FIELD: Supportive care HOSPITAL: Doxycycline Tetracycline Adult: 100 mg bid 500 mg QID
Alternative agents include: Rifampin, Chloramphenicol, Fluoroquinolones, and Trimethoprim. Duration of therapy varies depending on disease manifestation and patient condition. Determine appropriate therapy and duration at the time using current references. PROPHYLAXIS: Currently none recommended; consider Doxycycline, Tetracycline, or Fluoroquinolones. INFECTION CONTROL: Transmission via direct contact is possible. Observe standard barrier precautions. Disinfect fresh concentrations of blood, sputum and emesis with bleach solutions. Clean or decontaminate routinely with standard disinfectants. Launder clothing and linens as per hospital protocol.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Ricin FIELD: Supportive care HOSPITAL: Supportive care, if toxin was ingested, decontamination of GI tract. PROPHYLAXIS: None recommended INFECTION CONTROL: None recommended
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Smallpox FIELD: Supportive care HOSPITAL: Supportive care, antibiotics as indicated for secondary bacterial infections PROPHYLAXIS: Vaccination INFECTION CONTROL: Person-to-person transmission possible via aerosol. Immediately isolate all individuals in whom smallpox is suspected, preferably at home. Vaccinate and place under contact surveillance all household and other face-to-face contacts of smallpox cases. Vaccinate all health care workers at clinics or hospitals that might receive patients and all other essential disaster response personnel, such as police, firefighters, transit workers, public health staff and medical examiner and mortuary staff. Furlough employees for whom vaccination is contraindicated. If admitted to a hospital, confine patients to negative pressure rooms with highefficiency particulate air filtration. Consider designating a specific hospital for patients requiring hospitalization. Observe standard barrier precautions using gloves, gowns and masks. Adopt a special protocol for decontaminating rooms using consensus recommendations in JAMA 1999; 281(22):59-69. Place all laundry and waste in biohazard bags and autoclave before laundering or incinerating. Launder in hot water with added bleach. Clean surfaces with standard disinfectants. Cremate bodies. DECONTAMINATION: With announced threats, any person coming in direct physical contact with a substance credibly alleged to be smallpox should perform thorough washing of the exposed skin. Articles of clothing and other contaminated objects should be autoclaved or washed in hot water with bleach.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Staphylococcal Enterotoxin B FIELD: Supportive care HOSPITAL: Supportive care PROPHYLAXIS: None recommended INFECTION CONTROL: Observe standard barrier precautions. Clean or decontaminate with standard disinfectants. Launder clothing and linens as per hospital protocol. Tricothecene Mycotoxins (T2) FIELD: Supportive care, eye irrigation if needed HOSPITAL: Supportive care PROPHYLAXIS: None recommended INFECTION CONTROL: Observe standard barrier precautions. Clean or decontaminate with standard disinfectants. Launder clothing and linens as per hospital protocol.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Tularemia FIELD: Supportive care HOSPITAL: Preferred: IM Streptomycin IM or IV Gentamicin Alternatives: IV Doxycycline IV Chloramphenicol IV Ciprofloxacin 100 mg bid 15 mg/kg QID 400 mg bid > 45 kg: 100 mg bid < 45 kg: 2.2 mg/kg bid 15 mg/kg QID 15 mg/kg bid Adult: 1 gm bid 5 mg/kg QD Pediatric: 15 mg/kg bid 2.5 mg/kg IM/IV tid
Therapy with Streptomycin, Gentamicin, or Ciprofloxacin should continue for 10 days. Therapy with Doxycycline or Chloramphenicol should continue for 14-21 days. The treatment of pregnant women is similar to other adults excepting the use of Chloramphenicol. See consensus recommendations in JAMA 2001; 285(21):2763-73 for additional information and for treatment of immunosuppressed persons. MASS CASUALTY or POSTEXPOSURE PROPHYLAXIS: Preferred: PO Doxycycline PO Ciprofloxacin Adult: 100 mg bid 500 mg bid Pediatric: > 45 kg: 100 mg bid < 45 kg: 2.2 mg/kg bid 15 mg/kg bid
Therapy with all agents should continue for 14 days.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Tularemia (cont.) INFECTION CONTROL: Transmission via direct contact is possible. Observe standard barrier precautions and drainage and secretion precautions for open lesions. Clean or decontaminate with standard disinfectants. Launder clothing and linens as per standard hospital protocol. Notify laboratory of suspected Tularemia so safe specimen handling can occur. Cremate bodies if possible. DECONTAMINATION: With announced threats, any person coming in direct physical contact with a substance alleged to be Tularemia should perform thorough washing of the exposed skin and articles of clothing with soap and water. Further decontamination of directly exposed persons or of others is not necessary.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.) Viral Hemorrhagic Fevers FIELD: Supportive care HOSPITAL: IV Ribavirin (experimental) PROPHYLAXIS: None recommended INFECTION CONTROL: Transmission via direct contact with blood, secretions, organs and semen. Airborne transmission among humans has not been documented. Implement immediate strict barrier precautions with patient in isolation. Restrict contact with non-essential staff and visitors. Restrict testing to the minimum required. Alert laboratory staff of the nature of specimens. Laboratory tests should be done with maximum possible precautions using gloves and biological safety cabinets. Patients secretions, sputum, blood and all objects with which the patient has had contact, including laboratory equipment used to carry out tests on blood, should be disinfected with 0.5% sodium hypochlorite solution or 0.5% phenol with detergent and as far as possible with appropriate heating techniques (e.g., autoclaving, incineration or boiling). Identify contacts of cases and place under contact surveillance. Cremate bodies. 1st dose: 30 mg/kg, then 15 mg/kg q 6 hrs x 4 days then 8 mg/kg q 8 hrs x 6 days
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Treatment Protocols for Biologic Agents (cont.)
References: 1. The Working Group on Civilian Bio-defense. Anthrax as a Biological Weapon: Medical and Public Health Management. JAMA. 1999; 281(18):1735-45. 2. The Working Group on Civilian Bio-defense. Smallpox as a Biological Weapon: Medical and Public Health Management. JAMA. 1999; 281(22):59-69. 3. The Working Group on Civilian Bio-defense. Plague as a Biological Weapon: Medical and Public Health Management. JAMA. 2000; 283(17):2281-90. 4. The Working Group on Civilian Bio-defense. Tularemia as a Biological Weapon: Medical and Public Health Management. JAMA. 2004; 285(21):2763-73. 5. Control of Communicable Diseases Manual, American Public Health Association, 17th Edition, 2000, Edited by James Chin, MD, MPH. 6. Principles of Practice of Infections Diseases, Edited by G.L. Mandell, J.E. Bennett, R. Dolin, 5th Edition, 2000. 7. Medical Management of Biological Casualties Handbook, US Army Medical Research Institute of Infectious Diseases, Third Edition, July 1999.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS Chlorine FACT SHEET 1. Military Designation: None 2. Description: Chlorine is found as an amber liquid or greenish-yellow gas with a very characteristic irritating, pungent odor. Chlorine is severely irritating to the skin, eyes, and respiratory tract. Although generally stored as a liquid, when released, the resulting gas is about two times heavier than air. 3. Non-military Uses: Chlorine is used widely in industrial settings. These may include the organic synthesis and manufacture of antifreeze agents, solvents, refrigerants, resins, bleaching agents, and other inorganic chemicals. There is an exceptionally wide use of chlorine in non-commercial and home settings as a cleaning agent, bleaching agent, bacteriostatic, and disinfecting agent. Storage of this substance in a variety of liquid and granular forms is widespread. 4. Military Use: Chlorine was first used by the German military on 22 April 1915 in a cylinder-released gas attack that resulted in an estimated 15,000 Allied wounded and 5,000 Allied deaths. Because of its tendency to dissipate rapidly, very large concentrations were required. Chlorine was weaponized in projectiles, mortars and bombs. There is no current chlorine weaponry. 5. Health Effects: Chlorine exposure causes an immediate severe irritation to the eyes and mucous membranes. The upper airways are first involved with nose, throat, and sinus irritation. The lower airways are irritated with severe cough and chest pain. There may be nausea, vomiting, and fainting. Very high doses may cause significant pulmonary edema. Wheezing is likely to occur in individuals with a history of pre-existing asthma. Bronchitis often occurs, sometimes progressing to pneumonia. High concentrations also irritate the skin, causing burning, itching and occasional blister formation. There is no animal or human epidemiological data to suggest that chronic chlorine exposure may cause cancer or the occurrence of adverse developmental effects in the unborn fetus. 6. Environmental Fate: Chlorine is not persistent in surface water, ground water, or soil. Oxidation of environmental organic materials occurs rapidly, reducing its concentration rapidly. Dispersal of chlorine gas is rapid into the atmosphere.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) CHLORINE TREATMENT PROTOCOL 1. Information Required: History: exposure to a greenish-yellow gas with a pungent, acrid odor Symptoms: low dose; cough, eye irritation and lacrimation, chocking sensation Higher dose; hoarseness, wheezing, severe cough, sudden collapse due to laryngospasm 2. Objective Findings: Lacrimation Voice hoarse Skin erythema Increased work of breathing Wheezing Cough Cyanosis 3. Treatment:
BLS/FIRST RESPONDER Supportive Care. Eyes: flush with copious amounts of water. Skin: flush with copious amounts of water. High flow O2 if respiratory symptoms. If bronchospasm present, administer Epinephrine (1:1,000) 0.3 mg IM or SQ x 1 in severe cases. Albuterol nebulizer treatment if evidence of bronchospasm; repeat as necessary. Consider intubation for stridor/severe dyspnea/hypoxia/chest pain. Consider surgical/needle cricothyrotomy for laryngospasm if unable to maintain airway with BLS maneuvers or intubation. Continue Albuterol nebulizer therapy. IV access with NS TKO.
ALS HOT ZONE
ALS WARM/COLD ZONE
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) CHLORINE TREATMENT PROTOCOL (cont.)
HOSPITAL Continue Inhalational Beta-2 agonist bronchodilator therapy. If hypoxia continues, consider intubation. Be prepared for Adult Respiratory Distress Syndrome (ARDS); treat pulmonary edema with intubation and consider Positive End Expiratory Pressure (PEEP). Use diuretic therapy with caution due to risk of hypotension.
4. Precautions and Comments: All patients who have had a moderate or high level of exposure (respiratory distress or airway symptoms upon exam by EMS personnel) should be referred to a medical facility for examination and treatment. If utilized, the ETTs placement and patency must be strictly maintained at all times. Confirm ETT position (reassessed and documented) with any patient transfer. Confirm by direct visualization and/or end-tidal CO2 detection device.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) Hydrogen Cyanide and Cyanogen Chloride FACT SHEET Military Designation: AC (hydrogen cyanide) and CK (cyanogen chloride) Description: Both of these substances are liquids, but they vaporize (evaporate) at about 73 degrees F, so they will be in gaseous under most temperate conditions. AC has an odor of bitter almonds (which a percentage of the US population cannot smell); CK is pungent. AC is lighter than air, whereas CK is heavier than air. Cyanogen chloride is quickly metabolized to cyanide once absorbed into the body, and causes the same biological effects as hydrogen cyanide. In addition, CK is irritating to the eyes, nose and throat (similar to riot control agents), whereas AC is nonirritating. Non-military Uses: Large amounts of cyanide (most in the form of salts) are produced, transported and used by US industry. Cyanide is used in fumigation, photography, extraction of metals, electroplating, metal cleaning, tempering of metals, and the synthesis of many compounds. Hydrogen cyanide is released when wool, synthetic fibers and plastic burns. Military Use: The French and English used small amounts of cyanide during World War I, but the compound was not effective as a weapon because the amount needed is large and because cyanide, being lighter than air, drifted away from the target. Japan allegedly used cyanide against China before World War II and Iraq allegedly used cyanide against the Kurds in 1988. The US once had cyanide munitions, but all known stocks are believed to have been destroyed. Health Effects: Cyanide blocks the use of oxygen in cells of the body and thus causes cellular asphyxiation. The cells of the brain and heart are most susceptible to its effect. High concentrations of vapor may cause a brief increase in rate and depth of respirations (in 15 seconds), seizures (30 seconds) and cessation of breathing (3-5 minutes) and cardiac arrest and death (4-10 minutes). A smaller concentration will cause headaches, flushing, lightheadedness and other non-specific complaints. In addition, CK produces irritation of the eyes, nose and airway. Antidote (Sodium Thiosulfate) can be effective if administered in time. A large exposure may result in prolonged neurologic damage, secondary to hypoxia. Environmental Fate: Because of their volatility, these substances are not expected to persist in surface water or soil.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.)
HYDROGEN CYANIDE AND CYANOGEN CHLORIDE TREATMENT PROTOCOL
1. Information Needed: Exposure to a vapor or liquid that some patients may complain had a bitter almond smell or upper airway and eye irritation. Other patients may not notice anything unusual in their environment and may complain of: nausea headache anxiety agitation weakness muscle tremors 2. Objective Findings: Altered LOC: anxiety, agitation, stupor, coma Transient hyperpnea, followed by seizures, apnea and cardiovascular collapse Tremor Normal pupils Cough Diaphoresis 3. Treatment:
BLS/FIRST RESPONDER ALS HOT ZONE ALS WARM/COLD ZONE HOSPTIAL Supportive Care. High flow of O2 if available. Cardiac monitor. NS IV access. Sodium Thiosulfate IV: Adult dose: 12.5 grams (50 ml) Pediatric dose: 0.4 mg/kg Intubate and ventilate if apneic. Supportive care, including: Intubation & ventilation if necessary. Sodium Bicarbonate for acidosis ABG monitoring.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) HYDROGEN CYANIDE AND CYANOGEN CHLORIDE TREATMENT PROTOCOL (cont.) 4. Precautions and Considerations: Do not remove PPE to check for bitter almond smell. Pulse oximetry is of limited use in Cyanide poisoning. If the patient is symptomatic and O2 saturation is high, this may indicate either severe poisoning or the absence of Cyanide. If the patient is symptomatic and the O2 saturation is low, this may indicate another co-intoxicant or concurrent medical problem along with Cyanide that may be amendable to other treatment, such as bronchodilation. Nitrate therapy, such as Amyl Nitrate or Sodium Nitrate, has significant side effects and is not useful in empiric treatment. Most Cyanide treatment kits contain these drugs. Do not use them.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) Methylene Diphenyl Isocyanate (MDI), Methylene Diisocyanate, and Methyl Isocyanate (MIC) FACT SHEET Military Designations or Military Unique Use: None Description: MDI is found as a solid in white to yellow flakes. Various liquid solutions are used for industrial purposes. There is not odor to the solid or liquid solutions. The vapor is approximately eight times heavier than air. This chemical is a strong irritant to the eyes, mucous membranes, skin and respiratory tract. It is also a very potent respiratory sensitizer. Non-military Uses: Very large quantities of MDI are produced, transported, and used annually in the US. Various industrial processes utilize MDI in production of polyurethane foams, lacquers and sealants. MDI is a commonly used precursor in the industrial production of insecticides. Noncommercial uses of polyurethanes, such as in isocyanate paints or in cutting of uncured urethanes, may also cause exposure. Thermal degradation of these substances may produce MDI as a byproduct of combustion Health Effects: MDI as either a solid or liquid solution is a strong irritant to the eyes and the skin, resulting in discomfort and burning sensation. Severe inflammation may occur, along with irritation of the respiratory tract and bronchospasm. Very high concentrations may result in severe respiratory distress and pulmonary edema. MDI vapor is a strong sensitizer of the respiratory tract and may result in an asthma manifestation in individuals both with and without prior history of the disease. This sensitization may persist indefinitely. Repeated or long term exposure may result in permanent respiratory or skin problems. Environmental Fate: MDI / MIC is expected to remain almost entirely in vapor phase when released into the atmosphere.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) MDI / MIC TREATMENT PROTOCOL 1. Information Needed: Exposure to a white or yellow solid, or a heavier than air vapor Eye, mucous membrane or skin irritation Allergic symptoms such as wheezing, shortness of breath or urticaria 2. Objective Findings: Increased work of breathing Wheezing Cough Increased secretions and lacrimation Erythema of skin 3. Treatment:
BLS/FIRST RESPONDER ALS HOT ZONE Supportive Care. Eyes or skin irritation: flush with copious amounts of water as is feasible. High flow O2 if respiratory symptoms. If bronchospasm present, administer Epinephrine (1:1,000) 0.3 mg IM or SQ x 1 in severe cases Albuterol nebulizer treatment if evidence of bronchospasm; repeat as necessary. Consider intubation for stridor/severe dyspnea/ chest pain. Consider surgical/needle cricothyrotomy for laryngospasm if unable to maintain airway with BLS maneuvers or intubation. Continue Albuterol nebulizer therapy. IV access with NS TKO.
ALS WARM/COLD ZONE
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) MDI / MIC TREATMENT PROTOCOL (cont.)
HOSPTIAL Continue Inhalational Beta-2 agonist bronchodilator therapy. Solu-Medrol 125 mg IV. If hypoxia continues, Intubate and maintain oxygenation. Be prepared to treat ARDS; treat pulmonary edema with PEEP. Use diuretic therapy with caution due to risk of hypotension. Utilize Morphine Sulfate or Codeine for pain/cough suppression.
4. Precautions and Comments: All patients who have had a moderate or high level of exposure (respiratory distress, GI or cardiovascular signs or symptoms on exam by EMS personnel) should be referred to a medical facility for examination and treatment. If utilized, the ETTs placement and patency must be strictly maintained at all times. Confirm ETT position (reassessed and documented) with any patient transfer. Confirm by direct visualization and/or end-tidal CO2 detection device.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) Mustard (Sulfur Mustard) FACT SHEET Military Designations: H; HD; HS Description: Mustard is a blister agent that causes cellular damage by interfering with DNA function. It is a colorless to light yellow to dark brown oily liquid with the odor of garlic. It is not derived from, or chemically related to edible mustard. It does not evaporate readily, but may pose a vapor hazard in warm weather. It is a vapor and liquid hazard to skin and eyes, and a vapor hazard to airways. Its vapor is five times heavier than air. Non-military Uses: Sulfur mustard has been used as a research tool to study DNA damage and repair. A related compound, nitrogen mustard, was the first cancer chemotherapeutic agent and is still used for some purposes. Military Uses: Mustard was used extensively in World War I and was the largest producer of chemical agent casualties during that war. Mustard was used by Iraq against Iran in the 1980s. The US has a variety of munitions filled with sulfur mustard, including projectiles, mortars and bombs. Health Effects: Mustard damages DNA in cells, which leads to degradation of cellular function and cell death. Mustard penetrates skin and mucous membranes very quickly, and cellular damage begins within minutes. Despite this cellular damage, clinical effects may not become apparent until hours later; the range is 2 to 24 hours. The initial effects are in the eyes, skin and airways. After high doses, the effect is progressive from irritation to ulceration (cornea), blistering (skin), alveolar damage (lungs), gastrointestinal tract (vomiting & diarrhea) and suppression of bone marrow (pancytopenia). There is no specific antidote. Mustard may produce carcinogenic, developmental damage, airway stenosis and other long term effects. Environmental Fate: Persistence of mustard may last for weeks in the soil; deeper levels may be contaminated for years. Mustard is relatively insoluble in water; once dissolved, however, it breaks down into nontoxic byproducts.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) MUSTARD TREATMENT PROTOCOL 1. Information Needed: Exposure to a colorless to light yellow or dark brown oily liquid Odor of garlic Onset of signs and symptoms usually 4 to 8 hours after exposure 2. Objective Findings: Eyes: irritation, redness, foreign body gritty sensation Skin: erythema progressing to clear vesicles and blisters Cough Mucous membranes/airway: hoarseness/stridor 4 Sinus pain 4 Cough 4 Dyspnea 3. Treatment:
BLS/FIRST RESPONDER ALS HOT ZONE ALS WARM/COLD ZONE Supportive Care. None. Thorough decontamination especially important. Intubation, ventilation if needed. Flush eyes if symptomatic. Standard burn treatment for blistered areas. Preserve body temperature if blistered areas are large. Utilize mydriatic with sunglasses if photophobia is present. Topical antibiotic if evidence of significant conjunctivitis or keratitis may be useful. Control pain with systemic analgesic such as Morphine Sulfate or Codeine. Continue burn treatment for blistered areas. Humidified O2, bronchodilators, Codeine for cough suppression if symptomatic. Intubation and preservation of oxygenation if chemical pneumonitis develops. Monitor CBC for bone marrow suppression.
HOSPITAL
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) MUSTARD TREATMENT PROTOCOL (cont.) 4. Precautions and Comments: Liquid or vapor mustard penetrates the skin and mucous membranes and damages cells within minutes of exposure, so decontamination must be done immediately after exposure. Mustard agent can be very persistent; all surfaces with potential contamination must be carefully cleaned before assumed to be decontaminated.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) Nerve Agents FACT SHEET Military Designations: GA (Tabun); GB (Sarin); GD (Son): GF and VX. Description: Nerve agents are very toxic organophosphorus compounds that have biological activity similar to that of many insecticides. There is variable volatility, with some agents more likely than others to pose a toxic hazard by inhalation, and some agents likely to persist longer than others. All are wellabsorbed across the skin. Under temperate conditions, the liquids are clear, colorless, and mostly odorless. They cause biologic effects by inhibiting acetylcholinesterase, thereby allowing acetylcholine to accumulate and cause hyperactivity in the muscles, glands and nerves. Non-military Use: None. Military Use: Nerve agents were first synthesized pre-World War II, but were not used during that war. They were allegedly used by Iraq in its war with Iran. The US has a large stockpile of GA and VX weapons that are in the process of being destroyed. Health Effects: Nerve agents are among the most toxic chemical agents. Initial effects from small amounts of agent differ depending on the route of exposure. After a small vapor exposure, there is the immediate onset of effects in the eyes (miosis), the nose (rhinorrhea), and the airways (dyspnea due to wheezing and increased secretions). After a small skin exposure, there may be an asymptomatic interval of a few minutes to a few hours before the onset of sweating and fasciculations at the site of the droplet, which may be followed by nausea, vomiting and diarrhea. After exposure to a large amount of nerve agent by either route, there may be sudden loss of consciousness, fasciculations, seizures, copious secretions, paralysis, apnea and death. There is usually an asymptomatic interval of minutes after liquid exposure before these occur; effects from vapor occur almost immediately. The antidotes Atropine and Pralidoxime (2Pam) are effective if administered before circulation fails. Environmental Fate: GB will react with water to produce toxic vapors. Most GB spilled will be lost to evaporation. VX is moderately persistent in soil, and because it has low water solubility and low volatility, it could be mobile in surface and ground water systems.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) NERVE AGENT TREATMENT PROTOCOL 1. Information Needed: Eyes: blurry or dim vision Nausea, abdominal pain, cramps, diarrhea Dyspnea Tremors Weakness 2. Objective Findings: Mild: 4 Miosis 4 Rhinorrhea 4 Excess secretions 4 Diaphoresis 4 Vomiting 4 Diarrhea Severe: 4 Decreased level of consciousness 4 Fasciculations and muscle weakness 4 Seizures 4 Muscle paralysis leading to apnea and death 3. Treatment:
MILD EXPOSURE BLS/FIRST RESPONDER ALS HOT ZONE Supportive Care. SEVERE EXPOSURE Supportive Care. Atropine: Adult: 2 mg IM Infant: 0.05 mg/kg IM Repeat as needed 2-PAM 1 gram IM Ativan 2 mg IM for seizures
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) NERVE AGENT TREATMENT PROTOCOL (cont.)
MILD EXPOSURE ALS WARM/COLD ZONE IV access Atropine: Adult: 1 mg IV or IM Infant: 0.02 mg/kg, repeat q 5 min. Repeat Atropine as needed IV Pralidoxime (2-PAM) Adult: 1-2 gram Infant & child: 20-40 mg/kg SEVERE EXPOSURE IV access Repeat Atropine as needed IV 2-PAM Adult: 1-2 gram IM or IV; Infant & child: 20-40 mg/kg Treat seizures with Ativan (admin. over 25 min. slow IV): Adult 1-2 mg, repeat as needed; Infant & child 0.1 mg/kg, repeat at 0.05 mg/kg in 10 min. if needed. Continue Atropine and 2-PAM as needed Treat acidosis as needed
HOSPITAL
Continue Atropine and 2-PAM as needed (2PAM infusion is preferred over repeat boluses; give 200-500 mg/hr titrated based on improvement in muscle weakness)
4. Precautions and Comments Nerve agent poisoning can be very toxic. Large amounts of Atropine may need to be utilized (in the 100s of mgs). If the patient is initially symptomatic and no response is seen to the initial doses of medication, continue giving until a response is achieved. If the patient has enough symptoms to require Atropine treatment, they should also receive 2-PAM. In MCI nerve agent poisoning, consider the following dosage scheme for Atropine (and possibly 2-PAM) administration via auto-injectors in the hot zone:
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) CHEMICAL AGENTS (cont.) NERVE AGENT TREATMENT PROTOCOL (cont.)
* USE 3 AUTOINJECTORS IF:
USE BETWEEN 1 AND 3 ATROPINE AUTOINJECTORS IF:

(attempt to titrate dose)
DO NOT USE AUTOINJECTORS IF:
One or more signs of life, 2 or more signs of poisoning and: At least one sign of life (breathing, pulse, or conscious) Exhibiting 2 or more signs of poisoning (in addition to miosis) Non-ambulatory Elderly appearing No sign of life
Children appearing under age 14
Ambulatory
Prolonged extrication (if not expected to die). May need more than 3 auto-injectors and possibly 2-PAM. No seizures
Fits non-resuscitation group (expected to die) due to other, concomitant injury.
Seizures
No seizures
Bronchospasm and respiratory secretions are the best acute symptoms to monitor for response to Atropine/2-PAM therapy.
* If symptoms are severe, 3 Atropine auto-injectors and 3 2-PAM autoinjectors should be administered in rapid succession (stacked).
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Radiation Injury FACT SHEET Military Designations: None. Description: Radiation injury situations can be classified into two distinct scenarios: Detonation of a nuclear bomb (fission or fusion device) and contamination of people with radioactive material by a mechanism other than a nuclear bomb (e.g. a conventional explosive with radioactive covering or spilled radioactive materials). Non-military Use: Radioactive materials (isotopes) are utilized by hospitals and other health care facilities in many medical procedures, such as bone scans and research laboratory functions. Nuclear fission materials are utilized for power generation in electrical generating plants. Isotope materials are generally more readily accessible than fissionable materials. Military Use: Nuclear bombs utilize fission or fusion to rapidly produce an enormous release of energy from a small amount of material. The resulting blast devastates both the physical environment and the human population that is exposed to it. The only wartime uses of these devices were during World War II on Hiroshima and Nagasaki. Multiple nuclear device testing has been done since that time, much of it underground to minimize health effects. Health Effects: Nuclear Bomb: Health effects would be cataclysmic, and proportional to the explosive power of the device expressed as equivalent tons of TNT. Most current devices are in the 1 to 100 kiloton range (1,000 to 100,000 tons of TNT). Detonation of such a device would result in large numbers of immediate deaths with vaporization of many human remains. Blast injuries (pneumothoraces, closed head injuries, blunt abdominal trauma, spine and limb injuries) would be common along with severe burns all due to the thermal energy released by the device. Health effects due to radiation would be profound and are related to the amount of radioactive energy absorbed by the body, expressed as RADS, which are units of energy absorbed. Radioactive energies released by nuclear bombs are primarily gamma rays, which are short lived (they do not cause residual contamination once the blast is over) but are very powerful and can penetrate most materials. Protective factors are distance from the center of the explosion, material between the patient and the explosion (the more solid, the better) and the parts of the body exposed to radioactive effects.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Radiation Injury (cont.) Health Effects (cont.): Contamination: Health effects from exposure to radioactive contamination are more variable, and likely to be more survivable. Most radioactive contaminants are isotopes; these materials give off some gamma radiation, but more commonly alpha and beta rays, which are easily stopped by physical barriers such as clothing. Radioactive contaminants may be persistent however, and may pose a threat to the rescuer. Examples would be shrapnel wounds from a bomb that are contaminated with isotopes, or liquid radioactive material on the skin. Strict decontamination procedures, similar to those described in the Chemical Agent protocols, are an important part of therapy along with isolating any bodily secretions that may contain contaminants (such as vomitus).
Environmental Fate: Radiation may persist in the ground water and soil for a number of years. The predictable threat level is yet to be determined. The symptoms of radiation exposure are outlined in the following chart:
AMOUNT OF RADIATION EXPOSURE 800 Rads and above 600-800 Rads
ORGAN SYSTEM PREDOMINANTLY AFFECTED Central nervous system Central nervous system
SYMPTOMS
Coma and rapid death Altered LOC, seizures, coma Nausea, vomiting, diarrhea Partial and full-thickness burns See above and below
400-600 Rads
GI tract
200-400 Rads
Skin
200 Rads
This is the LD 50, or 50% of the patients exposed to this amount of radiation will eventually die
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Radiation Injury (cont.) Health Effects (cont.):
100-200 Rads Hematopoietic system (bone marrow, blood cells) Anemia, easy bruising and bleeding (including internal bleeding), secondary infection due to immuno compromise several dys after exposure Tumor development months to years after exposure; thyroid cancer particularly common
Less than 100 Rads
Endocrine and other systems (carcinogenesis, or excessive development of cancers)
0.1 Rad
Exposure from a typical chest X-Ray
RADIATION INJURY TREATMENT PROTOCOL 1. Information Needed: History: Type of exposure (bomb or contamination scenario) 4 Pre-existing medical condition 4 Time since exposure 4 Type of decontamination performed (decontaminate prior to treating patient in contamination situation 4 Age and pregnancy status Symptoms: as outlined in chart above 4 Low-dose Skin and mild GI findings, or no acute symptoms 4 Higher-dose Severe skin destruction, severe GI findings, altered LOC 2. Objective Findings: Burns Blast injuries Spine injury Long bone fractures Vomiting (may be bloody) Diarrhea Altered LOC
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Radiation Injury (cont.) RADIATION INJURY TREATMENT PROTOCOL (cont.) 3. Treatment:
BLS/FIRST RESPONDER ALS HOT ZONE ALS WARM/COLD ZONE HOSPITAL Supportive Care. Skin: cover any burned areas with clean dressings if available. High-flow O2 if respiratory symptoms. Decontamination of skin per Chemical/HazMat procedures. Respiratory support. Consider intubation for stridor/severe dyspnea/ hypoxia/chest pain. Consider needle decompression of chest if blast injury and S/S of tension pneumothorax. Continue burn and other wound dressing. IV access with NS, bolus. Institute appropriate wound and burn care (be aware of possible radioactive contamination of penetrating trauma wounds). Potassium Iodide 130 mg PO for all symptomatic patients, or those exposed to significant radiation per HazMat personnel. Also treat all children < 8 y/o and all pregnant females with Potassium Iodide. Pain management. CBC, including absolute lymphocyte count. Supportive treatment for CNS and GI symptoms. Prophylactic antibiotics not recommended.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.) Radiation Injury (cont.) RADIATION INJURY TREATMENT PROTOCOL (cont.) 4. Precautions and Comments: Follow HazMat radiation exposure plan for decontamination and disposal of all contaminated waste. In the nuclear bomb scenario, the casualty load will likely be excessive. Utilize austere care and mass casualty techniques with strict triaging to maximize available resources. ILLUSTRATION 6.D. HAZMAT ZONES
WARM ZONE
HOT ZONE
PROTOCOL 6.7: HELICOPTER UTILIZATION Indications: A. It is the purpose of this procedure to detail the actions of Rapid City/Pennington County EMS personnel (both ALS and BLS) when considering a request for a scene response by a helicopter during medical and rescue incidents. It is imperative that these requests for scene response are appropriate and operations involving them are conducted safely. This procedure will primarily be directed toward the use of the LifeFlight helicopter resource, but can apply to military helicopters as well. General Principles: A. It is a medically accepted fact that the rapid transport capabilities of the helicopter can potentially reduce the morbidity and mortality of the seriously injured or ill patient in the pre-hospital setting. This is especially true in a primarily rural setting such as western South Dakota. B. Following are some pertinent points to consider, and some guidelines that shall be followed if you find yourself considering requesting a scene response by the LifeFlight or National Guard helicopters. Procedures: A. The LifeFlight helicopter will not always be available for scene response on an immediate basis; it will occasionally be out of the area transferring patients into RCRH from the outlying localities. B. The National Guard Aviation unit is not a 24-hr. on-call service. At times they can fly almost immediately, at other times it may take them two hours or more to put a helicopter in the air. This being dependent on the time of day, day of week, time of year, weather, etc. C. Whenever a response by the LifeFlight or National Guard helicopter is considered, the first piece of information that should be gathered is whether or not the helicopter is immediately available and the time required to launch the helicopter and fly to the scene. This information can be obtained through Dispatch. This estimated time should be compared to the time it will take to utilize ground transport. If a rescue can be affected and ground transport take place in a shorter period of time, a helicopter should not be called. Under no circumstances should transport of a patient be delayed to use a helicopter for transport.
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.) Procedures (cont.): D. A request for a scene response by a helicopter should only be considered for the patient with a life-threatening injury or illness requiring rapid transportation in order to sustain life, or prevent aggravation of the injury or illness. E. A request for a response by a helicopter may be considered in the instance of a patient in a remote, difficult to access by ground, area. This patients injuries or illness may or may not be life-threatening, but a removal by ground may take such an extended period of time that removal by air is a better option for the patient. F. In situations where rescue personnel are considering a vertical extraction by helicopter and a hoist may be needed, keep in mind that the Guard helicopters are not always set up with a hoist. If Guard personnel have to install a hoist before a helicopter is put in the air, it may take an extended period of time and a ground extraction and transport may be more expedient. G. Dispatch launch of the LifeFlight helicopter will be automatic on selected trauma cases (see LifeFlight automatic launch criteria below) outside a 20minute ground travel zone calculated from the geographical center of Rapid City (see Illustration 6.E. 20-Minute Ground Travel Zone below). Ground EMS units will still be dispatched and respond per standard Dispatch protocol. If LifeFlight arrives on scene and ground EMS units are not needed, LifeFlight will cancel them and ground EMS units will return. If LifeFlight requires assistance from ground EMS units, they will continue and assist LifeFlight as needed. H. There will be no automatic Dispatch launch of the LifeFlight helicopter inside the city limits of Rapid City or inside the 20-minute ground travel zone from the center of the city. In most cases, a ground ambulance will be able to transport in a shorter time frame inside this zone. I. A scene response by the LifeFlight helicopter will not be precluded inside the city limits of Rapid City or inside the 20-minute ground travel zone. The senior Paramedic on scene at an incident or responding, may at their discretion, request a scene response by the LifeFlight helicopter. Any such request will be made through Dispatch, keeping in mind the parameters mentioned above. The most likely scenarios for any close-in scene responses will be multiple patient situations (serious MCI) and entrapment with prolonged extrication.
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.) Procedures (cont.): Any request for a scene response for the LifeFlight helicopter inside the city limits or inside the 20 minute ground travel zone will be examined postincident to assure that request for a scene response was appropriate. J. Outside of the 20-minute ground travel zone, first response agencies may make the decision to request a scene response by a helicopter. This may occur when first response agencies are called to an incident and find a situation that meets the criteria for an automatic launch, and initial information to Dispatch was unclear or incomplete to the point of not causing the automatic launch to occur. Any such request will be made through Dispatch, once again, keeping in mind the parameters mentioned above. The outside 20-minute zone automatic launch criteria list should be used as a guideline to determine what types of patients and situations that it would be appropriate to request a scene response for. In all situations where a scene response by a helicopter is being considered, the responding Paramedic should be consulted. In most cases these ALS personnel will usually be in the best position to make an accurate judgment of the time required to affect their own ground transport and help decide if transport by helicopter is or is not in the best interests of the patient.
K. Consideration should be given to possibly utilizing helicopter transport during a Mass Casualty Incident (MCI) keeping in mind the same time frame parameters mentioned previously. The use of helicopters during a MCI will be at the discretion of the IC (Incident Commander) or his designee. L. The transition of patient care from the attending Paramedic on scene to LifeFlight personnel will be the same as any other situation where patient care is transferred. The Paramedic on scene will give a complete face-toface verbal report to the LifeFlight crewmember that will be responsible for the patients continued care. In the instance of National Guard helicopter usage, the attending Paramedic will typically accompany the patient to the hospital in the helicopter. M. All circumstances surrounding a request for a scene response by a helicopter will be fully documented in patient care reports (PCRs) and FD incident report narratives.
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.) Landing Zone (LZ) Procedures: A. Ground EMS units, when requesting a scene response by a helicopter, should not concern themselves with an LZ unless they know of a suitable location at or very near the incident site. In all cases where a scene response has been requested, a Fire Dept engine company (from the jurisdiction where the incident occurred) should be detailed to LZ operations. B. A safe landing zone should be established prior to the helicopters arrival by LZ operations. In the event that the unit assigned to LZ operations experiences difficulties finding a suitable LZ, they should wait until the helicopter arrives. The helicopter may have a better vantage point in choosing an LZ and they will advise LZ operations. In the event that the LZ is remotely located and appears to be safe for landing, the pilot may elect to land without the assistance of LZ operations. This does not mean the unit assigned to LZ operations should be cancelled; they will be utilized for security, safety, and possible assistance with patient loading once the helicopter is on the ground. C. When setting up an LZ there are several things to keep in mind: 1. The pilot will generally determine how small an area he can safely land in, the bigger and freer of obstructions the area is, the better. Keep in mind that wires are very difficult to see from the air, especially at night. An area 100 larger than the rotor tips in all directions is a good starting point. 2. The LZ should be set up as to facilitate takeoffs and landings into the wind. Do not rely on Dispatch for correct wind direction, use visual indicators. 3. The approach and departure ends of the LZ should be clear of obstacles (any object > 40 feet tall that is within 100 feet of the LZ). 4. Any and all loose articles (wood, cans, plastic, sheets, blankets, etc) in the vicinity of the LZ that potentially could be affected by rotor down wash need to be secured or removed. Flying debris can damage both the helicopter and personnel on the ground. 5. If the LZ will be on a surface other than pavement, to minimize the hazard of blowing dirt, dust and sand, the LZ should be wet down as necessary. If the LZ will be on snow, an attempt should be made to clear the snow from the area to prevent it from obscuring the vision of the pilot.
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.) Landing Zone (LZ) Procedures (cont.): 6. No unauthorized person will be permitted to approach the helicopter. This will be the general responsibility of LZ operations. 7. It is not necessary to have a hose line pulled and charged. In the event of a catastrophic event involving the helicopter, strategy and tactics will be left up to the IC (Incident Commander). The pilot is both legally and operationally responsible for the safety of the aircraft. Therefore, the final decision on the suitability of the LZ is that of the pilot.
8.
Safety Procedures: A. Safety should always be of paramount concern when addressing operations involving helicopters. The first question you should ask yourself when youre considering the use of a helicopter is, can this be done safely? The helicopter is not inherently dangerous. The danger manifests itself in the form of people not understanding the potential hazards that exist on or near the helicopter. Following are a few basic safety rules to impart a basic understanding of where the potential dangers exist, and how to work around helicopters safely and effectively. Above all: Stay Alert!!! B. Absolutely no personnel will approach the helicopter until given an all clear by a helicopter crewmember, and then approach only in the pilots field of vision. C. Unless required to be closer, persons should stay 100 away from large helicopters at all times. When approaching nearer than this distance, always approach the helicopter from the side and near the front in full view of the pilot. NEVER approach a helicopter from the rear (tail rotor!). Note: The Blackhawk helicopter used by the National Guard should never be approached from the front, only the side. The main rotor pitches down in front. D. Keep clear of the main rotor and tail rotor at all times. The greatest threat when operating around a helicopter is the turning rotor blade. When the blades are turning, the high-speed tail rotor is virtually invisible! Physical contact with either of the blades while they are turning is almost always fatal.
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.) Safety Procedures (cont.): E. Never approach the helicopter from any side where the ground is higher than where the helicopter is standing or hovering. On uneven ground, always approach and depart the helicopter from the DOWNHILL side if possible. Keep in the pilots field of vision at all times. F. Do not face helicopters when they are landing, taking off, or hovering unless goggles are worn or visor is down. Fire Dept personnel involved in helicopter operations will wear full bunker gear, with collar up, gloves and helmet. Helmets will have chinstraps fastened. G. Avoid approaching a helicopter with long tools, rods, etc. If this is unavoidable, carry such objects horizontally to avoid possible contact with the rotor blades. H. Patients will be secured to backboards with a minimum of three (3) straps unless contraindicated by their medical condition. The feet must be secured at the ankles. If the patient is combative, place an additional strap above the knees. I. All bandages and dressing shall be affixed security. Coverings like sheets and blankets are potential hazards and will be secured or placed underneath straps. A minimum of four (4) personnel, one of which will be a helicopter crewmember, will carry the patient to the helicopter. Loading of the patient into the helicopter will be at helicopter crewmembers direction.
J.
K. The pilot or crewmembers approval shall be obtained first before any gear or personnel are placed in or on the helicopter. L. The pilot is responsible for the safety of his aircraft at all times; his decisions are final in this respect.
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.) Automatic launch criteria Regional LifeFlight Helicopter 911 Dispatch generated, Delta/Echo level trauma, outside 20 min. ground ambulance response zone Animal bites/Attacks Severe CENTRAL injuries Attacks or multiple animals Known poisonous snake Unconscious, not alert Assault Multiple patients (MCI) DANGEROUS injuries (abdomen, chest w/abnormal breathing, head/not alert) Unconscious Burns/Explosions Multiple patients (MCI) Large burns (>18% BSA) Face, airway involvement SEVERE RESPIRATORY DISTRESS Unconscious, not alert Explosion Carbon Monoxide/Inhalation/HazMat Multiple patients (MCI) SEVERE RESPIRATORY DISTRESS Unconscious, not alert Drowning (near)/Diving/Scuba Accident Not breathing Unconscious, not alert Neck/back injury with neuro deficit Electrocution/Lightning Multiple patients (MCI) Not breathing Unconscious, not alert
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.) Automatic launch criteria Regional LifeFlight Helicopter (cont.): Falls DANGEROUS injuries (chest w/abnormal breathing, head/not alert Fall >20 feet Unconscious, not alert Heat/Cold Exposure Unconscious, not alert Hemorrhage/Lacerations DANGEROUS hemorrhage (armpit, groin, neck, rectal (serious), vomiting bright red blood) Unconscious, not alert Industrial/Machinery/Farm Accidents Multiple patients (MCI) LIFE STATUS QUESTIONABLE (existence of any information suggesting: abnormal breathing, cardiac arrest, major injury, unconsciousness, uncontrollable bleeding) Trapped or caught in machinery Stab/Gunshot/Penetrating Trauma (Law Enforcement must secure scene) Multiple patients (MCI) Multiple wounds CENTRAL wounds Unconscious, not alert Traffic/Transportation Accident MAJOR INCIDENT (MCI, any evidence suggesting serious injuries to multiple patients. This includes aircraft, bus, train) Auto vs. pedestrian/bicycle/motorcycle Ejected from vehicle Trapped in vehicle > 20 minutes Vehicle off bridge/height Unconscious Traumatic Injuries (Specific) DANGEROUS injuries (chest w/abnormal breathing, head/not alert, neck/back injury with neuro deficit) Amputation excluding fingers, toes Unconscious, not alert
ILLUSTRATION 6.E. 20 MINUTE GROUND TRAVEL ZONE
Protocol 6.8: Infectious / Communicable Disease General Principles: A. Contact with patients carrying communicable diseases must be taken seriously and the appropriate protective measures taken to substantially reduce or eliminate the potential risk. This will assure not only the continued health and safety of EMS providers, but their families and other patients. B. If an exposure to a communicable disease does occur, the proper follow-up and treatment will minimize any possible effects of the exposure. C. Infection control measures will be addressed by following specific procedures in the following areas: 1. Body substance Isolation and barrier protection. 2. Equipment usage, maintenance and cleaning. 3. Hygiene. 4. Post-exposure follow-up. Definitions: A. Significant Exposure: 1. Direct mouth-to-mouth contact. 2. Any body fluids (including airborne droplets from a cough or sneeze) that come in contact with your: a. b. c. d. Mouth Eyes Nose (or other mucosal surface) Open sore, cut, or rash
3. Needle stick (by contaminated needle or other sharp) or a laceration by any object potentially contaminated with body fluids.
Protocol 6.8: Infectious / Communicable Disease (cont.) Procedures: Body substance isolation and barrier protection A. Body substance isolation practices dictate that all body fluids are to be considered potentially infectious agents and EMS providers will make every effort to avoid being exposed to same. Body substance isolation will primarily be accomplished with barrier protection through the use of personal protective equipment (PPE). The following items of PPE are to be used when and as described. 1. Gloves a. Disposable gloves (non-latex) shall be worn for all patient contacts. b. Gloves shall be changed after each patient contact. c. Cuts, rashes or sores on the hands shall be bandaged in addition to wearing gloves.
d. Structural firefighting gloves shall be worn over disposable gloves (whenever possible) when patient care is combined with extrication activities or any other contact with sharp or rough surfaces. 2. Eye protection a. Eye protection (protective eyeglasses or surgical-type masks with eye shields) shall be worn whenever there is a possibility that blood or other body fluids could be splashed into the providers eyes (e.g. intubation attempts, suctioning, combative patient, etc.). 3. Masks a. Surgical-type masks shall be worn whenever there is a possibility that blood or other body fluids could be splashed into the providers mouth and nose (e.g. intubation attempts, suctioning, combative patient, etc.). These will suffice in situations where no airborne infection threat is suspected.
Protocol 6.8: Infectious / Communicable Disease (cont.) Procedures (cont.): Body substance isolation and barrier protection (cont.) b. Disposable HEPA-filter type masks shall be worn whenever treating patients suspected of possibly carrying infectious airborne disease (TB, Meningitis, etc.) to avoid inhalation of airborne droplets. Any patient with fever, vomiting, cough or known history should be suspect. c. A non-rebreather O2 mask at a minimum of 8-10 LPM may also be put on a patient (if clinical condition and treatment allows) suspected of possibly carrying infectious airborne disease to further contain the threat.
d. A BVM with one-way valve shall be used for patient ventilation when needed. Mouth-to-mouth ventilation will not be done and is considered a Significant Exposure. 4. Gowns, shoe covers a. Gowns and shoe cover shall be worn when conditions permit and there is significant possibility that blood or body fluids could be splashed onto the providers clothes. Equipment usage, maintenance and cleaning A. Disposable equipment shall not be re-used or cleaned, if it is contaminated with body fluids it will be disposed of in a red bio-hazard bag. Red biohazard bags will be disposed of in the larger, red plastic bio-hazard containers found in the stations. Contaminated disposable equipment will not be put in with the regular station trash. B. Used, disposable equipment (including gloves) shall not be left anywhere in vehicles or stations unless disposed of properly in a red bio-hazard bag. C. Needleless supplies will be used whenever possible. Needles will not be recapped; used needles and all sharps will be placed in an approved sharps container after use. When sharps containers are full, they will be disposed of in the larger, red plastic bio-hazard containers found in the stations.
Protocol 6.8: Infectious / Communicable Disease (cont.) Procedures (cont.): Equipment usage, maintenance and cleaning (cont.) D. Hard, non-disposable equipment that becomes contaminated with body fluids will be cleaned with a commercial disinfectant and left to air dry in an area designated for that purpose. Equipment will not be cleaned in the living quarters of stations. E. When equipment is cleaned, it should generally be left to air dry. If it must be wiped off for immediate re-use, paper towels should be used whenever possible and not cloth towels. F. When the patient compartments of ambulances are cleaned, they should be cleaned with a commercial disinfectant and left to air dry with the doors open. Final cleaning may be done with an all purpose cleaner and towels. Cleaning supplies (mops, etc.) used in ambulances should only be used for that purpose. G. Appropriate PPE shall be used whenever cleaning equipment. This will at a minimum include gloves, and possibly a mask and gown if there is a significant splash hazard. H. If cloth towels or blankets become heavily contaminated with body fluids, they should be disposed of properly in bio-hazard bags or containers. If cloth towels and blankets are only lightly contaminated they may be put in linen bags in the stations for commercial cleaning (linen bags are considered to contain bio-hazard materials). I. Porous, non-disposable equipment (backboard straps, cot straps, etc.) that becomes heavily contaminated with body fluids will not be cleaned; it will be disposed of in the larger, red plastic bio-hazard containers found in the stations. When this is done, the Paramedic in charge of medical supply must be notified.
Hygiene A. Hands should be washed as soon as possible after removing gloves after any patient contact (immediately after with a waterless hand cleaner if possible, and then thoroughly with soap and water when available). B. Treat all cuts, rashes or abrasions promptly and cover or bandage them.
Protocol 6.8: Infectious / Communicable Disease (cont.) Procedures (cont.): Hygiene (cont.) C. Vehicles shall not be operated, radio microphones or computers used while wearing gloves used during patient contact. D. In the event of a needlestick type injury, the area should be cleaned with an antiseptic cleaner, then washed thoroughly with soap and water and bandaged. If the injury is a single needlestick, it may be cleaned initially with an alcohol prep, bandaged and then cleaned with soap and water when available. This is a Significant Exposure. E. In the event of body fluids being splashed into a providers face, mouth or nose, the face should be washed thoroughly with soap and water and possibly a shower taken. Eyes should be flushed with water or saline. This is a Significant Exposure. F. Uniforms should be changed and a shower taken if the arms, legs or trunk of the body are significantly exposed to body fluids. G. Uniform items that become contaminated with body fluids will be taken out of service as soon as possible. Items that are lightly contaminated should be sprayed with a commercial disinfectant and either commercially laundered or laundered in a Department washing machine intended for that purpose. Items that are heavily contaminated should have the gross contamination sprayed off (into a sanitary sewer drain), then sprayed with a commercial disinfectant. Those items should then be isolated in bio-hazard bags and referred to the Department Infection Control Officer for disposal or commercial cleaning. Post-exposure follow-up A. Following a Significant Exposure, the exposed individual will report the incident to their direct supervisor immediately, or as soon as is reasonably possible. B. If the exposed individual is actively engaged in patient care, whenever possible, care should be referred to another provider (of the same skill level or higher) so treatment can begin immediately. It is recognized this may not always be possible.
Protocol 6.8: Infectious / Communicable Disease (cont.) Procedures (cont.): Post-exposure follow-up (cont.) C. In all cases of Significant Exposure, the exposed individual will present to the RCRH Emergency Department for evaluation as soon as possible. This will be facilitated by the individuals direct supervisor. In no case should this be delayed any longer then is absolutely necessary. If this situation creates a staffing shortage, the shift commander will shift personnel or hire-back to resolve the shortage. D. The exposed individual will check in at the RCRH Emergency Department and be evaluated by an ED physician. The physician will determine if a Significant Exposure has in fact occurred, and if it has, what the potential threat is. If the exposed individual was determined to have had a Significant Exposure to a confirmed communicable disease, the individual shall undergo whatever treatment and post-exposure prophylaxis (PEP) is deemed advisable by the ED physician and/or the Department physician. E. If information about a source patients communicable disease status becomes available to the ED and the physician, that will be communicated to the exposed individual and the Department Infection Control Officer. F. At all times, information about the source patients identity and the exposed individuals communicable disease status will be kept strictly confidential. That information is protected by law. G. As soon as possible after the exposed individuals initial treatment, the proper paperwork will be completed to document the exposure and provide for follow-up care if needed. The paperwork to be completed will include: 1. 2. 3. 4. Blood/Body Fluid Exposure Notice South Dakota Employers First Report of Injury Workers Compensation Form Supervisors investigation Report
All of these forms will be completed by the end of the exposed individuals shift and forwarded to the Department Operations Chief within 24 hours. H. The Patient Care Report (PCR) pertinent to the exposure will include a description of events relating to the exposure. A copy of the PCR will be included with the other paperwork and copies of all documents will become part of the exposed individuals confidential medical file.
Protocol 6.8: Infectious / Communicable Disease (cont.) Additional Considerations: A. All EMS providers should maintain a high level of awareness and base knowledge relative to common blood borne and airborne diseases. This knowledge should include particular information about the diseases, their symptoms, means of exposure and potential follow-up care that might be provided in the event of a Significant Exposure. B. Vaccination is an important part of disease prevention. The Department provides Hepatitis B vaccination for all new employees, Hepatitis B titer checks and TB checks. Participation in these programs is mandatory if the employee has not already been vaccinated or checked. Documentation of vaccinations and checks will also become part of the employees confidential medical file.
Protocol 6.9: Inter-facility Transport (Critical Care)
Under Construction
Indications: General principles: Definitions: Procedures: Additional Considerations:
Protocol 6.9: Inter-facility Transport (Critical Care) (cont.):
Under Construction
Protocol 6.10: Multiple Casualty Incidents (MCI) Indications: A. Medical or trauma situation involving multiple patients where the combination of numbers of patients and types of injuries exceeds the capabilities of the EMS systems normal on-duty resources. General principles: A. The very nature of the MCI will typically dictate either multi-company and or multi-agency responses. This will require that some degree of Incident Command (IC) structure be established. IC structure should be set up rapidly and efficiently, and only that IC structure that is required to mitigate the incident should be set up. These incidents can deteriorate and patients can die while boxes are being filled in a chart. Note: RCFD Paramedics will seldom be required to fill General Staff IC positions in an incident that is within the city or in close proximity to it. Those positions will typically be filled by RCFD or VFD officers. (This does not preclude the necessity for RCFD Paramedics to be intimately familiar with all levels of IC structure). Dependent on the scope of the incident, RCFD Paramedics may be required to fill positions at the level of Medical Group Supervisor or below. (See Illustration 6.F., MCI IC Flowchart, below). B. The MCI with Biological, Chemical or Radiological implications and contaminated patients will require that patients are decontaminated prior to triage, treatment and transport. If patients are suspected or known to be contaminated, triage should only be accomplished by personnel in the proper level of personal protective equipment (PPE). PPE required for treatment and transport will generally be dictated by the level of decontamination that is able to be done. Haz-Mat operations will be consulted to determine the proper levels of PPE for all operational phases. See Protocol 6.6: Hazardous Materials / WMD Incidents for further information. C. The location of a triage/treatment area is very important; it should fulfill the following criteria as much as is possible: 1. It should be in a relatively safe area, away from the objective dangers of the incident. 2. It should be close enough for access from incident with stretchers. 3. It should be configured to be accessible by multiple transport vehicles, for both ingress and egress. Close coordination should be done with staging (if staging area is established) to assure that vehicles move smoothly in and out of the triage/treatment area.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) General principles (cont.): D. The MCI requires discipline within the team, be sure that leadership and individual roles are well identified and adhered to. Free-lancing only leads to poor patient outcomes and delays. E. The MCI will many times require that treatment decisions be made that fall outside of the normal parameters of EMS operations and ALS protocol. Time and resources should not be expended on patients that have a very poor chance of survival, START triage guidelines (see definition and Illustration 6.G. START Triage algorithm below) should be followed strictly. Definitions: A. For purposes of notification and response, Multiple Casualty Incidents will be classified into three (3) different levels. Level 1 incidents do not need to be declared. Level 2 and level 3 incidents will be declared. Note: When classifying Multiple Casualty Incidents, consideration should be given to the type of incident and the kinds of patients involved. For instance, an incident involving 16 patients and above where all patients are GREEN may not require some actions normally required by the Level 3 MCI classification. Perform those actions that the incident requires. 1. Level 1 MCI: a. Does not need to be declared. b. This will be an incident with a threshold of 5-8 patients. c. Local on-duty resources will be adequate.
d. First-due units will make medical facility notification of numbers and condition codes of patients (Priority, 1, 2, 3) as soon as numbers are known. Routine radio contact with medical facility by transport vehicles will apply.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Definitions (cont.): 2. Level 2 MCI: a. Does have to be declared. b. This will be an incident with a threshold of 9-15 patients. c. Local resources will be impacted, may require all physical RCFD Medic Units to be in service.
d. Dispatch will notify medical facility immediately of possible Level 2 MCI e. IC or designee, (Transport officer/Dispatch) will make medical facility notification of numbers and types of patients as soon as numbers are known. f. Individual transport vehicles will not contact medical facility when transport has begun, IC or designee, (Transport officer) will make medical facility notification of numbers and types of patients being transported.
3. Level 3 MCI: a. Does have to be declared. b. This will be an incident with a threshold of 16 patients and above. c. Local resources will be inadequate; all physical RCFD Medic Units will be in service and outside resources will have to be utilized.
d. Dispatch will notify medical facility immediately of possible Level 3 MCI. e. Dispatch will set off a Medical Strike Team page (list below), advise of a Level 3 MCI and request a response to staging. f. IC or designee, (Transport officer/Dispatch) will make medical facility notification of numbers and types of patients as soon as numbers are known.
g. Medical facility may request transport of some patients to alternative medical facilities.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Definitions (cont.): h. Individual transport vehicles will not contact medical facility when transport has begun, IC or designee, (Transport Officer) will make medical facility notification of numbers and types of patients being transported. B. Medical Strike Team resource list: 1. Hill City 1 ALS ambulance
2. Keystone 1 BLS ambulance 3. Piedmont 1 BLS ambulance 4. Rapid City 2 ALS ambulances, 2 BLS ambulances (if incident is in city or in very close proximity, all physical RCFD Medic Units may be sent. 5. Pennington County Search and Rescue Mass Casualty Trailer. C. START Triage: (Simple Triage And Rapid Treatment) will be the triage method used in the Rapid City/Pennington County EMS system. The START method of triage is designed to assess a large number of patients quickly, and can be used effectively by personnel with limited medical training. The START system triages patients into the following categories: 1. RED
(critical, life-threatening injuries, may survive if treated within 30 minutes)
(Priority 1) Immediate transport (Priority 2) Delayed transport
2. YELLOW
(serious injuries, may be life threatening. Very likely to survive if treated within 30 minutes to several hours)
3. GREEN
(minor injuries, not considered life-threatening. Care may be delayed several hours or in some cases days)
(Priority 3) Ambulatory (minor), alternative transport
4. BLACK
(dead, mortally wounded and expected to die)
(Priority 0) Deceased (non-salvageable)
For explanation of patient sorting through the START triage system see Illustration 6.G. START Triage algorithm below.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Procedures: MCI Operations Procedures are generally broken down into three (3) categories, Triage, Treatment and Transport that typically follow one another chronologically: Triage: A. First due-units of any skill level should begin START triage as soon as immediate threats are mitigated. First-due ALS personnel should assist and supervise this process as necessary. First due-Paramedic will assume role of Triage Officer (this Paramedic may also assume role of Medical Group Supervisor, Treatment Officer and or Transportation Officer depending on the scope of the incident. When span of control is exceeded, these positions should be assigned to other personnel). (See Illustration 6.F., IC Flowchart, below). B. Triage team should be deployed in an organized fashion to save time and avoid duplication of effort. Incidents covering a larger geographical area may be broken down into divisions or sectors with members of the team assigned to triage patients in a certain division. C. As soon as an approximate number of total patients can be obtained, sufficient transport resources should be ordered through Command if they are not already enroute. Consider alternative transport for GREEN patients. D. All GREEN patients (ambulatory / walking wounded / minor) should be separated from other patients and assembled together in a safe area. Assign minimal personnel (can be non-medical personnel initially) to keep them together and notify Command of their location. Do not forget these patients, they should be re-triaged as soon as is possible. E. Initial triage of all non-ambulatory patients should be performed where they lay if the area is safe, if a hazard exists, patients should be moved to a safe triage area. Triage should take 30 seconds or less, No treatment should be performed during the triage phase other than opening airways and inserting OPAs or NPAs. F. Initial triage should be performed utilizing Triage Ribbons (color coded plastic strips). One should be tied to an upper extremity in a VISIBLE location (wrist if possible). A short strip of the color ribbon utilized may be retained to assist in documentation of numbers and types (priority) of patients.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Procedures (cont.): Triage (cont.): G. Independent decisions should be made for each patient. Do not base triage decisions on the perception of too many REDs, not enough GREENs, etc. If borderline decisions are encountered, always triage to the most urgent priority (eg. GREEN /YELLOW patient - tag YELLOW). H. Once a patient reaches a triage level in the START algorithm, triage of this patient should stop and the patient should be tagged accordingly. I. Patients tagged BLACK should not be moved if at all possible until Law Enforcement has been consulted. (Note: Per National Transportation Safety Board (NTSB) regulations, aviation crash fatalities should not be moved until cleared to do so by a NTSB representative) If absolutely necessary, they can be moved to facilitate ingress and egress, but advise Law Enforcement as soon as possible if this has to be done (try to remember patients original position if possible).
Treatment: A. After initial triage is complete, secondary triage will be performed on all patients before they are transported. Secondary triage is typically performed when patients are moved to a triage/treatment area, but the scope of the incident will determine this. If the incident dictates there is no separate triage/treatment area, then all phases of triage and treatment may be performed on patients where they lay. During secondary triage, the patient will be re-assessed using the same START triage method (30 seconds or less). Triage Tags (METTAGs) (See Illustration 6.H., METTAG Triage Tag, below) will be utilized and affixed to the patient. Note: Once RED tagged patients are found at any level of triage, they should be transported immediately as transport units become available. These patients should not be delayed with prolonged secondary triage or treatment, they should have Triage Tags affixed and be transported expeditiously.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Procedures (cont.): Treatment (cont.): METTAG use: 1. Affix Triage Tag to one of the patients extremities (preferably a wrist if possible) and remove the ribbon. Do not affix Triage Tags to a patients clothing. 2. The ends of the METTAG Triage Tag will be removed to leave the colored portion matching the patients condition (ie. if the patient is determined to be in Priority 1 or RED condition, the green and yellow portions of the tag will be removed, leaving the red portion). 3. One corner of the triage tag that contains the triage tag number will be removed and retained by the Triage Officer (or the person fulfilling that role). The Triage Officer or his designee will document numbers of patients, their triage tag numbers and condition codes. This documentation will be duplicated by the Transportation Officer if the incident dictates there is one. 4. If during an assessment or reassessment a patient changes condition codes from lower to higher, the bottom colored portion of the tag will be removed to show the updated higher condition code. 5. If during an assessment or reassessment, a patient changes condition codes from higher to lower, a second triage tag must be added. All color coded sections should be removed from the bottom of the first tag, but the first tag (with its number) should remain on the patient along with the second tag that shows the status of a lower priority. Both triage tag numbers shall be documented and shall show as being assigned to the same patient. 6. Secondary triage will include a brief secondary exam with the assessment documented on the Triage Tag (if time permits). The information documented will include but is not limited to date, time, patients vitals signs and a brief description of the patients injuries.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Procedures (cont.): Treatment (cont.): METTAG use (cont.): 7. A second corner of the Triage Tag is available with the same triage tag number on it that can be removed and retained by the Transport Officer if the incident is of sufficient scope to require one. The Transport Officer is required to document numbers of patients, their triage tag numbers and condition codes. This documentation will duplicate the documentation performed by the Triage Officer, and numbers should be compared with the Triage Officers numbers for correctness. In all cases however, the documentation must be completed so patients can be tracked accurately. B. The Treatment phase is typically where patients are physically separated and moved into priority category (RED, YELLOW, GREEN, etc.) areas. It is important to physically separate these patients by priority wherever possible so transport priorities can be maintained. Moving the patients will be one of the most labor-intensive parts of the incident and will require the most personnel. C. Considerations for a Treatment area should include its capability to accommodate the number of patients, rescuers and equipment required. It should also consider weather, safety and HazMat implications. D. Treatment area ingress and egress areas should be set up to make the Treatment area a funnel. Ingress and egress areas (funnel points) should be designated which are readily accessible and relatively easy to move vehicles in and out of. E. The priority category areas (RED, YELLOW, GREEN, etc.) should be marked with colored tarps, flags or whatever equipment is available. Excessive amounts of time and manpower should not be spent setting up elaborate area marking, set up and mark the areas as quickly and efficiently as possible. F. Medical treatment should only be provided in the Treatment phase as time before transport allows. Do not delay a patients transport to provide extended treatment. Treatment provided should be only what is necessary to save life and preserve or possibly improve the patients condition while enroute to the medical facility. The endpoint of treatment should be to provide the greatest amount of good for the greatest number of patients in the shortest possible time.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Procedures (cont.): Transport: A. The Transport Officer (if one is designated) shall document numbers of patients, their triage tag numbers and condition codes. This documentation will duplicate the documentation performed by the Triage Officer, and numbers should be compared with the Triage Officers numbers for correctness. B. The coordination of the loading and transport of patients shall be done by priority (RED, YELLOW, GREEN, etc.). RED patients shall always be transported first, YELLOW patients shall be transported next and GREEN patients shall be transported last. Patients that are trapped and need to be extricated should be the only variable that changes this order. C. The very nature of a Multiple Casualty Incident will require that normal EMS transport parameters be changed. Multiple RED patients may have to be transported in one transport vehicle, possibly with a single caregiver. ALS patients can and should be transported with BLS personnel if ALS personnel are limited or unavailable. D. Strongly resist the urge to fill up transport vehicle space with GREEN patients mixed in with RED and or YELLOW patients. GREEN patients should be transported last and in alternative modes of transport (bus, etc.) whenever possible. E. When transport vehicles arrive, every effort should be made to keep the drivers of those units with their vehicles. If that is not possible due to those personnel being needed to perform other tasks (triage, etc.) then very close track should be kept of where those personnel are so when the vehicles are loaded with patients, they can leave without delay. Keys should always be left in unattended vehicles. F. The Transport Officer (if one is designated) shall coordinate air transport resources. The scope of the incident will dictate the expansion of any Air Operations Group, but a Landing Zone (LZ) Officer shall always be required when air resources are involved. This will be required to address operational and safety concerns involving establishing landing zones, and the safe landing and departure of aircraft.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) Procedures (cont.): Transport (cont.): G. With Level II and III MCIs, individual transport units will not contact medical facilities with patient information. The Transport Officer (if one is designated) shall contact receiving medical facilities with the following information: 1. Units transporting; 2. Number of patients being transported; 3. Their priority or condition codes (RED, YELLOW, GREEN, etc.); 4. Any special needs (eg. burns, trauma alert, etc.) H. Transport units should always be given specific instructions to drop off their patients at the receiving medical facility and then return immediately back to the incident. This should be done until it has been verified that there are no more patients to transport. Note: If this is not done, personnel may be easily caught up in assisting medical facility personnel when they and their transport vehicle are badly needed at the incident. Additional Considerations: A. All units will respond to staging unless otherwise directed by Command. First-due vehicles need to be parked in a safe place B. Ensure that all areas around the MCI scene have been checked for any possible missed patients, walking wounded, ejected/trapped patients, etc., and that all patients have been triaged. EMS MCI Command Structure Responsibilities: A. EMS Group Supervisor shall be responsible for: 1. Overall EMS operations at the incident
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) EMS MCI Command Structure Responsibilities (cont.): 2. Filling EMS Group positions as needed a. b. c. d. Triage Officer Treatment Officer Transportation Officer LZ officer
3. Notifying IC as to needs of EMS Group B. Triage Officer shall be responsible for: 1. Management of patients where they are found at the incident site 2. Sorting (triage) and moving all patients to treatment/transportation areas 3. Ensuring coordination between extrication teams and medical care providers to provide appropriate care for entrapped patients 4. Performing initial documentation on numbers and condition codes of patients C. Treatment Officer shall be responsible for: 1. Establishing treatment areas a. b. c. d. RED YELLOW GREEN BLACK
2. Patient care and triage decisions for patients in the treatment areas 3. Overseeing all aspects of patient care in the treatment areas D. Transport Officer shall be responsible for: 1. Arranging and coordinating appropriate transport (ALS, BLS, helicopter, etc.) for patients forwarded to treatment/transport areas 2. Coordinating and maintaining communication with medical facilities as to numbers, condition codes of patients and where they will be transported
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) EMS MCI Command Structure Responsibilities (cont.): 3. Performing documentation on numbers and condition codes of patients 4. Coordinating air transport resources and operations E. Landing Zone (LZ) Officer shall be responsible for: 1. Establishing safe landing zones for air transport resources 2. Coordinating with Transport Officer to safely move patients to landing zones for transport 3. Coordinating with air transport crews to safely and expeditiously load patients for transport ILLUSTRATION 6.F. MCI IC FLOWCHART
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) ILLUSTRATION 6.G. START TRIAGE ALGORITHM
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.) ILLUSTRATION 6.H. METTAG TRIAGE TAG
Protocol 6.11: No-Transport (Refusal, Cancel) General Principles: A. Non-transport of a patient when EMS is called to a scene is one of the greatest areas of exposure to legal liability that EMS agencies and individual EMS providers face. The EMS provider is responsible for a reasonable assessment of the patient and situation to determine if there is injury or illness, or a reason to treat and/or transport. When a non-transport situation occurs, care must be taken to assure that procedures are followed correctly and the encounter is documented fully. B. An adult patient that has decision making capacity has the legal right to refuse treatment, evaluation and transport in spite of the fact they may be injured or ill. The minor patient does not have that same legal right to refuse, a parent or legal guardian must represent them. C. Non-transport situations generally fall into two primary categories: Cancel and Refusal. Definitions: A. Cancels are calls where the response is discontinued prior to patient contact being made (by EMS personnel). B. Refusals are calls where patient contact is made by EMS personnel, but the patient(s) refuse treatment and or transport. C. When EMS personnel arrive on the scene of a call originally dispatched as an EMS call and after investigation find that no medical situation exists, these will also be categorized as Refusals for purposes of this protocol. D. A minor in SD is any patient less than 18 years of age. E. An emancipated minor in SD is any patient less than 18 years old that: 1. Has entered into a valid marriage, whether or not such marriage was terminated by dissolution; or 2. Is on active duty with any of the armed forces of the United States; or 3. Has been declared an emancipated minor by the courts. An emancipated minor is treated the same as an adult.
Protocol 6.11: No-Transport (Refusal, Cancel) (cont.) Procedures: Cancel: A. A response may be cancelled enroute to a call when a first-response Fire and or EMS agency already on scene advises to cancel. These cancellations may encompass a number of different situations, to include but are not limited to: 1. MVA or other trauma call with no patients claiming injuries. 2. Medical call where patient is refusing treatment and or transportation. 3. Man down/unknown problem call where first response agency has determined patient to be public inebriate only and Law Enforcement will handle. 4. Medical or trauma call where no patient has been found or patient has left the area. Note: Use extreme care in the no patient found or patient left the area scenarios. It is not uncommon for even a seriously ill or injured patient to wander a short distance from the area where they were initially reported to be. As much as is possible, assure that a thorough search for the patient was done before cancelling. This is particularly true in the rollover MVA and assault situation. B. Response to a MVA shall not be cancelled only on advice from Law Enforcement or civilians when they report no injuries. An evaluation must be done by a first response Fire and or EMS agency and they must advise no injuries before cancelling. An initial hot response may however, be downgraded to cold in this scenario. C. Response may be cancelled on advice from Law Enforcement in the following scenarios: 1. Reported MVA and LE has found no accident. 2. Reported MVA and LE has found no one around the vehicle or patient has apparently left the area. 3. Reported MVA turns out to be accident previously reported and already investigated.
Protocol 6.11: No-Transport (Refusal, Cancel) Procedures (cont.): Cancel (cont.): 4. Man down or unknown problem is determined to be a public inebriate by LE and they will handle. D. EMS personnel shall have the discretion to continue a response to a scene in spite of a first response Fire and or EMS agency request to cancel if the request to cancel seems inappropriate or if the information appears to be incomplete, incorrect or inaccurate. Communication is the key, if you are uncomfortable cancelling based on what youve heard, continue and try to get more information. Refusal: A. In all refusal situations, EMS personnel shall perform as complete an assessment as the situation and the patient(s) will allow (see assessment /documentation guidelines below). The results of the assessment (or the patients refusal to allow one) shall be documented fully in the Patient Care Report (PCR). A refusal with no assessment and accompanying documentation is an area of extreme legal risk for EMS personnel. B. When EMS personnel reach the scene of a MVA or other trauma call where patients are refusing service and: 1. There are no patients claiming injuries or with any visible injuries. 2. There are no patients requesting treatment and or transportation to a medical facility. 3. There is no significant mechanism of injury to suggest a possible hidden injury. 4. All affected patients at the scene are mentally competent, with decision making capacity. If an assessment reveals no problems, EMS personnel may treat these patients as involved not injured and clear the scene, no Refusal of Ambulance Services form is required (this includes all minors). If an assessment reveals injuries, patient(s) shall be offered treatment and transport to a medical facility.
Protocol 6.11: No-Transport (Refusal, Cancel) (cont.) Procedures (cont.): Refusal (cont.): C. When EMS personnel reach the scene of a MVA or other trauma call where patients are refusing service and: 1. There are patients claiming injuries or that have any visible injuries. 2. There is any significant mechanism of injury to suggest a possible hidden injury. 3. All affected patients at the scene are mentally competent, with decision making capacity. EMS personnel shall fully advise the patient(s) of the results of the assessment and of the risks of refusing treatment and transport and obtain a signed Refusal of Ambulance Services form for each affected patient before clearing the scene. If the patient(s) refuses to sign the Refusal of Ambulance Services form, it should be witnessed and documented fully in the Patient Care Report (PCR). D. If a non-emancipated minor at the scene of a MVA or other trauma call is attempting to refuse service and has: 1. Any visible/discovered on assessment injury ; or 2. Claims any injury; or 3. Is involved in a situation where there is any significant mechanism of injury to suggest a possible hidden injury; That minor may not refuse service and may not sign a Refusal of Ambulance Services form. The parent or a legal guardian of a minor must refuse treatment and or transport for their minor children in person and the minor left in their custody. If a parent or legal guardian is not able to arrive in an expedient manner to handle the refusal and take custody of the minor, that minor must be transported to a medical facility. Do not wait on scene for extended periods of time waiting for a parent/legal guardian to arrive.
Protocol 6.11: No-Transport (Refusal, Cancel) (cont.) Procedures (cont.): Refusal (cont.): E. When EMS personnel reach the scene of a medical call where a mentally competent adult patient(s), with decision making capacity that had or has a chief complaint is refusing service; EMS personnel shall fully advise the patient(s) of the results of the assessment and of the risks of refusing treatment and transport and obtain a signed Refusal of Ambulance Services form for each affected patient before clearing the scene. If the patient(s) refuses to sign the Refusal of Ambulance Services form, it should be witnessed and documented fully in the Patient Care Report (PCR). F. A non-emancipated minor at the scene of a medical call that had or has a chief complaint may not refuse service and may not sign a Refusal of Ambulance Services form. The parent or a legal guardian of a minor must refuse treatment and or transport for their minor children in person and the minor left in their custody. If a parent or legal guardian is not able to arrive in an expedient manner to handle the refusal and take custody of the minor, that minor must be transported to a medical facility. Do not wait on scene for extended periods of time waiting for a parent/legal guardian to arrive. G. EMS personnel may treat and release an adult hypoglycemic diabetic patient, given that the following conditions are met: 1. The patient must be a diagnosed diabetic being treated with a form of insulin. 2. The patient must not be taking any oral agents for the control of their blood sugar. 3. The patient must have had an initial blood glucose <70 before treatment, and a blood glucose >100 after treatment. 4. The patient must not have exhibited any focal neurologic deficits before treatment with glucose. 5. After treatment the patient must be exhibiting completely normal neurologic signs and have a Glasgow coma scale score of 15. 6. The patient must have access to food, or a source of food must be provided to the patient before releasing the patient from care. Obtain a signed Refusal of Ambulance Services form before clearing the scene. See Protocol 2.19: Diabetic Emergencies for further information.
Protocol 6.11: No-Transport (Refusal, Cancel) (cont.) Procedures (cont.): Refusal (cont.): H. In circumstances where a patient, parent or legal guardians mental competency is obviously in question; or the obvious presence of alcohol or chemical intoxication is interfering with decision making capacity, contact with Medical Control to help sort out the situation is strongly suggested. Seek the assistance of Law Enforcement when necessary. I. When EMS personnel respond to a scene where a verified suicide gesture has taken place, the patient(s) involved may not refuse service, they must be transported to a medical facility. If there is some dispute about whether or not the suicide gesture has actually taken place, investigate carefully and seek the assistance of Law Enforcement where necessary. Remember, patients that engage in suicide gestures many times have a reason to be untruthful, so do not rely on their word alone that a suicide gesture has not taken place. When EMS personnel respond to the scene of a reported illness or injury and after an investigation and assessment find that no medical situation exists, a Refusal of Ambulance Services form is not appropriate.
J.
Assessment / Documentation Guidelines: A. In refusal situations, particularly those with patients refusing against medical advice (AMA), EMS personnel wherever possible, shall assess and document: 1. Mental status i.e., orientation to person, place and time, and patients comprehension of the nature/severity of illness/injury and comprehension of the nature of treatment. 2. Vital signs (ECG also if potentially cardiac related). 3. Glasgow Coma Scale score. 4. Any plan for alternative care. 5. Risks of refusal up to and including death (inform patient).
Protocol 6.11: No-Transport (Refusal, Cancel) (cont.) Assessment / Documentation Guidelines (cont.): B. In adult patients refusing an assessment who have a chief complaint, have sustained an injury or might reasonably be suspected to have sustained an injury: 1. Evaluate the patients mental status as to coherency/decision making capacity. 2. Explain the significance of the mechanism of injury (if there is one). 3. Explain the possible related complications of the illness or injury. 4. Explain the possible consequences of the illness or injury if left untreated, up to and including death. 5. Have patient read (or read it to them) and sign a Refusal of Ambulance Services form and document discussion in Patient Care Report (PCR) narrative. If patient will not sign, document the refusal to sign in the narrative as well Additional Considerations: A. EMS personnel should err on the side of contacting Medical Control in Refusal situations that are unclear or are not covered by this protocol. B. Obtaining a signature on a Refusal of Ambulance Services form is always strongly encouraged when appropriate, because signing may be evidence of the patients decisional capacity and physical ability. However, remember that a signature does not relieve EMS personnel of the responsibility for a reasonable assessment and possibly treatment of the patient. C. For the patient who is refusing treatment/transport against medical advice (AMA), providing the patient with clear instructions and warnings is imperative (having them read or reading to them the Refusal of Ambulance Services form is recommended). Having this form co-signed by a witness that is not an employee of the RCFD is also recommended. D. For Cancel situations that are unclear or not covered by this protocol, contact the on-duty Battalion Chief or the EMS Chief.
Protocol 6.12: Patient Care Report (PCR) Requirements General principles: A. The Patient Care Report (PCR) is an integral component of patient care, the quality improvement process and is a professional responsibility of the EMS provider. B. The Patient Care Report (PCR) is many times the sole source of information regarding the patients condition and any pre-hospital treatment they received. It is imperative that the information is accurate, complete and provided to the receiving hospital in an expedient manner in order to provide for an efficient and safe transfer of care. C. The Patient Care Report (PCR) is the legal record of the EMS providers encounter with the patient, and the treatment and transport that patient received. The PCR is discoverable in a court of law and can be (and frequently is) subpoenaed. Given that fact, the PCR must be complete and it must be accurate in all respects. D. The Patient Care Report (PCR) is also the primary tool used by patient billing services to collect fees for ambulance services, which are the primary finding source for the EMS system. The PCR must be complete and it must be accurate to allow the billing process to take place in an expedient manner and to satisfy federal regulations regarding ambulance billing. Procedures: A. The procedures detailed herein apply to both the handwritten (paper) PCR and any electronic charting method the Department uses. B. The following minimum information shall be gathered and documented relative to the patient and their personal information: 1. 2. 3. 4. 5. 6. 7. Patient name Patient age and birth date Patient sex Patient social security number Patient residential address Patient phone number Patient health insurance company(s) and numbers (to include Medicare/Medicaid) 8. Patient next of kin or responsible party
Protocol 6.12: Patient Care Report (PCR) Requirements (cont.) Procedures (cont.): Note: It is understood that at the time of the call, some of the above information may be difficult to obtain in the event a patient is unconscious, intoxicated, etc. Every effort should be made to obtain the information in a timely manner if at all possible. Family members, friends, law enforcement and the hospital face sheet are all good potential sources for this information. C. The following minimum information shall be gathered and documented relative to the incident itself: Incident number Date incident occurred Run/call type and or reason for dispatch Incident location Response mode to the call and back to the hospital (hot/cold and any changes) 6. Location patient transported to 7. Times: a. Dispatch b. Enroute c. On Scene d. First Paramedic on scene (if applicable) e. Enroute to hospital f. Out at hospital g. Clear of call h. Cancelled (if pertinent) 8. 9. 10. 11. Patient loaded mileage Medic Unit number and station Receiving physician Crew names (signature) and skill level 1. 2. 3. 4. 5.
D. The following minimum information shall be gathered and documented relative to the patient and the medical care they received: 1. Patient chief complaint 2. Nature of the incident and or mechanism of injury 3. Results of physical exam/assessment to include but not limited to: a. Vital signs (BP, RR, HR, O2 Sat.) repeated every 10 minutes if transport > 10 min. b. LOC Mentation - GCS c. Skin signs
Protocol 6.12: Patient Care Report (PCR) Requirements (cont.) Procedures (cont.): d. ECG. (Where pertinent, copy of ECG shall be attached to all copies of report whenever an ECG is done) e. Lung sounds (where pertinent) f. End Tidal CO2 (where pertinent) g. Glucose (where pertinent) h. Motor function i. Any visible trauma or abnormality j. Pupil size and reactivity k. Temperature (where pertinent) 4. 5. 6. 7. 8. 9. 10. 11. Condition patient first found in. History of present event (brief). Known patient past medical history, medications, allergies. All treatment rendered (including treatment rendered prior to arrival). Treatment times shall be noted. Medication administrations shall include times and dose(s). Any changes in patient condition noted, and specifically those changes noted as a result of treatment (including lack of changes). Any orders requested and whether granted or denied (include physicians name). Any special circumstances (weather, facility divert, violence, prolonged extrication, etc.). Patient condition on arrival at medical facility.
E. For specific PCR requirements in refusal cases, see Protocol 6.11: NoTransport (Refusal, Cancel). F. Patient Care Reports for patients who have had invasive airway procedures done and or IV medications administered, shall be completed at the hospital and left there with the patient. All other ALS reports shall be printed out or copies left at the hospital within 12 hours of the call. All BLS reports shall be printed out or copies left at the hospital before the end of the shift. Additional Considerations: A. In all circumstances, Patient Care Reports shall be completed in sufficient detail to allow the receiving medical facility and system Medical Director to easily determine the nature and extent of the patients injury or illness and any treatment rendered.
Protocol 6.13: Public Inebriate Disposition General Principles: A. Medic Units and Engine Companies will at times receive requests from Law Enforcement to perform a medical evaluation of the public inebriate. These requests are valid due to the fact that the public inebriate population has a statistically higher incidence of serious medical problems than most other segments of society. B. Law Enforcement agencies and other allied agencies like the Pennington County Jail, Juvenile Services and Detox typically use an arbitrary BAC number of .400 or .500 as a limiting factor to determine whether a subject is suitable for transport to that particular facility. While these numbers may be suitable to determine if a subject is suitable for a particular facility, they are not suitable to determine if a subject requires transport to a medical facility by an ALS ambulance. The determination of whether or not one of these subjects will be transported to a medical facility by ambulance will be based on a clinical evaluation by the attending Paramedic and not on the BAC number generated by a portable breath tester. C. This protocol pertains only to the encounter with the public inebriate in public. When a facility (Pennington County Jail, Juvenile Services, Detox, etc.) requests transport for a subject/patient in their facility, those patients shall be transported immediately. D. When requests for an evaluation of the public inebriate are received, refer to the following: Procedures: A. These requests will be processed through Dispatch and will receive a cold (immediate) response unless triaged to a higher response by Dispatch. B. In times of system overload, these requests will be triaged to a delayed response and will be handled as soon as resources become available. If at any time, Dispatch indicates a need for a higher level of response, that will place the call higher in the queue and it will be responded to as appropriate. C. Representatives from agencies making these requests will be treated with the same courtesy and respect you would expect from them. These requests for medical evaluation are not an unnecessary interruption of our daily operations; they are a very necessary part of the public safety net for a segment of the population that is unable or unwilling to seek mainstream medical care.
Protocol 6.13: Public Inebriate Disposition (cont.): Procedures (cont.): D. On arrival at one of these incidents, the Paramedic will obtain a complete history of the requesting agencies contact with the subject (who, what, when, where, how long) make no assumptions. E. The determination of whether or not the subject will be transported by ambulance to a medical facility will be based on the following evaluation and parameters. 1. Complete history and exam finding the following: a. Subject must be easy to arouse b. Must have a minimum GCS of 14 c. Must be ambulatory with minimal assistance and have no focal motor or sensory deficits
2. Complete set of vital signs within the following parameters: a. Pulse b. SBP c. RR 60-110 90-160 12-25 > 94%
d. O2 Sat
e. Glucose 70-200 3. Subject not requesting transport to a medical facility. F. If the above parameters are not met, the subject will be transported to the appropriate medical facility by ambulance. G. If the above parameters are met, politely explain to the requesting agency representative that the subject does not meet our criteria for transport by ambulance. Brief them completely on your findings and your basis for declining to transport the subject. Further explain that if they still wish to have the subject transported to a medical facility after your evaluation, they will need to find alternative means to do so. All of this will be accomplished in a polite, professional, non-confrontational manner.
Protocol 6.13: Public Inebriate Disposition (cont.): Procedures (cont.): H. If at any time during one of these encounters, the subject requests transport to a medical facility because of an injury or illness, they will be transported by ambulance immediately. I. If the above vitals signs assessment and evaluation are not performed (or are not able to be performed), the subject will be transported to a medical facility by ambulance immediately. Document the encounter completely with vitals signs, see Protocol 6.11: No-Transport (Refusal, Cancel) for additional details.
J.
Additional Considerations: A. Remember, always err on the side of caution in questionable or unclear circumstances, it is medically-legally safer to transport someone to a medical facility that doesnt need to go than to not transport someone that does need to go. B. In situations where there is unresolved disagreement between a requesting agency and the attending Paramedic reference whether a subject should be transported by ambulance, contact the on-duty Battalion Chief or the EMS Chief.
Protocol 6.14: Radio Reports General Principles: A. The primary purpose of contacting the receiving medical facility is to provide them with enough information to allow the ED staff to decide what preparations they will need to make for the patient. This assures a safe, efficient transfer of care. B. Radio contact should only include essential, relevant information. Remember, the ED staff may be very busy and a report that isnt brief and to the point may be misunderstood or disregarded. C. This protocol applies to reports that are given over the phone as well as by radio. Procedures: Notification to Receiving Facility
REGIONAL HOSPITAL / This is Medic ____ We are enroute with a : ____ Y/O Male_____ Female_____ with a Chief Complaint of ______________ Brief description of problem / situation / mechanism of injury (MVA, etc.) Pt. is: awake, alert, confused, unresponsive (describe LOC) Vitals Signs: BP:____/____ HR:_____ RR:____O2 Sat:_____ (on room air, O2) Glucose: ____ Skin is: color__________ temp_________ moisture__________ ECG shows:_______________________ Lung Sounds:___________________ Any visible trauma, abnormality: _______________________________________ _________________________________________________________________ Treatment being provided: Airway:___________O2:_________IVs:_________ Meds administered :___________________C-Spine?______ Other:___________ Will relate further information on arrival if no questions or orders: ETA is:___________ Medic ____ Clear
____________________________________________________________
Protocol 6.14: Radio Reports (cont.): Procedures (cont.): Notification to Receiving Facility (cont.): A. The above format and information shall be used to notify the receiving facility of arrival. Information shall only be given to the extent it is pertinent. B. A response code to the facility only needs to be given when it is emergent and that is the term that should be used. Requests for Treatment Orders Note: Only a physician may provide authorization to a Paramedic to perform a procedure or administer a medication pursuant to these protocols. The requesting Paramedic shall be clear and concise in requesting that a physician be available for consultation or orders. A. Request to speak to a physician to obtain the order. B. Identify yourself and Medic Unit number to the physician and clearly state the order you are requesting. Be clear, concise and brief, many times the reason for declined orders can be traced back to the Paramedics failure to paint a clear picture relative to what is going on. C. Provide pertinent information that is the basis of the request, such as: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Enroute (emergent or not,) or still on scene. ETA to hospital. Patient age and sex. Chief complaint. Past medical history (only if pertinent). Level of consciousness. Vitals signs (include ECG if pertinent). Physical assessment findings. Treatment already in progress Restate or clarify order requested, if drug order, dosage and route to be administered.
D. In the event a request is for termination of cardiac arrest resuscitation, include information about the initial and present cardiac rhythm, response to resuscitation (or lack thereof), mechanism and duration of resuscitation efforts. If terminated, note exact time.
Protocol 6.14: Radio Reports (cont.): Procedures (cont.): Requests for Treatment Orders (cont.): E. Communication with Medical Control is appropriate if you are not sure whether or not a treatment, procedure or destination is appropriate for a patient. Medical Control contact should be considered as a consultation, not just a source of authorization for medications or procedures. F. Whenever treatment orders are requested, the Patient Care Report (PCR) narrative shall include the nature of the order requested, the name of the physician contacted and whether the order was granted or declined. Special Circumstances: A. In the event a communications failure does not allow Medical Control contact for an order request; or a physician is not able to come to the phone/radio in a timely manner, the Paramedic shall adhere to the treatment guidelines as defined by these protocols. Under no circumstances shall a Paramedic exceed their scope of practice as defined by their South Dakota State Board of Medical Examiners license/South Dakota state law and practice privileges authorized by the system Medical Director.
Protocol 6.15: Rules of Engagement Emergency Stuff

When dealing with a single call, closest unit always goes regardless of whose district its in, even with a call dispatched as cold. Only exception is a transfer. When dealing with multiple calls, units will always take the most critical call that is the closest. This will be based on dispatch information. In times of call overload, ALS engine companies and Medic 1 will handle calls as possible and necessary until ambulances are available. Hot and cold response modes from dispatch will always be followed unless there is a compelling reason to the contrary Two-tiered responses will remain as they always have, an ambulance and an engine in the same house will not change that. Two Paramedic response and treatment policy applies on cardiac arrests in the city or in very close proximity to the city. ALS engine or Medic 1 can satisfy policy. Incidents outside the city will have one unit respond and second unit will meet them inbound. With a known, significant trauma alert case, two Paramedic treatment policy will apply on cases in the city or in very close proximity to the city. ALS engine or Medic 1 can satisfy policy. Incidents outside the city will have one unit respond and second unit will meet them inbound. Response to seemingly significant trauma calls will be as dispatched (typically 1 ambulance) unless dispatch information or early-arriving engine companies make it very clear that more units are needed. If after responding to a 911 call, a patient (or patients family) requests transport to Ft. Meade or Hot Springs VA, that patient will not be transported to the VA unless it can be accurately determined that the VA has approved the transport. The patient (or their family) should be reminded that neither of the VA facilities has ED facilities and are not set up to accept patients without prior notice and approval. If the VA has not approved the transport, the patient will be offered transport to RCRH, if the patient wishes to refuse rather than accept transport to RCRH, that is their right. Units will notify out at the hospital just before backing in, not down the street. Units will call clear from the hospital immediately upon leaving. ALL copies of PCR's for patients transported to Regional Hospital will be at Regional Hospital before your shift ends. No reports will be left until the following day. Reports for patients that were intubated or given any IV medications will be done on the spot and left at the hospital before you leave. This essentially means you are out of service to do that report with the only exception being if while
Protocol 6.15: Rules of Engagement (cont.): Emergency Stuff (cont.):

at the hospital you are the closest unit to an ALS call or the only unit available, that only makes good sense. Reports for all other ALS patients must be at the hospital within 12 hours (within your shift), reports for BLS patients can wait longer, but in all cases will be at the hospital before your shift ends.
Transfer Stuff
Anything that goes to the hospital (RCRH or SS) is not a transfer, its a call and is handled like any 911 call. A transfer is a transport that goes anywhere besides the hospital (RCRH or SS). Use caution doing more than one transfer at a time with duty units, two duty units should not be tied up doing transfers unless ALS overload units are available. If ALS overload units are available, it may be possible to do 2 transfers at one time. If ALS overload units are not available, only one transfer should be done at a time. If the system is extremely busy, transfers should be temporarily postponed until sufficient resources are free to handle the call volume. Notification should always be made to the requesting facility that the transfer is being postponed, what the reason is and an approximate time that the transfer may potentially be done. Transfers by duty units should be done by the unit in whose area the destination is. This will keep the ambulances in their respective response areas more often. 911 calls that result in a transport to Ft. Meade or Hot Springs VA will be handled by the duty unit that originally responded to the call. Have dispatch notify Battalion 1 that you will be out of the area. ALS transfers that originate at RCRH (or another medical facility) that are going to Ft. Meade or the Hot Springs VA can be handled by a duty unit as long as the rest of the transfer rules are satisfied. If the three duty units are extraordinarily busy, an overload unit should handle these if one can be staffed with ALS personnel. A duty unit could handle these if on-duty manpower allows another ALS ambulance to be staffed immediately. If none of the above scenarios is possible, the facility requesting the transfer should be told it will have to wait until hire-back personnel can be brought in. These transfers (if they come in late at night) can sometimes wait until shift change when more personnel may be available. BLS transfers that originate at RCRH (or another medical facility) that are going to Ft. Meade or the Hot Springs VA should be assigned to a BLS crew whenever possible (either by hire-back or utilizing available on-duty manpower). ALS duty crews should not be used for these, but an ALS crew consisting of hire-back personnel or other available on-duty personnel could be utilized.
Protocol 6.15: Rules of Engagement (cont.): Transfer Stuff (cont.):

BLS transfers that originate at RCRH (or another medical facility) that are going to Ft. Meade or the Hot Springs VA that are solely at the patients request (the patients paperwork will prominently say that) should be referred to Medic 1 or Patient Billing Services before they are done. These transfers are commonly going to psych or re-hab. type units at the VA and are not paid for by the VA. Payment will typically have to be guaranteed before these are done. BLS transfers may be assigned to overload ambulances at the discretion of the Battalion Chief even if duty units are not all busy. A call that originates at Ft. Meade that is emergent or needs to be done immediately (per Ft. Meade) will be handled by a duty unit and we will back-fill as necessary. If overload ambulances are to be used for longer out of town transfers (> 3 hrs.), the on-duty Battalion Chief will attempt to hire-back personnel to maintain manpower levels. Hire-back personnel could also be used for the transfer if it can wait that long.
Everyday Stuff
Narcotics will be checked, documented and audited per administrative rule and protocol. Copies of Patient Care Reports will not be left lying on the dashes of vehicles or on a desk in a station. All copies of PCRs will be secured and taken to the hospital as soon as possible considering the rule noted above in Emergency Stuff about paperwork. Substations shall bring Billing PCR copies to Patient Billing Services every weekday morning as soon as is possible. Remote computers with Field Data collection software shall be data-linked (downloaded) a minimum of once a day at the start of the shift. It is recommended to download as much as 2-4 times a day to ensure that data is not lost in the event of a computer hard drive failure. All communications with Dispatch and other units will be acknowledged. Every time Dispatch or another unit gives you a piece of information, you shall acknowledge that you heard it. Anytime you respond to a scene where you have to go some appreciable distance from your vehicle to where the patient is (apartment house, elderly high rise, motel/hotel, private residence set back a considerable distance from the street, etc.). Take your cot, airway box, drug box and cardiac monitor with you. That will make the entire patient care process go quicker and smoother. Dont make the engine companies run (and your patient wait) for your equipment when you should have brought it with you in the first place.
Protocol 6.15: Rules of Engagement (cont.): Everyday Stuff (cont.):

Each ambulance has its own primary response area (district). Ambulances will not be taken out of their primary response area for personal reasons unless three rules are satisfied: First: Battalion 1 and or Medic 1 will be consulted to obtain permission to do so. The Company Officer in the station the ambulance is stationed at must also be brought into the permission loop. Second: the other two ambulances must be notified and asked if they will cover the uncovered area (one way and probably the best way) to do this is to temporarily exchange areas with another Medic Unit.). If one of the other two ambulances cannot or will not cover the uncovered area, then the ambulance will not be taken out of its area. Third: Dispatch shall be notified and told what is going on. Any time a unit is taken out of service for any length of time, Dispatch, Battalion 1 and the other duty units shall be notified. The notification shall include the reason the unit is being taken out of service and the expected time it will be out (or back in service). This can be accomplished with phone calls to the interested parties or airing the information to Dispatch on the EMS frequency. Duty ambulances and overload ambulances will both be kept clean (interior and exterior) in the same manner as the engines are. Drugs and other equipment in overload ambulances will be checked everyday. Overload ambulances will not have supplies or equipment scavenged to stock duty units. Off-going shifts will insure that duty units are fully stocked, have reasonable levels of oxygen, have at least tank of fuel and the interiors are clean. Failure to do this will result in immediate discipline. Sub stations will insure that dirty linen and medical waste is brought to Station 1 once weekly for pick up.
Section 7 Drug Summaries
DRUG SUMMARIES This section contains a description of those drugs approved for use (or transport) in the Rapid City/Pennington County EMS System. This description includes Actions, Indications, Contraindications, Side Effects, Dosages (adult and pediatric if applicable) and available forms of these drugs. RAPID CITY FIRE AND EMERGENCY SERVICES PARAMEDICS APPROVED DRUG LIST:
Adenocard (Adenosine) (6 mg/2 ml) or (12 mg/4ml) Albuterol (Proventil) (2.5 mg in 3 ml unit dose) Amiodarone (Cordarone) (150 mg/3 ml) Aspirin (Acetylsalicylic Acid) (81 mg tabs) Ativan (Lorazepam) (2 mg/1 ml) Atropine Sulfate (as a cardiac agent) (1 mg/10 ml) Atropine Sulfate (as an antidote for poisoning) (8 mg/20 ml) Benadryl (Diphenhydramine) (50 mg/1 ml) Calcium Gluconate (4.65 mEq/10 ml) Cyanokit (Hydroxycobalamin) (5 gm) Dextrose 50% (25 gm/50 ml) Dextrose 25% (2.5 gm/10 ml) Dopamine (Intropin) Infusion (400 mg/250ml) Epinephrine, (1:10,000) (1 mg/10 ml) Epinephrine, (1:1000) (1 mg/1 ml) Epinephrine, (1:1000) multi-dose, (30 mg/30 ml) Etomidate (Amidate) (40 mg/20 ml) Fentanyl (Sublimaze) (100 mcg/2 ml) Glucagon (1 mg (unit)/ 1 ml) Haldol (Haloperidol) (5 mg/1 ml) Haz-Mat / WMD drugs (Mark I Kit, (not stocked) Pralidoxime (2 Pam) Chloride Atropine Sulfate (as an antidote for poisoning)
RAPID CITY FIRE AND EMERGENCY SERVICES PARAMEDICS APPROVED DRUG LIST (cont.):
Inter-facility Transport drugs (not stocked) Heparin Infusion Nitroglycerin Infusion Integrilin Infusion IV Fluids: D5W, Normal Saline Lasix (Furosemide) (40 mg/4 ml) Lidocaine (100 mg/5 ml) Lidocaine Infusion (1 gm/250 ml) Lidocaine 2% viscous gel Morphine Sulfate (10 mg/1 ml) Narcan (Naloxone) (2 mg/2 ml) Neo-Synephrine (Nasal Spray) Nitroglycerin Spray/Tablet (0.4 mg/unit dose) Procainamide (1 gm/10 ml) Sodium Bicarbonate (50 meq/50 ml) Succinylcholine (Anectine) (200 mg/10 ml) Thiamine Hydrochloride (100 mg/2 ml) Valium (Diazepam) (10 mg/2 ml) Zemuron (Rocuronium) (50 mg/5 ml) Zofran (Ondansetron (4 mg/2 ml)
ADENOCARD (ADENOSINE) A. ACTIONS: Adenocard slows conduction time through the A-V node, can interrupt the reentry pathways through the A-V node and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (SVT), including SVT associated with Wolff-Parkinson-White Syndrome. The half-life is estimated to be less than 20 seconds. In controlled clinical trials, 92 % of patients with SVT were converted after a bolus dose of 12 mg. Adenocard is not effective in converting rhythms other than SVT, such as atrial flutter, atrial fibrillation or ventricular tachycardia. However, administration of Adenocard in such patients has not had adverse consequences. B. INDICATIONS: Conversion of SVT to Sinus rhythm including that associated with accessory bypass tracts (WPW). C. CONTRAINDICATIONS: 1. Second or third degree A-V Block (except in patients with a functioning artificial pacemaker). 2. Sick Sinus Syndrome (except in patients with a functioning artificial pacemaker). 3. Rhythms other than SVT, such as atrial flutter, atrial fibrillation or ventricular tachycardia. 4. Known hypersensitivity to adenosine. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - lightheadedness, dizziness, tingling, numbness. CV - facial flushing, headache, sweating, palpitations there may be a long sinus pause prior to conversion. GI - nausea, tightness in throat. Note: The more proximal the IV, the more likely this drug will convert the rhythm.
ADENOCARD (ADENOSINE) - (cont.) E. DOSAGE: Adult: Initial dose: 6 mg IV/IO administered rapidly over a 1-2 second period followed by a rapid saline flush. Repeat administration: If the first dose does not convert the SVT within 1-2 minutes, a second rapid 12 mg IV dose should be given. This 12 mg dose may be repeated a second time if required. Doses greater than 12 mg are not recommended. Pediatric: 0.1 mg/kg IV or IO rapid IV push followed by 10 ml NS IV flush. Repeat administration: Second dose if necessary and possible may be doubled (0.2 mg/kg). Maximum first dose: 6 mg; maximum second dose: 12 mg. F. HOW SUPPLIED: 6 mg in 2 ml pre-filled syringe or 12 mg in 4ml pre-filled syringe.
ALBUTEROL (PROVENTIL, VENTOLIN) A. ACTIONS: Albuterol is primarily a beta-2 sympathomimetic and as such, produces bronchodilatation. Because of its greater specificity for beta-2 adrenergic receptors, it produces fewer cardiovascular side effects and more prolonged bronchodilatation than some other drugs. Onset is within 15 minutes; peaks in 60-90 minutes. Therapeutic effects may be active up to 5 hours. B. INDICATIONS: Nebulized Albuterol is indicated for relief of bronchospasm in patients with reversible obstructive airway disease, including asthma. C. CONTRAINDICATIONS: Albuterol is contraindicated in patients with a history of hypersensitivity to Albuterol. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - Nervousness, tremor, headache, dizziness, insomnia. CV - Tachycardia, hypertension, angina. GI - Drying of oropharynx, nausea, vomiting, unusual taste. E. WARNINGS: 1. 2. 3 4. Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism, diabetes. Epinephrine should not be used at the same time as Albuterol, however, either may be used subsequent to a failure of the other. Administer cautiously to patients on MAO inhibitors or tricyclic antidepressants. Beta-Blockers and Albuterol will inhibit each other.
ALBUTEROL (PROVENTIL, VENTOLIN)-(cont.) F. DOSAGE: Each unit dose delivers 2.5 mg of Albuterol Sulfate in 3 ml total solution. Administer full unit dose in adults and children over 2 years of age. May be repeated twice if necessary. In children less than 2 years of age, administer half a unit dose. May be repeated once if necessary. G. HOW SUPPLIED: 3 ml unit dose (2.5 mg Albuterol Sulfate in 3 ml).
AMIODARONE (CORDARONE) A. ACTIONS: Amiodarone is generally considered a class III antiarrhythmic drug, but it possesses electrophysiologic characteristics of all four other classes of antiarrhythmic drugs. Like class I drugs, amiodarone blocks sodium channels at rapid pacing frequencies, and like class II drugs, it exerts a non-competitive antisympathetic action. One of its main effects is to lengthen the cardiac action potential, a class III effect. In addition to blocking sodium channels, amiodarone blocks myocardial potassium channels, which contributes to slowing of conduction and prolongation of refractoriness. Its vasodilatory action can decrease cardiac workload and consequently myocardial O2 consumption. B. INDICATIONS: 1. Shock refractory pulseless ventricular tachycardia / ventricular fibrillation. 2. Wide-complex tachycardia of uncertain origin. C. CONTRAINDICATIONS: 1. There are no contraindications to Amiodarone use in the treatment of ventricular fibrillation and pulseless ventricular tachycardia. 2. In other situations, Amiodarone is contraindicated in patients with known hypersensitivity to any of the components of Amiodarone, or in patients with cardiogenic shock, marked sinus bradycardia, and second or third degree AV block unless a functioning pacemaker is available. D. DOSAGE: Adult: 300 mg IV/IO, consider repeat dose of 150 mg IV in 3-5 minutes. In the setting of wide-complex tachycardia of uncertain origin, 150 mg IV over 10 minutes. Pediatric: 5mg/kg IV/IO in the setting of refractory VF/VT, (if Epinephrine and Lidocaine have been ineffective).
AMIODARONE (CORDARONE) (cont.) The use of Amiodarone in the setting of wide-complex tachycardia in the pediatric patient has not been fully studied, but it may have some use. E. HOW SUPPLIED: 150 mg in 3ml ampuls.
ASPIRIN (ACETYLSALICYLIC ACID A. ACTIONS: Aspirin is an over the counter non-narcotic analgesic with antipyretic and anti-inflammatory properties. It is used in the pre-hospital setting for its potential effectiveness as an anti-thrombotic agent. When an atherosclerotic plaque ruptures or erodes, within seconds platelets adhere to the damaged lining of the vessel and to each other, forming a plug. Sticky platelets secrete several chemicals, including thromboxane. These substances stimulate vasoconstriction, further reducing blood flow at the site. At this stage, antiplatelet agents are most effective. Aspirin blocks the synthesis of thromboxane, inhibiting platelet aggregation. B. INDICATIONS: 1. Chest pain or other signs / symptoms highly suggestive of acute coronary syndrome. 2. Unstable angina. 3. ECG changes highly suggestive of acute MI. C. CONTRAINDICATIONS: 1. Hypersensitivity to aspirin and / or non-steroidal anti-inflammatory agents. 2. Recent history of GI bleed. 3. Bleeding disorders (hemophilia). 4. Asthma and active ulcer disease are relative contraindications to the use of aspirin. D. DOSAGE: 324 mg, have the patient chew and swallow (4) 81 mg tablets as soon as possible after onset of symptoms. E. HOW SUPPLIED: 81 mg tablets (baby aspirin) in bottle.
ATIVAN (LORAZEPAM) A. ACTIONS: Ativan (Lorazepam) is a member of the benzodiazepine family. It has a tranquilizing action on the central nervous system to produce an anti-anxiety and sedative effect. No appreciable effect is noted on the respiratory or cardiovascular systems. B. INDICATIONS: 1. Status epilepticus or recurrent seizures. 2. Pre-medication prior to cardioversion or other procedures where a calming and anti-anxiety effect is desired C. CONTRAINDICATIONS: 1. 2. Ativan is contraindicated in patients with known sensitivity to benzodiazepines. Ativan is contraindicated in the patient with acute narrow-angle glaucoma.
D. SIDE EFFECTS AND ADVERSE REACTIONS: Confusion, muscular weakness, blurred vision, drowsiness and slurred speech. E. DOSAGE: Adult: 1-2 mg, IV or IM. IV route administer slowly over 1 minute. Pediatric: .05-0.2 mg/kg slow IV or IM (for IV use, dilute 1:1 in NS). F. HOW SUPPLIED: 2 mg in1ml vial.
ATROPINE SULFATE (as a cardiac agent) A. ACTIONS: Atropine is a potent parasympatholytic anticholinergic that reduces vagal tone and thus increases automatically the SA node and increases A-V conduction. B. INDICATIONS: 1. Symptomatic bradycardia. 2. Asystole / bradycardic PEA. C. CONTRAINDICATIONS: None in emergency situations D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - Restlessness, agitation, confusion, psychotic reaction, pupil dilation blurred vision, headache. CV - Tachycardia, may worsen ischemia or increase area of infarction, ventricular fibrillation. GI - Dry mouth, difficulty swallowing. GU - Urinary retention. Other Worsened pre-existing glaucoma E. WARNINGS: Too small a dose (< 0.5 mg) or if normal dose pushed too slowly, may initially cause the heart rate to decrease. Atropine is potentiated by antihistamines and antidepressants. A maximum dose of 3 mg should not be exceeded. F. DOSAGE: Adult: Symptomatic bradycardias: 0.5-1.0 mg IV/IO or ET, may repeat every 3-5 minutes until heart rate increased or total dose of 3 mg has been reached.
ATROPINE SULFATE (as a cardiac agent) - (cont.) Asystole: 1 mg IV/IO or ET, may repeat every 3-5 minutes to maximum dose of 3 mg (0.04 mg/kg). (ET dose 2-2.5 mg if IV access delayed or unavailable. Maximum dose also doubled if ET). Bradycardic PEA: 1 mg IV or ET, may repeat every 3-5 minutes to maximum dose of 3 mg (0.04 mg/kg). (ET dose 2-2.5 mg if IV access delayed or unavailable. Maximum dose also doubled if ET). Pediatric: Symptomatic bradycardias: 0.02 mg/kg IV/IO; may repeat once. 1. 0.1 mg minimum dose 2. Maximum single dose 0.5 mg in child; I mg in adolescent 3. Maximum total dose 1 mg in child; 2mg in adolescent Asystole/Bradycardic PEA: Atropine is not indicated in the pediatric patient in cardiac arrest. G. HOW SUPPLIED: Pre-filled syringes containing 1 mg in 10ml of solution.
ATROPINE SULFATE (as an antidote for poisoning) A. ACTIONS: Atropine is a potent parasympatholytic that bonds to acetylcholine receptors thus diminishing the actions of acetylcholine. Atropine stops the effect of the nerve agent by blocking the effects of over-stimulation and effectively counters the actions of the nerve agent at nerve receptors. Atropine also relieves the smooth muscle constriction in the lungs (wheezing, respiratory distress) and GI tract (diarrhea, cramps) and dries up respiratory tract secretions. B. INDICATIONS: 1. Organophosphate poisoning (e.g. parathion, malathion, sevin, diazinon and many common roach and ant sprays). 2. Nerve gas poisoning (Sarin gas, VX gas) with symptoms of excessive cholinergic stimulation. POISONING SIGNS ARE: Salivation Tearing (lacrimation) Urination Abdominal cramping C. CONTRAINDICATIONS: None when used in the management of severe organophosphate or nerve gas poisoning. D. SIDE EFFECTS AND ADVERSE REACTIONS: Victims or organophosphate poisoning can tolerate and may require large doses of Atropine. Signs of atropinization (flushing, pupil dilation, dry mouth, tachycardia) are the end point of treatment. Reduction of secretions is most important. E. WARNINGS: It is important that the patient be adequately oxygenated and ventilated prior to using Atropine, as Atropine may precipitate ventricular fibrillation in a poorly oxygenated patient. Pinpoint pupils Bradycardia Vomiting Airway secretions Rhinorrhea
ATROPINE SULFATE (as an antidote for poisoning)-(cont) F. DOSAGE: Adult: 2-5 mg IV/IO, repeat with 2-5 mg q 15 minutes until atropinization occurs. Pediatric: 0.05-0.1mg/kg, repeat q 15 minutes if necessary. G. HOW SUPPLIED: 1. Pre-filled syringes containing 1mg in 10ml. 2. Multi-dose bottles containing 8 mg in 20 ml.
BENADRYL (DIPHENHYDRAMINE) A. ACTIONS: Benadryl (Diphenhydramine) is an antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Benadryl prevents, but does not reverse histamine mediated responses, particularly histamines effects on the smooth muscle of the bronchial airways, gastrointestinal tract, uterus, and blood vessels. B. INDICATIONS: 1. 2. Dystonic reactions from phenothiazines. Anaphylaxis.
C. CONTRAINDICATIONS: Benadryl is not to be used in newborn or premature infants or in nursing mothers. Benadryl is also not to be used in patients with lower respiratory tract symptoms, including asthma. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - (most noted in elderly) Drowsiness, confusion, insomnia, headache, vertigo, hyperactivity in children. CV - Palpitations, tachycardia, PVCs, hypotension. GI - Nausea, vomiting, diarrhea, dry mouth, constipation. GU - Dysuria, urinary retention. RESP - Thickening of bronchial secretions, tightness of the chest, wheezing, nasal stuffiness. E. WARNINGS: 1. In infants and children especially, antihistamines in overdose may cause hallucinations, convulsions, or death. 2. Antihistamines may diminish mental alertness in both adults and children. In young children, they may produce excitation.
BENADRYL (DIPHENHYDRAMINE) - (cont.) 3. Benadryl has additive effects with alcohol and other CNS depressants (hypnotics, sedatives, tranquilizers, etc).
4. Antihistamines are more likely to cause dizziness, sedation, and
hypotension in the elderly (60 years or older) patient. F. DOSAGE: Adult: 25-50 mg IV or deep IM. Pediatric: 1 mg/kg IV or IM. G. HOW SUPPLIED: 50 mg diphenhydramine HCL in 2 ml pre-filled syringe or vial
CALCIUM GLUCONATE A. ACTIONS: Calcium is essential for maintenance of the functional integrity of nervous, muscular, skeletal system and cell-membrane and capillary permeability. The cation is essential in the transmission of nerve impulses, contraction of cardiac, smooth and skeletal muscles; renal function; respiration; and blood coagulation. B. INDICATIONS: Calcium Gluconate may be a consideration during resuscitation attempts when the following are suspected or known: 1. Acute hyperkalemia. 2. Hypocalcemia. 3. Calcium Channel Blocker toxicity. 4. Hypermagnesemia. It may be used as a temporizing measure to prevent and/or treat cardiac arrythmias in the face of hyperkalemia. C. CONTRAINDICATIONS: Calcium salts are not indicated during routine cardiopulmonary resuscitation (except as noted as above). It is suspected that high levels of Calcium may induce reperfusion injury and adversely affect the neurologic outcome of the patient. D. SIDE EFFECTS AND ADVERSE REACTIONS: Rapid IV injection of Calcium salts may cause vasodilation, decreased blood pressure, bradycardia, cardiac arrhythmias, syncope and cardiac arrest. E. WARNINGS: Calcium salts should not be injected IM, SQ, or into any perivascular tissue. They may cause mild to moderate local reactions.
CALCIUM GLUCONATE (cont.) F. DOSAGE: Adult in cardiopulmonary resuscitation: 2.3 - 3.7 mEq IV injected over 10-20 seconds, repeated at 10 minute intervals if necessary. Adult for treatment of hyperkalemia with secondary cardiac toxicity: 2.25 14 mEq IV injected over 1-2 minutes while monitoring ECG. Pediatric: Not indicated in the pediatric patient. If Calcium is required in the resuscitation of the pediatric patient, Calcium Chloride should be used. G. HOW SUPPLIED: 4.65 mEq in 10 ml bottle.
CYANOKIT (Hydroxycobalamin) A. DESCRIPTION: Cyanokit is an antidotal treatment for acute intoxication by hydrogen cyanide and its derivatives. B. ACTIONS: The active ingredient in the Cyanokit, hydroxocobalamin, is a precursor of vitamin B12. Hydroxocobalamin works by binding directly to the cyanide, creating cyanocobalamin, a natural form of vitamin B12, which is excreted in the urine. Methemoglobin is not produced and the oxygen carrying capacity of the patients blood is not lowered, making it suitable and safe for use in smoke inhalation patients. C. INDICATIONS: NOTE: Use of the Cyanokit is a Level II procedure and contact must be made with Medical Control before its use is considered. Indicated in the treatment of known or suspected hydrogen cyanide poisoning and its derivatives. If history is suggestive and clinical suspicion of cyanide poisoning is high, Cyanokit should be administered without delay. Note: Cyanide exposure occurs relatively frequently in patients with smoke inhalation secondary to being confined in residential or commercial structure fires. Cyanide poisoning may also occur in industry, particularly in the metal trades, mining, electroplating, jewelry manufacture and x-ray film recovery. It is also encountered in the fumigation of ships, warehouses flour mills and other similar large structures. Cyanides can also be used as suicidal agents, particularly among health care and laboratory workers. C. CONTRAINDICATIONS: None. D. SIDE EFFECTS AND ADVERSE REACTIONS: The most common side effect seen is injection site redness and a temporary pink or red discoloration of the skin, urine and mucous membranes. Allergic reactions can occur, but are rare. Rises in blood pressure have been noted, but are transient.
CYANOKIT (Hydroxycobalamin) (cont.): E. WARNINGS: Hydroxocobalamin is known to be incompatible with a number of other drugs in the same IV line, so it should be administered in its own dedicated IV line. F. DOSAGE AND ADMINISTRATION: Adult: Starting dose is 5 gm (both 2.5 gm vials) administered as an IV drip over 10-15 minutes. Depending on the severity of the poisoning and the clinical response, a second 5 gm dose may be needed later. Pediatric: The use of hydroxocobalamin in the pediatric patient has not been studied in the U.S., but in Europe a common starting dose is 70 mg/kg. Each 2.5 gm vial of hydroxocobalamin is to be reconstituted with 100 ml NS using the supplied sterile transfer spike. Following the reconstitution of the powder, each vial should be rocked for 30 seconds prior to infusion. G. HOW SUPPLIED: Each Cyanokit contains: 1. (2) 250 ml glass vials, each containing 2.5 gm lyophilized hydroxocobalamin dark red crystalline powder for injection. 2. (2) sterile transfer spikes. 3. (1) sterile IV infusion set. 4. Quick use reference guide and package insert.
DEXTROSE 50% (D50) A. ACTIONS: A monosaccharide, which provides calories for metabolic needs, spares body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. It is a hypertonic solution. B. INDICATIONS: Hypoglycemia. C. CONTRAINDICATIONS: Intracranial or intraspinal hemorrhage; Delirium Tremens with dehydration. Hyperglycemia, CVA, head injury, low perfusion states (unless hypoglycemia is confirmed). D. SIDE EFFECTS AND ADVERSE REACTIONS: CV Potential thrombosis, sclerosing if given in small peripheral vein. INTEG - Tissue damage, irritation if infiltrates. OTHERS - Acidosis, alkalosis, hyperglycemia, hypokalemia. E. WARNINGS: 1. May theoretically cause Wernicke-Korsakoff syndrome in acute alcohol intoxication. Perform a glucose check prior to administering dextrose. 2. Do not give D50 to pediatric patients < 2 y/o, use D25 or D10. 3. Do not give if glucose level > 70. F. DOSAGE: Adults: 50 ml of a 50% solution (25gms) IV. Pediatrics: See D25. G. HOW SUPPLIED: Pre-filled syringes containing 25 gm of glucose in 50 ml of solution.
DEXTROSE 25% (D25) A. ACTIONS: A monosaccharide, which provides calories for metabolic needs, spares body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. It is a hypertonic solution. B. INDICATIONS: Hypoglycemia. C. CONTRAINDICATIONS: Intracranial or intraspinal hemorrhage, hyperglycemia, CVA, head injury, low perfusion states (unless hypoglycemia is confirmed). D. SIDE EFFECTS AND ADVERSE REACTIONS: CV Potential thrombosis, sclerosing if given in small peripheral vein. INTEG - Tissue damage, irritation if infiltrates. OTHERS - Acidosis, alkalosis, hyperglycemia, hypokalemia. E. WARNINGS: 1. Do not give D25 to pediatric patients < 1 month, use D10. 2. Do not give if glucose level > 60. F. DOSAGE: Pediatrics: 2 ml/kg of 25% solution. Adults: See D50. G. HOW SUPPLIED: Pre-filled syringes containing 2.5 gm of glucose in 10 ml of solution.
DOPAMINE INFUSION (INTROPIN) A. ACTIONS: Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic receptors of the sympathetic nervous system. It exerts an inotropic effect on the myocardium resulting in an increased cardiac output. Dopamine produces less increase in myocardial oxygen consumption than does isoproterenol and its use is usually not associated with a tachyarrhythmia. Dopamine dilates renal and mesenteric blood vessels at low loses that may not increase heart rate or blood pressure. Therapeutic doses have predominant beta-adrenergic receptor stimulating actions that result in increases in cardiac output without marked increases in pulmonary occlusive pressure. At high doses, Dopamine has alpha receptor stimulating actions that result in peripheral vasoconstriction and marked increases in pulmonary occlusive pressure. B. INDICATIONS: 1. Hemodynamically significant bradydysrhythmias that have not responded to Atropine and/or when pacing is not available. 2. Hypotension that occurs after return of spontaneous circulation. 3. Hemodynamically significant hypotension in the absence of hypovolemia (cardiogenic shock). C. CONTRAINDICATIONS: 1. Hypovolemia. 2. Uncorrected tachydysrhythmias or VF. 3. Patients with pheochromocytoma. 4. Patients on MAO inhibitors. 5. Known hypersensitivity to sulfites or Dopamine. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - Headache. CV - Ectopic beats, tachycardia, anginal pain, palpitations, hypotension.
DOPAMINE INFUSION (INTROPIN) (cont.) SIDE EFFECTS AND ADVERSE REACTIONS: (cont.) GI - Nausea, vomiting. LOCAL - Necrosis and tissue sloughing with extravasation. OTHER - Piloerection, dyspnea. E. WARNINGS: Do not add Dopamine to any alkaline dilutent solution since the drug is inactivated in alkaline solution. F. DOSAGE: Adults: Dose range 5 to 20 mcg/kg/min. Begin infusion at 5 mcg/kg/min. Pediatrics: Dose range 2 to 20 mcg/kg/min. Use 40 mg/ml solution, to mix: add 30 mg (2.4 ml) to 250ml D5W. G. HOW SUPPLIED: Premixed solution containing 400 mg of Dopamine in 250 ml of D5W yielding a concentration of 1600 mcg/ml.
EPINEPHRINE (1:10,000) A. ACTIONS: Epinephrine is a sympathomimetic which stimulates both alpha and beta receptors. As a result of its effects, myocardial and cerebral blood flow are increased during ventilation and chest compression. Epinephrine increases systemic vascular resistance and thus may enhance defibrillation. B. INDICATIONS: 1. Cardiac arrest: asystole, ventricular fibrillation, pulseless VT, pulseless electrical activity (PEA), 2. Anaphylaxis with hypotension. 3. Symptomatic (unstable) bradycardia in the pediatric patient. C. CONTRAINDICATIONS: None in the cardiac arrest situation. D. SIDE EFFECTS: CNS - Anxiety, headache, cerebral hemorrhage. CV - Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. GI - Nausea and vomiting. E. WARNINGS: Epinephrine is inactivated by alkaline solutions - never mix with sodium bicarbonate. Action of catecholamines depressed by acidosis - attention to ventilation and circulation is essential. Antidepressants potentiate the effect of Epinephrine. F. DOSAGE: Adults - cardiac arrest: 1 mg IV/IO every 3-5 minutes for duration of pulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable. Adults - anaphylaxis with hypotension: 1 ml slow IV/IO over 3-5 min.
EPINEPHRINE (1:10,000) (cont.) DOSAGE (cont.) Pediatrics - cardiac arrest: 0.01 mg/kg, IV/IO every 3-5 minutes for duration of pulselessness. Pediatrics - anaphylaxis with hypotension: 0.01 mg/kg slow IV/IO over 35 min. (not to exceed 1 ml dose). Pediatrics - unstable bradycardia: 0.01 mg/kg IV repeated every 3-5 minutes at same dose G. HOW SUPPLIED Pre-filled syringes containing 1 mg/10ml.
EPINEPHRINE (1:1000) A. ACTIONS: Epinephrine is a sympathomimetic which stimulates both alpha and beta adrenergic receptors causing immediate bronchodilatation, increase in heart rate and an increase in the force of cardiac contraction. Subcutaneous dose lasts 5 - 15 minutes. B. INDICATIONS: 1. Anaphylaxis. 2. Pediatric asthma, adult asthma in extremis. 3. Cardiac arrest in pediatric patients. 4. May be used for ET dose in adult cardiac arrest (after diluting to 10 ml). 5. May be used for ET administration in pediatric symptomatic bradycardia if unable to start IV or IV delayed. C. CONTRAINDICATION: Hyperthyroidism, hypertension, cerebral and coronary artery arteriosclerosis. D. SIDE EFFECTS AND ADVERSE REACTIONS: Same as Epinephrine 1:10,000. E. WARNINGS: Same as Epinephrine 1:10,000. 1:1000 Epinephrine should not be given intravenously to adults or intravenously for pediatric asthma and anaphylaxis. F. DOSAGE: Adults - anaphylaxis: 0.3 - 0.5 mg (0.3 - 0.5 ml) SQ or IM. May be repeated every 15 minutes x 3 if necessary. Adults - asthma (in extremis): 0.3 - 0.5 mg (0.3 - 0.5 ml) SQ (requires contact with Medical Control). Adults - cardiac arrest (ET dose): Give 2 - 2.5 mg ET diluted to 10 ml until IV established.
EPINEPHRINE (1:1000) (cont.) Pediatrics - anaphylaxis/asthma: 0.01 mg/kg (up to 0.3 mg) SQ for both asthma and anaphylaxis. Pediatrics - cardiac arrest: 0.1 mg/kg for ET dose if IV delayed or unavailable. 0.1 to 0.2 mg/kg for second and subsequent doses after first dose of 1:10,000. G. HOW SUPPLIED: Ampule containing 1 mg/1 ml. Pre-filled syringe containing 1 mg/1 ml. Multi-dose vial in a concentration of 30 mg/30 ml.
ETOMIDATE (AMIDATE) A. ACTIONS: Etomidate is a imidazole sedative-hypnotic agent that causes sedation through enhanced GABA receptor activity. It produces rapid, deep sedation within one minute (many times within 15-30 seconds) with minimal cardiovascular effects. The duration of the sedation is approximately 5-10 minutes. B. INDICATIONS: 1. Used as an induction agent for Rapid Sequence Intubation. 2. Can be used for procedural sedation during painful procedures (cardioversion). C. CONTRAINDICATION: There is no contraindication to the use of Etomidate in the setting of Rapid Sequence Intubation. For procedural sedation, the only contraindication is the patient who has shown a hypersensitivity to the drug. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS Transient muscle contractions or twitching (Myoclonus). GU If used without concomitant paralytics, nausea and vomiting can occur. LOCAL Can cause transient mild local burning and venous irritation on administration. E. WARNINGS: Can cause rapid and deep sedation within 15-30 seconds. Should only be used when personnel and equipment are ready for appropriate airway and ventilatory management. F. DOSAGE: Adults Rapid Sequence Intubation: 0.3 mg/kg IV/IO Adults procedural sedation: 0.1 mg/kg IV
ETOMIDATE (AMIDATE) (cont.) F. DOSAGE (cont.): Pediatrics: Etomidate should not be used in the patient 10 years of age. If patient > 10 years of age, adult dose is used. G. HOW SUPPLIED: Pre-filled syringe containing 40 mg/20 ml (2mg/ml).
FENTANYL (SUBLIMAZE) A. ACTIONS: Fentanyl is a potent narcotic analgesic that suppresses pain by inhibiting ascending pathways in the central nervous system. It increases pain threshold, and alters pain reception via binding at opioid receptors in the brain. Onset of action if given IV is 1-2 minutes. Peak effects are seen within 3-5 minutes Duration of action is typically 30-60 minutes. Onset of action if given IM is 7-15 minutes. Peak effects are seen within 2030 minutes. Duration of action is typically 1-2 hours. B. INDICATIONS: 1. Severe pain from burns and isolated extremity injuries/fractures. 2. Chest pain from acute MI when patient allergic to Morphine. C. CONTRAINDICATIONS: 1. Patients with pain due to multi-system trauma or acute abdomen. 2. Patients with volume depletion or hypotension. 3. Patients with head, chest or abdominal trauma. 4. Alcoholism or antidepressant ingestion. 5. Any respiratory difficulty. Note: Fentanyl is a potent respiratory depressant. 6. Myasthenia Gravis and in those patients who have received MAO inhibitor therapy in the last 14-21 days as well as those who have a known hypersensitivity to the drug. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - Euphoria, drowsiness, dizziness, pupillary constriction, respiratory depression and arrest. CV - Bradycardia, hypotension.
FENTANYL (cont.): D. SIDE EFFECTS AND ADVERSE REACTIONS (cont.): GI - Nausea and vomiting. GU - Urinary retention. RESP Apnea, respiratory depression, Broncho and laryngospasm, decreased cough/gag reflex. E. WARNINGS: 1. Rapid administration may cause skeletal muscle (chest wall) rigidity. This may inhibit or make ventilation impossible. Administer slow (over 12 min.) IV. 2. Fentanyl should be used with great caution in patients who are concurrently using other narcotic analgesics, phenothiazines, benzodiazepines, sedative-hypnotics (including barbiturates), tricyclic anti-depressants and other CNS depressants (including alcohol). Respiratory depression or arrest, hypotension and profound sedation or coma may result. 3. May be reversed with Narcan (may require more than usual dose of Narcan). F. DOSAGE: Adults: 50-100 mcg (1 mcg/kg) slow (over 1-2 min.) IV/IO. May repeat as necessary to a maximum total dose of 150 mcg. If IV route not available, may give single IM dose of 100 mcg. Pediatrics: 1 mcg/kg IV/IO. G. HOW SUPPLIED: Pre-filled cartridges containing 100 mcg/2 ml.
GLUCAGON A. ACTIONS: Glucagon, produced in the pancreas by the alpha cells of the Islets of Langerhans, can cause an increase in blood glucose concentrations. It releases stores of glucose from the liver, causing blood glucose to rise. B. INDICATIONS: Glucagon is indicated for the treatment of hypoglycemia when a peripheral IV is either impractical or cannot be obtained. C. CONTRAINDICATIONS: Since glucagon is a protein, hypersensitivity is a possibility. D. SIDE EFFECTS AND ADVERSE REACTIONS: GI: Occasional nausea and vomiting. E. WARNINGS: 1. Glucagon should be administered with caution in patients with a known history of Insulinoma and/or Pheochromocytoma. 2. If patient has no stores of glucose, Glucagon may be ineffective. F. DOSAGE: Adults: 1.0 unit (1.0 mg.) of Glucagon IM. Pediatrics: Children under 20 kg should receive 0.5 mg (.5 unit) IM. If child over 20 kg may use adult dose. G. HOW SUPPLIED: Vial with 1.0 unit (1.0 mg) glucagon (dry powder) and pre-filled syringe containing 1 ml of diluting solution. Inject diluting solution into vial, mix together and draw back into syringe to administer.
HALDOL (HALOPERIDOL) A. ACTIONS: Haldol is an antipsychotic whose precise mechanism is not known. Competitively blocks dopamine receptors in the brain responsible for mood and behavior. Also known to have antiemetic properties. B. INDICATIONS: 1. Short-term management of acute, violent psychotic episodes. 2. Short-term management of aggressive, agitated and combative patients to facilitate transport. C. CONTRAINDICATIONS: 1. Patients in comatose states or experiencing CNS depression due to alcohol or other depressant drugs. 2. Patients with Parkinsons syndrome. 3. Do not administer to females who may be pregnant or nursing. 4. Any patient with known hypersensitivity to the drug. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS Extrapyramidal symptoms, especially akathisia and dystonias. Confusion, vertigo, seizures, CV Tachycardia, orthostatic hypotension, hypertension, ECG changes (torsades) with IV use. EENT Blurred vision. GI Dry mouth, diarrhea, nausea, vomiting. E. WARNINGS: If Extrapyramidal symptoms occur, treat with 50 mg Benadryl IV.
HALDOL (HALOPERIDOL) (cont.) F. DOSAGE: Adults: 5 mg IM or IV Pediatrics: Not indicated in the patient < 8 years of age. G. HOW SUPPLIED: Ampule containing 5 mg/1ml
Pralidoxime (2 Pam) Chloride (Mark I Kit, Auto-Injector) A. ACTIONS: Pralidoxime Chloride is a cholinesterase reactivator. Its principal action is to reactivate cholinesterase which has been inactivated by phosphorylation due to organophosphates or nerve gas compounds. The destruction of accumulated acetylcholine can then proceed and neuromuscular junctions will again function normally. B. INDICATIONS: The auto-injector for Pralidoxime Chloride is specifically indicated for intramuscular use as an adjunct to Atropine in the treatment of poisoning by organophosphates or nerve agents (Sarin gas, VX gas) having anticholinesterase activity. POISONING SIGNS ARE: Salivation Tearing (lacrimation) Urination Abdominal cramping C. CONTRAINDICATIONS: None when used in the management of severe organophosphate or nerve gas poisoning. D. SIDE EFFECTS AND ADVERSE REACTIONS: It is very difficult to differentiate between any adverse effects of Pralidoxime Chloride and Atropine and the toxic effects of organophosphate/ nerve gas poisoning. E. WARNINGS: When Atropine and Pralidoxime Chloride are administered together, the signs of atropinization (flushing, tachycardia, dryness of mouth and nose) may occur much earlier then might be expected when Atropine is used alone. This is especially true if the total dose of Atropine has been large and the administration of Pralidoxime Chloride has been delayed. Pinpoint pupils Bradycardia Vomiting Airway secretions Rhinorrhea
Pralidoxime (2 Pam) Chloride (Mark I Kit, Auto-Injector) (cont.) F. DOSAGE: Adults: For optimal effects, Atropine and Pralidoxime Chloride should be administered together as soon as possible after exposure. Depending on the severity of symptoms, immediately administer 1 Atropine auto-injector, followed by 1 Pralidoxime Chloride auto-injector. Atropine must be given first until its effects become apparent, and only then should Pralidoxime Chloride be administered. If nerve agent symptoms are still present after 15 minutes, repeat injections. If symptoms still exist after an additional 15 minutes, repeat injections for third time. If symptoms remain after third set of injections, do not give any more injections. If symptoms are severe, 3 Atropine auto-injectors and 3 Pralidoxime Chloride autoinjectors should be administered in rapid succession (stacked) See directions for use and picture below. Pediatrics: Safety and effectiveness in the pediatric patient has not been established. Do not use in the patient < 8 years of age. G. HOW SUPPLIED: Pralidoxime Chloride is supplied in aqueous solution pre-filled and premeasured in the auto-injector, 600 mg/2ml.
Directions for Use: 1. 2. Remove gray safety cap. Place black end against outer thigh and push hard until the injector functions. Hold firmly in place for 10 seconds, then remove. Massage the injection area. Dispose of properly. Place in sharps container or bend needle into a hook.
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Atropine Sulfate (Mark I Kit, AtroPen Auto-Injector) A. ACTIONS: Atropine is a potent parasympatholytic that bonds to acetylcholine receptors thus diminishing the actions of acetylcholine. Atropine stops the effect of the nerve agent by blocking the effects of over-stimulation and effectively counters the actions of the nerve agent at nerve receptors. Atropine also relieves the smooth muscle constriction in the lungs (wheezing, respiratory distress) and GI tract (diarrhea, cramps) and dries up respiratory tract secretions. B. INDICATIONS: The auto-injector for Atropine is specifically indicated for intramuscular use in conjunction with Pralidoxime Chloride for the treatment of poisoning by organophosphates or nerve agents (Sarin gas, VX gas) having anticholinesterase activity. POISONING SIGNS ARE: Salivation Tearing (lacrimation) Urination Abdominal cramping C. CONTRAINDICATIONS: None when used in the management of severe organophosphate or nerve gas poisoning. D. SIDE EFFECTS AND ADVERSE REACTIONS: Victims of organophosphate/nerve gas poisoning can tolerate and may require large doses of Atropine. Signs of atropinization (flushing, pupil dilation, dry mouth, tachycardia) are the end point of treatment. Reduction of secretions is most important. E. WARNINGS: It is important that the patient be adequately oxygenated and ventilated prior to using Atropine, as Atropine may precipitate ventricular fibrillation in a poorly oxygenated patient. Pinpoint pupils Bradycardia Vomiting Airway secretions Rhinorrhea
Atropine Sulfate (Mark I Kit, AtroPen Auto-Injector) (cont.) F. DOSAGE: Adult: For optimal effects, Atropine and Pralidoxime Chloride should be administered together as soon as possible after exposure. Depending on the severity of symptoms, immediately administer 1 Atropine auto-injector, followed by 1 Pralidoxime Chloride auto-injector. Atropine must be given first until its effects become apparent, and only then should Pralidoxime Chloride be administered. If nerve agent symptoms are still present after 15 minutes, repeat injections. If symptoms still exist after an additional 15 minutes, repeat injections for third time. If symptoms remain after third set of injections, do not give any more injections. If symptoms are severe, 3 Atropine auto-injectors and 3 Pralidoxime Chloride autoinjectors should be administered in rapid succession (stacked) See directions for use and picture below. Pediatrics: Safety and effectiveness in the pediatric patient has not been established. Do not use in the patient < 8 years of age. G. HOW SUPPLIED: Atropine is supplied pre-filled and pre-measured in the auto-injector, 2mg/2ml.
Directions for Use: 1. 2. Remove yellow safety cap. Place green end against outer thigh and push hard until the injector functions. Hold firmly in place for 10 seconds, then remove. Massage the injection area. Dispose of properly. Place in sharps container or bend needle into a hook.
1. Yellow Safety Cap
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4.
2. Green End 3. Thigh
HEPARIN INFUSION (transport only, not stocked) A. ACTIONS: Heparin inhibits reactions that lead to the clotting of blood and the formation of fibrin clots. Heparin acts at multiple sites in the normal coagulation system. Small amounts of Heparin in combination with antithrombin III (Heparin co-factor) can inhibit thrombosis by inactivating active factor X and inhibiting the conversion of prothrombin to thrombin. Heparin does not have fibrinolytic activity, so it will not dissolve existing clots. B. INDICATIONS: 1. Prevention of clotting in arterial and heart surgery. 2. Anticoagulant therapy in prophylaxis and treatment of venous thrombosis 3. Prophylaxis and treatment of pulmonary embolism. 4. Atrial fibrillation with embolization. C. CONTRAINDICATIONS: 1. Heparin should not be used in patients with severe thrombocytopenia (abnormal decrease in the number of platelets in the blood) in whom suitable blood coagulation tests cannot be performed at appropriate intervals (this contraindication refers to full-dose Heparin, there is usually no need to monitor coagulation parameters in patient receiving low-dose Heparin. 2. Heparin should not be used in patients with an uncontrollable active bleeding site. 3. Patients with documented hypersensitivity to Heparin should only be given the drug in clearly life-threatening circumstances. D. SIDE EFFECTS AND ADVERSE REACTIONS: Hemorrhage is the chief complication that may result from Heparin therapy. Bleeding can occur at virtually any site, but it should be appreciated that internal bleeding that is hard to detect can occur, and any unexplained fall in blood pressure or other symptoms of hypotension may be caused by a hemorrhagic event that is related to the Heparin therapy.
HEPARIN INFUSION (transport only, not stocked) (cont.) E. WARNINGS: 1. Heparin is not intended for intramuscular use. 2. Heparin should be used with extreme caution in disease states in which there is increased danger of hemorrhage. If patient develops signs of hemorrhaging, infusion should be discontinued. F. DOSAGE Loading dose: 80 units/kg (Loading dose usually given prior to starting maintenance drip) Maintenance Dose: 500-1500 units/hour to maintain PTT 1.5-2.5 times control. Weight Based Dosing: 80-100 units/kg loading dose, followed by 15-25 units/kg/hour to maintain target PTT. G. HOW SUPPLIED: 25,000 units in 250 ml NS (pre-mixed)
NITROGLYCERIN INFUSION (transport only, not stocked) A. ACTIONS: Nitroglycerin is a direct vasodilator which acts primarily on the venous system, although it also produces direct coronary artery vasodilatation. There is a decrease in venous return which decreases the workload on the heart and decreases myocardial oxygen consumption, preload and afterload. Nitroglycerin is metabolized by the liver, excreted in urine and has a half-life of 1-4 minutes. IV onset of action is immediate, duration is variable. B. INDICATIONS: 1. Acute, unstable myocardial ischemia (Angina). 2. Acute Myocardial Infarction. 3. Relief of persistent chest pain that does not respond to first-line medications. 4. Congestive heart failure. C. CONTRAINDICATIONS: 1. Known sensitivity to nitrates. 2. Increased intracranial pressure (ICP) from head trauma, hemorrhagic CVA or other cerebral hemorrhage. 3. Hypotension. 4. Uncorrected hypovolemia. 5. Use of Viagra (Sildenafil Citrate) within 24 hrs. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS Headache, dizziness, pallor or flushing, sweating. CV Hypotension, reflex tachycardia. GI Nausea, and vomiting.
NITROGLYCERIN INFUSION (transport only, not stocked) (cont.) E. WARNINGS: 1. Use with caution in patients with the following conditions: a. Pregnant or lactating. b. Hepatic or renal disease. c. Pericarditis d. Postural hypotension. 2. Glass infusion bottles and non-polyvinyl tubing must be used as plastics will absorb Nitroglycerin. Plastic IV infusion bags may be used for shortterm transports. 3. Do not use in-line filters. 4. Do not mix with any other medications in same bag/bottle. F. DOSAGE: Rate of administration is titrated to patient pain relief response, typically starting at 10mcg/min. and increasing in 5 mcg increments every 3-5 minutes until response is noted (Be alert for developing hypotension). G. HOW SUPPLIED: Nitroglycerin infusion encountered at a facility will either be full strength: 50 mg/250 ml of NS or D5W or: half strength: 25 mg/250 ml or 50 mg/500 ml of NS or D5W. Pre-mixed will be in glass bottles. Teams will occasionally mix vials of Nitroglycerin (25 or 50 mg) in 250 ml bags of D5W for short transports.
INTEGRILIN INFUSION (transport only, not stocked) A. ACTIONS: Integrilin (Eptifibatide) is a cyclical heptapeptide that reversibly prevents platelet aggregation by preventing the binding of fibrinogen and other adhesive ligands to specific platelet receptors. The effects are specific to platelets, avoiding interference with other normal cardiovascular processes. The effects are reversed upon Integrilin discontinuation. Integrilin has a half-life of 2.5 hours and is cleared renally. B. INDICATIONS: 1. As an adjunct to aspirin and Heparin, for the prevention of acute cardiac ischemic complications in patients with acute coronary syndrome (unstable angina or non Q-wave myocardial infarction). 2. For the treatment of patients undergoing (PCI) percutaneous coronary intervention (balloon angioplasty, intracoronary stent placement). C. CONTRAINDICATIONS: 1. History of bleeding diathesis, or evidence of active abnormal bleeding within the last 30 days. 2. Uncontrolled hypertension (SBP > 200 and/or DBP > 110). 3. Major surgery or trauma within the preceding 6 weeks. 4. History of stroke within 30 days or any history of hemorrhagic stroke. 5. Known hypersensitivity to any component of the drug. D. SIDE EFFECTS AND ADVERSE REACTIONS: CV Bleeding is the most common complication encountered during Integrilin therapy, it is associated with an increase in major and minor bleeding. Most major bleeding has been at the arterial access site for cardiac catheterization or from the gastrointestinal or genitourinary tract.
INTEGRILIN INFUSION (transport only, not stocked) (cont.) E. WARNINGS: 1. If bleeding cannot be stopped with pressure, infusion of Integrilin and concomitant Heparin should be stopped immediately. 2. Use with caution in patients with concomitant Warfarin use and hemorrhagic retinopathy. F. DOSAGE: Typical recommended dosing of Integrilin for acute coronary syndromes is a bolus of 180 mcg/kg, followed by a continuous infusion of 2 mcg/kg/min. Dosing for PCI may be different. G. HOW SUPPLIED: Supplied in 10 ml vials containing 20 mg and 100 ml vials containing 75 mg. Requires vented IV tubing and may share same line with NTG or Heparin. 10 ml vial typically used for bolus dose. 100 ml vial typically used for infusion with IV set spiked directly to vial.
LASIX (FUROSEMIDE) A. ACTIONS: Lasix is a sulfonamide derivative and potent diuretic which inhibits the reabsorption of sodium and chloride in the proximal and distal renal tubules, as well as in the loop of Henle. This results in an increase in the urinary excretion of sodium, chloride and water, creating a profound diuresis. It also has a significant vasodilatory effect not related to its renal actions. With IV administration, onset of diuresis is within 5-10 minutes; peaks in 30 minutes; and has a duration of 2 hours. Onset of vasodilatory effects can be within 2 minutes. B. INDICATIONS: 1. Pulmonary edema. 2. Congestive heart failure. C. CONTRAINDICATIONS: 1. Hypersensitivity to Furosemide or sulfonamides. 2. Hypovolemia/hypotension. 3. Electrolyte depletion. 4. Anuria. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - Dizziness, tinnitus, hearing loss (with rapid administration), headache, blurred vision, weakness. CV - Hypotension. GI - Anorexia, vomiting, nausea. OTHER - Pruritus, urticaria, muscle cramping. E. WARNINGS: 1. Can cause excessive fluid loss and dehydration, resulting in hypovolemia and electrolyte imbalance.
LASIX (FUROSEMIDE) (cont.) E. WARNINGS (cont.): 2. Use with caution in patients with Diabetes mellitus, dehydration and severe renal disease. 3. Lasix should be protected from light. F. DOSAGE: Adults: 0.5-1.0 mg/kg (20-40 mg) IV slowly over 1-2 minutes. If the patient is on oral Lasix therapy, consider an initial IV dose that is twice the daily oral dose. Pediatrics: 1.0 mg/kg IV slowly over 1-2 minutes. G. HOW SUPPLIED: Vials or pre-filled syringes containing 40 mg/4ml (10 mg/1 ml).
LIDOCAINE (XYLOCAINE) A. ACTIONS: Inhibits the influx of sodium through the fast channels of the myocardial cell membrane and decreases conduction in ischemic cardiac tissue. This decreases the excitability in ischemic tissue and suppresses ventricular irritability. Raises the ventricular fibrillation threshold. B. INDICATIONS: 1. Control of hemodynamically compromising PVCs. Note: Treatment of PVCs with Lidocaine can be controversial. Lidocaine should only be considered in the symptomatic patient with significant ventricular irritability after other AMI treatments have been given (O2, ASA, NTG, Morphine). 2. Ventricular fibrillation / pulseless V-tach. 3. Prior to intubation in the setting of the head-injured trauma patient (suspected increased intracranial pressure). C. CONTRAINDICATIONS: 1. Hypersensitivity to Lidocaine or amide-type local anesthetics. 2. Severe sinoatrial, atrioventricular or intraventricular block (2nd and 3rd degree). 3. Stokes-Adams syndrome. 4. Wolff-Parkinson-White syndrome. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS Seizures, drowsiness, numbness, dizziness, blurred vision, tinnitus, euphoria, muscle twitching, tremors. CV - Rare, but with toxic levels - hypotension, widening of QRS complex, bradycardia, cardiac arrest. RESP - At toxic levels - respiratory depression and/or arrest.
LIDOCAINE (XYLOCAINE) (cont.) E. WARNINGS: 1. Lidocaine may be lethal in a bradycardia with a ventricular escape rhythm. 2. If PVCs occur in conjunction with sinus bradycardia or incomplete heart clock, the bradycardia must be treated first. 3. Lidocaine is metabolized in the liver. Bolus dosage should be decreased by half in patients with liver disease and low cardiac output states, e.g., acute MI, shock, congestive heart failure, patient more than 70 years old. F. DOSAGE: Adults cardiac arrest: 1-1.5 mg/kg/IV/IO bolus, repeat with 1-1.5 mg/kg q 5 - 10 minutes if necessary, not to exceed a total of 3 mg/kg. Pediatrics cardiac arrest: 1 mg/kg IV/IO bolus. Repeat bolus of 1 mg/kg q 5 - 10 min. if needed, to a total of 3 mg/kg. Maintenance Infusion: Lidocaine infusion containing 1 gm Lidocaine in 250 ml D5W given at a rate of 2-4 mg/min. (30-60) microdrops/min.). See Infusion Charts, Page 7-0. Note: Infusions are rarely necessary in pediatrics; treatment of ectopy should focus on maximization of oxygenation and ventilation and bolus doses of antiarrhythmic if needed. ET dose: Double IV dose. PVCs: 1mg - 1.5mg/kg IV or ET, subsequent doses 0.5 - 0.75 mg/kg not to exceed 3 mg/kg. Head Trauma: 1 mg/kg IV/IO. G. HOW SUPPLIED: Pre-filled syringes: 2% = 100 mg/5ml. Pre-mixed infusion solution: 1 gm/250 ml D5W.
LIDOCAINE 2 % VISCOUS GEL (Xylocaine) A. ACTIONS: Lidocaine stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby causing local anesthetic action. B. INDICATIONS: Lidocaine Gel is indicated as an anesthetic lubricant of accessible mucous membranes of the nasopharynx and oropharynx. It is useful for nasotracheal intubation and placement of nasopharyngeal airways. C. CONTRAINDICATIONS: Lidocaine is contraindicated in patients with a known history of hypersensitivity to local anesthetics of the amide type or to other components of Lidocaine 2% Gel. D. WARNINGS: Lidocaine 2% Gel should be used with extreme caution in the presence of sepsis or severely traumatized mucosa in the area of application, since such conditions have the potential for rapid systemic absorption. E. DOSAGE: A single application should not exceed 50 mg of Lidocaine 2% Gel. F. HOW SUPPLIED: 2% viscous gel in tubes or pre-filled syringes of 100 mg/5 ml (20 mg/ml).
MORPHINE SULFATE A. ACTIONS: Morphine is a narcotic (opiate) analgesic which depresses the central nervous system and suppresses pain via binding at opioid receptors of the brain. It increases venous capacitance, decreases venous return, and produces mild peripheral vasodilatation. Morphine also decreases myocardial oxygen demand and reduces anxiety. B. INDICATIONS: 1. Pain from acute myocardial infarction. 2. Pain from isolated extremity fractures. 3. Pain from burns. 4. Pulmonary edema. C. CONTRAINDICATIONS: 1. Multi-systems trauma or acute abdomen. 2. Volume depletion or hypotension. 3. Head trauma, acute alcoholism and acute asthma (relative). 4. Anyone with a known hypersensitivity to the drug. D. SIDE EFFECTS AND ADSVERSE REACTIONS: CNS - Euphoria, drowsiness, pupillary constriction, respiratory arrest. CV - Bradycardia, hypotension. GI - Decreases gastric motility, nausea and vomiting. GU - Urinary retention. RESP - Bronchoconstriction, decrease cough reflex. E. WARNINGS: Morphine is detoxified by the liver. It is potentiated by alcohol, antihistamines, barbiturates, phenothiazines, and other sedatives.
MORPHINE SULFATE (cont.) F. DOSAGE: Adults: 2-4 mg in 2 mg increments, slow IV. May repeat if necessary to a total of 10 mg. Pediatrics: 0.1 mg/kg slow IV. G. HOW SUPPLIED: Pre-filled syringe containing 10 mg/2 ml.
NARCAN (NALOXONE) A. ACTIONS: Narcan antagonizes the effects of opiates by competing at same receptor sites. Prevents or reverses the effects of narcotics/opiates, including respiratory depression, sedation and hypotension. When given IV, the action is apparent within (2) minutes. IM or SQ administration is somewhat less rapid. B. INDICATIONS: Narcan is indicated to rule out or reverse coma and/or respiratory depression secondary to narcotics/opiates: 1. Heroin. 2. Meperidine (Demerol). 3. Codeine. 4. Morphine. 5. Methadone. 6. Lomotil. 7. Hydromorphone (Dilaudid). 8. Pentazocine (Talwin). 9. Propoxyphene (Darvon or Darvocet). 10.Percodan. C. CONTRAINDICATIONS: Narcan is contraindicated in patients known to be hypersensitive to the drug (rare). D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - Tremors, agitation, belligerence, pupillary dilation, seizures, increased tear production, sweating. CV - Hypertension, hypotension, ventricular tachycardia, pulmonary edema, ventricular fibrillation. GI - Nausea, vomiting.
NARCAN (NALOXONE) (cont.) E. WARNINGS: 1. Narcan should be administered cautiously to persons (including newborns of mothers) who are known or suspected to be physically dependent on narcotics/opiates. May precipitate acute withdrawal syndrome. 2. May need to repeat Narcan if patients LOC and respiratory status start to decline, since duration of action of some narcotics may exceed that of Narcan. 3. Rapid administration can cause projectile vomiting, 4. Use caution during administration as patient may become agitated or violent as level of consciousness increases. 5. Higher doses of Narcan may be indicated for certain synthetic narcotic overdoses such as Talwin or Darvocet. F. DOSAGE: Adults: 2 mg slow IV. IM, SQ or ET may also be used. Consider larger dose with synthetic narcotic. Pediatrics: 0.1 mg/kg slow I. IO, IM, SQ or ET may also be used. G. HOW SUPPLIED: Pre-filled syringe with 2 mg/2ml.
NEO-SYNEPHRINE A. ACTIONS: 12-hour nasal decongestant. Causes vasoconstriction of superficial blood vessels in the nasal mucosa, which decreases the possibility of bleeding. B. INDICATIONS: Used to minimize bleeding during nasotracheal intubation. C. WARNINGS: Do not exceed recommended dosage because untoward symptoms may occur such as burning, stinging, sneezing, or increase of nasal discharge. D. DOSAGE: Adults and children 8 years of age and over: Spray two or three times in each nostril.
NITROGLYCERIN SPRAY / TABLET A. ACTIONS: Nitroglycerin is a direct vasodilator which acts primarily on the venous system, although it also produces direct coronary artery vasodilatation as a result. There is a decrease in venous return which decreases the workload on the heart and decreases myocardial oxygen demand. Sublingual Nitroglycerin spray is preferred as it is more easily absorbed and bioavailable. B. INDICATIONS: 1. Myocardial ischemia (angina). 2. Acute myocardial infarction. 2. Hypertensive crisis. 3. Pulmonary edema. C. CONTRAINDICATIONS: 1. Known sensitivity to nitrates. 2. Increased intracranial pressure (ICP) from head trauma, hemorrhagic CVA or other cerebral hemorrhage. 3. Hypotension. 4. Uncorrected hypovolemia. 5. Use of Viagra (Sildenafil Citrate) or other ED drugs within 24 hrs. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS Headache, dizziness, pallor or flushing, sweating. CV Hypotension, reflex tachycardia. GI Nausea, and vomiting.
NITROGLYCERIN SPRAY / TABLET (cont.) E. WARNINGS: 1. Use with caution in patients with the following conditions: a. Pregnant or lactating. b. Hepatic or renal disease. c. Pericarditis d. Postural hypotension. 2. Because of an easily developed tolerance, patients on chronic nitrate therapy may require larger doses of nitroglycerin during acute anginal episodes. 3. Nitro tablets are inactivated by light, air and moisture. Must be kept in amber glass containers with tight-fitting lids. Do not leave cotton in container. 4. Consumption of alcohol will accentuate vasodilatation and hypotensive effects. F. DOSAGE: Adults: 1 tablet or 1 puff sublingually. May repeat q 5 minutes to a total of 3 doses if necessary. Hold spray canister upright, do not shake. Note: Advise patient to open mouth and bring the canister as close as possible, press button firmly with forefinger to release spray onto or under tongue. Advise patient not to inhale spray. Tablet should be placed under tongue. Pediatrics: Not indicated. G. HOW SUPPLIED: Spray canister that dispenses 0.4 mg/metered dose per spray. Bottles with 0.4 mg tabs.
PROCAINAMIDE (PRONESTYL) A. ACTIONS: Ventricular and supraventricular antiarrhythmic. Slows conduction through myocardium, elevates ventricular fibrillation threshold, suppresses ventricular ectopic activity. B. INDICATIONS: 1. Recurrent V-Fib, pulseless V-Tach refractory to Lidocaine. 2. Stable, wide-complex tachycardia refractory to Lidocaine. C. CONTRAINDICATIONS: 1. Complete AV block in the absence of an artificial pacemaker. 2. Patients hypersensitive to Procaine or other ester-type local anesthetics. 3. Digitalis toxicity. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS Anxiety, nausea, convulsions (monitor for CNS toxicity). CV Hypotension. Widening of QRS. E. WARNINGS: Procainamide should be discontinued when/if any of the following occurs: a. b. c. d. Dysrhythmia is suppressed. QRS is widened by 50% of original width. Hypotension ensues. Total of 17 mg/kg has been given.
F. DOSAGE: Adults: 20 mg/min slow IV/IO bolus until one of the above occurs. If successful conversion of V-Tach occurs with bolus Procainamide, a maintenance infusion of 1-4 mg/min. may be used. See Infusion Charts, Page 7-0.
SODIUM BICARBONATE A. ACTIONS: An alkalizing agent used to buffer acids present in the body during and after severe hypoxia. Bicarbonate combines with excess acids (usually lactic acid) present in the body to form a weak, volatile acid. This acid is broken down into CO2 and H2O. Sodium bicarbonate is effective only when administered with adequate ventilation and oxygenation. B. INDICATIONS: 1. Tricyclic antidepressant overdose with widening of the QRS to 0.10 seconds or longer. 2. Cardiac arrests associated with overdoses of tricyclic antidepressants or Phenobarbital. 3. Dialysis patient in cardiac arrest due to suspected hyperkalemia. C. CONTRAINDICATIONS: When used for situations above, there are no absolute contraindications. In the absence of the above situations, congestive heart failure and alkalotic states are contraindications. D. SIDE EFFECTS AND ADVERSE REACTIONS: CV - Metabolic alkalosis, hypernatremia, sodium and H20 retention which can cause CHF, hypotension, tachycardia. CNS Syncope, headache and flushing. E. WARNINGS: 1. Excessive bicarbonate therapy inhibits the release of oxygen and may result in alkalosis. Alkalosis is very difficult to reverse and may cause as many problems in resuscitation as acidosis. 2. Sodium Bicarbonate does not improve the ability to defibrillate. The most effective treatment for acidosis associated with cardiac arrest is effective ventilation.
SODIUM BICARBONATE - (cont.) E. WARNINGS (cont.): 3. May inactivate simultaneously administered catecholamines and will precipitate if mixed with calcium chloride. Administration should be guided by arterial blood gases and ph. F. DOSAGE: Adults: 1 mEq/kg (1 ml/kg) IV. Repeat with 0.5 meq/kg IV q 10 minutes. Pediatrics: 1 mEq/kg (I ml/kg) IV. Repeat with 0.5 meq/kg IV q 10 minutes. G. HOW SUPPLIED: Pre-filled syringes containing 50 meq/50 ml (I mEq/ml).
SUCCINYLCHOLINE (ANECTINE) A. ACTIONS: Succinylcholine is a short-acting, depolarizing-type skeletal muscle relaxant. It combines with the cholinergic receptors of the motor end plate to produce depolarization. This depolarization may initially be observed as fasciculations. Onset of flaccid paralysis with apnea is rapid (usually less than one minute after IV administration), and with single administration lasts approximately 4-6 minutes. B. INDICATIONS: Paralyzing agent to facilitate endotracheal intubation of primarily the combative, head-injured patient. Other candidates for RSI may include: 1. Patients with potential or actual airway compromise due to depressed LOC (GCS of 8 or less) or whose combativeness threatens the airway or spinal cord. 2. Patients who demonstrate a very high probability of airway compromise during transport (i.e. severe smoke inhalation injury). 3. Patients who need ventilatory assistance or airway protection. C. CONTRAINDICATIONS: 1. Persons with personal or familial history of malignant hyperthermia. 2. Presence of neuromuscular disease (i.e. myasthenia gravis or multiple sclerosis). 3. Severe burns or multiple trauma greater than 48 hours old. 4. Penetrating eye injury. D. SIDE EFFECTS AND ADVERSE REACTIONS: 1. Adverse reactions to succinylcholine consist primarily of extensions of its pharmacological actions. Profound muscle relaxation resulting in apnea may be prolonged. 2. Increased intraocular pressure. 3. Muscle fasciculations.
SUCCINYLCHOLINE (ANECTINE) (cont.) E. WARNINGS: 1. Succinylcholine should be administered with great caution to patients suffering from electrolyte abnormalities and those who may have massive digitalis toxicity, because in these circumstances, Succinylcholine may induce serious cardiac arrythmias or cardiac arrest due to hyperkalemia. 2. Succinylcholine is not a sedative! Do not administer to the patient who is awake or partially awake. Sedate first with Morphine, Valium or Etomidate.
F. DOSAGE: 2mg/kg , both adult and pediatric. Contact with MEDICAL CONTROL required BEFORE administering Succinylcholine! G. HOW SUPPLIED: 200 mg/10 ml (20 mg/ml) multi-dose vials.
THIAMINE HYDROCHLORIDE A. ACTIONS AND INDICATIONS: 1. Thiamine is indicated and is effective in the treatment of Wernickes Encephalopathy. Wernickes Encephalopathy, also known as Wernickes Syndrome is an inflammatory, hemorrhagic, degenerative condition of the brain, characterized by lesions in several parts of the brain. The condition is characterized by double vision, involuntary and rapid movements of the eyes, lack of muscular coordination, and decreased mental function, which may be mild or severe to the point of unconsciousness. Wernicke s encephalopathy is caused by a Thiamine deficiency and is seen in association with chronic alcoholism. 2. Thiamine is also effective in the treatment of beriberi (Thiamine deficiency), whether of the dry (major symptoms related to the nervous system) or wet (major symptoms related to the cardiovascular system) variety. B. CONTRAINDICATIONS: History of sensitivity to thiamine or to any of the components of the drug. Anaphylactic/allergic reactions are possible, but exceedingly rare. C. DOSAGE: 100mg IV or IM. D. HOW SUPPLIED: 100mg/2ml (50 mg/ml) vial. E. ADDITIONAL: Patients with marginal thiamine status (chronic alcoholic) to whom dextrose is being administered should also be considered for administration of IV or IM Thiamine.
THIAMINE HYDROCHLORIDE THIAMINE HYDROCHLORIDE (Vitamin B1) (Vitamin B1) THIAMINE HYDROCHLORIDE (Vitamin B1) THIAMINE HYDROCHLORIDE (Vitamin B1) THIAMINE HYDROCHLORIDE (Vitamin B1) THIAMINE HYDROCHLORIDE (Vitamin B1)
VALIUM (DIAZEPAM) A. ACTIONS: Valium is a tranquilizer and is a member of the benzodiazepine family. It depresses the limbic system, thalamus, and hypothalamus resulting in calming effects. Valium produces an amnestic effect and is also an anticonvulsant and skeletal muscle relaxant. B. INDICATIONS: 1. Status epilepticus and generalized seizures. 2. Pre-medication prior to cardioversion or other painful procedures. 3. Acute anxiety states C. CONTRAINDICATIONS: 1. Patient with acute alcohol intoxication. 2. Do not use in pregnant patient or in neonates. D. SIDE EFFECTS AND ADVERSE REACTIONS: CNS - Confusion, muscular weakness, blurred vision, drowsiness, respiratory depression, respiratory arrest, slurred speech. CV - Bradycardia, hypotension, cardiovascular collapse. E. WARNINGS: 1. Do not mix Valium with any other solutions or drugs. When injecting IV, administer slowly through the IV tubing as close as possible to the IV site to prevent precipitation with the IV fluid. 2. Do not administer into small veins such as those on the dorsum of the hand may cause local irritation and possibly venous thrombosis in small veins.
VALIUM (DIAZEPAM) (cont.) F. DOSAGE: Adults: 5-10 mg IV or IM. IV route should be administered slowly - no faster than 5 mg/min. (acute anxiety if ordered by Medical Control 2-5 mg). Pediatrics: 0.2 mg/kg IV, not to exceed 10 mg. IV route should be administered slowly no faster than 1 mg/min. May be administered rectally. To administer Valium rectally, draw up 0.5 mg/kg of valium in tuberculin syringe. Lubricate end of syringe (without needle) and insert into rectum past sphincter, 4-5 cm (often done most easily with child prone). G. HOW SUPPLIED: Pre-filled syringes containing 10 mg/2ml (5 mg/ml).
ZEMURON (ROCURONIUM) A. ACTIONS: Zemuron (Rocuronium) is a non-depolarizing neuromuscular blocking agent that acts by competing for cholinergic receptors at the motor end plate. Onset of flaccid paralysis with apnea is rapid to intermediate at approximately 1 minute with a duration of approximately 30 minutes. B. INDICATIONS: 1. Paralyzing agent for prolonged paralysis during longer transports of the patient that has already been intubated. 2. Per physician request only, may be used as an alternative for Succinylcholine in Rapid Sequence Intubation. C. CONTRAINDICATIONS: 1. Contraindicated in patients with a known hypersensitivity to the drug. 2. Zemuron will be contraindicated as an initial paralyzing agent in Rapid Sequence Intubation in the patient who presents as a difficult oral intubation. The drugs intermediate to long duration of 30 minutes or more dictates the patient will require prolonged airway support. D. SIDE EFFECTS AND ADVERSE REACTIONS: Adverse reactions to Zemuron consist primarily of extensions of its pharmacological actions (prolonged neuromuscular blockade). E. WARNINGS: Zemuron is not a sedative! Do not administer Zemuron to the patient who is awake, partially awake or starting to awaken from the administration of Succinylcholine. Sedate first with Morphine, Valium or Etomidate, then administer Zemuron. F. DOSAGE: .6 mg/kg IV or IO, both adult and pediatric. Contact with MEDICAL CONTROL required BEFORE administering Zemuron!
ZEMURON (ROCURONIUM) (cont.) G. HOW SUPPLIED: 50 mg/5 ml (10 mg/ml) multi-dose vial.
ZOFRAN (ONDANSETRON) A. ACTIONS: Antiemetic, the antiemetic properties of Zofran appear to be the result of it being a selective blocking agent of the serotonin 5-HT3 receptor type. Onset of action: Intravenous - 5 min. Intramuscular - 6-8 min. Oral dose - TBA Pharmacological effects persist for - 6 - 8 hrs. B. INDICATIONS: 1. Patients experiencing significant nausea and/or vomiting during transport. 2. To control nausea and vomiting in the patient that has had narcotic analgesics administered to control pain.
C. CONTRAINDICATIONS: Contraindicated in patients with a known hypersensitivity to the drug. D. SIDE EFFECTS AND ADVERSE REACTIONS: None. E. WARNINGS: None. F. DOSAGE: Adults: 4 mg IV/IM. 2nd dose of 4 mg may be administered after 15 minutes if first dose ineffective. Pediatrics .1 mg/kg to max of 4 mg. G. HOW SUPPLIED: 4 mg/2 ml (2 mg/ml).
Infusion Charts (Adult, Pediatric, Critical Care)
INFUSION CHARTS
Table 7.A. Dopamine Drip

Dose: 2 - 20 mcg/kg/minute Preparation: 400 mg in 250 ml D5W Concentration: 1600 mcg/ml (pre-mix) mcg/kg/ Patient weight in kg min. 2.5 5 10 20 30 40 50 60 70 80 90 2 mcg * * * 1.5 2 3 4 5 5 6 7 5 mcg * 1 2 4 6 8 9 11 13 15 17 10 mcg 1 2 4 8 11 15 19 23 26 30 34 15 mcg 1.4 3 6 11 17 23 38 34 39 45 51 20 mcg 2 4 8 15 23 30 38 45 53 60 68
Microdrops per minute (also ml/hr)
100 8 19 38 56 75
Table 7.B. Epinephrine Drip

Dose: 1 - 10 mcg/minute. Preparation: 1 mg in 250 ml D5W or NS Concentration: 4 mcg/ml mcg/min drops 1 15 2 30 3 45 Epinephrine Drip 4 5 6 60 75 90 7 105 8 120 9 135 10 150
Table 7.C. Lidocaine Drip

Dose: 1 - 4 mg/minute Preparation: 1 gm in 250 ml D5W Concentration: 4 mg/ml (pre-mix) Lidocaine Drip mg/minute drops/minute (ml/hr)
1 mg 2 mg 3 mg 4 mg
15
30
45
60
INFUSION CHARTS (cont.)
Table 7.D. Procainamide Drip

Dose: 1 - 4 mcg/minute. Preparation: 1 gm in 250 ml D5W Concentration: 4 mg/ml Procainamide Drip mg/minute 1 mg 2 mg drops/minute (ml/hr) 15 30
3 mg 45
4 mg 60
Table 7.E. Pediatric Infusions
PEDIATRIC MEDICATION INFUSIONS

DOPAMINE (use 40 mg/ml solution) DOSE 2 20 g/kg/minute. To mix: add 30 mg (2.4 ml) to 250ml D5W. 1 microdrop /kg/minute of this solution = 5 mcg/kg/minute. EPINEPHRINE (use 1:1000 solution, 1 mg/ml) DOSE: 0.1 1 mcg/kg/minute. To mix: add 1.5 mg (1.5 ml) to 250 ml D5W. 1 microdrop /kg/minute of this solution = 0.1 mcg/kg/minute. LIDOCAINE Drip use 2% solution, 20 mg/ml) DOSE: 2050 mcg/kg/minute. To mix: add 300 mg (15 ml) to 250 ml D5W. 1 microdrop /kg/minute of this solution = 20 mcg/kg/minute. Rule of 6 for Dopamine or Dobutamine infusions: 6 mg x wt in kg; Add this amount to 100 ml. 1 ml/hr = 1 mcg/kg/minute. Rule of 6 for Epinephrine, Norepinephrine, or Isoproterenol infusions: 0.6 mg x wt in kg; Add this amount to 100 ml. 1 ml/hr = 0.1 mcg/kg/minute.
INTERFACILITY TRANSPORT INFUSIONS
Table 7.F. Heparin Drip

drops/minute, or ml/hr Mix 25,000 IU in 500 ml D5W (50 U/ml) & run at: Heparin Drip Patient weight 50 kg 60 kg 70 kg IV drip: 12 IU/kg/hr 12 gtt 14 gtt 17 gtt
80 kg 19 gtt
90 kg 20 gtt
100 kg 20 gtt
Table 7.G. Nitroglycerin Drip

10 - 12 / minute. Increase by 5 - 10 g/minute q 5 minutes until desired effect. Mix 25 mg in 250 ml D5W (100 g/ml) & run at: Dose in (g/min) 5 g 10 g 20 g 30 g 40 g 50 g 60 g 70 g 80 g 90 g 100 g gtts/minute (or ml/hr) 3 gtts/min. 6 gtts/min. 12 gtts/min. 18 gtts/min. 24 gtts/min. 30 gtts/min. 36 gtts/min. 42 gtts/min. 48 gtts/min. 54 gtts/min. 60 gtts/min. Dose in (g/min) 110 g 120 g 130 g 140 g 150 g 160 g 170 g 180 g 190 g 200 g gtts/minute (or ml/hr) 66 gtts/min. 72 gtts/min. 78 gtts/min. 84 gtts/min. 90 gtts/min. 96 gtts/min. 102 gtts/min. 108 gtts/min. 114 gtts/min. 200 gtts/min.
= = = = = = = = = = =
= = = = = = = = = =
Note: use glass IV bottle and non-PVC IV tubing.

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RAPID CITY PENNINGTON COUNTY ADVANCED LIFE SUPPORT PROTOCOLS

These protocols are effective as of August 2009

Name (please print)

Rapid City Department of Fire and Emergency Services Paramedics

Rapid City Department of Fire and Emergency Services Paramedics

INDEX ADVANCED LIFE SUPPORT PROTOCOLS

INDEX (CONT.) ADVANCED LIFE SUPPORT PROTOCOLS

INDEX (CONT.) ADVANCED LIFE SUPPORT PROTOCOLS

INDEX (CONT.) ADVANCED LIFE SUPPORT PROTOCOLS

INDEX (CONT.) ADVANCED LIFE SUPPORT PROTOCOLS

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

G. See Neurologic Assessment

Section 1 Patient Assessment

B. Head: 1. 2. Signs of trauma. Fontanelle, if open: abnormal depression or bulging.

F. Abdomen: distention, rigidity, bruising, tenderness.

Section 1 Patient Assessment

See Neurologic Assessment

Premature Newborn 6 months 1 year 3 years 5 years 8 years

20-38 20-38 20-30 20-24 20-24 20-24 12-20

N/A N/A 80 palp 90 palp 95 palp 95 palp 100 palp

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

Section 1 Patient Assessment

B. Associated complaints: patient at this time?

Section 1 Patient Assessment

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Contact Medical Control prior to further fluids being infused.

Section 2 Treatment Protocols - Medical

I.4 I.5. I.6.

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (hyperkalemia, metabolic acidosis)

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

II.5. II.3. II.4.

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

TABLE 2.A. APGAR Score

Heart Rate Respiratory Effort Muscle Tone Irritability Color

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Section 2 Treatment Protocols - Medical

Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (Hyperkalemia, metabolic acidosis).

Section 2 Treatment Protocols - Medical