Regional Patient Care Guidelines

1MAY 2009

Thomas Jefferson Regional Patient Care

Guidelines

2

Information Special ThanksUse of GuidelinesLevels of Certification Universal Care Protocol

General Medical EmergenciesAbdominal PainAcute Psychological AgitationAlcohol Related EmergenciesAllergic ReactionEnvenomationHyperthermiaHypotension (Symptomatic)HypothermiaNear DrowningPoisoning/ Overdose

Cardiac EmergenciesCardiac Arrest: General ManagementAsystole/ PEAAtrial Fibrillation/ FlutterBradycardiaChest Pain/ Acute Coronary SyndromeNarrow Complex Tachycardia- Paroxysmal SVTVentricular Fibrillation/ Pulseless Ventricular TachycardiaWide Complex Tachycardia (Ventricular Tachycardia with pulse)Special Resuscitation: Hypothermic ArrestPost Cardiac Arrest: Induced Hypothermia

Neurological EmergenciesAltered Level of ConsciousnessSeizuresStroke

Table of Contents

Respiratory EmergenciesRespiratory Distress: General ManagementCHF/ Pulmonary EdemaCOPD/ BronchospasmPneumonia

OB/ GYN EmergenciesChildbirth, Cephalic PresentationChildbirth, Breech PresentationChildbirth, Prolapsed Cord/ Limb PresentationEclamptic SeizuresSexual AssaultVaginal Bleeding

Trauma EmergenciesTrauma: General ManagementAmputationBurnsCNS

26272931333537394041

9101213151618192122

4567

434547

50515354

565859606162

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l

Pediatric Neurological EmergenciesAltered Level of ConsciousnessSeizures

3

Pediatric General Medical EmergenciesAllergic ReactionHyperthermiaNear DrowningPoisoning/ Overdose

Pediatric Trauma EmergenciesGeneral Trauma ManagementAmputationBurnsCNS Injuries

Thomas Jefferson Regional ProceduresAED Utilization FormAccessing Central Venous LinesAllergic Reaction ReportCapnographyCardiopulmonary ResuscitationCardioversionCISM Activation ProcedureContinuous Positive Airway Pressure (CPAP) ProcedureDrug Box ContaminationEndotracheal Tube Introducer (Bougie)External Jugular CannulationImmobilization Decision MatrixImpedance Threshold Device

Pediatric Respiratory EmergenciesRespiratory Distress

Thomas Jefferson Regional PoliciesAdvanced Life Support GuidelineDocumentation StandardsDurable DNRCriteria for Withholding ResuscitationEmergency Custody OrderEMS/ Hospital Diversion PlanEMS Personnel and Agency AffiliationFinal Authority on Medical CommandHelicopter OperationsHospital Transport ClassificationsInfection ControlPediatric ImmobilizationProvider Clearance ProcessRecertification Testing WaiverRefusals and DocumentationRegional Ambulance Restocking AgreementRegional Course TrackingRegional EMT Network and Regional EvaluatorsResource CancellationSkill Drill RequirementsTermination of Resuscitative Efforts in FieldTransfer of Care to Provider of Lesser CertificationTreatment of Patients Under 18

Pediatric Cardiac EmergenciesGeneral Management of Cardiac Arrest or Pre-Cardiac ArrestAsystole/ PEABradycardiaNarrow Complex TachycardiaVentricular Fibrillation/ Pulseless VTWide Complex Tachycardia (VT with pulse)Newborn Resuscitation

71737475

77798082848687

8991

92

93959697

99100101103104107110111112113115116117119120122123124125126129130131

133135136137138139140141143144145146147

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Medication InformationDrug FormularyDrug Dose CalculationsDopamine InfusionEpinephrine InfusionAmiodarone InfusionPediatric Drug Dose Chart

Thomas Jefferson Regional ProceduresIntraosseous Insertion, Bone Injector GunIntraosseous Insertion, EZ-IOIntraosseous Insertions, JamshidiKing AirwayManual DefibrillationNeedle CricothyrotomyNeedle DecompressionOrogastric Tube InsertionPulse OximetryRSI ProgramSTART TriageSubcutaneous/ Intramuscular InjectionsSurgical CricothyrotomyTourniquet ProcedureTranscutaneous PacingVenous Access12 Lead ECG Procedure

Reference SectionWong-Baker FACES Pain Rating ScalePediatric Blood PressurePediatric Endotracheal Tube SizeEstimation of Pediatric WeightCapnography WaveformGlascow Coma ScoreAPGAR ScoreRule of 9’sUVa TRCCs SystemDevice Specific Energy Settings

Thomas Jefferson Regional OMD Position PapersBeta Blockers in Acute Chest PainDestination/ Transport Guidelines

148150152153154155156157158159162163164165166167168

170170170170171172172172172173

175-188 189 190 191 191 192

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Special Thanks

This document was created for your use through the work and contribution of many people, all of whom are dedicated to providing excellent emergency medical care to the citizens of Central Virginia.

Regional Operational Medical Directors: George Lindbeck (AMC), Scott Just (AMC), Jeff Alberts (MJH), Debra Perina (UVa), Sabina Braithwaite (UVa), Bill Brady (UVa), and Scott Syverud (UVa), and Robert O’Connor (UVa).

Other contributing physicians: Nina Solenski (UVa), Alex Grunsfeld (MJH),Jeff Young (UVa), Forrest Calland (UVa).

Contributing EMS agencies: County of Orange Fire and EMS, Madison County Emergency Medical Service, Charlottesville-Albemarle Rescue Squad, Albemarle County Fire and EMS

Contributors: Kostas Alibertis, Tom Joyce, Jake Benner, Anthony Judkins,Donna Burns, Donna Evatt, Stephen Rea, Cookie Conrad, Hal Schaffer

Reviewers: Jackie Peters, Jon Howard, Mark Sikora, Jim Burdge, Alex Belgard, Patrick Watson, Booker Moritz, Barry Norris, Hal Schaffer, Carrie Weber, Jared McNeal, Susan Schueler, Bob Townsend, Jason See, Lyle Plitt, Valerie Quick, Kostas Alibertis, Bill Keene

Cover were designed by UVA Marketing Communications: Diane Butler, Reecye Modny, Bob Larsen, and Eric Swenson

Special recognition to Wake County EMS (North Carolina) who placed their protocols on-line for public use and, in turn, heavily influenced this document.

Many, many heartfelt thanks to Tom Berry for securing the financial pieces to make distribution possible, and to the University of Virginia Center for Emergency Management for supporting this project from inception to completion.

Christy Hodge, BA, NREMT-P

UVa Prehospital Education

5

These patient care guidelines have been established in close cooperation of the Regional Operational Medical Direction Committee, the Thomas Jefferson EMS Council, and the University of Virginia Prehospital Program in conjunction with many outside resources and in collaboration with the EMS providers of Central Virginia.

The intent of these guidelines is to equip providers with a rapid and readily available resource to better enable excellent patient care. This book is in no way designed to encompass every clinical encounter. Rather, it should be viewed as a resource that is outlines the most common clinical presentations and fosters sound clinical decision making. The order of treatment is not rigid and allows for the flexibility of prioritizing treatment as dictated by the patient condition. Likewise, all treatments listed on a patient care guideline may not be indicated for every patient presenting with that complaint. Therefore, some treatments listed may be deferred if justification can be made based on the patientʼs presentation.

You will first notice that this format is color coded by level of certification. The color associated with each line of the protocol represents the minimal level of certification to consider this treatment. For example: When the line is proceeded by a blue box marked “I/P” as above, only Intermediate and Paramedic level providers are authorized to administer this treatment. However, the Intermediate and Paramedic providers are responsible for all treatments at and below their level of certification. That is, advanced level providers are expected to perform treatments that are color coded to be basic and enhanced level treatments.

Conditions that require Medical Command will be outlined in a red box. This reflects when consultation with medical command is necessary. Medical command should be utilized freely whenever the clinical situation is unclear, the patient presents as unstable, no protocol directly applies, or if you prefer consultation with a physician. If at any time, communication with medical command cannot be established within 2 minutes and the patientʼs condition is critical, you may proceed with the standard treatment.

Additionally, you will note that each patient care guideline has three sections at the top. The first column is History. This outlines what medical history and history of current event that you might expect with the given complaint. This could be used to prompt further questioning and assist with documentation. The second column is Physical Exam. The physical exam outlines signs and symptoms that should be assessed for each given complaint. These should be documented as pertinent negatives or as positive assessment findings on the PPCR. Lastly, the third column is Differential Diagnoses. This column encourages providers to consider other causes of typical presentations (i.e. all chest pain is not associated with myocardial infarction). If the patientʼs history and physical exam findings are not consistent with the listings on the page, it is particularly important to evaluate whether or not the treatment listed on that page is appropriate. On the bottom of the guideline pages, you will also see a section entitled Pearls. This section is intended to give you important reminders and caution against common pitfalls specific to the respective complaint or treatments.

The basic framework of all EMS calls (scene safety, patient assessment, vitals signs, etc) are not outlined on each specific page. Rather, these foundations are established in the Universal Protocol. These principles are no less important but need not be repeated on every page.

It is our sincere hope, that this document will assist you in delivering quality, comprehensive, and compassionate care to the citizens of Central Virginia......Primum non nocere (first do no harm).

Use of Guidelines

6

B EMT Basic

J EMT-Johnson

EN EMT-Enhanced

I/P Intermediate or Paramedic

P Paramedic Only

MC Medical Command

Levels of Certification

7

Universal Patient Care ProtocolScene Safety/ Personal Protective Equipment

Primary Survey

Initial interventions as needed

Supplemental O2

Obtain and document:

Vital signs

SAMPLE history

Pain assessment

OPQRST (medical)

DCAP BTLS (trauma)

Consider glucometry if indicated

Pulse oximetry if indicated

Capnography if indicated (mandatory if intubated)

Cardiac monitor

12 Lead ECG if acute coronary syndrome is suspected and the patient is hemodynamically and electrically stable

Appropriate protocol/ consider differential diagnoses

If no protocol applies or condition is unknown, consult medical command

Transport per guidelines

Pearls:Complete vital signs should be taken every 5 min for critical and 15 min for

non-critical patients.Complete vitals include a minimum of HR, RR, and BP.

In most cases, on scene times should be limited to 10 minutes.Do not delay oxygen therapy to obtain pulse oximetry reading.

8

9

Emergency Physicians

History•Age

•Past medical/ surgical history

•Medications

•Onset

•Provocation/ palliation

•Quality

•Radiation

•Severity

•Time

•Fever

•Last oral intake

•Last bowel movement/emesis

•Menstrual history

•Diarrhea

•Constipation

Physical•Pain

•Tenderness

•Nausea/ vomiting

•Dysuria/hematuria

•Vaginal bleeding/discharge

•Pregnancy

•Fever

•Headache

•Malaise

•Location of pain

Differential Diagnoses•Trauma

•Pregnancy

•Pneumonia

•Pulmonary embolism

•Liver (hepatitis, CHF)

•Peptic ulcer disease

•Gastritis

•Gallbladder

•Myocardial Infarction

•Pancreatitis

•Kidney stone

•Abdominal aneurysm

•Appendicitis

•Bladder/ prostate

•Pelvic inflammatory

•Ovarian cyst

•Spleen enlargement

•Diverticulitis

•Bowel obstruction

•Gastroenteritis

Abdominal Pain

Pearls:Acute, undiagnosed abdominal pain should not receive analgesics in the field

without medical command

10

B Universal Care Protocol B

EN IV Procedure EN

EN For persistent nausea and vomiting, consider ondansetron 4 mg IV, may repeat in 10 minutes

EN

Abdominal Pain

11

History

•Situational crisis

•Psychiatric illness/medications

•Injury to self

•Threat others

•Medic alert

•Substance abuse/overdose

•Diabetes

•Disease process

Physical

•Anxiety, agitation, confusion

•Change in affect

•Hallucinations

•Delusional thoughts

•Bizarre behavior

•Combative/ violent

•Expression of suicidal or homicidal thoughts

Differential Diagnoses

•Hypoxia

•Alcohol intoxication

•Medication or illicit drug effect

•Withdrawal syndromes

•Depression

•Bipolar disorder

•Schizophrenia

•Anxiety disorders

•Brain cancer

B Universal Care Protocol BI/P Haloperidol 5 mg IM for adults to control acute agitation when

pt is risk to themselves or others.

For patients over 65, Haloperidol 2 mg IM.

I/P

I/P For patients who remain agitated, repeat haloperidol 5 mg IM and midazolam 2 mg IM.

I/P

MC If patient refuses transport, consider Emergency Custody Order.

MC

Acute Psychological Agitation

Pearls:Substance-induced disorders, diabetic emergencies, and hypoxia must be

ruled out.Suicidal patients are not permitted to sign a refusal.

Consultation with law enforcement, mental health professionals, and medical command should guide patient disposition.

Verbally deescalating the patient is preferable to medication therapy.Watch for extrapyramidal symptoms and treat with diphenhydramine if

needed.

12

History

•Last alcoholic drink

•Daily amount of alcohol intake

Physical

•Tremors

•Anxiety

•Unsteady gait

•Spider angiomas

•Distended abdomen


•Hypoglycemia

•Traumatic injury

•Drug intoxication

•Sepsis in elderly


B Monitor for respiratory depression B

B If seizures occur, refer to the Neurological/Seizure Protocol B

EN IV Procedure EN

B Treat suspected hypoglycemia B

I/P For agitation, tachycardia, or hallucinations secondary to alcohol withdrawals, consider diazepam (Valium) 5 mg IV or midazolam

(Versed) 5 mg IM. May repeat either in 10 minutes

I/P

Alcohol Related Emergencies

13

History

•Onset and location

•Insect bite or sting

•Food allergy/exposure

•New clothing, soap, detergent

•Past history of reactions

•Past medical history

•Medication history

Physical

•Itching or hives

•Coughing or wheezing

•Chest or throat constriction

•Difficulty swallowing

•Hypotension or shock

•Edema

•Vomiting


•Rash only

•Anaphylaxis

•Shock

•Angioedema

•Aspiration/ airway obstruction

•Vasovagal event

•Asthma or COPD

•CHF

Allergic Reaction

Pearls:Ipratroprium is not indicated for allergic reaction.

14


B Remove from source of exposure. B

B Assist with prescribed auto injector for severe hives, respiratory distress, and/or shock if >8 years or >30 kg.

B

J 1. Epinephrine (1;1000) 0.3 mg SQ or IM. May repeat in 10 minutes.

2. Albuterol 2.5 mg nebulized for wheezing/ bronchospasm.

2. Diphenhydramine 50 mg IM.

J

EN 1. Epinephrine (1;1000) 0.3 mg SQ or IM. May repeat in 10 minutes.

2. Albuterol 2.5 mg nebulized for wheezing/bronchospasm.

3. Diphenhydramine 25 mg IM or IV for mild to moderate reactions, 50 mg IM or IV for severe reactions. May repeat

once in 10 minutes to a max of 50 mg.

4. Methylprednisolone 125 mg IV over 1 minutes for severe hives or difficulty breathing.

EN

EN IV Procedure EN

MC IV Epinephrine per Medical Command Only MC

MC Epinephrine 2-10 mcg/min to maintain BP >90 mmHg MC

Allergic Reaction

15

History

•Type of sting/bite

•Description of animal involved

•Time, location, size of bite/sting

•Previous reaction

•Domestic vs. wild

•Tetanus and rabies risk

•Infection risk

•Immunocompromised patient

Physical

•Rash, skin break, wound

•Pain, soft tissue swelling, redness

•Blood oozing from wound

•Evidence of infection

•Shortness of breath, wheezing

•Allergic reaction

•Hypotension


•Animal bite

•Human bite

•Snake bite

•Spider bite

•Insect sting

•Anaphylaxis


B Refer to allergic reaction protocol if needed. B

B Minimize activity, remove tight clothing or jewelry, immobilize extremity at level of heart.

B

B For exotic animals (Coral snakes, cobra’s), contact Poison Control. Do not delay transport.

B

EN IV Procedure EN

I/P Consider morphine 2-4 mg IV, up to a total of 10 mg for pain. I/P

MC Dopamine 2 to 20 mcg/kg/min IV infusion for hypotension unresponsive to fluid therapy.

MC

Envenomation

Pearls:Signs of pit viper envenomation are swelling that begins at the bite mark and

spreads proximally within minutes, ecchymosis, hemorrhagic blisters, and severe pain.

Avoid using constricting bands or tourniquets, cold application, incision, suction, and extractor devices in pit viper envenomations.

Black widow spider envenomations may present with painful muscle spasms.Blue Ridge Poison Center 434-924-5543 or 1-800-451-1428

16

History

•Age

•Exposure to increased temperature or humidity

•Past medical history/ medications

•Extreme exertion

•Time and length of exposure

•Poor PO intake

•Fatigue

•Muscle cramping

Physical

•Altered mental status

•Hot, dry or sweaty

•Hypotension

•Seizures

•Nausea


•Fever

•Dehydration

•Medications

•Hyperthyroidism

•Delirium tremens

•Heat cramps

•Heat exhaustion

•Heat stroke

•CNS lesions or tumors

Hyperthermia

Pearls:Tricyclic antidepressants, phenothiazines, anticholinergics, and alcohol

predispose patients to hyperthermia.Cocaine, amphetamines, and salicylates may elevate body temperature.The major difference between heat exhaustion and heat stroke is CNS

impairment.Avoid dramatic decreases in temperature which can cause shivering and

increase temperature.Dehydration and volume depletion may not occur in classic stroke. Vigorous fluid administration may result in pulmonary edema, particularly in the elderly.

17


B Move to cooler environment, remove excess clothing, protect from further heat gains.

B

B For heat exhaustion, PO water if patient can tolerate. Cool with wet towels or fans.

B

B For heat stroke, use aggressive evaporation (fine mist water spay, ice packs to groin and axillae).

B

EN IV Procedure EN

Hyperthermia

18

History

•Blood loss

•Fluid loss

•Infection

•Cardiac ischemia

•Medications

•Allergic reaction

•Pregnancy

•History of poor oral intake

Physical

•Restlessness, confusion

•Weakness, dizziness

•Weak, rapid pulse

•Pale, cool, clammy skin

•Delayed capillary refill

•Coffee-ground emesis

•Tarry stools


•Shock Hypovolemic Cardiogenic Septic Neurogenic Anaphylactic

•Ectopic pregnancy

•Dysrhythmias


•Tension pneumothorax

•Medication effect

•Vasovagal

•Physiological (pregnancy)

B If anaphylaxis, refer to Severe Allergic Reaction protocol

B

EN IV Procedure EN

I/P Dopamine 5-20 mcg/kg/min to maintain BP >90 mmHg if no response to IV therapy or if CHF is

present.

I/P

Hypotension (Symptomatic)

Pearls:Hypovolemia must be corrected prior to dopamine infusion.

Identify and manage underlying cause.Consider drug side effects or overdose.

19

History


•Medications

•Exposure to environment, even in normal temperatures

•Exposure to extreme cold

•Extremes of age

•Drug use

•Infections/ sepsis

•Length of exposure/wetness

Physical

•Cold, clammy

•Shivering


•Extremity pain or sensory abnormality

•Bradycardia

•Hypotension


•Sepsis

•Environmental exposure

•Hypoglycemia

•CNS dysfunction Stroke Head injury Spinal cord injury

Hypothermia

Pearls:If patient is centrally cold to touch, consider severely hypothermic.

Avoid rough handling.Warm fluids as close to 109° as possible by placing on heater or hot packs.

Do not microwave.Avoid intubation if possible in the severely hypothermic patient.

Consider “urban hypothermia” with high association of poverty or drug/alcohol abuse.

20


B Refer to Special Arrest: Hypothermic Arrest Protocol if needed B

B Remove wet garments. B

B Protect from further heat loss. Increase ambient temperature. B

B Apply heat packs if patient is responsive. B

B If moderate to severely hypothermic, wrap head and core with blankets.

B

EN Airway management EN

EN IV Procedure EN

Hypothermia

21

History

•Submersion in water

•Associated trauma

•Duration of immersion

•Temperature of water

•Fresh vs. salt water

•Contamination of water

Physical

•Unresponsive


•Decreased vital signs

•Vomiting

•Cough

•Aspiration


•Trauma

•Pre-existing medical problem

•Pressure injury

barotrauma

decompression

sickness

B Remove from water if trained and safe to do so. B

B Spinal immobilization if indicated. B

B Prevent heat loss, refer to “Hypothermia” protocol if indicated. B

EN IV Procedure EN

I/P Refer to specific cardiac arrhythmias protocol as needed. I/P

Near Drowning

Pearls:Most near drowning victims will be hypothermic to some extent.

Assess type of incident (surface impacted, object strike, propeller trauma).Assess water conditions (depth of submersion, length of time).

Monitor airway status closely.

22

Poisoning/ OverdoseHistory

•Ingestion of toxic substance

•Route and quantity of ingestion

•Time of ingestion

•Reason (suicide, accident)

•Available medications near patient


•Medications

•Illicit drug abuse

Physical


•Hypotension

•Decrease respiratory rate

•Tachycardia

•Dysrhythmias

•Seizures


•Tricyclic antidepressants

•Acetaminophen

•Depressants

•Stimulants

•Anticholinergics

•Cardiac medications

•Solvents, cleaning agents

•Insecticides (organophosphates)

Pearls: Intubated patients should not receive naloxone unless hemodynamically

unstable.Tachycardia is not a contraindication to atropine administration.Poison control should be consulted on all complex toxicology at

434-924-5543 or 1-800-451-1428.Aeromedical resources will not transport contaminated patients.

23


B Identify substance and assure decontamination. B

B Flush skin/membranes with water unless contraindicated. B

EN IV Procedure EN

J Naloxone 0.8 mg IV or IM for suspected narcotic overdose with respiratory depression.

J

EN Diphenhydramine 1 mg/kg slow IVP for dystonic reaction (max dose of 50 mg).

EN

I/P For Symptomatic Tricyclic Antidepressant Overdose:( if QRS >0.12 secs, hypotension, or dysrhythmia)

• Sodium bicarbonate 1mEq/kg slow IVP over 2 minutes

I/P

I/P For Symptomatic Calcium Channel Blocker Overdose:(if bradycardic, QRS >0.12 secs, heart block, hypotension,

lethargy, slurred speech, nausea, vomiting)• Calcium chloride 20 mg/kg slow IVP over 10 minutes• Sodium bicarbonate 1 mEq/kg slow IVP over 2 minutes.

I/P

I/P For Symptomatic Organophosphate Poisoning:(secretions, bronchospasm, seizures, bradycardia)

• Atropine 0.05 mg/kg IV doubled every 5-10 minutes until decreased secretions.

I/P

MC Consider and treat for other types of overdoses or poisonings.

MC

Poisoning/ Overdose

24

Center for Emergency ManagementLife Support Learning Center

First intercostal space is below the clavicle at the sternal border. The first palpable space at the sternal border is considered thesecond intercostal space.

V1—4th intercostal space at the right sternal borderV2—4th intercostal space at the left sternal borderV3—Directly between V2 and V4V4—5th intercostal space at midclavicular lineV5—5th intercostal space at anterior axillary lineV6—5th intercostal space at midaxillary line

www.hsc.virginia.edu/internet/lslc

25

http://www.hsc.virginia.edu/internet/lslc

http://www.hsc.virginia.edu/internet/lslc

I

Lateral aVR

V1

Septal

V4

Anterior

II

Inferior aVL Lateral

V2

Septal

V5

Lateral

III

Inferior

aVF

Inferior

V3

Anterior

V6

Lateral

Location STEMI Reciprocal

Septal V1, V2 None

Anterior V3, V4 None

Anterosepatal V1, V2, V3, V4 None

Lateral I, aVL, V5, V6 II, III, aVF

Anterolateral I, aVL, V3, V4, V5, V6

II, III, aVF

Inferior II, III, aVF I, aVL

Posterior None V1, V2, V3, V4

History

•Events leading to arrest

•Estimated down time


•Medications

•Terminal illness

•Signs of rigor/lividity

•DNR

Physical

•Unresponsive

•Apneic

•Pulseless


•Medical vs. trauma

•V-fib/pulseless v-tach

•Asystole

•PEA


B Criteria for Death/ No Resuscitation? B

B CPR Interrupt compressions only as per AED prompt or every 2

minutes (5 cycles of CPR)

B

B AED• If witnessed or bystander CPR in progress, apply immediately• If unwitnessed, use after 2 minutes of CPR

B

I/P Assess Rhythm (do not use AED mode), Refer to appropriate protocol/algorithm

I/P

EN IV or IO Procedure EN

B Advanced Airway Management Ventilate no more than 10/min (1 breath every 6-8 seconds)

B

I/P Capnography Procedure if advanced airway is in place. I/P

Cardiac Arrest: General Management

Pearls:Change compressors every 2 minutes.

Allow full chest recoil.Check femoral/carotid pulse to verify effective CPR.

27

History:


•Medications


•End stage renal disease


•Suspected hypothermia

•Suspected overdose

•DNR

Physical:

•Pulseless

•Apneic

Differential Diagnoses:

•Device error

•Hypoxia

•Hypothermia

•Hydrogen ion (acidosis)

•Hypo-/Hyperkalemia

•Hypoglycemia

•Hypovolemia

•Trauma


•Thrombosis coronary/pulmonary

•Toxins

•Tamponade

Asystole / Pulseless Electrical Activity

Pearls:Vasopressin should be administered only one time in place of either the first or

second epinephrine dose.

28

B General Cardiac Arrest protocol B

I/P Confirm asystole in more than one lead if applicable I/P

I/P Administer vasopressin 40 units (one time dose)Begin epinephrine after 3-5 minutes

I/P

I/P Consider and treat for reversible causes as listed in differential diagnoses

I/P

I/P Atropine 1 mg IV/IO every 3-5 minutes up to 3 doses if rate <60 bpm

I/P

I/P 1 mg epinephrine (1:10,000) IV/IO every 3-5 minutes up to 3 doses before considering

termination of arrest.

I/P

MC Contact Medical Command for special resuscitation situations MC

MC Termination of Care Policy MC

Asystole / Pulseless Electrical Activity

29

History

•Medications Aminophylline, diet pills, thyroid supplements, decongestants, digoxin

•Drugs nicotine caffeine


•History of palpitations

•Syncope/ near syncope

•Use and compliance of anticoagulants

Physical

•HR >150/min

•QRS <0.12 secs

•Rhythm is irregularly irregular

•Dizziness, CP, SOB


•Heart Disease (WPW)

•Sick Sinus Syndrome

•Myocardial infarction

•Electrolyte imbalance

•Exertion, pain, stress

•Fever

•Hypoxia

•Hypovolemia or anemia

•Drug effects

•Hyperthyroidism

•Pulmonary embolus

Atrial Fibrillation/Flutter

Pearls:Energy settings for cardioversion should be per manufacturer

recommendation.Pharmacological rate control is preferred over cardioversion unless the patient

is unstable.Unstable is defined as BP less than 90 mmHg, altered mental status, or signs

of decreased perfusion.Adenosine is not effective in converting atrial fibrillation or flutter.

Document all rhythm changes with monitor strips.Determine onset of symptoms (chronic vs. onset <48 hours).

Atrial fibrillation/flutter generally does not need to be treated for HR < 150.

30


EN IV Procedure EN

I/P For a stable patient who is symptomatic with a ventricular rate 150 or greater, consider metoprolol (Lopressor) 5 mg IV.

May be repeated every 10 minutes to a max of 15 mg to achieve ventricular rate of 120 or less.

I/P

I/P For an unstable patient, sychronized cardioversion (total of 2 attempts).

I/P

I/P For patients who do not respond to cardioversion or who have recurrent tachycardia, metoprolol (Lopressor) 5 mg IV

prior to repeated cardioversion.

I/P

MC Amiodarone 150 mg in 100 mL of D5W IV Piggyback over 10 minutes

MC

MC Midazolam 2-5 mg IV if needed prior to synchronized cardioversion

MC

Atrial Fibrillation/Flutter

31

History


•Medications Beta blockers Calcium channel blockers Clonidine Digitalis ACE Inhibitors

•Pacemaker

Physical

•HR<60

•Chest pain

•Respiratory distress

•Hypotension


•Syncope


•Acute myocardial infarction

•Hypoxia

•Hypothermia

•Athletes

•Head injury (ICP)

•Stroke

•Spinal cord lesion

•Sick sinus syndrome

•AV blocks

•Overdose

Bradycardia

Pearls:Unstable is defined as BP less than 90 mmHg, altered mental status, or signs

of decreased perfusion.TCP is the preferred treatment in 2nd degree, Type II and 3rd degree blocks.

Transplanted hearts will not respond to atropine.Fluid therapy should be initiated as an adjunct to rate therapies. Administer

fluid cautiously to patients with symptomatic bradycardia.

32


EN IV Procedure EN

I/P For a symptomatic patient, consider atropine 1mg repeated every 3-5 minutes as needed to a maximum of 3 mg.

I/P

I/P For patients who have not responded to TCP and atropine, consider dopamine (Intropin) 5 to 20 mcg/kg/min to maintain

BP of 90 mmHg.

I/P

MC Consider Midazolam (Versed) 2-5 mg IV if needed during TCP when BP >90 mmHg.

MC

Bradycardia

33

History

•Age

•Medications

•Use of Viagra, Cialis, Levitra or herbal equivalents


•Recent physical exertion

•Onset

•Palliation/Provocation

•Quality

•Radiation

•Severity

•Time

Physical

•Chest Pain (pain, pressure, aching, tightness)

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

•Pale, diaphoretic

•Dyspnea

•Nausea, vomiting

•Anxiety


•Trauma vs. medical

•Angina vs. STEMI

•Pericarditis


•Asthma/ COPD

•Pneumothorax

•Aortic dissection or aneurysm

•Reflux or hiatal hernia

•Esophageal spasm

•Pleuritic pain

•Cocaine overdose

Chest Pain/ Acute Coronary Syndrome

Pearls:If use of Viagra or Levitra use within the past 24 hours or Cialis within 72

hours, contact medical command.Inferior STEMI’s are preload dependent and may not tolerate NTG or

morphine well, use IV fluids as needed.Use of nitropaste may be preferable to SL NTG if hypotension is likely to

occur.Diabetics, females, and geriatric patients often present with atypical chest pain

or generalized complaints.

34


B Transmit 12 Lead ECG, Consult Medical Command for possible STEMI alert

B

B Transport to cath lab facility for known or suspected MI. B

B Aspirin 325mg (4 baby aspirin) chewed. B

EN IV Procedure EN

B Nitroglycerin 0.4 mg every 5 minutes as needed. No maximum, keep BP >100 mmHg.

B

J Apply 1 inch 2% Nitropaste (15 mg) topically keeping BP >100 mmHg.

J

I/P For vomiting, consider ondansetron 4 mg IV repeated in 10 minutes if needed.

I/P

I/P For persistent vomiting after two doses ondansetron, consider promethazine 12.5 mg IV.

if > 65 years, reduce to promethazine 6.25 mg IV

I/P

I/P Consider morphine sulfate 2 mg slow IV. May be repeated every 5-10 minutes to a max of 6mg keeping BP >100mmHg

I/P

I/P Refer to hypotension and dysrhythmia protocols as indicated I/P

Chest Pain/ Acute Coronary Syndrome

35

History

•Medications Aminophylline Diet pills Thyroid supplements Decongestants Digoxin

•Drugs nicotine cocaine MSG toxicity


•History of palpitations

•Syncope/ near syncope

Physical

•HR >150

•QRS <0.12 secs

•Dizziness

•CP

•Dyspnea

•Poor perfusion/peripheral pulses


•Heart disease

•Sick sinus syndrome

•Myocardial infarction


•Exertion, pain, stress

•Fever

•Hypoxia

•Hypovolemia or anemia

•Drug effect or overdose

•Hyperthyroidism


Narrow Complex Tachycardia- Paroxysmal SVT

Pearls:“Stable” is defined as a patient who is symptomatic with normal perfusion,

normal vitals, and no alteration in mental status.Adenosine should be administered in a proximal injection port followed by a 20

mL flush.Metoprolol should be avoided if cocaine, methamphetamine, or other

sympathomimetic use is known or suspected. Use manufacturer recommendations for escalating energy settings.

Document all rhythm changes with monitor strips.

36


EN IV Procedure EN

I/P If patient is stable, attempt vagal maneuvers. I/P

I/P If symptomatic, adenosine 6 mg rapid IVP. If no response, adenosine 12 mg rapid IVP.

I/P

I/P If patient is unstable, synchronized cardioversion. May repeat cardioversion for a total of two attempts.

I/P

I/P If no response to cardioversion or recurrent or refractory arrhythmias, metoprolol 5 mg slow IV push.

I/P

MC If no response to metoprolol, amiodarone 150 mg IV piggyback over 10 minutes

MC

MC Contact Medical Command for 3rd cardioversion attempt after metoprolol or amiodarone has been infused.

MC


MC

Narrow Complex Tachycardia- Paroxysmal SVT

37

History



•Medications


•DNR

Physical

•Unresponsive

•Apneic

•Pulseless

•Ventricular fibrillation or ventricular tachycardia on ECG

•Torsades


•Asystole

•Artifact/device failure

•Endocrine/Metabolic

•Drugs

Ventricular Fibrillation/ Pulseless Ventricular Tachycardia

Pearls:Interruption of CPR should be minimal and occur only in 2 minute intervals.

Follow manufacturers recommendations for energy settings.Treatment priorities are uninterrupted compressions, defibrillation, IV/IO

access, airway control. Medic level providers should utilized AED’s only when manual defibrillation is

not possible.

38

B Cardiac Arrest Protocol B

B Ensure quality CPR B

I/P Defibrillate per manufacturer’s recommendation• immediately if witnessed or bystander CPR• after 2 min CPR if unwitnessed

I/P


I/P Vasopressin 40 units IV/ IO X 1 dose.(Use epinephrine after 3-5 minutes.)

I/P

I/P Epinephrine (1:10, 000) 1 mg IV/ IO every 3-5 minutes. I/P

I/P After 3rd shock, amiodarone 300 mg IVP. May repeat once at 150 mg.

I/P

I/P Consider magnesium sulfate, 1-2 grams IVP for torsades. I/P

I/P Search for and treat reversible causes. I/P

MC Termination of Care Policy MC

Ventricular Fibrillation/ Pulseless Ventricular Tachycardia

39

History

•History Wolffe-Parkinson-White (WPW)

•Onset

•Medications

•Palpitations

Physical

•Diaphoresis

•Pallor


•Labored respirations


•Pulseless v-tach

•Polymorhphic V-tach (torsades)

•Reentry tachycardia

•Bundle branch blocks


EN IV Procedure EN

I/P If patient is stable, amiodarone 150 mg in 100 mL D5W IV piggyback over 10 minutes. May repeat in 10 minutes if no

response.

I/P

I/P If patient is unstable, synchronized cardioversion at 100j and repeat with escalating energy per manufacturer

recommendations.

I/P


MC

Wide Complex Tachycardia (Ventricular Tachycardia with Pulse)

Pearls:“Stable” is defined as a patient who is symptomatic with normal perfusion,

normal vitals, and no alteration in mental status.“Unstable” is defined as BP less than 90 mmHg, altered mental status, or

signs of decreased perfusion.Follow manufacturer’s recommendations for escalating energy settings.

When drawing up amiodarone, use a large bore needle, draw slowly, and do not draw in air to avoid bubbling.

40


B Confirm pulselessness for 30 seconds. Refer to CPR and AED protocol if needed.

B

B Remove wet garments.Protect from further heat loss.

Apply heat packs if patient is responsive.

B

EN IV Procedure EN

I/P Modify ACLS algorithms for cardiac arrest. Administer one round of IV medications.

Attempt one defibrillation. Repeat medications and defibrillation as temperature rises.

I/P

MC Consider termination of efforts if no response to initial therapy and prolonged time to definitive care.

MC

Special Resuscitation: Hypothermic Arrest

Pearls:If patient is centrally cold to touch, consider severely hypothermic.

41

EN Confirm patient is a candidate:• Return of spontaneous circulation after cardiac arrest• Unresponsive• Not pregnant

EN

EN Chose and apply the most clinically appropriate method(s) depending upon the patient scenario ( ice packs, cooling

blankets, chilled IV fluid therapy).• To expedite the cooling process, 2 liters of cold normal

saline are administered rapidly •Place ice packs to the armpits, neck, torso, groin, and limbs

EN

EN Withdraw cooling protocol if patient develops hemodynamic or cardiac electrical instability.

EN

MC Contact medical command for continuation if patient regains consciousness

MC

Post Cardiac Arrest:Induced Hypothermia

42

Face: Ask the person to smile. Does one side of the face droop?

Arms: Ask the person to hold both arms up evenly. Does one arm drift downward?

Speech: Ask the person to repeat a simple sentence. Are the words slurred or mixed up?

Time: If the person shows any of these symptoms, call 911 immediately.

Think F.A.S.T.

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43

History

•Known diabetic

•Drugs


•Medications

•History of trauma

Physical

•Change in baseline mental status

•Bizarre behavior

•Cool, diaphoretic skin (hypoglycemia)

•Warm,dry skin, signs of dehydration (hyperglycemia)

•Fruity breath odor

•Kussmaul respirations


•Head trauma

•Stroke

•Seizure

•Tumor

•Infection/ sepsis

•Cardiac dysrhythmia

•Thyroid

•Shock

•Diabetes

•Toxins

•Intoxication

•Acidosis/alkalosis

•Exposure

•Hypoxia

•Electrolyte abnormality

•Psychiatric disorders

•Diabetic ketoacidosis

Altered Level of Consciousness

Pearls:Medications are a common cause of altered mental status.

Glucometers may be helpful but used cautiously, particularly if values are borderline.

Intubated patients should not receive naloxone unless hemodynamically unstable.

Goal of reversal therapy is to reverse respiratory and circulatory collapse. Repeated administration of small doses is desirable.

Naloxone must be split into two doses. Max of 2mL per injection site.

44



J 1. Glucagon 1mg IM. 2. Naloxone 0.8 mg IM or slow IVP for suspected narcotic

overdose.

J

EN IV Procedure. EN

EN 1. Dextrose 50% 25 grams slow IVP.2. Glucagon 1 mg IM if no IV access.

EN

EN Naloxone 0.8 mg IV or IM titrated to respirations. May repeat up to 4 mg.

EN

EN For hyperglycemia (BS >400 mg/dl), infuse I liter NS over 30-60 minutes, followed by NS at 250 mL/hr.

EN

Altered Level of Consciousness

45

History

•Reported/witnessed seizure activity

•Previous seizure history

•Medic alert information

•Seizure medications


•History of diabetes

•History of pregnancy

Physical


•Sleepiness

•Incontinence

•Observed seizure activity

•Evidence of trauma

•Unconsciousness


• Head trauma

•Tumor

•Metabolic, hepatic, or renal failure

•Hypoxia


•Medication non-compliance

•Infection/ fever

•Alcohol withdrawal

•Eclampsia

•Stroke

•Hyperthermia

•Hypoglycemia

Seizures

Pearls:Care during the post-ictal phase should be supportive only.

Status epilepticus is defined as a prolonged seizure without recovery interval; it is a true emergency.

Generalized seizures: loss of consciousness, incontinence, and tongue trauma.

Focal seizures: come from one area in the brain and often affect only one part of the body, usually not associated with loss of consciousness.

Complex partial seizures: altered but no loss of consciousness.

46


B Protect patient. Do not attempt to restrain. B

B If patient is pregnant and no history of seizure, refer to OB/GYN Eclamptic Seizure protocol

B

J Glucagon 1mg IM. J

EN IV Procedure EN

EN Dextrose 50% 25 grams slow IVP for suspected hypoglycemia.Glucagon 1 mg IM if no IV access.

EN

I/P Diazepam 5mg IVP if actively seizing. May repeat as needed. I/P

I/P Midazolam 5 mg IM if no IV access. May repeat as needed. I/P

Seizures

47

History

•Previous CVA or TIA

•Previous cardiac or vascular surgery

•Diabetes

•Hypertension

•Coronary artery disease

•Atrial fibrillation

•Mediations (blood thinners)


Physical


•Weakness/ paralysis

•Blindness or other sensory loss

•Aphasia

•Syncope

•Vertigo/dizziness

•Vomiting

•Headache

•Seizures


•TIA

•Seizure

•Hypoglycemia

•Thrombotic or embolic stroke

•Hemorrhagic stroke

•Tumor

•Trauma

•Migraine

Stroke

Pearls:Obtain and document onset of symptoms (time), medications, and contact

information for medical decision maker.Determine whether or not the patient is taking warfarin (Coumadin) or other

anticoagulants (heparin, clopidagrel, Lovenox).

48


B Identify witness to last time pt was seen normal. Transport with pt if possible or obtain contact info for immediate

contact by ED physician upon arrival.

B

B Focused neurological exam. Cincinnati Prehospital Stroke Scale. Repeat every 15 minutes.

B

B Instant glucose 15 grams for suspected hypoglycemia and able to maintain airway.

B

J Glucagon 1 mg IM. J

EN IV Procedure EN

EN Dextrose 50% 25 grams IV for suspected hypoglycemiaGlucagon 1 mg IM if no IV access.

EN

MC For onset of symptoms <3 hours, contact medical command immediately for possible stroke alert and

expedite transport.

MC

Stroke

Pearls:Time of onset is established as last time patient was seen normal.

All efforts should be made to establish the onset without delaying transport.Advise witness to expect contact by ED physician.

49

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50

Respiratory Distress: General Management

Universal Patient Care Protocol

Oxygen, Pulse Ox, ETCO2*, Cardiac Monitoring

Airway and IV Protocols

Consider Differential Diagnoses

Pulmonary Edema/CHF

Bronchospasm/COPD

Pneumonia Unknown/Does not fit protocol

Contact Medical Command

*if available

51

CHF/ Pulmonary Edema

History

•CHF

•Cardiac history

•Digoxin, Lanoxin, Nitrates

•Diuretics (furosemide, Bumex)

•Orthopnea

•Gradual or sudden onset

•Weight gain

Physical

•JVD

•Peripheral Edema

•Rales, wheezes, or rhonchi

•Pink, frothy sputum

•Diaphoresis

•Anxiety

•Air hunger

•Chest pain

•Hypotension

•Altered LOC

Differential

Diagnoses

•Myocardial Infarction

•Asthma

•Anaphylaxis

•Aspiration

•COPD

•Pneumonia

•Pulmonary

Embolism

•Toxic Exposure

•Anxiety

Pearls:All wheezing is not asthma.Lasix is not a first line drug.Allow position of comfort.

Use of nitropaste may be preferable to SL NTG if hypotension is likely to occur.

Avoid NTG with use of Viagra, Cialis, or Levitra or herbal equivalents within past 24 hours.

Use of IV fluids to treat hypotension may be harmful. Auscultate breath sounds prior to administration of IV fluids.

52

B General Respiratory Distress Protocol B

B Consider CPAP protocol B

EN IV Procedure EN

EN NTG 0.4 mg SL every 3-5 min if BP >100 mmHg. Repeat as needed until BP <140 mmHg.

EN

EN 1 inch nitropaste if BP >100. EN

B 12 Lead EKG, proceed to Chest Pain protocol if acute coronary syndrome is suspected

B

I/P Morphine 2-4 mg slow IV push if BP >100mmHg I/P

I/P Consider dopamine 2 to 20 mcg/kg/min for BP <90 mmHg I/P

CHF/ Pulmonary Edema

53

COPD/Bronchospasm

History

•Tobacco use

•Smoked or inhaled drugs

•COPD/Emphysema/

•Chronic Bronchitis

•Asthma

•Sudden weather change

•Home O2

•Prescribed MDI

•Prescribed steroids

•Prescribed bronchodilators

Physical

•Air hunger

•Diaphoresis

•Retractions

•Accessory muscle use

•Tripoding

•Cyanosis

•Clubbed fingernails

•Barrel Chest

•JVD

•Wheezes

•Silent chest


•Asthma

•Anaphylaxis

•Aspiration

•COPD

•Pneumonia

•Pulmonary Embolism

•Pneumothorax

•Cardiac (MI or CHF)

•Hyperventilation

•Inhaled toxin

•Anxiety

•Pulmonary edema

B General Respiratory Distress Protocol, Refer to Allergic Reaction Protocol if needed

B

B Assist with prescribed MDI, may repeat in 5 min B

B Consider CPAP Procedure B

J Albuterol 2.5 mg/ipratropium 0.5 mg neb. May repeat treatments of albuterol as needed.

J

EN IV Procedure EN

EN Consider methylprednisolone125 mg slow IV push if not relieved after first albuterol treatment.

EN

Pearls:Silent chest is a sign of impending respiratory arrest.

Increased PEEP with CPAP may increase risk of barotrauma to COPD patients.

54

PneumoniaHistory

•Decreased oral intake

•Chills

•Exertional dyspnea

•General illness


•Prescribed or OTC medications

Physical

•Fever

•Productive cough

•Chest pain

•Nausea/vomiting

•Tachycardia

•Tachypnea

•Rales or decreased breath sounds•Hypotension (sepsis, dehydration)

•Poor skin turgor


•Asthma

•Aspiration

•Cardiac (CHF, MI)

•COPD

•Septic shock

•Pulmonary effusion

B General Respiratory Distress Protocol B

B Consider CPAP Protocol B

J Albuterol 2.5 mg/ ipratroprium 0.5 mg neb if wheezing J

EN IV Procedure EN

55

History

•Due date

•Time contractions started, interval

•Rupture of membranes

•Vaginal bleeding

•Sensation of bowel movement

•Past medical and delivery history

•Medications

•Drug use

•Gravida/ Para status

•High risk pregnancy

Physical

•Spasmodic pain

•Vaginal discharge or bleeding

•Crowning

•Urge to push

•Meconium


•Abnormal presentation

•Prolapsed cord

•Placenta previa

•Abruptio placenta

Childbirth, Cephalic Presentation

Pearls:A pregnant patient in cardiac arrest should be managed per ACLS guidelines

with rapid transport. Do not delay transport for delivery of the placenta.Manual vaginal exams should not be performed in the field.

If birth is imminent, stay and deliver the baby. If high risk, attempt delivery en-route to hospital.

Seizures during pregnancy represent a medical emergency, contact medical command promptly.

If amniotic sac has not ruptured, it should be ruptured manually.

57


B Visualize perineum for crowning and imminent delivery. B

B Transport 3rd trimester patients in left lateral recumbent position. If immobilized, tilt spine board to left.

B

EN IV Procedure EN

B Assess for amniotic sac rupture. If not ruptured and delivery is in progress, tear membrane.

Support infant’s head over perineum.Once head appears, suction mouth then nostrils with bulb

syringe.Check for cord around the neck.

Apply gentle traction downward on head until anterior shoulder appears.

Guide infant upward to deliver posterior shoulder.Keep infant at same level of placenta.

Clamp cord at 8 inches and 10 inches from the infant.Cut cord between the clamps.

Keep infant warm, particularly the head.Record time of birth.

B

B Assess and record APGAR at 1 and 5 minutes. B

Childbirth, Cephalic Presentation

58



EN IV Procedure EN

B Support the baby’s extremities or buttocks until the upper back appears.

Grasp the baby’s hips and apply gently downward traction.Do not apply traction to baby’s legs or back.

Swing the infant’s body in the direction of least resistance. By alternate swinging, both shoulders will deliver posteriorly.Splint the humerus and apply gentle traction so the arms can

be delivered.Gentle abdominal compression of the uterus to engage baby’s

head.Apply downward traction until the baby’s hair is visible.

Grasp iliac crests to swing legs upward until the body is in vertical position which delivers head.

Suction mouth then nostrils using bulb syringe.Clamp and cut cord at 8 inches and 10 inches from baby.

Record time of birth.

B

B Assess and record APGAR’s at 1 and 5 minutes. B

Childbirth, Breech Birth

Pearls:Always contact medical command for guidance with any complicated delivery.Seizures during pregnancy represent a medical emergency, contact medical

command promptly.

59



EN IV Procedure EN

B Do not attempt to push the cord or limb back in.Insert 2 fingers of gloved hand into vagina to raise presenting

part off cord.Check cord for pulsations in vagina.

Push baby’s head away to keep pressure off cord and maintain.Place mother in knee-chest position. If unable, use

Trendelenburg instead.Continue to hold pressure off cord.Keep cord moist with sterile saline.

Transport immediately with early notification to ED.

B

Childbirth, Prolapsed Cord/ Limb Presentation

Pearls:Always contact medical command for guidance with any complicated delivery.Seizures during pregnancy represent a medical emergency, contact medical

command promptly.

60

History


•Hypertension meds

•Prenatal care

•Gravida/ Para

Physical

•Seizures

•Hypertension

•Severe headache

•Visual changes

•Edema of hands and face

•RUQ pain


•Pre-eclampsia

•Eclampsia


EN IV Procedure EN

MC Magnesium Sulfate 10% 2 to 4 grams IVP at no greater than 1 gram per minute until seizure stops or 4 grams has been

given. (To obtain 10% solution, dilute with 8 mL NS).

MC

Eclamptic Seizures

Pearls:Hypertension in the pregnant patient is defined as 140/90 or an increase of 30

mmHg systolic or 20 mmHg diastolic from patient’s normal BP.Seizures during pregnancy represent a medical emergency, contact medical

command promptly.Side effect of magnesium include muscle weakness and respiratory

depression. Treat with IV calcium as a reversal agent.

61

History

•Witness or alleged sexual assault

Physical

•Vaginal bleeding

•Emotional upset

•Signs of trauma

•Abdominal cramping


•Non-traumatic vaginal bleeding

•Criminal abortion


B Confirm scene safety. B

B Do not examine genitalia unless a hemorrhage requires bleeding control.

B

B Save any clothing and place in paper bag. B

B Advise patient not to urinate, defecate, douche, or wash before ED evaluation.

B

B Transport to facility with sexual assault examiner capabilities. B

EN Consider IV Procedure EN

Sexual Assault

Pearls:Obtain only pertinent facts related to the trauma.

Do not question about prior events or information not directly related to care (assailant description, etc).

Ensure law enforcement has been informed.Transport with provider of same gender if possible.

62

History

•Gestational history

•Time of onset

•Amount of bleeding

•Presence of clots or products of conception

•Recent sexual intercourse

•Abdominal Pain

•Diagnosis of placental complications

•History of current pregnancy

•Prenatal care

•Last exam? By whom?

•Start of Last menstrual period

•Prior non-menstrual bleeding

•Ovarian cysts

•History of ectopic pregnancies

•Endometriosis

Physical

•Vaginal bleeding

•Rigid abdomen

•Presence of contractions

•Signs of shock


•Placenta previa

•Abruptio placetae

•Sponatneous abortion

•Abnormal menses

•Trauma related

•Hematuria

•Endometriosis

•Ectopic pregnancy

•Other non-obstetric causes


B Collect any tissue or fetal parts. Place in paper bag then into plastic bag for physician examination.

B

B If hypotensive, refer to hypotensive protocol. B

EN Consider IV Procedure EN

Vaginal Bleeding

Pearls:Determine last menstrual period.

Always consider pregnancy and complications in women of child bearing age.3rd trimester bleeding may constitute a medical emergency; contact medical

command promptly. 63

Trauma: General ManagementHistory

•Time and mechanism of injury

•Damage to structure or vehicle

•Location in structure or vehicle

•Others injured or dead

•Speed and details of MVC

•Restraints/ protective devices


•Medications

Physical

•Deformity

•Contusion

•Abrasions

•Punctures, penetrations

•Burns

•Lacerations

•Tenderness

•Swelling


•Hypotension

•Arrest


•Chest Tension pneumothorax Flail chest Pericardial tamponade Open chest wound Hemothorax

•Intra-abdominal bleeding

•Pelvis/ femur fracture

•Spinal fracture/cord injury

•Head injury

•Extremity trauma

•HEENT trauma

•Hypothermia

•Distracting injury

Pearls: GCS should be assessed and documented.

65



B Notify MedCom if possible trauma alert (red or yellow category):

Advise mechanism of injury, age and sex of patient, sites of injury, vitals if available, ETA.

B

B For evisceration, cover with moist sterile dressing then with plastic.

Do not push organs back into abdominal cavity.

B

B For open chest wound, cover immediately with occlusive dressing.

B

B Maintain patient warmth. B

EN IV Procedure EN

EN Needle Chest Decompression Procedure if absent breath sounds and symptoms of shock

EN

I/P Morphine sulfate up to 10 mg slow IVP with BP >90 mmHg for moderate to severe pain from isolated distal extremity

fracture/ dislocation

I/P

MC Consider cessation of efforts for patients in traumatic cardiac arrest if transport time is greater than 15 minutes.

MC

Trauma: General Management

66

AmputationHistory

•Mechanism of injury

•Time of injury

•Wound contamination

•Medical history

•Medications

Physical

•Deformity

•Diminished pulse, capillary refill


•Complete amputation

•Incomplete amputation


B Spinal Immobilization. B

B Apply direct pressure to control hemorrhage. Elevate and consider tourniquet procedure.

B

B If incomplete amputation, splint entire digit or limb in physiological position.

B

B Place part in damp gauze, place in plastic bag, wrap in trauma dressing, place on ice/water mix.

B

EN IV Procedure EN

I/P Morphine sulfate up to 10 mg slow IVP with BP >90 mmHg for moderate to severe pain.

I/P

Pearls: Tourniquets should be used with the smallest amount of pressure over the

widest area.Never freeze the part by placing directly on ice.

67

BurnsHistory

•Type of exposure

•Inhalation injury

•Time of injury


•Medications

•Other trauma

•Loss of consciousness

•Tetanus status

Physical

•Burns, pain, swelling

•Dizziness


•Hypotension

•Airway compromise

•Singed facial or nasal hair

•Hoarseness/wheezing


•Superficial

•Partial thickness

•Full thickness

•Chemical

•Thermal

•Electrical

•Radiation

Pearls: In electrical burns, search for additional traumatic injury.In thermal burns, assess for carbon monoxide exposure.

Remove jewelry and non-adherent clothing.Avoid establishing IV distal to extremity burn.

Severe burns should not receive succinylcholine.Early intubation should be considered if airway edema is present or likely to

develop.

68


B Apply dry sterile dressings. B


B Irrigate chemical burn with water if water is appropriate to chemical.

If powdered chemical, brush off.

B

B Splint fractures after applying dressing. B

EN Advanced airway management EN

EN IV Procedure EN

I/P Morphine sulfate up to 10 mg slow IVP with BP >90mmHg for moderate to severe pain. May repeat in 4 mg increments to a

max of 20 mg.

I/P

Burns

69

CNS InjuriesHistory

•Time of injury

•Mechanism of injury•Loss of consciousness

•Bleeding

•Medical history

•Medications•Evidence of multitrauma•Helmet use or damage

Physical

•Pain, swelling, bleeding


•Unconsciousness

•Respiratory distress/failure

•Vomiting

•Significant mechanism of injury


•Skull fracture

•Brain injury

•Epidural hematoma

•Subdural hematoma

•Subarachnoid hemorrhage

•Spinal injury

•Abuse



B Elevate patient’s head if not hypotensive. Elevate head of spine board if immobilized.

B


EN Advanced airway management EN

EN IV Procedure EN


Hyperventilation (10 breaths over normal ventilation) only if evidence of herniation (blown pupil, posturing, or bradycardia) to a capnography reading

of 30- 35 mmHg. Intracranial pressure may cause hypertension, bradycardia, and altered

respiratory rate.Haloperidol should not be administered to these patients.

Avoid advanced airway procedures if there is any indication of an intact gag reflex.

70

History

•Onset and location

•Insect sting or bite

•Food allergy/ exposure

•Medication allergy/exposure

•New clothing, soap, detergent

•Past history of reactions


•Medication history

•Is this a reaction that your MD advised you to use the epi-pen?

Physical

•Itching or hives

•Coughing or wheezing

•Chest or throat constriction

•Difficulty swallowing

•Hypotension or shock

•Edema


•Rash only

•Anaphylaxis

•Shock

•Angioedema

•Aspiration/ airway obstruction

•Asthma

Pediatric: Allergic Reaction

Pearls:Any patient receiving epinephrine must be transported.

72

B Universal Care Protocol, with emphasis on adequate oxygenation

B

B Remove from source of exposure. B

B Assist with prescribed auto injector (Epi-Jr 0.15 mg) for severe hives, inadequate perfusion, or respiratory distress.

B

EN 1. Epinephrine (1;1000) 0.01 mg/kg SQ or IM. Max 0.3 mg. May repeat in 10 minutes.

2. Albuterol 2.5 mg nebulized for wheezing/bronchospasm.3. Diphenhydramine 1 mg/kg IM or IV. Max 50 mg.

4. Methylprednisolone 125 mg IV over 1 minutes for severe hives or difficulty breathing.

EN

EN IV Procedure EN

MC Consider additional doses of Epinephrine. MC

Pediatric: Allergic Reaction

73

History

•Age

•Exposure to increased temperature or humidity

•Past medical history/ medications

•Extreme exertion

•Time and length of exposure

•Poor PO intake

•Fatigue

•Muscle cramping

•History of fever/ chills/ illness

•Environmental condition

Physical


•Hot, dry or sweaty

•Hypotension

•Seizures

•Nausea


•Fever

•Dehydration

•Drugs

•Hyperthyroidism

•Delirium tremens

•Heat cramps

•Heat exhaustion

•Heat stroke

•CNS lesions or tumors

B Universal Care Protocol, with emphasis on adequate oxygenation B

B Move to cooler environment, remove excess clothing, protect from further heat gains.

B

B For heat exhaustion, PO water if patient can tolerate. Cool with wet towels or fans.

B

B For heat stroke, use aggressive evaporation (fine mist water spay, ice packs to groin and axillae).

B

EN IV Procedure EN

Pediatrics: Hyperthermia

Pearls:The major difference between heat exhaustion and heat stroke is CNS

impairment.Avoid dramatic decreases in temperature which can cause shivering and

increase temperature.Dehydration and volume depletion may not occur in classic heat stroke.

Vigorous fluid administration may result in pulmonary edema, particularly in the very young.

74

History

•Submersion in water

•Associated trauma

•Duration of immersion

•Temperature of water

•Fresh vs. salt water

•Time patient was removed from water

•Contamination of water

Physical

•Unresponsive


•Decreased vital signs

•Vomiting

•Cough

•Aspiration


•Trauma

•Pre-existing medical problem

•Pressure injury

•Pressure injury barotrauma decompression sickness


B

B Remove from water if trained and safe to do so. B


B Prevent heat loss, refer to “Hypothermia” protocol if indicated. B

EN IV Procedure EN

I/P Refer to specific cardiac arrhythmias protocol as needed. I/P

Pediatric: Near Drowning

Pearls:Most near drowning victims will be hypothermic to some extent.

Assess type of incident (surface impacted, object strike, propeller trauma).Assess water conditions (depth of submersion, length of time, water temp).Complications can appear up to 24 hours later. Transport should be highly

encouraged.

75

Pediatric: Poisoning/ OverdoseHistory

•Ingestion/ exposure of toxic substance

•Route and quantity of substance ingested

•Time of ingestion/exposure

•Reason (suicide, accident)

•Available medications near patient

•Past medical history, medications

Physical

•Mental status change

•Hypo-/hypertension

•Decreased respiratory rate

•Tachycardia

•Dysrhythmias

•Seizures

•Behavioral changes


•Tricyclic antidepressants

•Acetaminophen

•Depressants

•Stimulants

•Anticholinergics

•Cardiac medications

•Solvents, cleaning agents

•Insecticides (organophosphates)

•Aspirin

•Smoke inhalation

Pearls: Intubated patients should not receive naloxone unless in cardiac arrest.

Tachycardia is not a contraindication to atropine administration.Poison control should be consulted on all complex toxicology at

434-924-5543 or 1-800-451-1428.Aeromedical resources will not transport contaminated patients.

76


B

B Identify substance and assure decontamination. B

B Flush skin/membranes with appropriate solution if indicated. B

EN IV Procedure EN

EN Naloxone 0.1 mg/kg IV or IM for suspected narcotic overdose. Max 2 mg.

EN

EN Diphenhydramine 1 mg/kg slow IV or IM for dystonic reaction (max dose of 50 mg).

EN

I/P For Symptomatic Tricyclic Antidepressant Overdose:( if QRS >0.10 secs, hypotension, or dysrhythmia)

• Sodium bicarbonate 1mEq/kg slow IVP over 2 minutes

I/P

I/P For Symptomatic Calcium Channel Blocker Overdose:(if bradycardic, QRS >0.12 secs, heart block, hypotension,

lethargy, slurred speech, nausea, vomiting)• Calcium chloride 10 mg/kg slow IVP over 10 minutes• Sodium bicarbonate 1 mEq/kg slow IVP over 2 minutes.

I/P

I/P For Symptomatic Organophosphate Poisoning:(secretions, bronchospasm, seizures, bradycardia)

• Atropine 0.05 mg/kg IV doubled every 5-10 minutes until decreased secretions.

I/P

Pediatric: Poisoning/ Overdose

77

Pediatrics: General Management of Cardiac Arrest or Pre-Arrest

History

•Time of arrest

•Medical history

•Medications

•Possibility of foreign body

•Suspected abuse

Physical

•Pulseless

•Apneic


•Respiratory failure Foreign body Secretions Infection

•Hypovolemia

•Congenital heart disease

•Trauma


•Toxin or medication

•Hypoglycemia

•Acidosis

•SIDS

Pearls: If pediatric pads are not available, use of adult pads is acceptable. Ensure

they do not touch.IV medications should be followed by a 10 mL bolus NS.

ETT doses are less desirable, flush with 2-3 mL NS.ETT placement should be confirmed every time the patient is moved or for

change of status.Continuous ETCO2 is mandatory in intubated patient.

Consider orogastric tube for abdominal distention.Use length-based resuscitation tape.

.

78


B

B Check adequacy of CPR.Perform chest compressions if HR persistently <60 in child/infant

or <80 in newborn.15:2 for multiple rescuer / 30:2 for single rescuer

B

B AED protocol using pediatric pads if stand alone defibrillator.Use adult pads when using multifunction device in AED mode.

Ensure pads do not touch.

B

B Ensure patient warmth. B

B Transport immediately with BLS measures while requesting ALS. B


I/P Airway management I/P

I/P Evaluate cardiac rhythm. Go to appropriate protocol for further management.

I/P

Pediatrics: General Management of Cardiac Arrest or Pre-Arrest

79

Pediatrics: Asystole/ PEAHistory

•Trauma


•Medications

•Evaluate history of respiratory illness

•Evaluate history consistent with possible shock

Physical

•Pulseless

•Apneic



•Device error

•Hypoxia

•Hypothermia



•Hypoglycemia

•Hypovolemia

•Trauma



•Toxins

•Tamponade


B

B Pediatric General Management of Cardiac Arrest Protocol B

I/P Epinephrine IV/IO (1:10,000) 0.01 mg/kg max 1 mgRepeat every 3-5 minutes

I/P

I/P Identify and treat reversible causes I/P

Pearls: IV medications should be followed by a 10 mL bolus NS.

ETT placement should be confirmed every time the patient is moved or for change of status.

Continuous ETCO2 is mandatory in intubated patient.Consider orogastric tube for abdominal distention.

Use length-based resuscitation tape..

80

Pediatrics: BradycardiaHistory


•Foreign body


•Apnea

•Toxic or poison exposure

•Congenital disease

•Medication (maternal or infant)

Physical

•Cyanosis

•Mottled, cool skin

•Hypotension


•Decrease capillary refill



•Respiratory obstruction Foreign body Secretions Croup/epiglotitis

•Hypovolemia

•Hypothermia

•Infection/sepsis

•Medication or toxin

•Hypoglycemia

•Trauma

Pearls: Bradycardia is commonly a manifestation of hypoxia.

IV medications should be followed by a 10 mL bolus NS.ETT placement should be reconfirmed every time the patient is moved or for

change of status.Continuous ETCO2 is mandatory in intubated patient.

Consider orogastric tube for abdominal distention.Use length-based resuscitation tape.

.

81


B

B If HR is persistently <60 for child/infant or <80 for neonates, begin CPR. Refer to General Management of Cardiac Arrest

or Pre-arrest protocol

B



I/P

I/P Atropine sulfate 0.02 mg/kg IV/IO repeat every 5 minutesMax single dose for child 0.5 mg: total max 1mg

I/P

I/P Identify and treat reversible causes I/P

MC Consider transcutaneous pacing MC

Pediatrics: Bradycardia

82

Pediatrics: Narrow Complex Tachycardia

History


•Medications or ingestion Aminophylline Thyroid supplements Decongestants Digoxin



•Syncope or near syncope

Physical

•Heart rate

•Pale or cyanotic

•Diaphoresis

•Tachypnea

•Vomiting

•Hypotension

•Altered level of consciousness

•Pulmonary congestion

•Syncope



•Hypoxemia or anemia

•Hypovolemia

•Hyperthermia


•Tamponade


•Anxiety, pain, stress

•Fever, infection, sepsis

•Hypoxia

•Hypoglycemia

•Medication, toxins, drugs

•Trauma

Pearls:Treatment of sinus tachycardia should be aimed at searching for and

treating reversible causes.

83

B Universal Care Protocol, with adequate oxygenation B

EN IV/IO Procedure EN

I/P Probable Sinus Tachycardia: (P waves present and normal, variable R-R with constant P-R

child rate <180, infant rate <220 )Search for and treat potential causes as listed above in

differential diagnoses.

I/P

I/P Probable Supraventricular Tachycardia:(QRS <0.08 secs, P waves absent, abrupt change to or from

normal, child rate >180, infant rate >220 )Consider vagal maneuvers if stable

I/P

MC Adenosine 0.1 mg/kg rapid IV/IO max initial dose 6 mg, may repeat one time at twice the first dose to a max of 12 mg.

MC

MC Synchronized cardioversion 0.5 to 1 j/kg may increase up to 2 j/kg if ineffective

MC

MC Consider midazolam 0.1 mg/kg IV/IO max single dose 2 mg. Do not delay cardioversion.

MC

Pediatrics: Narrow Complex Tachycardia

84

Pediatrics: Ventricular Fibrillation/ Pulseless VT

History



•Medications


Physical

•Pulseless

•Apneic


•Asystole

•Artifact/device failure


•Hypoxia

•Hypothermia



•Hypoglycemia

•Hypovolemia

•Trauma



•Toxins

•Tamponade

Pearls: Sodium bicarbonate should not be used during brief resuscitation attempts.If pediatric pads are not available, use of adult pads is acceptable. Ensure

they do not touch.IV medications should be followed by a 10 mL bolus NS.

ETT placement should be confirmed every time the patient is moved or for change of status.

Continuous ETCO2 is mandatory in intubated patient.Consider orogastric tube for abdominal distention.

Use length-based resuscitation tape.

85


B

B General Management of Cardiac Arrest Protocol B

B AED protocol using pediatric pads if stand alone defibrillator.Use adult pads when using multifunction device in AED

mode. Ensure pads do not touch.

B

I/P Attempt defibrillation at 2 j/kg I/P


I/P

I/P Attempt defibrillation at 4 j/kg after 2 minutes of CPR.Continue every 2 minutes.

I/P

MC Consider amiodarone 5 mg/kg IV/IO MC

Pediatrics: Ventricular Fibrillation/ Pulseless VT

86

Pediatrics: Wide Complex Tachycardia

(VT with Pulse)History

•Medical history

•Time of onset

•Medications


•Prolonged QT syndrome

•Renal disease

Physical

•Pallor

•Diaphoresis

•Hypotension



•Pulseless ventricular tachycardia

•Medication effects

B Universal Care Protocol, with emphasis s on adequate oxygenation

B


I/P Confirm QRS >0.08 sec I/P

I/P If unstable, sychronized cardioversion 0.5 to 1 j/kg, may increase up to 2 j/kg if ineffective.

I/P

MC Consider amiodarone 5 mg/kg IV/IO over 10 to 20 minutes MC

MC Consider midazolam 0.1 mg/kg IV/IO.Do not delay cardioversion.

MC

Pearls: VT is uncommon in the pediatric patient.

The ventricular rate may vary from near normal to near 400 bpm.Slow rates may be well tolerated.

The majority of children who develop VT have underlying structural heart disease or prolonged QT syndrome.

IV medications should be followed by a 10 mL bolus NS.

87

History

•Due date and gestational age

•Multiple gestation

•Meconium

•Delivery difficulties

•Congenital disease

•Maternal medications

•Maternal risk factors (substance abuse)

Physical

•Apneic

•Central cyanosis

•Unresponsive

•Bradycardic

•Pulseless


•Airway failure Secretions Respiratory drive

•Infection

•Maternal medication effect

•Hypovolemia

•Hypoglycemia

•Congenital heart process

•Hypothermia

Pediatric: Newborn Resuscitation

Pearls:IV fluids should be administered over less than 20 minutes.

IO access should be attempted if no peripheral access in 2 attempts or 90 seconds.

88


B

B Assess ABC’s using base of umbilical cord, brachial or femoral artery, or auscultation of heart sounds.

B

B Place newborn on back with neck in neutral position. B

B Suction mouth prior to nose. Note any meconium presence. B

B After delivery, use mild stimulation (dry, warm, suction). If effective respirations are not present after 5-10 seconds of

stimulation, BVM at 40-60 breaths/minute.

B

B If heart rate is <80 bpm with no improvement after BVM for 30 seconds, begin CPR.

B

B Dry the newborn, wrap in blanket, head cap to maintain warmth. Do not allow newborn to become hypothermic.

B

EN Evaluate or treat for hypoglycemia.Dextrose 12.5% 4 mL/kg IV or IO

EN

B Record APGAR’s at 1 and 5 minutes. B

I/P IO if required for medication administration. I/P

I/P Follow specific algorithms for bradycardia, tachycardia, or cardiac arrest.

I/P

Pediatric: Newborn Resuscitation

89

History

•Known diabetic

•Drugs, paraphernalia

•Report of drug use or toxic ingestion


•Medications


Physical

•Change from baseline mental status

•Bizarre behavior

•Cool, diaphoretic skin (hypoglycemia)

•Warm,dry skin with signs of dehydration (hyperglycemia)

•Fruity breath odor

•Kussmaul respirations


•Head trauma

•Stroke

•Tumor

•Seizure

•Infection/ sepsis

•Thyroid

•Shock

•Diabetes

•Acidosis/alkalosis

•Environmental exposure


•Psychiatric disorder

Pediatric: Altered Level of Consciousness

Pearls:Poison Control cannot act as medical command, contact for advise only.

Do not use patient’s glucometer.

90


B

EN IV Procedure EN

EN Administer glucose:• Children >8 years, Dextrose 50% 1mL/kg IV or IO.•Children 1 month to 8 years, Dextrose 25% 2 mL/kg IV or IO.• Neonates <1 month, Dextrose 12.5% 4 mL/kg IV or IO.

•

EN

EN Glucagon 1 mg IM if no IV access. EN

EN Naloxone 0.1 mg/kg IV, IO, or IM for suspected narcotic overdose with respiratory depression. Max 2 mg.

EN

Pediatric: Altered Level of Consciousness

91

History

•Fever

•Prior history of seizure

•Seizure medications

•Head trauma

•Congenital abnormality

Physical

•Observed seizure activity


•Hot, dry skin

•Elevated body temperature


•Fever

•Infection

•Head trauma


•Hypoxia

•Hypoglycemia

•Metabolic abnormality

•Tumor


B

EN IV Procedure EN

EN Administer glucose:• Children >8 years, Dextrose 50% 1mL/kg IV or IO.• Children 1 month to 8 years, Dextrose 25% 2 mL/kg IV

or IO.• Neonates <1 month, Dextrose 12.5% 4 mL/kg IV or IO

EN

EN Glucagon 1mg IM if no IV access. EN

I/P Diazepam 0.1 mg/kg IV max single dose 5 mg. May repeat once in 5 minutes for persistent seizure.

I/P

I/P Midazolam 0.1 mg/kg IM if no IV access, max single dose 5 mg. May repeat once in 5 minutes for persistent seizure.

I/P

MC Contact medical command if seizure persists after two doses of benzodiazepines.

MC

Pediatric: Seizures

92

History

•Time of onset

•Possibility of foreign body

•Medial history

•Medications

•Fever or respiratory infection

•Sick siblings


Physical

•Wheezing or stridor

•Retractions

•Increased heart rate

•Altered LOC

•Anxious appearance

•Nasal flaring



•Asthma

•Aspiration

•Infection (pneumonia, croup)



•Trauma

•Airway obstruction


B

B Allow child to assume position of comfort. B

B Assist patient with prescribed Metered Dose Inhaler. B

J Albuterol 2.5 mg and ipratroprium nebulizer for bronchospasm. May repeat albuterol as long as patient is

symptomatic.

J

EN NS 2-3 mL nebulized for suspected croup or epiglottitis EN

EN IV Procedure EN

I/P Epinephrine (1:1000) 2 mg plus 1 mL NS (total volume of 3 mL) nebulized for moderate to severe patients with suspected

croup or epiglottitis.

I/P

MC Epinephrine (1:1000) 0.01 mg/kg SQ, single max dose 0.3 mg for severely symptomatic patient. May repeat every 20

minutes for a max of 3 doses if still symptomatic.

MC

MC Methylprednisolone 1 mg/kg IV for severe asthma or croup. MC

Pediatric: Respiratory Distress

Pearls:“Severely symptomatic” is defined as inability to speak normally, severe wheezing, absent or diminished breath sounds, and/or poor perfusion.

In upper airway airway disorders, invasive airway maneuvers should be avoided if possible.

Consider aeromedical request for prolonged transports. 93


B


B Notify MedCom if possible trauma alert (red or yellow category):

Advise mechanism of injury, age and sex of patient, sites of injury, vital if available, ETA.

B

B For evisceration, cover with moist sterile dressing then with plastic.

Do not push organs back into abdominal cavity.

B


EN IV or IO Procedure. EN

EN Needle Chest Decompression Procedure if indicated EN

I/P Morphine sulfate up to 0.1 mg/kg slow IVP or IM for moderate to severe pain from isolated distal extremity

fracture/ dislocation. Max dose 10 mg.

I/P

MC Consider cessation of efforts for patients in traumatic cardiac arrest.

MC

Pediatric: General Trauma Management

94

History

•Time and mechanism of injury

•Damage to structure or vehicle

•Location in structure or vehicle

•Others injured or dead

•Speed and details of MVC

•Restraints/ protective devices


•Medications

Physical


•Hypotension

•Arrest

•Deformity

•Contusions

•Abrasions

•Punctures/penetrations

•Burns

•Tenderness

•Lacerations

•Swelling


•Chest Tension pneumothorax Flail chest Pericardial tamponade Open chest wound Hemothorax Pulmonary contusion

•Intra-abdominal bleeding

•Pelvis/ femur fracture

•Cord injury/spinal fracture

•Head injury

•Extremity trauma

•HEENT trauma

•Hypothermia

Pediatric: General Trauma Management


Preservation of body heat is paramount.

95

Pediatric: AmputationHistory


•Time of injury

•Wound contamination

•Medical history

•Medications

Physical

•Blood loss

•Diminished pulse, capillary refill


•Complete amputation

•Incomplete amputation


B

B Spinal Immobilization. B

B Apply direct pressure to control hemorrhage. Elevate and consider tourniquet if needed.

B

B If incomplete amputation, splint entire digit or limb in position found.

B

B Place part in damp gauze, place in plastic bag, wrap in trauma dressing, place on ice/water mix.

B

EN IV Procedure. EN

I/P Morphine sulfate up to 0.1 mg/kg slow IV/IO/IM. Max dose 10 mg.

I/P

Pearls: Tourniquets should be used with the smallest amount of pressure over the

widest area.Never freeze the part by placing directly on ice.

96

Pediatric: BurnsHistory

•Type of exposure

•Inhalation injury

•Time of injury


•Other trauma

•Medications


Physical

•Burns, pain, swelling

•Dizziness


•Hypotension

•Airway compromise

•Singed facial or nasal hair

•Hoarseness/wheezing


•Superficial

•Partial thickness

•Full thickness

•Chemical

•Thermal

•Electrical

•Radiation

•Abuse


B

B Apply dry sterile dressings. B

B Irrigate chemical burn with water if water is appropriate to chemical.

If powdered chemical, brush off.

B


EN IV Procedure EN

I/P Morphine sulfate up to 0.1 mg/kg slow IVP or IM for moderate to severe pain. Repeat as needed up to 10 mg.

I/P

Pearls: In electrical burns, search for additional traumatic injury.In thermal burns, assess for carbon monoxide exposure.

Remove jewelry and nonadherent clothing.Avoid establishing IV distal to extremity burn.

97

Pediatric Trauma: CNS InjuriesHistory

•Time of injury



•Bleeding

•Medical history

•Medications

•Evidence of multi-trauma

•Helmet use or damage

Physical

•Pain, swelling, bleeding


•Unconsciousness

•Respiratory distress/failure

•Vomiting

•Significant mechanism of injury

Differential Diagnosis

•Skull fracture

•Brain injury

•Epidural hematoma

•Subdural hematoma

•Subarachnoid hemorrhage

•Spinal injury

•Abuse


B






98

99

Thomas JeffersonRegional Policies

100

Advanced Life Support GuidelinesTechnicians may only provide care that has been approved by the Operational Medical Director of each respective agency. In special situations, an on-line physician may authorize an ALS technician to perform a procedure outside the area protocol but within the scope of the technician’s training.

The Operational Medical Director must approve changes in medical procedures.

All issues that cannot be solved locally to the satisfaction of all those concerned may be brought to the Medical Direction Committee for recommendation.

The Operational Medical Director of each agency is ultimately responsible for all patient care. Therefore, the OMD has the right to suspend an ALS technician who fails to perform his/her duty as trained or flagrantly exceeds the authority given to him by the OMD and these rules and regulations.

In order to practice as an ALS technician in this area, the technician must have the approval of the agency OMD and be released by their primary EMS agency as an EMT attendant-in-charge (AIC).

If in a life or death situation, a sole Junior ALS technician may provide ALS care within the scope of their training.

Anytime a technician operates outside the established regional protocols, the technician should notify their OMD and may be subject to review by the OMD and/ or the Medical Direction Committee.

Technicians are highly encouraged to attend all meetings where ALS calls run by their agency are discussed, and where both practical and lecture materials are reviewed.

ALS technicians are responsible for meeting their continued education requirements. All required category one and category two hours must be completed prior to recertification.

All ALS technicians must demonstrate skill proficiency to the ALS prehospital coordinators in the setting of the annual skills drill held at the September ALS meeting or equivalent approved by agency medical director. Moreover, EMT-Intermediates and Paramedics must participate in an annual “Mega-Code” drill held at the March ALS meeting or equivalent approved by agency medical director.

If an ALS technician fails to complete his/her skills drill or Mega-Code and/or the required number of successful IV starts, he/she will automatically become ineligible to provide ALS care until he/she has worked with one of the prehospital coordinators or their designee. The suspension of privileges becomes effective at the end of the affected month.

An ALS technician cannot be inactive for more than ninety-days (90) within any twelve-month (12) period. If an individual is inactive for more than 90 consecutive days, they must file for special review by the prehospital ALS coordinators and the Operational Medical Director.

ALS providers who are trained outside the TJEMS region and for those who are trained through a non-UVA training program must have a session involving their agency OMD or designee to evaluate their knowledge of the TJEMS Regional Protocols as well as orient to the training and reporting process for this region with the UVa Prehospital program prior to actual field practice as an ALS provider.

101

Documentation StandardsThe following policy outlines the minimum documentation required for each patient contact.

• History of present illnesso Includes chief complaint, SAMPLE, OPQRST, and pertinent negatives

• Physical exam o Use of body systems approach is recommended

• Complete vital signs are defined as pulse, respirations, and BP.o May include pulse oximetry, capnography, and pain scale as indicated.o Repeat and document every 15 minutes for stable patients, every 5 minutes for

unstable patients o Repeat and document after every medication administrationo BP not required in children under 3 years but parameters of perfusion should be

assessed and documented (skin condition, capillary refill, mental status, distal vs peripheral pulses).

o Record the time all vital signs are takeno Any abnormal vital sign should be repeated and closely monitored.

• Use only standard medical abbreviations.• Medication administrations should include dosage, route of administration, time of

administration, assessment of response, and provider who administered medication.• Treatments should be listed and documented with time of procedure and provider who

performed procedure as well as assessment of response.• For immobilization of extremity or spine, document pulse, motor, and sensation prior to

and after immobilization.• For IV administration, document size of catheter, location of placement, provider who

initiated IV, number of attempts, type of fluid, flow rate, and total amount of fluid infused at time of transfer of care. The IV site should also be labeled “field” and the gauge of the catheter.

• ECG interpretations should be documented. Attachment of printed strip to PPCR is recommended. Any changes in rhythm should be documented.

• 12 Leads performed in the field should be documented on the PPCR. A copy of the 12 lead attached to the PPCR is recommended.

• Advanced airway documentation should include method of confirmation, size of device, number of attempts, capnography and SAO2 readings, provider performing procedure, centimeters at teeth (ETT only). A separate regional airway form is also required.

• Medical command orders requested (whether approved or denied) should be documented with time and name of physician as well as the exact order given. Obtain physician signature on arrival at hospital.

• Waste of narcotic administration should be documented with name of person wasting, witness (hospital personnel when available), and the amount and name of medication wasted.

• Pink copy of the PPCR should be turned over to receiving nurse as promptly as possible (this becomes part of the patient’s chart). The gold copy is turned into pharmacy if drug box is exchanged. If the drug box is not exchanged, the gold copy is turned in to ED registration. The white copy is the original to be retained by the transporting agency.

102

Durable DNREmergency regulations governing the Durable Do Not Resuscitate (DDNR) program, adopted by the Virginia State Board of Health, became effective January 3, 2000. The emergency regulations amend the EMS Do Not Resuscitate (DNR) regulations and establish a DDNR order that follows the patient throughout the entire health care setting. Once issued by a physician for his patient, the DDNR Order applies wherever that patient may be – home, EMS vehicle, hospital, nursing home, adult care residence or other health care facility.

DDNR Orders can now be written for anyone, regardless of health condition or age. Inclusion of minors is a significant change in the emergency DDNR Order. Durable DNR Orders can be recognized by qualified EMS personnel at all times and in all settings. Valid EMS DNR Orders are considers Durable DNR Orders and do not expire on or after July 2, 1998. Qualified EMS personnel may honor written DNR Orders written for patient in a licensed health care facility.

The responding EMS provider should:

Perform routine patient assessment and resuscitation or intervention until it is confirmed that the patient has either a Virginia Durable DNR Order or the EMS DNR Order, issued on or after July 2, 1998.

Request the original Virginia Durable DNR Form or the EMS DNR Order or look for either form at patient’s bedside, on the back of the patient’s bedroom door, on the refrigerator or in the patient’s wallet. If either of these forms has been defaced, consider the DNR Order to be invalid.

Make a good faith effort to verify identity of the patient through family, friends, and other health care personnel present or photo ID (such as a driver’s license).

Be aware that a Virginia Durable DNR Form can be revoked by the following persons:The patient, by destroying the Virginia Durable DNR Form or EMS DNR Form or by verbally withdrawing consent to the order.

The person authorized to consent on the patient’s behalf.

A physician who is physically present at the patient’s side.

Observe standard Durable DNR or EMS DNR orders:

These comforting interventions are encouraged:Airway (excluding intubation or advanced airway management)SuctionSupplemental oxygen delivery devicesPain medications or intravenous fluidsBleeding controlPatient positioningOther therapies deemed necessary to provide comfort care or alleviate pain

Contact patient’s physician or On-Line Medical Direction if questions or problems arise.

103

Durable DNR (continued)

These Resuscitative measures should be avoided:

Withhold or withdraw if resuscitation has begun prior to confirmation of Virginia Durable DNR status:

Cardiopulmonary Resuscitation (CPR)Endotracheal intubation or other advanced airway managementArtificial ventilationDefibrillationCardiac resuscitation medicationsContinuation of related procedures, as prescribed by the patient’s physician or medical protocols

Document the call:

Use the standard Pre-Hospital patient Care Report (PPCR) or agency run report to document which identification was used to confirm DNR status: Virginia Durable DNR Order Form, approved alternate form of identification, EMS DNR Order Form or other DNR form.

Indicate the Virginia Durable DNR Order Form number and the patient’s attending physician’s name.

Comfort the family if the patient has expired on arrival and follow agency’s procedure for death at home.

Complete a PPCR or the agency run report.

104

Criteria for Death/ Withholding ResuscitationDNR Patients

Indications:• Pulseless, non-breathing patient who would normally require resuscitation AND• Possess and on scene, properly completed, Virginia DDNR form

Procedure:• Verify that the patient is the person named on the DDNR form.• Cease all resuscitation efforts.• Notify law enforcement• Attach original DDNR to the completed PPCR.

Considerations:• If the patient requires care and is NOT in cardiac arrest, provide care up to the limits of

the DDNR and transport patient and DDNR form.• Prehospital providers cannot honor other legal documents (living wills,etc) without

contacting medical command.• DDNR forms may be overridden by patient, guardian of patient, or on-scene physician

Deceased Patients

Indications:• Rigor mortis and/or lividity• Decapitation• Traumatic cardiac arrest upon arrival

Procedure:• Do not resuscitate any patient who meets the above criteria. If resuscitation

efforts are in progress, consider consulting medical command for discontinuation of efforts (see Discontinuation Policy)

• Notify law enforcement

105

Emergency Custody Order Decision Tree

106

Order of substitute decision makers for incompetent patient: (Virginia Code § 54.1-2986)1. Legal guardian for patient (such as Medical Power of Attorney or agent for

healthcare decisions in writing)2. Patient’s spouse (except where divorce has been filed and is not final)3. Adult child of the patient4. Parent of the patient5. Adult brother or sister of the patient6. Other relative in descending order of blood relationship.

(Girlfriends, neighbors, others with no blood relationship DO NOT qualify as legal substitute decision makers).Criteria for any ECO: a condition that is an immediate or imminent life threat with1. a patient who “because of mental illness . . . or any other mental disorder or physical

disorder which precludes communication or impairs judgment, is incapable of making an informed decision about providing, withholding or withdrawing a specific medical treatment . . .”

2. Note religious caveat (i.e. Jehovah Witness) that “no person shall authorize treatment . . . that such person knows is contrary to the religious beliefs of the patient unable to make a decision, whether expressed orally or in writing.”

3. Virginia Code § 16.1-336. Definitions: • "Consent" means the voluntary, express, and informed agreement to treatment in a

mental health facility by a minor fourteen years of age or older and by a parent or a legally authorized custodian.

• "Incapable of making an informed decision" means unable to understand the nature, extent, or probable consequences of a proposed treatment or unable to make a rational evaluation of the risks and benefits of the proposed treatment as compared with the risks and benefits of alternatives to the treatment. Persons with dysphasia or other communication disorders who are mentally competent and able to communicate shall not be considered incapable of giving informed consent.

Psych ECO (Virginia Code § 37.2-808).

Does NOT require a physician assessment to get from magistrate—family or witness to suicidal thoughts / actions / evidence of significant risk of self-harm can call magistrate and request.“probable cause to believe that any person (i) has a mental illness and that there exists a substantial likelihood that, as a result of mental illness, the person will, in the near future, (a) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any, or (b) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs, (ii) is in need of hospitalization or treatment, and (iii) is unwilling to volunteer or incapable of volunteering for hospitalization or treatment.”

Emergency Custody Order

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Medical ECO (Virginia Code § 37.1-134.21, § 37.2-1103). Emergency custody orders for adult persons who are incapable of making an informed decision as a result of physical injury or illness.

Requires: Application by a licensed physician verifying that the “adult patient is incapable of making an informed decision as a result of physical injury or illness AND that the medical standard of care indicates that testing, observation, and treatment are necessary to prevent imminent and irreversible harm.”

The physician’s opinion of incapacity shall only be rendered after:•either personal evaluation or electronic communication with EMS personnel on scene

regarding their evaluation•an attempt to communicate directly (or electronically) with the adult person to corroborate the

EMS assessment of incapacity•an attempt has been made to obtain consent from the adult person•the adult person has failed to consent

The magistrate shall ascertain that the adult person:• has no legally authorized person to give consent AND• is incapable of making an informed decision regarding necessary treatment AND• has refused transport AND• has indicated intention to resist transport AND• is unlikely to become capable of making an informed decision within the time required.

Should the patient’s condition change and the patient become capable of making an informed decision (i.e. hypoglycemia resolved), the physician must be contacted and the patient’s wishes respected.Information needed from you for magistrate to issue medical ECO (“adult person” = patient)

• Name and permanent address of “adult person” if known• Name of law enforcement agency on scene (+ officer, badge # if possible)• Name, hospital affiliation, and contact number of licensed physician requesting ECO• Present location of “adult person” • Name and address of hospital that “adult person” is to be transported to. (UVA Hospital,

1215 Lee Street, Charlottesville, VA 22908)

You may also be asked what evaluation you plan to undertake. Since you haven’t seen the patient yet, but you can’t legally do anything that isn’t on the order unless the patient consents, you may want to be fairly broad here. Some options may be: physical exam, radiologic studies (potentially including CT scan or MRI), intravenous access, medication therapy, possible mechanical ventilation, hospital admission, laceration repair, fracture management.

Emergency Custody Order

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EMS/Hospital Diversion PlanAt times, internal and external factors affect the ability for a facility to properly care for specific

category of patients. When these events occur, facilities may need to go on “EMS diversion” for

ambulance transported patients. In addition, not all patients can be seen for every classification

of injury or medical complaint at all facilities. This EMS/Hospital Diversion Plan is intended to

identify which category of patients are to be transported to which facilities within the Thomas

Jefferson EMS Council region and to establish a standardized format for notification of EMS

agencies (emergent and transport) when a facility on diversion status, for what reason and for

how long.

Facility Patient Population

Martha Jefferson Hospital

Martha Jefferson Hospital offers a 24 hour emergency department, however there are certain

categories of patients which they are not equipped to service and in fact should be directed to

the regional trauma center:

Adult:

Trauma: with any of the following –

Respiratory: Rate <8 / >30 Assisted ventilations Partial / complete airway obstruction Unable to establish / maintain airway

Neuro: Unconscious / Unresponsive Does not follow commands Unable to move extremities GCS<13 Revised trauma Score <11

Cardiovascular: Systolic BP < 90 with S/S of hypo perfusion (shock) Pulse > 120 Uncontrolled bleeding

Penetrating Injury: Head, neck, chest or abdomen Extremities with uncontrolled bleeding and/or loss of pulse Amputation above finger tip

Mechanism of Injury: Falls > 20 feet Ejection from vehicle MVA speed > 35 – 40 mph / or velocity change of > 20 mph

Rollover Pedestrian vs. auto > 5 mph Motorcycle accident with separation of rider and bike Intrusion into passenger compartment > 12 inches Steering wheel deformity

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Hospital Diversion (continued):

Burn Criteria: 2nd degree / 3rd degree > 20 % Body Surface Area 2nd degree / 3rd degree burns to face, hands, feet, genitalia, perineum and areas overlying major joints. 3rd degree burns > 5% Body Surface Area 2nd or 3rd degree > 10% in patients under 10 or over 50 years Gross inhalation Burns Significant electrical burns including lightning

Pediatric:

Trauma: with any of the following –

Airway: requires constant observation for patency, O2 administration, assisted ventilationsPartial / complete airway obstructionUnable to establish or maintain an airwayIntubated

Neuro: Unconscious / Unresponsive Does not move extremities

Cardiovascular: < 22lbs (10 kg) – Systolic < 50 OR 22-44 lbs (11-20 kg) – Systolic <70 OR >44 lbs (20 kg) – Systolic < 90 AND Poor peripheral pulses Poor perfusion Uncontrolled bleeding

Penetrating Injury: Head, neck, chest, abdomen Extremities with uncontrolled bleeding and/ or loss of pulse Amputation above fingertip

University of Virginia Medical Center

No exclusions – Level I Trauma Center

Clear Text Messaging

The following format shall be utilized when transmitting information between facilities and to the

Charlottesville/Albemarle Emergency Communications Center for dispersal to the EMS agencies

(emergent and commercial).

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Thomas Jefferson EMS CouncilCleartext Communications

EMS/Hospital Diversion

Report Date/Time:

Facility: Martha Jefferson Hospital

University of Virginia Medical Center

Facility Status: Operational – open unrestricted access to all EMS

Quarantined – public health emergency access/exit of

facility controlled VDH

Secured – locked down, limited access

Saturated – pt load is utilizing all current ED/hospital

resources listed below units advised to transport to another

facility, if possible (identify service below add text as

necessary for clarification)

Specify Service: ICU Emergency Department

Scanner Cath Lab Ob/Gyn

Other: ________________________

Evacuated – closed as indicated Partial Full

Anticipated Duration and/or anticipated update on status:

Time Diversion cancelled:

Authorized Signature:

Fax this form twice – once when initiated, once when cancelledTo be faxed to Charlottesville/Albemarle Emergency Communications, 434-971-4845, Attention EMS Supervisor.

Office Use Only

Reviewed: Date:

Off Diversion Time:

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EMS Personnel and Agency Affiliation

With the availability for EMS personnel to be multi-agency affiliated and the ability to readily leave one agency and affiliate with another, the Thomas Jefferson Regional Operational Medical Director’s Committee announces the following policy regarding EMS Personnel and Agency Affiliation:

1. The agency Operational Medical Director of record will be notified of any new agency membership application (membership defined as those involving patient care activities). Notification can be satisfied via written (email or otherwise) format.

2. In the event an updated roster is provided to OEMS, the same roster will be supplied to the agency’s Operational Medical Director of record.

3. The Operational Medical Director will only be responsible for those personnel listed by the “Agency Affiliation” on the OEMS website or as notified by their agency of record.

Complying with this agency policy will allow the Operational Medical Director knowledge of those people under their umbrella as well as potentially protecting the provider, the agency and the Operational Medical Director.

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Final Authority on Medical Command

In the majority of situations, on-line medical command provided by hospital based communication services will meet the needs of providers faced with situations that require medical command to initiate procedures/treatments or are not addressed with standing orders or protocols.

In the case where medical command has been sought and received, the provider will be expected to follow those orders. If the on-line medical command orders are contradictory to local protocols, or exceed the training/certification of the provider(s), then the on-line medical command physician needs to be informed immediately that the orders cannot be carried out. In the event that there is a disagreement between the provider and the on-line medial command physician, the provider must communicate that concern to the medical command physician, and describe the reason(s) for concern in following the orders. Once this communication has occurred, if the recommended orders are within the training/certification of the provider(s) and in keeping with regional protocols, then those orders will be expected to be carried out.

In the event that there is a disagreement between the provider(s) and the on-line medical command physician, the provider may consult with their agency OMD regarding the patient’s care as long as the agency OMD is immediately available to provide medical command. If agency OMD is immediately available and willing to assume medical command, then the agency OMD will become the on-line medical command physician on that call. The provider involved is responsible to notify the previous on-line medical command provider that this change has occurred.

If there is a physician on-scene who is adequately identified to the providers, is qualified and willing to assume responsibility for direct medical command, then that physician’s orders will supercede on-line medical command. An EMS physician who is on-scene may assume medical command even if they are not the agency OMD for the providers involved in the patient’s care.

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Helicopter OperationsWhen requesting helicopter medevac:

Contact MedCom with exact location for rendezvous. Include route numbers, any pertinent landmarks, landing zone, commander identification, and radio frequency.

Provide MedCom with all available patient information and care being administered. Minimum information should include chief complaint, age, sex, weight, systolic BP, respiratory rate and Glasgow Coma Scale.

Set up a landing zone that is at least 100 X 100 feet square and free of any obstructions or loose material, (i.e. dirt, gravel or snow). Provide as level a surface as possible. Mark all four corners of the landing zone with flares or other marker and place a fifth on the down wind side. Be sure to secure the markers, as the rotor wash can blow them a great distance and could possibly be a fire hazard. You can also mark the landing zone with rescue vehicles parked in a triangular fashion with their headlights on low beam until helicopter in on final approach, then no white lights (head lights or scene lights) at the landing zone. Also remember red flashing lights are an excellent way to mark your location. NEVER AIM ANY LIGHTS INTO THE PILOT'S EYES. THIS COULD DESTROY HIS OR HER NIGHT VISION AND RESULT IN A CRASH!

If setting up your landing zone in the roadway, it is essential that you mark all utility lines and relay their exact location as well as any other hazards to the pilot. Utility lines must be marked with a line of flares (or other warning device) below the wires spaced 5 - 10 feet apart. Do this for all utility lines in the area. Remember utility lines are invisible from the air and can cause a catastrophe if not properly marked and identified to the pilot.

Once the aircraft has landed allow no one to approach the craft. You should only approach the craft after being instructed to do so by a member of the flight crew. Never approach the helicopter from the rear or on the uphill side if landing on a slope. Always stay in the pilot's view. Even though some helicopters have high set main rotors, some do not. To be safe, always walk in a slightly crouched position. No hats, except firefighter type with chin straps fastened, under the main rotor if helicopter is running. Never carry anything above the level of your head and secure blankets, sheets, etc. STAY AWAY FROM THE TAIL SECTION OF THE CRAFT AT ALL TIMES!

When loading your patient, a member of the flight crew will accompany you. Keotheraway from the craft. Maintain communications with MedCom and the helicopter at all times on the frequency you initially called in on unless otherwise specified by MedCom.

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Hospital Transport ClassificationsOnce a patient has been assessed, all patients should be assigned a transport classification based on the acuity as determined by the transport attendant-in-charge. In accordance with Virginia’s Mass Casualty Plan, UVa Department of Emergency Medicine, and as outlined by the Governor’s EMS Advisory Board, the following patient designations will be utilized:

RED - Immediate (highest priority):

Trauma Related - Airway concerns AmputationsAny burns with this inclusive listingAssisted ventilationsBurns with > 50% BSAGCS < 13ParalysisPediatric head injury with altered mental statusPenetrating injury to headPenetrating wounds to neck or trunkPregnant with abdominal pain or signs of abdominal traumaRapid infusion to maintain a SBP > 90 mmHg (adult)Signs / Symptoms of respiratory distressSigns of shock or SBP < 100 in an adult or < (2xage in years)+ 80 for childUncontrolled hemorrhageUnresponsive

Medically Related- Acute neurological issues Airway management difficulties Breathing issuesPost- resuscitationSignificant perfusion challengesAny unstable patient

YELLOW - Delayed (second priority)

Trauma related - MVC with any of the following:Ejection from moving vehicleDeath in the same passenger compartmentAuto roll-overSteering wheel damageAuto-pedestrian incidentAuto-bicycle collisionsExtrication time > 20 minutesMotorcycle crashes > 20 mphFalls

> 10 feet in patients < 10 yrs or > 55 yrs of age> 20 feet in other patients

Venomous snakebites

Medically related - Any stable or potentially unstable patient, (i.e., Chest pains resolved, Dyspnea – resolved, diabetic crisis resolved, Seizures resolved, etc).

GREEN - Minor (third priority)

Trauma related - Minor painful swollen deformities Minor soft tissue injuries

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Hospital Transport Classifications (continued)

BLACK - Dead (lowest priority)

EMS should provide the most rapid access to appropriate emergency medical care while using the EMS system as efficiently as possible. In other words, EMS should transport to the closest appropriate emergency facility for rapid evaluation by a physician. If facilities are of equal distance and able to provide equivalent care, then the patient should certainly be offered the choice of destinations. Transport to facilities farther away when an emergency exists may compromise care of the patient as well as the operation of the EMS system involved. EMS crews in conjunction with medical command physician may identify instances when transport to a more distant facility is appropriate, but, without medical command, the assessment by the crew of the patient’s status and needs dictate the course followed.

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Infection Control (Universal Precautions)

1. Always carry disposable gloves and a pocket mask with a one-way valve when on duty or first responding. 2. Gloves should be worn whenever there is the potential to be exposed to blood/body fluids.3. All open wounds and sores must be protected and covered.4. If blood/body fluids get into your mouth, immediately rinse mouth with mouthwash or alcohol. Never put fingers, pencils and etc. into your mouth.5. DO NOT RECAP NEEDLES.6. Masks should be worn if your patient has a rash, fever, cough, or jaundice of unknown origin.7. Eye protection and masks should be used whenever there is the

potential for blood/body fluid splashes and when performing airway care such as suctioning and intubation.8. Protective clothing should be worn if there is the potential for large amounts of blood/body fluids to be present. (childbirth, arterial bleeding).9. A thorough hand washing with soap and water is the single most

effective preventive measure. Alcohol or an alcohol based hand rinse should be used until soap and water is available.

Blood/Body Fluid Exposures

1. A reportable blood/body fluid exposure occurs when you: a. Accidentally receive a puncture wound from a sharp object that has previously been exposed to blood/body fluids. b. Get blood/body fluid in an open lesion, cut or rash. c. Get blood/body fluids splashed into a mucous membrane. d. Have a large blood spill on your intact skin or have a prolonged exposure.

2. If you are exposed to blood/body fluids: a. Register as a patient at the hospital that received the patient. This needs to be done while the patient is still physically in the ER. DOA's should be brought to the hospital, so their blood may be drawn. b. Notify your Designated Infection Control Officer c. Notify your squad's insurance company.

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Pediatric ImmobilizationResearch of current literature does not offer any conclusive information regarding the conditions requiring the removal of a pediatric patient from a child safety seat involved in a motor vehicle crash for immobilization. In consultation with Dr. Pamela Ross, Pediatric Attending with the University of Virginia Medical Center, the following criteria has been developed:

In the event a pediatric patient secured in a child safety seat has been involved in a motor vehicle crash, the patient must be removed from the child safety seat for immobilization on a pediatric immobilization device under the following circumstances:

1. Integrity of the child seat has been violated (seat broken).2. The patient exhibits a focal neurological deficit. Focal neurologic deficit refers to

abnormality that results in a child not being able to function normally. It can include but is not limited to decreased function/movement of an extremity, eye deviation, and incontinence in a potty-trained child. Understand that a broken arm could present as a "focal deficit". If there is any question or mechanism for potential neurologic/ spine injury - then caution should be toward protecting and immobilizing the spine. i.e. a child is ejected from a car seat 15 feet an has an obvious arm/leg deformity in which they are not able to move the extremity; EMS attributes the focal deficit to the fact that the extremity is broken, however, the mechanism provides potential for spinal cord injury - therefore, the child should be fully immobilized with appropriate pediatric spine stabilization equipment.

Note: Be reminded the smaller child’s head is larger proportionately to the remaining torso and therefore requires additional padding to compensate for the space (void) difference to maintain neutrality of the cervical spine and maintain airway. Because the head is larger and is not “restrained” during a motor vehicle collision, it is important to review the mechanism of injury when deciding to utilize the child safety seat as an immobilization device.

Rolled towels can be utilized to immobilize the pediatric patient’s within their child safety seat

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Provider Clearance ProcessEnhanced Release Points

The “ALS Preceptor Evaluation Form” is the guideline for awarding points. Preceptors should write comments as applicable.

• Not every area will have points awarded on every call. Preceptors should write NA when points are not awarded.

• The Jr. Enhanced technician should be present when the preceptor fills out the evaluation form. This will allow the call to be critiqued and learning maximized. Once the evaluation

tool is complete, the Jr. Enhanced will keep it, a copy of the call sheet and airway forms when applicable.

• All forms should be turned in to one of the Prehospital Coordinators. If airway points are the only missing points, contact the Prehospital Coordinators to discuss your release.

Scene Management 25 points

Patient Assessment 25 points

Airway Maintenance* 9 points

Circulation 15 points

Medications** 15 points_______

Total 89 points

*Airway points should only be awarded when true airway management is done such as suctioning, O.P./N.P./Combitube/E.T. insertion. Placing the patient on oxygen does not earn

points.

** At least two medications must be other than nitroglycerine, ASA or Albuterol.

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EMT to Intermediate/Paramedic Release PointsThe “ALS Preceptor Evaluation Form” is the guideline for awarding points. Preceptors should write comments as applicable. Jr. Intermediate/ Paramedic technicians must run a minimum of

20 ALS calls and a minimum of 4 months as a Jr. Intermediate/Paramedic.

• Not every area will have points awarded on every call. Preceptors should write NA when

points are not awarded.• The Jr. Intermediate/ Paramedic technician should be present when the preceptor fills out

the evaluation form. This will allow the call to be critiqued and learning maximized. Once the evaluation tool is complete, the Jr. Intermediate/Paramedic will keep it, a copy of the call

sheet and airway forms when applicable. • All forms should be turned in to one of the Prehospital Coordinators. If airway points are the

only missing points, contact the Prehospital Coordinators to discuss your release.

Scene Management 50 points

Patient Assessment 50 points

Airway Maintenance* 25 points

Circulation 25 points

Medications** 25 points

EKG Interpretation 25 points_______

Total 200 points

*Airway points should only be awarded when true airway management is done such as

suctioning, O.P./N.P./Combitube/E.T. insertion. Placing the patient on oxygen does not earn points.

** Medication points are awarded for medications other than nitroglycerine and Albuterol.

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Recertification Testing Waiver

Requesting Exemptions: Anyone requesting exemption from the Virginia Office of EMS written recertification test needs to notify the TJEMS Training Specialist (BLS)/ UVa Prehospital Coordinators (ALS) at least ninety (90) days in advance of their expiration date (as listed on their certification card). This allows for completion of the necessary forms, verification of Continuing Education hours, notification and signature of the Operational Medical Director and delivery of the Virginia EMS Certification Application to the Office of EMS before the provider’s expiration date.

To be considered for exemption, providers must meet the following criteria:

Be a member of a licensed EMS agencyComplete all required hours for their level of certification (This may be completed by attending monthly continuing education classes or successful completion of a refresher course).Received an Eligibility Letter from the Office of EMS.Completed all required TJEMS/UVa Prehospital Program “Skills Drills” held during their certification period.Regularly attend monthly BLS/ALS continuing education classes.Have been in “good standing” during their certification period (suspensions of clinical privileges, corrective actions, etc.).Provide a current CPR certification with a completed application (OEMS approved courses). Effective April 1, 2003.

The provider’s Operational Medical Director has the final disposition on exemption from testing.

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Refusals and Documentation

Anytime a patient refuses treatment and transport, an EMS informed consent to refuse statement should be attained. PPCR’s (prehospital patient care report) that do not have the “Informed Consent to Refuse” standardized will have to write the refusal out on the PPCR and then have the patient sign. The Virginia OEMS PPCR has the standardized format on the back of the original copy. Please make sure you are documenting refusals properly, this includes any procedures deemed necessary by the attendant-in-charge (AIC) but refused by the patient, (i.e., spinal immobilization, intravenous cannulation, etc.). Any refusal of treatment and/or transportation by or for a pediatric patient (under 4 years of age) or any ALS complaint patient must have Medical Control consultation.

Refusals you are writing out must include the following:Decision made is of sound mind and not under the impairment of any alcohol or substance, and/or disease processBeen informed of potential need for further evaluationFurther medical diagnostic test (x-ray, lab, etc.)Further injury/illness care or managementFurther medical evaluation by a health care professionalOther: ______________________________________________________________

ANDBeen informed of the potential risks associated with the refusal of servicePotential risk associated may include, but not limited to:Undiagnosed injury or illnessImproper healing of injuryWorsening of injury or illness with or without changing signs or symptomsSubsequent changes in condition including unconsciousness (coma) shock or deathOther: _______________________________________________________

ANDUnderstand this refusal in no way reduces my ability to recall EMS services in the future.Witness signatures for patient refusals may be a by-stander, law enforcement, family member, etc. The use of response personnel as witnesses to refusals should be avoided.

Emergency Custody Orders (ECO)

A person who is:

1. Mentally ill, and 2. In need of hospitalization. And 3. Who is incapable of volunteering or unwilling to volunteer for treatment, and is either:An imminent danger to his or her self or others as a result of mental illness, or Is so seriously mentally ill as to be substantially unable to care for his or her self

Meets the criteria to be taken into emergency custody by law enforcement and transported for evaluation by a designee of a Community Services Board to determine the need for involuntary hospitalization.

Alcoholism and drug abuse may be considered mental illness for the purposes of determining whether or not a person meets the criteria.

An ECO will generally not be issued for a person that you believe is in need of medical treatment but is refusing care, and will certainly not even be considered unless there is an immediate threat to the persons life. However, a law enforcement officer that has taken a person into custody may seek medical evaluation and treatment of the person if necessary.

A person meeting the criteria may be taken into emergency custody in two ways:

A law enforcement officer may take the person into custody without an order being issued by a magistrate, and may transport the person for evaluation, or

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Refusals and Documentation (continued)

An Emergency Custody Order may be issued by a magistrate on the sworn petition of “any person” if he finds the person to be detained meets the criteria set out above, and law enforcement will serve that order. However, not all magistrates will issue such an order for anyone other than an employee of the Community Services Board, like Region Ten. Not all magistrates will issue an order for someone other than the Community Services Board if law enforcement is present but has declined to take the person into custody.

There are many variables involved in this process. The fastest way for a person that meets the criteria to be taken into custody is to have a law enforcement officer take them into custody. However, because that requires the officer to be tied up for up to four hours, and not all officers may agree that the person meets the criteria, you should attempt to call the on-call person from the Community Services Board and have them decide whether or not to seek an order from the magistrate.

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Regional Ambulance Restocking AgreementJanuary 3, 2002 is the effective date for the Medicare and State Health Care Programs: Fraud and Abuse; Ambulance Replenishing Safe Harbor Under the Anti-Kickback Statute (42 CFR Part 1001), otherwise referred to as the Ambulance Restocking Arrangements, Final Safe Harbor Conditions. The following outlines the regional process for those facilities within the Thomas Jefferson EMS Council region:

Hospitals will restock all ambulance providers who transport patients to their facility from the following category: all non-profit and governmental providers.The restocking will include all medications, medical supplies and linen on a one-for-one basis used by ambulance providers in the treatment of the arriving patient. This includes the exchanging of opened or expired drug boxes from all agencies (for-profit or non-profit) that participate in the Thomas Jefferson EMS Council regional drug box program.

There are no charges created to the patient by the ambulance provider for the use of the afore mentioned supplies and medications.

There are no charges generated to the ambulance providers for the restocking of the supplies as detailed in line 2 by the receiving facility.

Restocking of the ambulance provider pertains to both emergent and non-emergent transports.

All medications and supplies used by the ambulance provider will be documented on the agency “call report” and a copy provided to the receiving hospital. Minimum information includes the patient’s name, date of service (transport) and pertinent medications and/or supplies exchanged.

All ambulance providers within the Thomas Jefferson EMS Council must comply with all applicable Federal and state rules and regulations.

For further information regarding the Regional Ambulance Restocking Agreement or to obtain additional copies, please contact the Thomas Jefferson Regional EMS Council at (434) 295-6146.

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Regional Course TrackingThe following notification process has been developed to enable the TJEMS Council, the Operational Medical Director’s, the Clinical Practice and Education Committee and the agencies within the TJEMS region to:

1. Better track available training classes,2. Identify and complete any major breaks in a provider’s continuing education,3. Assist providers in obtaining additional continuing education hours and relevant EMS training (i.e., EVOC, Hazardous Materials, etc.)

All open courses announced to the Office of EMS (OEMS) are to have notification to the TJEMS office prior to the start of the program (thirty days).

Technical programs that do not have OEMS certification credit should also be announced to the TJEMS office prior to the start date (thirty days).

This process includes all career and volunteer agencies within the region as well as those program taught by non-regional instructors (outside vendors for service).

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Regional EMT-Instructor Network and Regional Evaluators

The Virginia Office of EMS requires an established EMT-Instructor Network for each regional Council. This process allows at least one venue where EMT-instructors and regional Council staff and Consolidated Test Site staff can meet to review challenges and issues unique to the region as well as offer suggestions to be forwarded to OEMS for consideration. These meetings also allow review and revision to the planned and future test sites based on proposed EMT and ALS courses for the region. In the past, the evaluators for the test sites have had independent sessions (normally not scheduled) from the instructors.

The Regional EMS Office will maintain a database of all regional EMT Instructors and test site evaluators to include those instructors not from the TJEMS region, but who routinely teach courses for agencies within the region. The Council will schedule a minimum of two (2) EMT-Instructor and Regional Evaluators meetings for the calendar year. All OEMS EMT-Instructors who teach within the TJEMS region and approved evaluators are to attend a minimum of one (1) meeting per year. The impetus for this requirement is to share with and among the Regional Council, the OMD’s, the EMT-Instructors and evaluators a consistent information format in order to deliver a quality product for the students and the region.

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Resource Cancellation

Once EMS has established patient contact, only the Attendant-in-Charge (AIC) or scene medical command may cancel additional resources that have been requested for patient care. Anyone not on scene shall not cancel or change the resources that have been requested without specific agreement of the AIC/scene medical command. Additional resources may include helicopters, ALS support and specialty teams.

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Scene Authority For Patient CareScene authority and transition of patient care may occur on several levels within our system. With these protocols, each OMD has agreed to, and assigned each provider with a specific patient care level (EMT-P, EMT-I, EMT-Enhanced, EMT-J, EMT-B). Based on their proven medical knowledge and mastery of practical skills, the senior level patient care provider may assume responsibility of prehospital care. In the event of a multi-agency response (1st Responder agency, transport agency, etc.), the agency assigned with the task of transport shall obtain and maintain the senior level of provider care responding to the incident. If there are concerns regarding the care of the patient, Medical Control shall be consulted.

Patient Care Transfer:

The 1st Responder responsible for patient care will provide a verbal report to the assuming transport provider. Once the report is received, the transport provider assumes patient care responsibilities. The transfer of care shall be noted on the call report and/or by radio communications.The transport provider may request the assistance from the 1st Responder agency for “manpower” for those calls that are resource intensive (cardiac arrests, major illness/injury, etc). Should disagreements arise between the 1st Responder responsible for initial patient care and the receiving transport provider, they should be resolved in a quiet, professional manner prior to transport. If a resolution cannot be reached prior to transport, either Medical Control may be contacted for further resolution or the 1st Responder responsible for initial patient care may be requested to accompany the patient to the receiving facility. Each agency’s OMD (or designee) shall be notified of the incident within twenty-four (24) hours.Once ALS level of care has been initiated (IV therapy, EKG monitoring, medication administration, etc), that same level of care must be maintained until transfer of care to the appropriate receiving facility.

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Skills Drill Requirements – ALS

To assure standards remain consistent and care provided is effective and of the highest quality, the UVa Prehospital Coordinators, on behalf of the Operational Medical Directors for the Thomas Jefferson EMS Council require the following skills drills or equivalent approved by the agency medical director for all regional ALS providers:

• The mandatory skills drills will be held in September/March of each year. The March program is the annual “Mega Code” drill requiring all regional Intermediate and Paramedics to attend.

• ALS providers who fail to complete their skill drill (September) or “Mega Code” (March), and/or the required number of successful IV starts, will have their privileges to practice as an ALS provider suspended until remediation is completed with the UVa Prehospital Coordinator(s) or their designee. The suspension of privileges become effective at the end of the affected month.

• An ALS provider cannot be inactive for more than ninety (90) consecutive days within any twelve (12) month period. Individuals who are inactive for more than 90 days must file for a special review with the UVa Prehospital Coordinator(s) and the agency Operational Medical Director.

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Skills Drill Requirements - BLS

To assure standards remain consistent and care provided is effective and of the highest quality, the Operational Medical Directors for the Thomas Jefferson EMS Council require two-mandatory skills drill or equivalent as approved by the agency OMD be completed by all BLS EMS personnel operating in the region (yearly). The following list those procedures regarding the skills drill:

The mandatory skills drill will be held in April and October of each year.All EMS certified BLS personnel, affiliated with a licensed EMS agency in the region are required to attend the mandatory skills drill.

EMS personnel successfully completing a state test (written and 3 practical stations) in the months of April or October are exempt from the skills drill for the calendar year. Written notification to the TJEMS office, attention Training Specialist, must be completed by June 1 to qualify for the aforementioned exemption.

BLS providers not able to attend a scheduled skills drill in their own community may attend any other skills drill within the region with prior permission from the TJEMS office. Registration is available by phone.

BLS providers unable to attend a scheduled skills drill must make arrangements in advance with the TJEMS staff to schedule a skills session at the TJEMS office. Reasons acceptable for rescheduling include occupational and personal conflicts. Such requests are to be forwarded in writing to the Training Specialist.

BLS providers who do not successfully complete the various stations within the skills drill will have their privileges (Attendant-in-Charge) temporarily suspended until such time remedial training can be completed. The Operational Medical Director determines and approves any remedial training.

BLS providers who miss two (2) consecutive mandatory skills drill automatically have their privileges-to-practice (Attendant-in-Charge) suspended until such time remediation has been completed as directed by the Operational Medical Director. The Operational Medical Director or their designee may complete remediation.Failure to attend mandatory skills drills will nullify any waiver from written recertification testing. In addition, the BLS provider in question will be required to successfully complete practical skills evaluation.

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Termination of Resuscitative Efforts in the FieldUnless special circumstances exist, patients who are victims of cardiac arrest, either traumatic or non-traumatic, may be candidates for resuscitative efforts to be withheld or terminated in the field in certain situations.

A 1999 National Association of EMS Physicians position paper recommends that termination of resuscitation be considered if the adult non-traumatic out-of-hospital cardiac arrest patient receives cardiopulmonary resuscitation, definitive airway management, intravenous access, and at least 20 minutes of resuscitative efforts, yet remains in asystole or pulseless electrical activity with no return of spontaneous circulation in the field. This would include patients attended by BLS providers who have had no shocks recommended by an AED or when 20 minutes or greater has elapsed since the last shock recommendation. Patients who have continued or recurrent ventricular tachycardia, ventricular fibrillation, or continued “shock” recommendations by an AED are candidates for continued resuscitative efforts. Any patient who exhibits return of spontaneous circulation is a candidate for continued resuscitative efforts and transport.

Victims of traumatic cardiac arrest (blunt or penetrating) may have resuscitative efforts withheld if they are found to be pulseless and apneic, without signs of life including pupillary reflexes, spontaneous movement (including respiratory efforts), or organized ECG activity. Any patient who has return of signs of life, including organized ECG activity, should have resuscitative efforts continued and be transported to a trauma center. Termination of efforts should be considered in patients who suffer an EMS witnessed arrest and have not responded to 15 minutes of resuscitative efforts, or in who total transport time to an appropriate trauma center is more than 15 minutes from the time of arrest.

Once resuscitative efforts have been initiated, termination of those efforts must be discussed with on-line medical command. Special circumstances may exist that might modify recommendations for transport, particularly hypothermia and drowning. These recommendations do not apply to infants and children, who are frequently candidates for continued resuscitative efforts, and who should have resuscitative efforts initiated unless they exhibit obvious signs of death such as cooling, rigor, and dependent lividity.

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Transfer of Care to Provider of Lesser Certification

• The provider with the highest level of certification on the scene should conduct physical exam and patient assessment to determine chief complaint and level of distress.

• If it is determined that the patient is stable and all patient care needs can be managed by the lower level provider, patient care can be transferred to a provider of lower certification for transport.

• All personnel on scene are encouraged to participate in patient care while on scene regardless of who “attends” the patient while en route to hospital.

• Determination of the attendant in charge should be based upon the patient’s immediate treatment needs and any reasonably anticipated treatment needs en route to the hospital.

• Both the transporting provider and the provider who transferred care must write a narrative documentation that covers all aspects of assessment, care, and disposition. This can be done on one PPCR.

Patients who do not meet this policy criteria include:• Post ictal seizure patients • Patients who have been medicated may only be transferred to a provider of lower

certification whose scope of practice includes the medications that were administered.• Chest pain of suspected cardiac origin• Moderate to severe respiratory distress• Hypertensive crisis• Multisystem trauma• Imminent childbirth• Any patient in which transport would be delayed waiting for a unit with lesser certification

to arrive.• Any patient for which all EMS providers on scene do not agree can be safely transported

under care of provider with lower level of certification

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Treatment for Patients Under Age 18Persons Subject to this Policy: This Policy applies to persons under the age of 18 (except those that have an Order of Emancipation from a Juvenile and Domestics Relations District Court) who are in need of medical or surgical treatment, including such person who report being sick or injured; who have obvious injury; and/or have a significant mechanism of injury which suggests the need for medical evaluation.

Authority of Parents, Guardians or Others: Parents have the authority to direct or refuse to allow treatment of their children. A court appointed guardian, and any adult person standing in loco parentis, also has the same authority. “In loco parentis” is defined as “[I]n the place of a parent; instead of a parent; charged, fictitiously, with a parent’s rights, duties, and responsibilities.” Black’s Law Dictionary, 708 (5th ed. 1979). 1987-88 Va. Op. Atty. Gen. 617 “Furthermore, I would point out that §54-325.2(6) allows any person standing “in locos parentis” to consent to medical treatment for a minor child. This signifies, in my judgment, an intent to allow any responsible adult person, who acts in the place of a parent, to consent to the treatment of a minor child, particularly in emergency situations.” 1983-84 VA. Op. Atty. Gen. 219. Such a person may be a relative, schoolteacher or principle, school bus driver, baby-sitter, neighbor, or other adult person in whose care of the child has been entrusted.

Persons Subject to Policy with Altered Mental Status: A person meeting the criteria of paragraph 1 that is unconscious, has an altered mental status, signs of alcohol or substance abuse or head injury shall be treated under implied consent and transported, unless a parent or guardian advises otherwise. Medical control must be consulted if a parent or guardian or person in loco parentis refuses to allow treatment or transport.

Persons Subject to Policy Under Age 14: A person meeting the criteria of paragraph 1 that is under the age of 14 shall be treated and transported unless a parent or guardian or person in locos parentis advises otherwise. Do not delay treatment or transport for extended periods simply trying to contact a parent or guardian. If you believe that treatment is necessary, but the parent or guardian or person in locos parentis refuses to allow treatment, medical control should be consulted.

Persons Subject to Policy Aged 14-18: A person meeting the criteria of paragraph 1 who is between the ages of 14 and 18 may refuse treatment and transport, unless a parent or guardian or person in locos parentis advises otherwise. If you believe that treatment is necessary, but the person refuses, an attempt should be made to contact a parent or guardian, and medical control should be consulted. If you believe that treatment is necessary, but the parent or guardian or person in locos parentis refuses to allow treatment, medical control should be consulted.Persons Subject to Policy Married or Previously Married: A person meeting the criteria of paragraph 1 who is, or has been married, shall be deemed an adult for purposes of consenting or refusing medical treatment. Code of Virginia § 54.1-2969.

Persons Subject to Policy that are Pregnant: A person subject to this policy that is pregnant shall be deemed an adult for the sole purpose of giving consent for herself and her child to medical treatment relating to the delivery of her child; thereafter, the minor mother of such child shall be also be deemed an adult for the purpose of giving consent to medical treatment for her child. Code of Virginia § 54.1-2969.

Pediatric Non-Transport: All pediatric patients under four (4) years of age who are not going to be transported after 911 access has been made will need to consult with Medical Control via UVa MedCom (434) 924-9287. Document all pertinent information including physician’s name involved with the consultation.

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Procedure Section sponsored by

the Department of Community Relations, Outreach, and Service

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AED Utilization Form

In the event a Thomas Jefferson Regional EMS agency provider utilizes their Automated External Defibrillator (AED) either as a stand-alone or combination unit, a TJEMS & UVa Prehospital Defibrillation Report Form” shall be completed and forwarded to the Thomas Jefferson EMS Council (if patient not transported to hospital) or left in the UVa Prehospital/TJEMS receiving bins at UVa Hospital. The importance of prompt quality management demands these forms to be completed immediately after the release of patient care or within forty-eight (48) hours of the AED use. Included with the forms shall be the “Code Summary” report (either hard copy or electronic version).

Agency: _____________________________ Unit #: ____________ Date: ____/____/ ____

Date of Call ___/___/___ Defibrillation Tech: _____________________________Call Received: __________ Defibrillation Tech: _____________________________Dispatched: __________ Other: _____________________________Responding: __________ Other: _____________________________Arrival (scene): __________ Departure: __________ Miles to scene: ____________Hospital Arrival: __________ Miles to hospital : ____________

Dispatched For: _________________________ Pt. turned over to: ________________________

Patient’s Age: ________ Gender: Male _____ Female _________

Ethnicity: Caucasian ___ Hispanic _____ African-American ____ Asian _____ Other __________

Probable Cause of Arrest: Cardiac ____ Trauma ____ Unknown _____ Other _____________

Incident Location: Home □ Work □ Nursing Care Facility □ Public Place □ Sporting Event □ Recreational Area □ Public Street □ Vehicle Non-trauma □ Vehicle Trauma □ Other: ____________________________________________________

Witnessed Arrest: Yes □ No □ Estimated Down Time: ____________________CPR Prior to AED Arrival: Yes □ No □ Estimated CPR Time: _____________________Who Performed CPR: Citizen ___ Law Enforcement ___ Fire ___ Security ___ Health Care Staff ____ First Responders ___ Other: ____________________________________________________

PLEASE COMPLETE SEQUENCE OF EVENTS

Defibrillation Analysis Time: _______________ Pulse CPRSeq. #1 ___ Shock Advised Yes No Yes ________min ___ No Shock Advised

Seq. #2 ___ Shock Advised Yes No Yes ________min ___ No Shock Advised


Pulse Present: Yes No

CPR __________minutes BLS Load-n-go ______ ALS Arrival: _______________

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AED Utilization Form (continued)

Thomas Jefferson EMS & UVa Prehospital ProgramDefibrillation Report Form

Pulse CPRSeq. #4 ___ Shock Advised Yes No Yes ________min ___ No Shock Advised



Pulse Present: Yes No

CPR __________minutes BLS Load-n-go _______ ALS Arrival: _______________

Patient Transported: UVa □ MJH □ Funeral Home □ Morgue □ Other: ____________________________________________________

Defibrillator Model: LP 300 □ LP 500 □ Zoll 1600 □ Agilent □ Other: ____________________________________________________

Did patient resume spontaneous breathing: Yes □ No □

Was Medical Direction Advisory needed? Yes □ No □Reason: ______________________________________________________________________

Any problems encountered? Yes □ No □If yes, explain: _________________________________________________________________

Type of Airway adjunct used: OPA/NPA □ BVM □ Combitube □ Other: _______

Signature of Defibrillation Tech(s): _________________________________________________ __________________________________________________

Name of Medical Direction Physician: _______________________________________________

Follow-up requested: Yes □ No □

P.ease place in EMS Box located in MEDCOM

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Accessing Central Venous LinesCentral venous catheters encountered in the field commonly include dialysis catheters, Porta-Caths, Hickman or Groshong style central lines, and PICC lines (peripherally inserted central catheters). These devices are used in patients who require regular central venous access for medication administration, blood sampling, or hemodialysis, or who have had repeated difficulties with venous access. They typically involve a surgical procedure to place the line and, particularly in patients with chronic illnesses, may have been placed because there is no longer any available peripheral venous access. Many patients have had significant complications with their indwelling lines including infections, multiple line placements, and clot formation either in the catheter or in the central venous system. In these patients, their central line represents a particularly valuable and sometimes fragile component of their care. In addition, some catheters such as large bore dialysis catheters are “blocked” with heparin (as much as 10,000 units per lumen) and inadvertent administration of the heparin could cause dangerous hemorrhagic complications. Proper technique in accessing the lines is important to avoid damage to the line and to avoid complications such as contamination and infection of the line.

Central lines of any sort should only be accessed in the field by providers who are familiar with their use; training in the use of central lines is not a component of current ALS curricula but in some cases may have been provided as part of supplemental training. There is no “blanket” approval for the use of central venous lines at any pre-hospital certification level. Central venous lines should only be used in the case of the need for emergency medication administration, such as resuscitation drugs in a cardiac or near cardiac arrest situation. They are not to be accessed for fluid administration or adjunctive drug therapy (e.g. corticosteroids, pain medications, sedatives). Outside of a cardiac arrest situation, their use is “medical command” only from on-line medical command.

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Allergic Reaction Report

In the event a Thomas Jefferson Regional EMS agency provider utilizes the Ana-Kit, a “Thomas Jefferson EMS Council, UVa Prehospital Allergic Reaction Report Form” shall be completed and forwarded to the Thomas Jefferson EMS Council (if patient not transported to hospital) or left in the UVa Prehospital/TJEMS receiving bins at UVa Hospital. The importance of prompt quality management demands these forms to be completed immediately after the release of patient care or within forty-eight hours (48) of the Ana-Kit use.

Allergic Reaction Report

Thomas Jefferson EMS & UVa Prehospital ProgramAllergic Reaction Report

Agency: _______________________________ Unit #: _____________ Date: ____/____/_____

Patient’s Age: __________ Gender: Male _____ Female _________

Suspected Allergen: Bee Sting ___ Chocolate ___ Seafood ___ Pollen ___ Nuts ___ Other: _____________________________

Time from exposure to 1st symptoms: _______________________Time from exposure to 1st epinephrine injection: _______________ 1st dosage: _____mgGiven by: ___________________________ Level: EMT ST CT PM Park Medic

Medication administration: Before After Medical CommandMedication administration: Before After Ambulance Arrival

Epinephrine obtained from: Patient Yourself Ambulance Other: ____________________Epinephrine came in: Ana-kit Prehospital Program Kit Regional Drug Box Epi-Pen

Initial Signs and SymptomsB/P: ________ Pulse: _______ Respirations: _________ Level of Consciousness: _________Breath Sounds: Clear Wheezing Shallow Labored AbsentSkin: Normal Ashen Cool Cold Clammy Cyanotic Flushed Red Hot Dry DiaphoreticSwelling (edema): Face Lips Eyes Hands Feet All Over NoneRash (urticaria): Face Chest Extremities All Over None

10 Minutes Post Medication AdministrationB/P: ________ Pulse: _______ Respirations: _________ Level of Consciousness: _________Breath Sounds: Improved No Change WorseSwelling: Improved No Change WorseRash: Improved No Change Worse

Was 2nd dose of epinephrine administered? Yes No If Yes; _________mgIf so, time from last dose: ________________Other drugs administered? Yes No Drugs: _________________________________

Patient Disposition: Transported Non-Transport Local MD

Please place in EMS Box located in MEDCOM

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CapnographyCapnography should be used when available on all endotracheal or King airways. It may also be used with spontaneously breathing patients whose respiratory status may be further evaluated with the use of side-stream capnography.

Procedure:1. Attach capnography sensor to King airway, endotracheal tube, nebulizer, or oxygen delivery device.2. Note CO2 level and waveform changes.3. The capnometer shall remain in place and be monitored throughout transport.4. Documentation of initial reading and reading at the time of transfer of care should be recorded. Both strips should be attached to regional airway form. Attaching a copy of the strips to the PPCR is also recommended.

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Cardiopulmonary ResuscitationIndications: A patient who is pulseless and apneic

Procedure:1. Compressions should be performed at a ratio of 30:2 with the following exceptions:

a. Two rescuer CPR on child or infant (15:2)b. After an advanced airway has been placed, compressions should be continuous

at a rate >100 and ventilations should occur asynchronously with one breath delivered over 1 second

2. Ventilations should be given over 1 second with enough volume to cause the chest to begin rising (avoid over ventilating with both rate and volume of air).

3. Allow full chest recoil between compressions.

4. Provider performing compressions should be rotated every 2 minutes.

5. Pulse and rhythm checks should only be performed every 2 minutes (5 cycles CPR) with minimal time off the chest (less than 10 seconds).

6. Chest compressions should continue while the defibrillator is charging. Use extreme caution to ensure the patient is cleared prior to defibrillation.

7. Adequacy of CPR can be assessed by palpating femoral pulse while compressions are performed and assessing improved perfusion of the patient.

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Cardioversion

Indications:• Unstable patient with rapid atrial fibrillation, supraventricular tachycardia, or ventricular

tachycardia with pulse.

Procedure:1. Ensure patient is properly attached to monitor/defibrillator.2. Set energy selection to appropriate setting per manufacturer recommendations.3. Set monitor to synch mode.4. Charge the device.5. Ensure the patient is clear of all personnel.6. Press and hold the button to cardiovert. Stay clear until energy has been

delivered (there may be a delay from the time the shock button is pushed until the energy is delivered).

7. Note response and perform immediate defibrillation if indicated.8. If patient’s condition is unchanged, repeat using escalating energy until

maximum setting or the rhythm stabilizes.9. Document procedure, response, time, and energy settings on PPCR.

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CISM Activation ProcedureRequest or Notification:Field personnel contact Charlottesville Fire Department: (434) 980-3240. Ask for the Officer in Charge indicating that they have a CISM request.

OrField personnel contact Charlottesville Emergency Communications Center: (434) 977-9041, ask for the Shift Supervisor and advise them they have a CISM request.

CFD/ECC notifies CISM for one of the following:Pediatric trauma resulting in deathLine of duty death or severe injury of squad member, firefighter or police officerSuicide or unexpected death of squad member, firefighter or police officerAn accident involving an ambulance, fire apparatus or police vehicle resulting in injuryMass casualty incidentProlonged events > 90 minutesAny event in which a dispatcher or officer has concerns for the mental health of providersAny person calling and requesting CISM services

Obtaining Information:CFD/ECC will obtain the following information to be given to the CISM investigator for a confirmed request: (defusing, debriefing or on-scene)

Name of person to callAgency namePhone number(s) w/area code(s) to call the individual backTell them a CISM investigator will call them back within 30 – 45 minutes

If CFD/ECC is just notifying about an incident without an actual request or message of a potential defusing, debriefing or on-scene request, the information can be snap-paged to a CISM Coordinator. See 5.0

Notification Procedure:CFD/ECC alerts the CISM Coordinator or one of the investigators on the call down list. (Note – First three (3) can be group paged on snap if preferred). See 5.0Coordinator should return page within 15 minutes. If not, Re-page the Coordinator. If no response again after 10 minutes, Group Page CISM or page in order down the call list (See 5.0)Once an investigator has answered the page, CFD will give the information obtained in section 2.1 or 2.2.

Other Information:The CISM Coordinator will notify CFD/ECC of any on call changes or changes to the notification procedure via telephone and/or memo.In case of some strange or unusual circumstances where CFD/ECC was unable to reach the first three investigators, and investigators #5.4, 5.5, and 5.6 were unable to be reached – call the Clinical Coordinator:Clinical Coordinator – Christy Miller H – (434) 296-5439 P – (434) 923-7009 Cell

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Continuous Positive Airway Pressure (CPAP) ProcedureContinuous positive airway pressure (CPAP) is a treatment modality that is used in conjunction with medical therapy in the management of pulmonary edema. Pulmonary edema most frequently occurs due to cardiac causes (congestive heart failure), although it can also occur from non-cardiac causes such as near drowning and fluid overload from renal failure. CPAP maintains a positive pressure in the respiratory system throughout the respiratory cycle and can reduce the work of breathing and improve oxygenation in patients with pulmonary edema. This protocol has been developed for use with the s Whisperflow CPAP system, but the general principles apply to any CPAP system. CPAP is a non-invasive therapy that can be used by both ALS and BLS providers

Indications for CPAP: Pulmonary edema due to CHF, fluid overload, or near-drowning Hypoxia – pulse oximetry less than 90% Significant respiratory distress including use of accessory muscles and retractions Associated signs of CHF including edema of the legs, neck vein distention, and rales/ wheezing on chest examination

Contraindications for CPAP include: Lack of spontaneous respiration Unconsciousness Inability to maintain an open airway Pneumothorax Significant trauma to the face or chest Hypotension (systolic BP < 90) Uncontrolled vomiting

Procedure for applying CPAP in the field using the WhisperFlow device: (these procedures may need to be modified for other devices per manufacturer recommendations)1. Attach the CPAP generator to an oxygen source capable of providing 50 psi (portable O2 bottle or wall mounted adaptor, not low flow regulator).2. Attach air filter to the generator3. Attach patient circuit tubing to the generator and to the patient mask.4. Attach pressure valve to the patient mask5. Attach head straps to the patient mask6. Allow the patient to hold the mask over their face in order to feel the fit of the mask and become accustomed to the gas flow from the generator.7. Once the patient has become accustomed to the mask, extend the head straps around the patient’s head and adjust for a snug fit, adjust if leaks around the mask are identified.

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Monitor patient’s vital signs:If the patient is unable to tolerate the CPAP mask, therapy may need to be discontinued and high flow oxygen therapy re-instituted.

The CPAP mask must be removed if the patient begins vomiting, and not reapplied until vomiting is controlled.

If the patient’s condition deteriorates to the point they lose consciousness or they lose the ability to maintain their posture and the seal of the mask, then CPAP will need to be discontinued and BVM assistance of respiration initiated.

If the patient’s blood pressure drops below 90 systolic, discontinue CPAP therapy.

If the patient has adapted to using the CPAP mask and the system is operating properly, and oxygen saturations remain less than 90%, increase the inspired oxygen concentration by attaching standard oxygen tubing to the port just below the pressure valve adapter and add oxygen using the low pressure oxygen regulator – begin at flow rates of 2 L/minute and increase by 2 L/minute until saturations improve to 90% or better.

If the patient does not seem to be responding to CPAP:

Double check connections from the oxygen source to the generator and from the generator to the patient circuit.

Make sure that your oxygen source has adequate reserve to power the generator – gas flow to the patient is dependent on the high pressure flow (50 psi) from the oxygen source to the generator.

CPAP requires a closed system to maintain positive pressures, so check for leaks around the mask and the connections.

Inform the receiving hospital that CPAP therapy has been initiated so that a CPAP generator can be made available when the patient reaches the emergency department.

The corrugated patient circuit tubing, the mask and head straps, and the pressure valve are single patient use only.

The air filter may be re-used unless it becomes contaminated or is visibly dirty and then it should be replaced with a clean filter.

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Drug Box ContaminationProcedures for cleaning rescue squad drug boxes that are contaminated with VRE, GRE, and

MRSA.

1. Contamination is defined as known or suspected exposure to blood or body fluid.

2. In order to avoid contamination of the drug box, ensure that the contents of the drug box must only be touched by ‘clean’ hands. If a gloved worker just touched a patient, they would have to remove the gloves, cleanse their hands, handle the drugs, then put gloves back on. Or the other worker could be considered ‘clean’ and not touch anything dirty and be responsible for handling the drugs.

3. If at any time contamination is suspected, proceed with the following decontamination procedure.

4. Two providers will be needed. First provider holds clean basin (obtain from ED staff). Be sure that clean basin is not placed on any contaminated surface. Second provider wears

gloves and empties all drugs in plastic bags into clean basin. All drugs that are not in plastic bags will be discarded into Contaminated Materials Boxes.

5. Empty drug box, along with contaminated surfaces in ambulance, will be sprayed with

Sanimaster III and left wet for 10 minutes. Don’t forget bottom of drug box. Drug box and ambulance surfaces can be dried after 10 minutes.

6. Rewrite ambulance report form on a clean form. ADD: “Drug box has been decontaminated.

Drugs not in plastic bags have been placed in CMC box and drugs in plastic bags have been returned in clean basin.”

7. If narcotics were not in plastic bags or have been contaminated, waste the drugs in the

presence of the shift manager and have shift manager sign as witness.

8. Bring clean drug box, rewritten call sheet (signed by M.D.) and basin of clean drugs to pharmacy for drug box exchange.

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Endotracheal Tube Introducer (Bougie) Guideline

The bougie, often called a gum elastic bougie (GEB), is a long, flexible stylet which is introduced through the glottic opening before the ETT, whether visualization of the vocal cords can be achieved or not. The distal end is curved upward, and there are markings at 10 cm intervals to measure ETT insertion depth. This shape and size of the GEB are designed to be easier to place in the trachea than the ETT when faced with a difficult airway. The following guideline is meant to facilitate the use of this highly efficient and easy-to-use difficult airway tool.

Indications:1. Unsuccessful intubation attempts2. Predicted difficult intubation

Contraindications:1. Age less than eight (8)2. ETT size less than 6.5 mm

Procedure:1. Select proper ETT without stylet, test the cuff and prepare suction.2. Lubricate the distal end and cuff of the ETT and the distal ½ of the bougie (note:

Failure to lubricate the Bougie and the ETT may result in failure)3. Visualize the vocal cords using laryngoscopy and introduce the bougie with

curved tip anteriorly. The tip should be seen passing through the vocal cords or above the arytenoids if the cords cannot be visualized.

4. Once inserted, gently advance the bougie until you meet resistance (“hold-up”) or movement of the tip on the tracheal rings (“washboard”). If resistance is not met and/or tracheal rings are not felt then a probable esophageal intubation has occurred and insertion should be attempted again.

5. Once the tip has been properly placed, a second provider should be used to load the ETT and hold proximal control of the bougie to keep it in the trachea while the operator is still holding laryngoscopic pressure.

6. Gently advance the bougie and loaded ETT until you feel hold-up or tracheal rings again, thereby assuring proper placement.

7. While maintaining a firm grasp on the proximal bougie, slide the ETT over the bougie to the appropriate depth.

8. If you are unable to advance the ETT into the trachea and the bougie and ETT are adequately lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER-clockwise to turn the bevel of the ETT posteriorly. If this technique fails, direct laryngoscopy while advancing the ETT might be necessary (this will require an assistant to maintain the position of the bougie and advance the ETT)

9. Once the ETT is correctly placed, hold it securely and remove the bougie.10.Confirm tracheal placement with all pertinent methods, secure tube, and

reassess frequently.

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External Jugular CannulationIndications:

• Critically ill patient who is > 12 years of age and requires IV access for fluid or medication administration when an extremity cannulation is not possible.

• Can be attempted initially in life threatening situations where no obvious peripheral site is noted.

• Consider intraosseous insertion as a viable alternative.

Procedure1. Use personal protective equipment.2. Gather all necessary equipment. Attach extension tubing when possible.3. Place the patient in a supine, head down position. This helps distend the vein and

decreases the chance for air embolism.4. Turn the patient’s head toward the opposite site of insertion site if no risk of cervical

injury exists.5. Prep the site as per the peripheral IV.6. Align the catheter with the vein and aim toward the same side shoulder.7. “Tourniqueting” the vein lightly with one finger above the clavicle, puncture the vein

midway between the angle of the jaw and the clavicle to cannulate the vein in the usual method.

8. Attach the IV and secure the catheter avoiding circumferential dressing or taping. 9. Label with “field”, date, and initials of person performing procedure.10.Set proper flow rate.11.Use caution to not inadvertently pull out the line.12.Document procedure, time, type of fluid, flow rate, total infusion at the time of transfer,

provider who performed procedure, and response to treatment.

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Immobilization Decision Matrix

Standard Trauma Evaluation Includes patients 18 years and older

LOW RISK Mechanism of Injury?

YES NO

Reliable Patient History/Examination? IMMOBILIZE alert and oriented not intoxicated no psychological/psychiatric no head injury (includes LOC)

no distracting injuries able to communicate adequately

YES NO

Spine Pain or Tenderness? IMMOBILIZE

palpate entire axial spine

may need to log roll

NO YES

IMMOBILIZE

Normal Sensory/Motor Exam? ability to move symmetrical movement of all extremities assess light touch

Normal Abnormal

Consider NO Immobilization* IMMOBILIZE

* Document "Backboard Protocol followed"

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Impedance Threshold DeviceThe ResQPOD® is an impedance threshold device that prevents air from entering the chest during the decompression phase of CPR. When air is prevented from rushing into the lungs as the chest wall recoils, the vacuum (negative pressure) in the thorax pulls more blood back to the heart, resulting in a doubling of blood flow to the heart and brain.

Indication Cardiopulmonary arrest in patients 12 years or older

Contraindications Traumatic Cardiopulmonary arrest

Patients under 12 years of age

ProcedureA. Confirm absence of pulse and begin CPR immediately. Assure that chest wall

recoils completely after each compression.B. Using the ResQPOD on a facemask:

1. Connect ResQPOD to the facemask.2. Connect ventilation source (BVM) to top of ResQPOD. 3. Establish and maintain a tight face seal with mask throughout

chest compressions. Use a two-handed technique or head strap.4. Do not use the ResQPOD’s timing lights during CPR utilizing a facemask

for ventilation.5. Follow the appropriate ACLS algorithm.6. Prepare for endotracheal intubation when clinically feasible and

appropriate.C. Using the ResQPOD on an endotracheal tube, Combitube or King

Airway:1. Endotracheal intubation is the preferred method of managing the airway

when using the ResQPOD.2. Place advanced airway, confirm placement, and secure the tube.3. Move the ResQPOD from the facemask to the advanced airway and turn

on timing assist lights (remove clear tab).4. Continue CPR with minimal interruptions:

a. Provide continuous (no pauses) chest compressions (approximately 10 per light flash) and ventilate asynchronously over 1 second when light flashes (10/min).

5. Perform ACLS interventions as appropriate.6. If perfusion is restored, remove the ResQPOD and assist ventilations as

needed.

Special Considerations Do not delay chest compressions if the ResQPOD is not readily available.

The two minute cycles of CPR should not be interrupted. If at an assessment interval the patient has a change in ECG and a palpable pulse, discontinue use of the ResQPod. If the patient re-arrests, resume CPR with the ResQPOD.

Always place ETCO2 detector between the ResQPOD and the ventilation source.

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INTRAOSSEOUS INSERTION, B.I.G™ Bone Injector GunINDICATIONS: The B.I.G™ is approved for patients greater than 12 years of age. The pediatric B.I.G™ is approved for patients 12 years of age or younger. Placement is indicated when a patient is in or approaching extremis and either intravascular fluid resuscitation or medications are essential to resuscitation efforts, but traditional vascular access techniques are not possible or require multiple or prolonged attempts. Such patients should undergo two RAPID IV attempts prior to utilizing the B.I.G™ system.

Appropriate Patient Examples (not all inclusive): near arrest, status epilepticus (no response to IM versed), patients in profound shock with or without altered level of consciousness, severe burns, cardiac arrest; post resuscitation; profoundly hypoglycemic patients with no response to glucagon after 5-10 minutes.

Patients who are NOT appropriate candidates: unconscious but without significant trauma or hemodynamic instability; seizure.

CONTRAINDICATIONS: Fracture of the bone you intend to place the IO in (tibia)Previous orthopedic procedures (i.e. knee replacement) in the area of intended insertion (as indicated by a large scar)The extremity is compromised by a pre-existing condition (i.e. tumor) Skin infection at the insertion site (i.e. redness, skin lesions)Inability to locate landmarksExcessive tissue over the insertion site.

If any of these contraindications are noted, check another extremity for possible insertion.

EQUIPMENT:Appropriate B.I.G™ for patient size (pediatric B.I.G™ is red). 10ml syringeAlcohol or Chlorhexidine swabsExtension setIV Fluid, Tape or GauzePressure bag and/or bolus fluid administration setup

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PROCEDURE:1. Observe BSI precautions and aseptic techniques2. Locate the proper site for B.I.G™ use (tibia only for adult and pediatric patients)3. Clean the insertion site thoroughly using alcohol or Chlorhexidine for at least a 3” diameter around the site.4. Adjust the penetration depth.5. Insert the IO cannula using the B.I.G™ 6. Attach a 10 cc syringe and attempt to aspirate marrow (no aspirate alone does not indicate improper placement)7. Flush the IO with 10cc’s NS8. Confirm placement with one or more of the following criteria:

• Firm 90 degree position• Blood at the tip of the stylet• Aspiration of marrow• The device flushes easily and fluids flow freely without subcutaneous swelling or fluid leakage.

13. Attach the infusion, secure and stabilize the catheter to the insertion site.14. Monitor for any change in placement and remove as necessary.15. Assure that you can fully visualize the area of insertion so that you can fully assess. 16. Ongoing assessment should include frequent palpation and inspection of the placement site both anteriorly and posteriorly to assure there is no infiltration or extravasation of fluid.17. Due to the anatomy of the IO space, flow rates may be slower compared with normal IV catheters. Use a pressure bag for rapid infusions, or administer by slow bolus via syringe. PEDIATRICS: administration should be by syringe bolus only.18. Apply wristband to patient to identify that an IO has been placed (optional).19. Document use of B.I.G™ on PPCR with indication and placement confirmation method per #8.20. For pain with fluid administration, administer 2% lidocaine (preservative free) 20- 40 mg for adults, 0.5 mg/kg for children. Use extreme dosage precautions to avoid medication error.

REMOVALIf there is indication of improperly placed B.I.G™ cannula, attempt in another extremity.

NEVER ATTEMPT A SECOND IO IN THE SAME BONE AS A PREVIOUS ATTEMPT.

If improper placement is suspected, gently pull out the needle, seal off the access and advise hospital staff on your arrival of improper placement, so that the site can be properly monitored for any complications during the patient’s hospital course.

This policy and procedure is based upon a similar one provided through the courtesy of Sabina Braithwaite, MD, FACEP and Albemarle County Fire Rescue

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INTRAOSSEOUS INSERTION, EZ-IO®

INDICATIONS: The EZ-IO® is approved for patients weighing 40kg (88lbs) or more. The EZ-IO PD® is approved for patients weighing 3-39kg (6.5-85lbs). Placement is indicated when a patient is in or approaching extremis and either intravascular fluid resuscitation or medications are essential to resuscitation efforts, but traditional vascular access techniques are not possible or require multiple or prolonged attempts. Such patients should undergo two RAPID IV attempts prior to utilizing the EZ-IO® System.

Appropriate Patient Examples (not all inclusive): near arrest, status epilepticus (no response to IM versed), patients in profound shock with or without altered level of consciousness, severe burns, cardiac arrest; post resuscitation; profoundly hypoglycemic patients with no response to glucagon after 5-10 minutes.

Patients who are NOT appropriate candidates: unconscious but without significant trauma or hemodynamic instability; seizure.

CONTRAINDICATIONS: Fracture of the bone you intend to place the IO in (tibia or humerus)Previous orthopedic procedures (i.e. knee replacement) in the area of intended insertion (as indicated by a large scar)The extremity is compromised by a pre-existing condition (i.e. tumor) Skin infection at the insertion site (i.e. redness, skin lesions)Inability to locate landmarksExcessive tissue over the insertion site. (If the 5mm mark on the IO needle is not visible once the needle has been placed through the skin, but has not reached to the bone, then there is too much tissue.)

If any of these contraindications are noted, check another extremity for possible insertion.

EQUIPMENT:EZ-IO® driver and appropriate needle set for patient size (EZ-IO PD® is pink). 10ml syringeAlcohol or Chlorhexidine swabsExtension set or EZ-ConnectIV Fluid, Tape or GauzePressure bag and/or bolus fluid administration setup

PROCEDURE:Observe BSI precautions and aseptic techniquesLocate the proper site for EZ-IO® insertion (tibia only for pediatric patients, tibia or humerus for adult)Adult tibial insertion: With the leg extended, locate the patella (kneecap), feel the anterior surface of the leg just below the patella, approximately 2 finger widths. This round, oval bump is the tibial tuberosity. From the tibial tuberosity move 1 finger width medial (towards the centerline of the body) to the flat part of the tibia. This is the insertion site.Adult humeral insertion: Expose the shoulder and place the patient’s arm against the patient’s body, resting the elbow on the stretcher or ground and the forearm resting on the abdomen. Note the humeral head on the anterior-superior aspect of the upper arm or the anterior-lateral shoulder. Palpate and identify the mid-shaft humerus and continue palpating toward the proximal end (humeral head). Near the shoulder feel for a small protrusion, this is the base of the greater tubercle and the insertion site. With the opposite hand, “pinch” the anterior and inferior aspects of the humeral head, while confirming the identification of the greater tubercle. This will help ensure that you have located the midline of the humerus.Pediatric tibial insertion: If the tibial tuberosity CAN be palpated, the insertion site is one finger width below the tuberosity and then medial along the flat aspect of the tibia. If the tibial tuberosity CANNOT be palpated, the insertion site is two finger widths below the patella and then medial along the flat aspect of the tibia. EZ-IO PD Pediatric is ONLY for tibial insertion, not humerus.

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1. Clean the insertion site thoroughly using alcohol or Chlorhexidine for at least a 3” diameter around the site.2. Prepare the EZ-IO®

3. Remove the driver and one EZ-IO® cartridge.4. Open the cartridge and attach the proper size needle set to the driver (you should feel a “snap” as the set connects to the driver)5. Remove the needle set from the cartridge6. Remove the safety cap from the needle set. With the needle facing you, grasp the cap tightly and rotate clockwise to loosen and remove. (Attempting to pull the cap may remove the needle set from the driver, and rotating counterclockwise will cause the catheter and stylet to separate.)7. Insert the EZ-IO® needle set8. Hold the driver in one hand, and stabilize the insertion site laterally with the opposite hand. Make sure your hands and fingers are out of the path of insertion, and that the patient is prevented from moving suddenly (i.e. do not position your hand behind the extremity).9. Position the driver at the insertion site with the needle at a 90 degree angle to the bone.10. Power the needle set through the skin at the insertion site until it encounters the bone surface. If in doubt, verify that there is enough needle length (not too much tissue) by observing the 5mm mark.11. Apply firm and steady pressure on the driver and apply power, ensuring the driver is maintained at a constant 90 degree angle to the bone.12. Stop when the needle flange touches the skin or a sudden decrease in resistance is felt. This indicates entry into the marrow cavity. “STOP WHEN YOU FEEL THE POP.”13. Remove the driver from the needle set.14. Support the needle set in on hand, gently pull straight up on the driver and lift away.15. Remove the stylet form the catheter by grasping the hub firmly with one hand, rotate the stylet counter clockwise (unscrew the stylet from the catheter). Pull the stylet out and place in a sharps container.16. Attach a 10 cc syringe and attempt to aspirate marrow (no aspirate alone does not indicate improper placement)17. Flush the IO with 10cc’s NS18. Confirm placement with one or more of the following criteria:•Firm 90 degree position•Blood at the tip of the stylet•Aspiration of marrow•The device flushes easily and fluids flow freely without subcutaneous swelling or fluid leakage. 19. Attach the infusion, secure and stabilize the catheter to the insertion site.20. Monitor for any change in placement and remove as necessary.21. Assure that you can fully visualize the area of insertion so that you can fully assess. 22. Ongoing assessment should include frequent palpation and inspection of the placement site both anteriorly and posteriorly to assure there is no infiltration or extravasation of fluid.23. . Due to the anatomy of the IO space, flow rates may be slower compared with normal IV catheters. Use a pressure bag for rapid infusions, or administer by slow bolus via syringe. PEDIATRICS: administration should be by syringe bolus only.24. Apply wristband to patient to identify that an IO has been placed (optional).25. Document use of EZ-IO® on PPCR with indication and placement confirmation method per #18.26. For pain with fluid administration, administer 2% lidocaine (preservative free) 20- 40 mg for adults, 0.5 mg/kg for children. Use extreme dosage precautions to avoid medication error. REMOVALIf there is indication of improperly placed EZ-IO®, attempt in another extremity. NEVER ATTEMPT A SECOND IO IN THE SAME BONE AS A PREVIOUS ATTEMPT.If improper placement is suspected, seal off the access and advise hospital staff on your arrival of improper placement, so that the site can be properly monitored for any complications during the patient’s hospital course. Removal should be a smooth clockwise rotation of the needle, NOT a rocking motion.

This policy and procedure is provided through the courtesy of Sabina Braithwaite, MD, FACEP and Albemarle County Fire Rescue

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Intraosseous Infusion with Jamshidi NeedleIndications:

• Patients requiring access when rapid, intravenous access is unavailable including:o Cardiac arresto Multisystem trauma o Vascular collapse with loss of consciousnesso Respiratory failure or arrest

Contraindications:• Fracture proximal to injection site• Previous IO insertion in same bone

Procedure:1. Use personal protective equipment.2. Gather needed equipment.3. Select NS fluid and microdrip (60 gtt set) with 3-way stop cock attached4. Identify landmark. This should be 2 finger widths (1-2 cm) below the bony prominence

that is located on the medial side of the proximal tibia just below the knee cap (tibial tuberosity).

5. Clean the site with alcohol.6. Insert the needle at a 90 degree angle pointed toward the feet to avoid the growth plate.

Insertion of the needle should be with a twisting, boring motion until a “pop” or sudden decrease in resistance is felt. Do not advance the needle any further.

7. Remove the stylet and place in sharps container.8. Attach syringe filled with 5 mL NS and attempt to aspirate bone marrow and then inject 5

mL NS to clear the lumen of the needle. This may be performed through the use of the 3 way stop cock.

9. Attach the IV line and adjust flow rate.10.Fluid boluses should be drawn into a syringe and pushed via the 3-way stop cock to

ensure precise fluid administration and avoid inadvertent fluid overload.11.Stabilize needle and secure needle in manner to ensure it remains as clean as possible.12.Following administration of IO medications, flush the line with 10 mL NS.13.Document the procedure, time, and provider performing the procedure, type of fluid, rate

of fluid administration, total volume of infusion at time of transfer, and response to treatment.

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King AirwayDescription: Sterile single use latex–free device. Curved tube with ventilation ports between 2 cuffs. Both cuffs are inflated using a single valve/pilot balloon. The cuffs are designed to seal the esophagus and oropharynx.

Indications: Airway Management in the patients over 35 inches in height.

Contraindications: 1. Responsive patients with intact gag reflex.2. Patients with known esophageal disease.3. Patients who have ingested caustic substances.

Warnings: 1. King airway does not protect the airway from aspiration or regurgitation.2. High airway pressures may leak air into the stomach or atmosphere.3. Intubation of the trachea is possible (although not reported). 4. Lubricate only the posterior surface of the King airway.

Insertion: 1. Check baseline breath sounds.2. Choose correct size: Green connector #2 for patients 35-45 inches or 12-25 kg. Orange connector #2.5 for patients 41-51 inches or 25-35 kg. Yellow connector # 3 for patients 4 to 5 feet in height. Red connector # 4 for patients 5-6 feet in height. Purple connector # 5 for patients over 6 feet in height.3. Test cuffs with maximum recommended volume of air. Green #2 fill with 35 mL of air. Orange #2.5 fill with 40 mL of air. Yellow # 3 fill with 60 mL of air. Red # 4 fill with 80 mL of air. Purple # 5 fill with 90 mL of air.4. Apply lubricant to beveled distal tip and posterior side of tube avoiding air ports.5. Pre-oxygenate, if possible6. Position head in “sniffing” (ideal) or neutral position.7. Hold tube at colored connector end with dominant hand. With non-dominant hand open mouth open and apply chin lift.8. Hold tube rotated laterally such that the blue line is touching the corner of the mouth, introduce tip into mouth and advance behind base of tongue.9. As tip passes under tongue, rotate tube back to midline. Blue line will face chin.10. Without exerting excessive force, advance tube until base of connector is aligned with teeth or gums.11. Inflate cuffs with volume as above. 12. Attach bag/valve. While gently bagging, simultaneously withdraw airway until ventilation is easy and free flowing.13. Note cm depth markings.14. Confirm proper position by auscultation, chest movement and verification of CO2 by capnography if available.15. Readjust cuff volume to just seal airway.

16. Secure airway with tape or tube holder device.

Removal: Airway is well tolerated until the return of protective reflexes.1. Turn on suction and place patient on side.2. Deflate cuffs.3. Withdraw tube.4. Re-assess ABC’s

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Manual Defibrillation

Indications:• Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia.

Procedure:1. Ensure adequate chest compressions. This includes:

Palpable femoral pulse with compressions, Ratio of 30:2 for adults or 15:2 for pediatrics Adequate depth of compression Adequate chest recoil

2. Defibrillation should occur immediately when the cardiac arrest is witnessed. If the arrest is not witnessed and bystander CPR was not performed, defibrillation should occur after 2 minutes of CPR.

3. Apply defibrillation pads.

4. Set the appropriate energy setting per manufacturer recommendation. If appropriate energy setting is unknown, use 200j for biphasic devices.

5. Charge the defibrillation while continuing chest compressions.

6. Stop compressions and “clear” the patient visually and verbally ensuring no person is contact with the patient and the oxygen source has been adequately removed.

7. Press the shock button to deliver the shock.

8. Immediately resume compressions. Pulse check should not be performed after the defibrillation if the cardiac monitor shows an obviously non-perfusing rhythm (ventricular fibrillation or asystole).

9. After 2 minutes of CPR, assess rhythm and check pulse if appropriate for rhythm.

10.Repeat procedure every 2 minutes with energy settings per manufacturer recommendation. If appropriate energy setting is unknown, use 200j for biphasic devices.

11.Limit interruptions of CPR and limit pulse checks to every 2 minutes. Any interruption in CPR should ideally be less than 10 seconds.

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Needle Cricothyrotomy

A needle cricothyrotomy airway is a standing-order, medic-level procedure designed for the viable patient whose airway cannot be successfully managed with the available non-invasive (BVM) or invasive airway devices/procedures, which include the supraglottic devices and endotracheal intubation. This procedure provides limited, short term oxygenation but provides little ventilation. It should be used only as a temporary airway. Providers performing one of these skills must be released at their designated skill levels and be approved by the medical director.Level of Care: EMT-Intermediate, Paramedic

Indications:1. Massive facial trauma2. Foreign body aspiration3. Laryngoedema4. Laryngospasms5. Airway burns6. Laryngeal fracture7. Epiglottitis

Complications:1. Vocal cord injury2. Failure to place catheter in trachea

Procedure:1. Place patient in a supine position and hyperextend the neck using stable

positioning. Consider keeping the trauma patient’s head in a neutral position. 2. Prepare equipment including 14 ga Jelco type needle, 10 cc syringe, ventilation

tubing (pre-made kits should consist of short piece of IV tubing with hub in tact with the other end inserted and taped into a piece of oxygen tubing in which a slit has been made).

3. Secure the larynx laterally between thumb and forefinger. Identify the cricothyroid membrane puncture site which is bounded superiorly by the thyroid cartilage and inferiorly by the cricoid cartilage.

4. Cleanse the area properly with alcohol.5. Insert 14 ga catheter at a 45 degree angle toward the feet.6. Attach a 10 cc syringe and attempt to aspirate air.7. Thread the catheter completely to hub.8. Connect tip to adapter with 15 L O2.9. Occlude the slit that has been cut into the oxygen tubing to provide a breath for

the patient. The slit should be covered for one second and uncovered for 3 seconds to allow for the necessary prolonged expiratory phase.

10.Additional needles may be placed in the cricothyroid membrane as needed and there is space to do so. Placement of additional catheters will allow for better ventilation. The hubs of all catheters should be occluded for one second inhalation and uncovered for 3 second exhalation.

11.Assess placement and secure.12.Documentation should include person performing procedure, indication for

procedure, other methods of airway interventions that were attempted, time of procedure, and response to treatment. A regional airway form should also be completed.

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Needle DecompressionIndications:

• Patient with hypotension, clinical signs of shock, and absent breath sounds on one side.• Patient is in traumatic arrest with chest trauma for whom resuscitation is indicated.

Bilateral decompression may be required if breath sounds are absent.

Procedure:

1. Use gloves and eye protection.2. High flow oxygen.3. Identify the intercostal space between the 2nd and 3rd ribs at the midclavicular line on

the affected side. 4. Cleanse the site with alcohol.5. Select a 14 ga needle at least 2 inches in length from the drug box. Note Jelco

needles are supplied in the medication drawer.6. Insert the catheter into the skin over the top of the 3rd rib into the intercostal space.7. Advance the catheter until a “pop” is felt and either air or blood is noted from the

catheter.8. Remove the needle, leaving he catheter in place.9. Secure the catheter hub to the chest wall.10.Consider placing a finger cut from a glove over the hub after cutting a small hole in

the end of the finger to make a flutter valve.

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Orogastric Tube InsertionIndications:

• Gastric decompression in intubation or ventilated patients.

Procedure:1. Estimate length of insertion by measuring from corner of mouth, around ear, to the

xiphoid process.2. Lubricate the distal end of the tube.3. Pass through the patient’s mouth along the tongue.4. Continue to advance tube until appropriate depth of insertion as measure above is

reached.5. Confirm placement by using a Toomey syringe filled with air. Auscultate over the

stomach for a “swish” of air or bubbling. Aspiration of gastric contents may also be attempted.

6. Secure the OG tube to the patient’s face with tape.7. Decompress the stomach by connecting tube to suction (100 mmHg) or manually

aspirating with Toomey syringe.8. Document procedure, time, and person performing procedure

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Pulse OximetryIndications:

• Patients with suspected hypoxia.

Procedure: 1. Apply probe to patient’s finger. For children, use of toe or earlobe may be necessary.2. Allow machine to register SAO2.3. Record time and note either room air or oxygen delivery at the time of reading (98% on 15L NRB).4. Verify pulse rate on machine correlates to patient’s actual pulse.5. Monitor continuously during transport and document with vital signs and in response to any treatments provided.6. Generally, normal SAO2 is 97-99%. Below 94%, respiratory compromise should be suspected and ALS assessment should be requested.7. The SAO2 reading should not be used to withhold oxygen. Oxygen should be applied when clinically indicated without regard to good readings.8. Reliability of the pulse oximeter can be affected by:

Decrease perfusion to extremity (blood volume, hypotension, hypothermia

Excessive motion of the device Fingernail polish Carbon monoxide poisoning (expect a falsely high reading) Irregular cardiac rhythms Jaundice Placement of BP cuff or tourniquet on same extremity

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RSI ProgramRequirements for RSI Pilot program: 1. NREMT-P certification, current, preferably CCEMT-P or equivalent training with approval of OMD 2. Second provider on scene who is cleared to perform intubation. 3. Drugs will only be pushed by RSI cleared provider. 4. Written approval by OMD of agency where RSI will be used. 5. There will be 100% QI review of pilot program patient encounters

Maintenance of RSI certification: 1. RSI recert quarterly, documented appropriately with OMD or designee.

a. includes practical demonstration/ scenarios b. may include pharmacology quiz or written test c. may include required reading on which (b) may be based

2. Continued approval of agency medical director. Contents of RSI pack: (Pack to be stored in secured area like drug boxes) (2) Etomidate 20 mg 19 ga needles (2) Vecuronium 10 mg with filter needles (2) 10 cc sterile water diluent 30 cc syringe (1) Succinylcholine 200 mg 10 cc syringes Indications for RSI: (RSI may be done under standing orders if needed) 1. Age over 18 unless specific permission given prior to procedure by medical command. 2. Need for intubation:

a. Burns with suspected significant inhalation injury b. GCS < 8 related to traumatic injury c. Acute or impending airway loss (including inability to protect airway), RR < 10 or > 30

3. No known contraindication to RSI drugs Procedure: 1. Preparation

• monitoring (continuous ECG and SpO2, and BP pre- and post-) • functional laryngoscope and BVM with high flow oxygen • endotracheal tube(s), stylet, 10cc syringe • alternate airway (i.e.,Combitube) and cricothyrotomy equipment immediately available • all medications drawn up and labeled • patent IV • assess for difficult intubation: LEMON • suction on and ready • tube confirmation equipment available (EtCO2 + EDD)

2. Preoxygenation • Either 100% oxygen x 5 minutes or 8 vital capacity (deep) breaths on 100% O2 • minimize BVM ventilation and gastric distention • patient on continuous pulse oximeter monitoring

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3. Paralysis and Induction • Etomidate 0.3 mg/kg (20-30 mg) • Succinylcholine 1.5 mg/kg (120 mg)• **contraindicated** with • burns >24 hrs old • crush injury > 72 hrs old • denervation process (ex: para/quadriplegia) • risk of hyperkalemia (ex: ESRD) 4. Protection • Sellickís maneuver: hold from pretreatment through proof of proper placement 5. Placement with Proof • place ETT, confirm with 3 or 4 methods • breath sounds auscultated over lungs, no gastric sounds • end-tidal CO2 color change or proper waveform • EDD/bulb aspiration • oxygen saturations maintained > 95% at 1 min and 5 min • secure endotracheal tube, note position 6. Postintubation management • long-term paralytic: Vecuronium 0.1 mg/kg (9 mg) • sedation: Midazolam 0.1 mg/kg/hr Paperwork: 1. PPCR 2. Airway form 3. RSI form: Exchange: Kit will be exchanged in return for PPCR + Airway form + RSI form ONLY

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T=0

IV Etomidate 0.3 mg/kg50 kg=15 mg=7.5 mL75 kg=22.5 mg=11mL100 kg= 30 mg= 15 mL125 kg= 37.5 mg= 19 mL

IV Succinylcholine 1.5 mg/kg50 kg= 75 mg=4 mL75 kg= 110 mg= 5.5 mL100 kg= 150 mg= 7.5 mL125 kg= 187 mg= 9 mL

Post-placement/ paralysis

IV Vecuronium 0.1 mg/kg50 kg= 5 mg= 5 mL75 kg= 7.5 mg=7.5 mL100 kg= 10 mg= 10 mL125 kg= 12.5 mg= 125 mL

Sedation

IV Midazolam 0.02-0.2 mg/kgCheck BP first. Will produce hypotension.Start low and titrate PRN

50 kg=1-5 mg75 kg=1.5 - 7.5 mg100 kg= 2-10 mg125 kg= 2.5- 12.5 mg

RSI Medications

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S.T.A.R.T. Triage

Is patient breathing?

RED Tag

> 30 breaths/min

Control Bleeding

RED Tag

Radial PulseNot Present

Can patient followsimple commands?

RED Tag

NO

YELLOW Tag Or GREEN Tag

YES

MENTAL STATUS

RadiRadial PulsePulsePresent

CIRCULATION

<30 breaths/min

YES

RED Tag

YES

BLACK Tag

NO

Is patient breathing now?

Reposition Airway

NO

VENTILATIONS

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Subcutaneous / Intramuscular InjectionsIndication:

• Patient needing medication administration when the specific medication must be given via the SQ or IM route or as an alternative route in selected medications.

Procedure:1. Receive and confirm medication order or perform according to standing orders.2. Prepare equipment and medication, expelling air from the syringe. Use of a filter needle

is required for withdrawing medications from a glass ampule.3. Explain the procedure to the patient and reconfirm allergies.4. The most common site for SQ injections is the arm. Injection volume should not exceed 1

mL.5. The possible injections sites for IM injection include the arm, buttock, and thigh. Injection

should not exceed 1 mL for the arm and not more than 2 mL in the thigh or buttock.

6. Pediatric patients <3 years should receive injections in the thigh only with total volume not more than 1 mL.

7. Expose the selected area and cleanse with alcohol.8. Insert the needle into the skin with a smooth, steady motion.

o SQ- the angle of insertion is 45 degrees with skin pinchedo IM- the angle of insertion is 90 degrees with skin flattened

9. Aspirate for blood. 10.If no blood is seen, inject the medication.11.If blood is seen, withdraw the syringe without injecting medication and chose another site.12.Withdraw the needle and dispose in Sharp’s container without recapping needle.13.Monitor patient for desired therapeutic effects as well as any possible side effects.14.Documentation should include medication, dosage,site, route, time, person administering

medication, and response to treatment.

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Surgical CricothyrotomyA surgical airway is a standing-order, medic-level procedure designed for the viable patient whose airway cannot be successfully managed with the available non-invasive (BVM) or invasive airway devices/procedures, which include the supraglottic devices (LMA, King, Combitube) and endotracheal intubation. Providers performing one of these skills must be released at their designated skill levels and be approved by the medical director.

Level of Care: EMT-Paramedic

Indications:1. Massive facial trauma2. Foreign body aspiration3. Laryngoedema4. Laryngospasms5. Airway burns6. Laryngeal fracture7. Epiglottitis

Complications:1. Severe bleeding2. Vocal cord injury3. Failure to place catheter in trachea

Procedure:1. Place patient in a supine position and hyperextend the neck using stable

positioning. Consider keeping the trauma patient’s head in a neutral position. 2. Secure the larynx laterally between thumb and forefinger. Identify the

cricothyroid membrane puncture site which is bounded superiorly by the thyroid cartilage and inferiorly by the cricoid cartilage.

3. Cleanse the area properly with betadine swab 4. With scalpel, make a 1.0 cm shallow, vertical incision over the skin. Have

fingers on either side providing mild to moderate spreading pressure to open the If landmarks are obscured by marked obesity or subcutaneous air, make a 2.0 cm vertical incision through the skin, and dissect bluntly down to identify the cricothyroid membrane.

5. Once the membrane has been located, make a 1.0 cm horizontal puncture.6. Enlarge the incision with the handle of the scalpel or other appropriate surgical

instrument. NEVER enlarge the incision with the scalpel blade. A bougie can be used to determine whether the incision was made all the way through the anterior wall of the trachea. While moving the bougie, proper positioning should be indicated by feeling a “washboard” feeling as the bougie tip rubs against the tracheal rings.

7. Insert the appropriate size tracheostomy tube (in the absence of a tracheostomy tube, an endotracheal tube may be used). Insert the tube only until the cuff enters the trachea, then inflate the cuff. Remove the obturator, ventilate and confirm successful airway placement:

Observe chest wall rise on ventilationAuscultate for bilateral breath soundsETCO2 waveform / SpO2 monitoring are both required to determine and maintain correct tracheal tube placement

8. Secure the tube with twill tape.

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Tourniquet Procedure1. Select either a commercial tourniquet, a multilayered bandage folded to 4 inches wide, or a BP cuff.2. Wrap the bandage twice around the extremity.3. Tie a single knot and place a stick on the top of it.4. Tie a square knot over the stick, and then twist the stick until the bleeding stops.5. Secure the stick so that it will not unwind.6. Write “TK” and the exact time you applied the tourniquet on the patient’s forehead.7. Notify the hospital personnel in radio report and upon arrival in the emergency department.

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Transcutaneous PacingIndications:

• Heart rate less than 60 beats per minute with signs and symptoms of inadequate perfusion as evidenced by hypotension and/or altered mental status.

Procedure:1. Attach cardiac monitor leads.2. Apply multifunction or pacing pads with anterior/posterior placement per

manufacturer recommendation.3. Select pacing function on cardiac monitor.4. Set heart rate to 80 bpm for adult and 100 bpm for child.5. Note pacer spikes on ECG screen.6. Slowly increase output (mA) from the lowest setting until electrical capture is

attained. Electrical capture occurs when the pacer spike immediately preceeds the QRS complex.

7. If unable to capture while at maximum current output, turn the pacer off.8. If electrical capture is attained, check the patient for corresponding pulse

(mechanical capture) and assess vital signs.9. Consider use of sedation or analgesia if indicated when BP >100 mmHg.10.Document response to pacing. Attachment of ECG strips to the PPCR is

recommended.

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Venous AccessIndications:

• Any medical or traumatic patient where either fluid or medication therapies are needed or the need for such may arise.

Procedure:1. Gather necessary equipment.2. Select appropriate fluid and administration set.

NS is generally the fluid of choice. Use macrodrip (15 gtt sets) for trauma patients and medical patients

where fluid overload is unlikely and infusion of IV medications is not anticipated

Use microdrip (60 gtt sets) when possibility of fluid overload is a concern (CHF or pediatric patients) or when infusion of IV medications may be indicated (dopamine or amiodarone drips)

Use of extension tubing is required on all insertions. Use of the short or long extension tubing is at the discretion of the provider according to patient condition.

3. Apply personal protective equipment.4. Select appropriate site.

Begin with the most distal site suitable. Avoid the use of both hands if establishing bilateral IV’s. Cardiac arrest and SVT should have antecubital IV.

Avoid extremities with injury or where venous access is contraindicated (radical mastectomies, dialysis, etc).

Lower extremities should be avoided in patients with poor distal circulation such as diabetics.

5. Perform the IV insertion using aseptic technique.6. Set the appropriate rate.

KVO or TKO rates are 30-60 mL/hr. Fluid boluses when indicated should generally be 500 mL and can be

repeated until a maximum of 3 liters, BP reaches 100 mmHg, or fluid is auscultated in the lung fields.

Fluid boluses of less than 500 mL may be indicated according to patient condition. It is appropriate to use less than 500 mL when indicated per patient condition.

Pediatric fluid boluses should be 20 cc/kg repeated as needed for poor perfusion.

Neonatal (<30 days) boluses should be 10 cc/kg as needed for poor perfusion.

7. Secure the IV in a manner to ensure it remains as clean as possible. Use of commercial products such as Tegaderms are encouraged when

available. Sterile dressing can be folded and placed over the hub of the catheter

prior to taping. Taping should be applied in a manner that uses the least amount of tape

feasible and reasonably allows tubing to be disconnected. All field insertions should be labeled with “Field” and the gauge of

catheter.8. Consider insertion of second line when shock is present or anticipated. 9. Document procedure, time, provider performing insertion, number of attempts,

type of fluid, rate of administration, total infusion at the time of transfer, and any response to fluid therapy.

169

12 Lead ECG Procedure• Providers of all levels should be trained to acquire 12-lead ECG. Continuing cardiac

(rhythm) monitoring remains an EMT-I/P skill.• 12-lead ECG may be indicated for chest pain or severe dyspnea (difficulty breathing).• Obtaining a 12-lead ECG should not delay patient transport more than 2-3 minutes.

Initiating care of the unstable patient takes precedence over 12-lead ECG; whenever possible patient care and 12-lead ECG to take place simultaneously.

• Once a 12-lead ECG has been obtained, the patient will be transported, and every effort will be made by a BLS provider to obtain ALS-level care for the patient.

• If an acute ischemic event is suspected on the 12-lead ECG, it should be transmitted for Medical Command review if possible. If transmission is not possible, the computer interpretation of the 12 lead should be discussed with Medical Command.

• If an acute ischemic event is suspected, Medical Command physician should be should be contacted promptly, the care of the patient discussed, and additional resources may be mobilized as necessary to expedite patient care (i.e., potentially including re-toning ALS, ALS rendezvous, critical care transport, Medevac). When contacting UVA for medical command on possible myocardial infarction, the attending physician should be requested.

• Obtaining the field 12-lead ECG is valuable for comparison to later 12-lead ECG’s.• There will be no change in patient destination unless patient requested receiving facility

diverts through Med Com.

For EMT-Basic and Enhanced level providers:

• If 12-lead ECG trained, obtain 12-lead ECG and transmit if possible. Leave 12-lead electrodes in place in case a repeat ECG is desired, and disconnect the leads and turn off the monitor until ALS assistance is secured.

• If no ALS is immediately available, and the software interpretation indicates an acute ischemic event, contact MedCom and advise you are an EMT requesting physician consultation for a chest pain patient.

For Intermediate and Paramedic Providers:

• Repeat ECG with change in patient’s condition. If there is any significant change demonstrated on the 12-lead ECG, request medical command and re-transmit 12-lead ECG to MedCom if possible.

• “Normal” 12-lead does not allow non-transport, nor does it allow transfer to BLS level care.

Procedure:

1. Expose chest and prep as necessary.2. Apply chest leads and extremity leads using following landmarks:

V1—4th intercostal space at the right sternal borderV2—4th intercostal space at the left sternal borderV3—Directly between V2 and V4V4—5th intercostal space at midclavicular lineV5—5th intercostal space at anterior axillary lineV6—5th intercostal space at midaxillary line

3. Instruct patient to hold still.4. Press appropriate button to acquire 12 Lead.5. Print and transmit ECG include patients sex and age

170

Reference Section Sponsored by:

Center for Emergency Management

MedcomFusion Center

Pegasus Air and GroundEmergency Transport TeamBlue Ridge Poison CenterEmergency Preparedness

Life Support Learning CenterSpecial Events Medical Management

Neonatal Emergency Transport SystemPrehospital Education Program

171

Wong-Baker FACES Pain Rating Scale

No Hurt

Hurts Little Bit

Hurts Little More

Hurts Even More

Hurts Whole Lot

Hurts Worst

Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn’t hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can image, although you don’t have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling. Rating scale is recommended for persons age 3 years and older. Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose face that best describes own pain and record the appropriate number. From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P: Wong’s Essentials of Pediatric Nursing, 6/e, St. Louis, 2001, P. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.

Pediatric Blood PressureMinimal systolic BP = 70 + (2 x age)Normal systolic BP = 90 + (2 x age)

Pediatric Endotracheal Tube SizeETT Size = 4 + age

4

Estimation of Pediatric Weight(2 x age) + 8 = weight in kg

172

A-B is the flat respiratory baseline when no CO2 is present. It represents late inspiration and early expiration.

B-C is the expiratory upstroke showing arrival of CO2 at the sampler. This should be a sharp and quick rise unless there is a delay getting CO2 exhaled.C-D is the plateau when the flow of CO2 molecules should be constant.

Normal Value is 35-45 mmHg

B

DC

A

D marks the point when maximum CO2 is exhaled and is the recorded value. It begins the inspiratory phase.

E F

D-E is the inspiratory phase when the presence of CO2 returns to 0.

Glascow Coma Score

I. Motor Response6 - Obeys commands fully5 - Localizes to noxious stimuli4 - Withdraws from noxious stimuli3 - Abnormal flexion, i.e. decorticate posturing2 - Extensor response, i.e. decerebrate posturing1 - No response

II. Verbal Response5 - Alert and Oriented4 - Confused, yet coherent, speech3 - Inappropriate words and jumbled phrases consisting of words2 - Incomprehensible sounds1 - No sounds

III. Eye Opening4 - Spontaneous eye opening3 - Eyes open to speech2 - Eyes open to pain1 - No eye opening

APGAR Score

Heart rate >100/ min 2 <100/min 1 Absent 0

Respirations Good, crying 2 Slow, irregular 1 Absent 0

Muscle tone Active motion 2 Some flexion 1 Limp 0

Reflex irritability Cough or sneeze 2 Grimace 1 No response 0

Color Completely pink 2 Pink with blue ext. 1 Blue or pale 0 1 minute APGAR

7-10 no intervention needed4-6 stimulate, suction, O20-3 ventilations and compressions

Obtain AGPAR at 1 and 5 minutes

UVa TRCCS System(for follow up on trauma patients)

Retrieval steps:

(You will notice "Physician ID" and "Patient ID" mentioned in the prompt. This is because the system is designed for physicians to communicate lab results to their patients.)

Dial 1-888-888-3803“Physician ID” number prompt – Enter 33447“Patient ID” number prompt – Enter 98765 and the last four digits of your patient's pre-hospital report or flight number.

173

Device Specific Energy Settings Settings

174

Philips MRxDefibrillation 150 j, 150j, 150 jCardioversion SVT, V-tach with pulse 100j, 150 j, 200j Atrial fibrillation 100j, 150 j, 200j, 200j Atrial flutter 50 j, 100j, 150 jPediatric defibrillation 1-2 j/kg, 2-3 j/kg, 3-4 j/kgPediatric synchronized cardioversion 0.5-1 j/kg, 1-2 j/kg

Medtronics/Lifepak 12Medtronic devices are designed to be re-configured by the user.

Factory default setting for defibrillation are 200j-300j-360jPer the regional OMD committee, use of 100 j as the standard setting for synchronized

cardioversion is accepted for this region.

Zoll MonophasicDefibrillation 200j, 300j, 360j, 360jSynchronized cardioversion 100j, 200j, 300j, 360jPediatric defibrillation 2j/kg

Zoll BiphasicDefibrillation 120j, 150j, 200j, 200jSynchronized cardioversion 70j, 120j, 150j, 200jPediatric defibrillation 2j/jg

176

ADENOSINE EMT-I, EMT-P(ADENOCARD) Medical Command for Pediatrics

INDICATIONSSupraventricular tachycardia (SVT) CONTRAINDICATIONS ventricular arrhythmias including ventricular tachycardia, 2nd and 3rd degree heart blocks, or sick sinus syndromeInteraction precautions: aminophylline will negate effects of adenosine. Persantine will markedly potentiate bradycardic side effects.

EFFECTS Slows conduction through the AV node

SIDE EFFECTS Bradycardia, hypotension, facial flushing,transient dyspnea, chest pressure, headache, nausea, or bronchospasm. Expect an asystolic/bradycardic period.Do not treat for 1 minute HOW SUPPLIED 6 mg/2 mL

QUANTITY 3

DOSAGE AND ROUTE 6 mg IV rapidly over 1-2 seconds. If no effect after 2 minutes, give 12 mg IV rapidly over 1-2 seconds.Pediatric: 0.1 mg/kg 10 kg child = 0.33 mL

ALBUTEROL EMT-J, EMT-E, EMT-I, EMT-P, Park Medic(PROVENTIL)

INDICATIONS Bronchospasm related to asthma, chronic bronchitis, emphysema,and allergy

CONTRAINDICATIONS Tachydysrythmias

EFFECTS Bronchodilation

SIDE EFFECTS Tachycardia, anxiety, nausea & vomiting

HOW SUPPLIED 2.5 mg/3mL

QUANTITY 6

DOSAGE & ROUTE 1 unit dose of 2.5 mg/ 3ml through hand-held nebulizer with oxygen flow at 4-6 liters. May repeat if necessary. A modified nebulizer may be used with a BVM or a simple facemask.Pediatric: Same as adult.

177

AMIODARONE EMT-I, EMT-P(Cordarone)Medical Command Only for Pediatrics

INDICATIONS Used for treatment of arrhythmias including ventricular tachycardia, ventricular fibrillation, and supra-ventricular arrhythmia

CONTRAINDICATIONS None in cardiac arrest situation; bradycardia, heart block, hypotension, pregnancy

EFFECTS Antiarrythmic, several different effects, primarily beta-blockade acutely

SIDE EFFECTSHypotension, bradycardia, increased heart block HOW SUPPLIED 150 mg/ 3 mL vials

QUANTITY 3

DOSAGE & ROUTE Cardiac arrest situations, 300 mg IV push.Unstable arrhythmias, 150 mg IV over 10 minutes mixed in 100mL D5W, may be repeated once if needed for recurrent arrhythmiaPediatrics: 5 mg/kg medical command only 10 kg child = 1 mL

ASPIRIN All Levels

INDICATIONS Chest pain of suspected cardiac origin

CONTRAINDICATIONS Trauma, active bleeding, or allergy to medication

EFFECTS Inhibits platelet aggregation

SIDE EFFECTS None HOW SUPPLIED 81 mg chewable tabs

QUANTITY 1 bottle

DOSAGE & ROUTE 4- 81 mg tabs chewed after first Nitroglycerin

178

ATROPINE SULFATE EMT-I, EMT-P

INDICATIONS Bradycardia with hypotension, asystole; organophosphate poisoning

CONTRAINDICATIONS Glaucoma

EFFECTS Increased heart rate

SIDE EFFECTS Blurred vision, headache, dilated pupils, thirst, flushed skin, dysuria HOW SUPPLIED 1 mg/10 mL

QUANTITY 4

DOSAGE & ROUTE Bradycardia: 1 mg IV up to total 3 mgAsystole: 1 mg IV up to total of 3 mgOrganophosphate poisoning: 2 mg IV every 5-10 min (0.05 mg/kg child). Pediatric: 0.02 mg/kg (Minimum dose 0.1 mg, max dose of 0.5 mg)10 kg child = 2 mL

CALCIUM CHLORIDE 10% EMT-I, EMT-P

INDICATIONS Used for calcium channel blocker toxicity, hypermagnesemia, and hyperkalemia

CONTRAINDICATIONS VF, digitalis toxicity, hypercalcemia

EFFECTS Electrolyte

SIDE EFFECTS Extravasation causes necrosis, dysrhythmias, hypotension, CNS changes

HOW SUPPLIED 1 gm/ 10 mL

QUANTITY 1

DOSAGE & ROUTE 20mg/kg slow IV Pediatric: 10 mg/kg IV or IO slowly 10 kg child = 1 mL

179

50% DEXTROSE EMT-E, EMT-I, EMT-P, Park Medic(D50)

INDICATIONS Unconscious diabetics; altered level of consciousness; seizures due to hypoglycemia

CONTRAINDICATIONS Known intracranial hemorrhage

EFFECTS Increases blood sugar

SIDE EFFECTS Rare, neurologic symptoms in alcoholics; tissue necrosis if extravasation HOW SUPPLIED 25 gm/50 mL

QUANTITY 2

DOSAGE & ROUTE 25 gm bolus in free flowing IVPediatric: 0.5 gm/kg. See dilution on pediatric dosage chart.

DIAZEPAM EMT-I, EMT-P(Valium)

INDICATIONS Prolonged seizure, severe agitation

CONTRAINDICATIONS Pregnancy

EFFECTS CNS depressant SIDE EFFECTS Hypotension, stupor, respiratory arrest

HOW SUPPLIED 10 mg/2mL

QUANTITY 1

DOSAGE & ROUTE 2.5 – 5 mg slow IV Pediatric: 0.1 mg/kg10 kg child = 0.2 mL

180

DIPHENHYDRAMINE HCL EMT-J, EMT-E, EMT-I, EMT-P, Park Medic(BENADRYL) INDICATIONS Anaphylaxis; allergic reactions, dystonic reaction

CONTRAINDICATIONS Asthma, nursing mothers

EFFECTS Block histamine effects, antiemetic, sedative, to reverse side effects of phenothiazines

SIDE EFFECTS Hypotension, headache, tachycardia, and sedation

HOW SUPPLIED 50 mg/mL

QUANTITY 2

DOSAGE & ROUTE 25-50 mg IV or deep IM per specific guidelinePediatric: 1.0 mg/kg slow IV push (over 2 minutes) maximum dose of 50 mg 10 kg child = 0.2 mL

DOPAMINE HCL EMT-I, EMT-P(INOTROPIN)

INDICATIONS Cardiogenic & septic shock, refractory bradycardia CONTRAINDICATIONS Use only after volume deficit is corrected in cardiogenic and septic shock

EFFECTS Increases heart rate, contractile force, and blood pressure; constricts small blood vessels

SIDE EFFECTS Ventricular tachyarrhythmias, hypertension

HOW SUPPLIED 200 mg/5 mL

QUANTITY 1

DOSAGE & ROUTE Drip only: 200 mg in 250 mL D5W IV piggyback 2 to 20 mcg/kg/min titrated to BP of 90 mmHg systolic

Quick calculation: drops/min = kg x micrograms/kg/min x 0.075

181

EPINEPHRINE 1:1000 EMT-J, EMT-E, EMT-I, EMT-P, Park Medic(ADRENALIN)Medical Command for Asthma

INDICATIONS Anaphylaxis; severe asthma

CONTRAINDICATIONS None in anaphylaxis. Do not give: If over the age of 50 yrs with cardiac history; if pulse is greater than 140/min in adult or 180/min in child; if hypertensive.

EFFECTS Bronchodilation; increases BP and heart rate

SIDE EFFECTS Palpitations, hypertension, and dysrhythmias

HOW SUPPLIED 1 mg/mL

QUANTITY 4

DOSAGE & ROUTE 0.3 mg SQ. May repeat every 10-20 min Pediatric: 0.01 mg/kg SQ10 kg child = 0.1 mL

EPINEPHRINE 1:10,000 EMT-I, EMT-P(ADRENALIN) INDICATIONS Asystole; ventricular fibrillation; ventricular tachycardia with no pulse; PEA

CONTRAINDICATIONS None

EFFECTS Increases heart rate, force, & automaticity SIDE EFFECTS Tachyarrhythmias


QUANTITY 8

DOSAGE & ROUTE Cardiac arrest: 1 mg IV every 3-5 min. Pediatric: 0.01 mg/kg, repeat every 3-5 min10 kg child = 1 mL

182

FUROSEMIDE EMT-I, EMT-P(LASIX)Medical Command Only

INDICATIONS CHF; pulmonary edema CONTRAINDICATIONS Hypotension, pregnancy, hypokalemia

EFFECTS Increases urine output, vasodilation

SIDE EFFECTS Dehydration, decreases potassium HOW SUPPLIED 40mg/4 mL

QUANTITY 3

DOSAGE & ROUTE 40 mg IV over 2-3 min. May consider higher dose for patients already on diureticsPediatric: 1-2 mg/kg10 kg child = 1-2 mL

GLUCAGON EMT-J, EMT-E, EMT-I, EMT-P, Park Medic INDICATIONS Hypoglycemia if unable to establish IV

CONTRAINDICATIONS Rare

EFFECTS Causes breakdown of glycogen to glucose

SIDE EFFECTS Rare HOW SUPPLIED 1 unit (1 mg/mL to be mixed)

QUANTITY 1

DOSAGE & ROUTE 1 unit (1 mL) IMPediatric: Same as adult

183

HALOPERIDOL EMT-I, EMT-P(Haldol)

INDICATIONS Severe agitation, acute psychosis

CONTRAINDICATIONS Parkinsonism, lactation, pregnancy, children under 18, history of prolonged QT syndrome, suspected or known cardiac arrhythmias.

EFFECTS Antipsychotic

SIDE EFFECTS Extrapyramidal symptoms,(treat with Benadryl), hypotension, seizures, respiratory depression and cardiac arrhythmias.

HOW SUPPLIED 2- 5mg/mL vials

DOSAGE & ROUTE 5 mg IM for adults, 2 mg IM for over 65 to control acute agitation

IPRATROPIUM EMT-J, EMT-E, EMT-I, EMT-P, Park Medic(Atrovent) INDICATIONS Bronchospasm related to asthma, chronic bronchitis, and emphysema

CONTRAINDICATIONS Tachydysrythmias

EFFECTS Bronchodilation

SIDE EFFECTS Tachycardia, myocardial ischemia

HOW SUPPLIED 0.5 mg/3mL

QUANTITY 1

DOSAGE & ROUTE 1 unit dose of 0.5 mg/3mL through hand-held nebulizer with oxygen flow at 4-6 liters. Mixed with 1st dose of albuterol. A modified nebulizer maybe used with a BVM or a simple face mask.

184

MAGNESIUM SULFATE EMT-I, EMT-PMedical Command for Eclampsia

INDICATIONS Refractory VT/VF; eclampsia

CONTRAINDICATIONS None

EFFECTS Changes calcium transport in the cells

SIDE EFFECTS Flushing, nausea

HOW SUPPLIED 1 gm/2 mL

QUANTITY 4

DOSAGE & ROUTE Refractory VF – 1 to 2 grams of 50% solution diluted in 10 mL of NS slow IV push (Dilute each gram of Magnesium with 8cc of NS). Eclampsia – Medical Command only - 10% solution 2 to 4 grams IV push at no greater than 1 gram per minute, until seizure stops or a maximum dose of 4 grams have been given.

MET0PROLOL EMT-I, EMT-P(Lopressor)Medical Command only for STEMI

INDICATIONS Used for hypertension, acute MI, adult v-fib, pulseless wide complex tachycardia CONTRAINDICATIONS Shock, 2nd or 3rd degree AV heart block, sinus bradycardia, CHF, bronchial asthma

EFFECTS B1-blocker

SIDE EFFECTS Hypotension, dysrhythmias, CHF, N/V, CNS changes

HOW SUPPLIED 5 mg in 5 mL ampules QUANTITY 3

DOSAGE & ROUTE 5 mg IV once over 2 minutes, may repeat every 10 minutes to a max of 15 mg to achieve ventricular rate of 120 or less

185

METHYLPREDNISOLONE EMT-E, EMTI, EMT-P, Park Medic(Solu-Medrol)

INDICATIONS Used for anaphylaxis, severe allergic reaction and asthma/COPD

CONTRAINDICATIONS None in anaphylaxis; premature infants; pregnancy

EFFECTS Anti-inflammatory, natural glucocorticoid

SIDE EFFECTS CHF, HTN, N/V

HOW SUPPLIED 125 mg/ 2 mL

QUANTITY 1

DOSAGE & ROUTE 125 mg IV over 1 minutePediatrics: 1mg /kg IV10 kg child = 0.16 mL

MIDAZOLAM EMT-I, EMT-P, Park Medic(Versed)

INDICATIONS Used for sedation and seizures

CONTRAINDICATIONS Shock, acute narrow angle glaucoma EFFECTS CNS depressant, anticonvulsant and amnesic

SIDE EFFECTS Respiratory depression, hypotension, decreased HR

HOW SUPPLIED 5mg/mL

QUANTITY 2

DOSAGE & ROUTE Adult sedation: 2-5 mg IV; seizures 5 mg IM if no IV Pediatric:sedation: 0.1mg/kg IV, max 2 mgseizures 0.1mg/kg IM10 kg child = 0.2 mL

186

MORPHINE SULFATE EMT-I, EMT-P, Park Medic

INDICATIONS Pulmonary edema; pain in AMI; & pain associated with identifiable injuries such as fractures, burns, etc.

CONTRAINDICATIONS Hypotension; head injury

EFFECTS CNS depressant; vasodilator; decreases venous return to heart; decreases pain

SIDE EFFECTS Hypotension, bradycardia, respiratory depression, dizziness


QUANTITY 2

DOSAGE & ROUTE IV: 2-5 mg slow IV push every 5-10 min titrated to desired effect (max 15 mg) IM: 5-10 mg Pediatric: 0.1 mg/kg IV or IM 10 kg child = 0.1 mL

NALOXONE HCL EMT-J, EMT-E, EMT-I, EMT-P, Park Medic(NARCAN) INDICATIONS Suspected narcotic OD

CONTRAINDICATIONS Intubated patients

EFFECTS Reverses effects of narcotics

SIDE EFFECTS Withdrawal syndrome


QUANTITY 1

DOSAGE & ROUTE up to 0.8 mg slow IV, IM, titrated to respirations. Repeat dose1.6 mg.Pediatric: 0.1 mg/kg IV, IO or IM up to 2 mg10 kg child = 2.5 mL

187

NITROGLYCERINE EMT-J, EMT-E, EMT-I, EMT-P, Park Medic

INDICATIONS Chest pain of suspected cardiac origin; pulmonary edema; CONTRAINDICATIONS Hypotension, trauma, ICH, use in consultation with Medical Control Physician with patients using Viagra, Levitra and Cialis or herbal equivalent, BP < 100 mmHg

EFFECTS Vasodilation

SIDE EFFECTS Headache, hypotension, and dizziness

HOW SUPPLIED 0.4 mg (tablet), 1/150th grain QUANTITY 1 bottle

DOSAGE & ROUTE 1 tablet SL titrated to pain relief or normalization of BP

NITROPASTE EMT-J, EMT-E, EMT-I, EMT-P, Park Medic

INDICATIONS Pulmonary edema; chest pain of suspected cardiac origin;

CONTRAINDICATIONS Hypotension, trauma, ICH, Use in consultation with Medical Control Physician with patients using Viagra, Levitra and Cialis, or herbal equivalents

EFFECTS Vasodilation

SIDE EFFECTS Hypotension, dizziness (wipe off if side effects occur)

HOW SUPPLIED 1 inch of paste in prefilled packets

QUANTITY 2

DOSAGE & ROUTE 1-2 inches topically

188

Ondansetron EMT-E, EMT-I, EMT-P(Zofran)

INDICATIONS Treatment and prevention of nausea and vomiting

CONTRAINDICATIONS Hypersensitivity

EFFECTS Antiemetic

SIDE EFFECTS Headache, malaise, bronchospasm, rare cardiac arrhythmia

HOW SUPPLIED 4mg /2mL vials

QUANTITY 2

DOSAGE & ROUTE 4 mg IV, slow over 2-5 minutes, may repeat 4 mg IV in 20 minutes. Pediatric: 0.1 mg/kg up to 20 kg, for greater than 20 kg give adult dose10 kg child = 0.5 mL

PROMETHAZINE EMT-I, EMT-P, Park Medic(PHENERGAN) INDICATIONS Nausea, vomiting

CONTRAINDICATIONS Acute asthma attack

EFFECTS Anti-emetic

SIDE EFFECTS Drowsiness, anxiety, euphoria, confusion, hypotension, tachycardia, increased secretions, wheezing, rash, nasal stuffiness, blurred vision

HOW SUPPLIED 25 mg/ 1 mL

QUANTITY 2

DOSAGE & ROUTE Adult: 12.5 – 25 mg IV, 25 mg IMPediatric: 0.5 mg/kg IM10 kg child = 0.2 mLmust be diluted for IV administration

189

SODIUM BICARBONATE EMT-I, EMT-P 8.4%

INDICATIONS Cardiac arrest only after prolonged anoxia, tricyclic antidepressant overdose, known acidosis

CONTRAINDICATIONS Not to be given as initial drug therapy

EFFECTS Increases pH

SIDE EFFECTS Metabolic alkalosis, increased sodium

HOW SUPPLIED 50 mEq/50 mL

QUANTITY 2

DOSAGE & ROUTE 1 mEq/kg IV followed by 1/2 the initial dose every 10 min.Pediatric: 1 mEq/kg. Dilute 1:1 with IV fluid10 kg child = 10 mL plus 10 mL NS

VASOPRESSIN EMT-I, EMT-P(Pitressin)

INDICATIONS Used in ventricular fibrillation, pulseless v-tach, asystole, PEA

CONTRAINDICATIONS None in Cardiac Arrest

EFFECTS Stimulates smooth muscle resulting in vasoconstriction SIDE EFFECTS None applicable in cardiac arrest HOW SUPPLIED 20 unit/mL

QUANTITY 2

DOSAGE & ROUTE 40 units IV

190

Drug Dose Calculations

2 X age + 8 = approximate weight in kg

weight in pounds / 2.2 = weight in kg

Desired Dose (mg) = mL to administer amount in 1 mL

191

Dopamine DripEstablish primary IV line with 15 gtt set TKODraw up dopamine 200 mg into 10 mL syringeOpen 250 mL bag D5WClean medication addition port and inject dopamineLabel 250 mL bag with “medication added” labelSpike 250 mL bag with 60 gtt set and clear tubing of air Clean medication port on primary line and connect 250 mL bagHang the 250 mL bag higher than your primary IV bagEnsure primary line is TKO and open to the desired flow rateObserve drip chamber to ensure dopamine is infusing

Mix 200 mg in 250 mL of D5W (800 mcg/mL) as above:

mcg/kg/min 40 kg 50 kg 60 kg 70 kg 80 kg 90 kg 100 kg

2 mcg/kg/min 6 8 10 10 12 14 15

5 mcg/kg/min 15 18 22 26 30 34 38

10 mcg/kg/min 30 38 45 52 60 68 75

15 mcg/kg/min 45 56 68 78 90 102 112

20 mcg/kg/min 60 76 90 104 120 136 150

Weight in kg

Mcg per minute (or mL per hour)

192

Epinephrine DripEstablish primary IV line with 15 gtt set TKODraw up epinephrine 1mgOpen 250 mL bag D5WClean medication addition port and inject epinephrineLabel 250 mL bag with “medication added” labelSpike 250 mL bag with 60 gtt set and clear tubing of air Clean medication port on primary line and connect 250 mL bagHang the 250 mL bag higher than your primary IV bagEnsure primary line is KVOpen to the desired flow rateObserve drip chamber to ensure epinephrine is infusing

Mix 1 mg epinephrine in 250 mL of D5W as above:

1 mcg/min 15 drops/min



Amiodarone Drip(Patients with a Pulse)

Establish primary IV line with 15 gtt set TKODraw up Amiodarone 150 mg into 3 mL syringeOpen 100 cc bag D5WClean medication addition port and inject amiodaroneLabel 100 cc bag with “medication added” labelSpike 100 cc bag with 60 gtt set and clear tubing of air Clean medication port on primary line and connect 100 cc bagHang the 100 cc bag higher than your primary IV bagEnsure primary line is KVOOpen the 100 cc bag to run wide open over 10 minutesObserve drip chamber to ensure amiodarone is infusing

193

Medication Medication Neonate <30

10 kg 20 kg 30 kg 40 kg 50 kg

Adenosine 0.1 mg/kg 0. 33 mL 0.66 mL 1 mL 1.3 mL 1.7 mL

Amiodarone 5 mg/kg 1 mL 2 mL 3 mL 3 mL 3 mL

Atropine 0.02 mg/kg 2 mL 4 mL 4 mL 4 mL 4 mL

Calcium chloride

10 mg/kg 1 mL 2 mL 3 mL 4 mL 5 mL

Dextrose 0.5 mg/kg 20 mL D12.5%

20 mLD 25%

40 mLD25%

30 mLD50%

40 mLD50%

50 mLD50%

Diazepam 0.1 mg/kg 0.2 mL 0.4 mL 0.6 mL 0.8 mL 1 mL

Diphenhydramine 1 mg/kg 0.2 mL 0.4 mL 0.6 mL 0.8 mL 1 mL

Epi 1:000 0.1 mg/kg 0.1 mL 0.2 mL 0.3 mL 0.3 mL 0.3 mL

Epi 1:10, 000 0.01 mg/kg 0.5 mL 1 mL 2 mL 3 mL 4 mL 5 mL

Glucagon 1 unit 1 mL 1 mL 1 mL 1mL 1 mL 1 mL

Methyprednisolone 1 mg/kg 0.16 mL 0.32 mL 0.48 mL 0.64 mL 0.8 mL

Midazolam 0.1 mg/kg 0.2 mL 0.4 mL 0.6 mL 0.8 mL 1 mL

Morphine 0.1 mg/kg 0.1 mL 0.2 mL 0.3 mL 0.4mL 0.5 mL

Naloxone 0.1 mg/kg 1.25 mL 2.5 mL 5 mL 5 mL 5 mL 5 mL

Normal Saline 20 mL/kg 50 mL 100 mL 200 mL 300 mL 400 mL 500 mL

Ondansetron 0.1 mg/kg 0.5 mL 2 mL 2 mL 2 mL 2 mL

Sodium bicarb 1 mEq/kg 10 mL + 10 mL NS

20 mL+ 20 mL NS

30 mL+ 30 mL NS

40 mL+ 40 mL NS

50 mL+ 50 mL NS

Pediatric Drug Dose Chart

194

Thomas JeffersonRegional OMDPosition Papers

195

Beta Blockers in Acute Chest Pain Position Paper Given recent information regarding the use of beta-blockers (metoprolol) in the setting of acute myocardial infarction that has raised some concerns, their use in the field is worth re-evaluating.

There was a significant amount of evidence that suggested that beta-blockers were of benefit to patients suffering from acute myocardial infarction. This benefit seemed reasonable, as beta-blockers could help to decrease oxygen demands of the heart during an acute event by decreasing heart rate and contractility, and because beta-blockers are potent anti-arrhythmics and could help prevent malignant arrhythmias such as ventricular fibrillation and ventricular tachycardia. These studies looked at patients after their hospital admission, generally looked at starting beta-blocker therapy in the first 24 to 48 hours after admission, and frequently evaluated treatment regimens that involved oral beta-blocker therapy with increasing doses of medication. Although it seemed reasonable to extend the results of these studies, and the benefits to patients, into the ED and pre-hospital time periods, those regimens were not specifically studied. Clearly beta-blockers have proven to be beneficial in the long term management of patients after myocardial infarction, hypertension, and angina, but those benefits may not apply to their use urgently in the immediate period of time after, or even during, an acute MI.

Recent studies have raised concerns about the use of beta-blockers during the immediate time after an acute myocardial infarction. It has been found that in cases where all STEMI patients were given IV beta-blockers urgently, there were higher rates of heart block, and of symptomatic heart failure. This has suggested that IV beta blockers should be used cautiously in patients with acute MI, and that in many cases beta-blocker therapy should wait until the patient’s clinical situation becomes clarified.

Intravenous beta-blockers should not be given indiscriminately to all patients with acute MI.

Patients with inferior and inferior-posterior MI should generally not receive IV beta-blocker therapy in the field given their already higher risk of suffering heart block requiring intervention, and of hypotension.

Patients with anterior, antero-septal, and antero-lateral infarctions may be candidates for IV beta blocker therapy if they are persistently tachycardic (heart rates of 110 nor greater) and hypertensive (blood pressures of 140/90 or greater).

If IV beta-blockers are administered, they should be given slowly and incrementally with adequate time between doses (10-15 minutes) to evaluate their effect on the patient. The full loading dose of three 5 mg doses is not necessary in all cases, and a partial loading dose should be given in most cases.

The use of intravenous beta-blockers in undifferentiated chest pain scenarios has not been supported, and chest pain without EKG evidence of STEMI should be managed with traditional therapy with oxygen, aspirin, nitroglycerine, and analgesics.

Hypertension alone does not generally require urgent pre-hospital management. In some cases, such as acute stroke and true hypertensive emergency, overly aggressive blood pressure reduction can result in poorer patient outcomes. In most cases when elevated blood pressure is an important part of the presenting constellation of symptoms, such as congestive heart failure, blood pressure will fall as the underlying process is treated (such as oxygen, nitrates and CPAP in heart failure patients) and as the patient’s clinical status improves. Patients with elevated blood pressures and no indication of an associated emergent condition, do not require urgent pre-hospital therapy.

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Destination/Transport GuidelinesAlthough most emergent transports by 911 agencies do not present challenges in terms of destination, there are cases where the decision of where to take the patient becomes complicated by both the patient’s clinical situation and patient or family desires/requests.

In general, it is advantageous for the EMS agency to transport the patient to the closest appropriate hospital; that is, the physically closest hospital with the appropriate facilities to provide optimal care. Strategies have been developed to assist in those decisions for trauma patients, more recently stroke patients, and even more recently STEMI patients. These strategies typically identify the appropriate receiving hospital for the problem identified, outline communication pathways and informational requirements, and usually provide general guidelines for patient selection, including clinical guidelines (patient age, vital signs, specific injuries, etc.) and geographic criteria. The method of transport, generally ground versus air, can also be considered as part of the decision process. These clinical and resource based guidelines will frequently outline situations in which one hospital may be bypassed in order for the patient to obtain definitive care more directly.

Many systems have developed criteria that recognize time periods during which individual facilities may not be able to accept patients who would otherwise lie within their scope of care because of inadequate resources temporarily. Commonly referred to as “diversion”, providers may be required to change destinations in order to avoid taking the patient to a facility that has recognized that they are unable to care for the patient at a given time. This situation may require that the closest facility be bypassed, and that transport and recovery times are longer than desired. These situations may also contradict patient/family desires if their preferred hospital is not able to accept transports.

Patients and their families will often express preferences regarding transport destinations. In some cases the preference is based on a history of previous care and a desire to be treated in a familiar facility by care providers who are knowledgeable with the patient’s history and who have access to pertinent medical records. In other cases the decision is more subjective – a particularly positive or negative experience or the reputation of a facility – but still very important to the patient or their family. There may also be community expectations for transportation that need to be considered. Health care providers involved with requests for transport may also express preferences regarding transport destinations which may take into account continuity of care issues, patient or family concerns, or practice patterns.

EMS systems have the desire to try and maximize the availability of resources by minimizing transport and turnaround times, thus keeping transport units available and in their first due areas as much as possible. Providers may also be less willing to make longer transports for both system and personal reasons.

Although the rules, regulations, and statutes that govern EMS systems and practices vary from state to state, and in some cases may address transport destinations, there are currently no regulations in Virginia that specify where a patient must be taken in a given situation. Decisions regarding transport destinations are left to local EMS resources, including regional EMS councils, EMS agencies, and operational medical directors. In general, 911 responding agencies have limited their destinations to identified hospital emergency departments, although other options could be considered in specific cases.

When providers are faced with transportation decisions, the following factors will influence the choice of destination:

Triage guidelines for specific clinical situations such as trauma, burns, pediatric critical care, acute stroke, and STEMI should be given primary consideration when determining destination and method of transportation.

Patients who are determined to be acutely ill or unstable, using objective clinical criteria, should be taken to the closest appropriate hospital emergency department if the situation is not addressed by a specific triage plan. On-line medical command should be used as a resource in making real-time decisions about patient transportation guidelines.

Thomas Jefferson EMS Council Policy and Procedures Revised: March 2009

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Patient, family, and health care provider requests for particular destinations should be honored unless they clearly exceed the resources and capabilities of the responding EMS agency or are felt to endanger the patient. Patients should be evaluated using objective clinical criteria when assessing their level of risk for transport. On-line medical command and/or agency resources may be needed to assist in making this decision if there is disagreement in a particular instance. Identification of receiving facilities for a particular agency that are felt to meet patient needs clinically, EMS system needs logistically, and patient and community expectations should be identified in advance by the agencies involved in cooperation with their operational medical directors and local government.

Patients who decline transport to the facility recommended by the transporting agency should be offered transport to the facility of their choice, in keeping with previously described criteria. Patients should be informed of the risks, if any, involved in their decision and should sign a release form acknowledging their understanding and acceptance of those risks.

Each agency should develop a written policy, in conjunction with agency leadership, medical direction, and local government that identifies:

Hospitals that provide resources for specialized care based on patient clinical needs (including, but not necessarily limited to services such as trauma, pediatric care, burns, stroke care, and STEMI)

Hospitals that are considered within the reasonable transport umbrella of the agency for patients that are considered clinically stable. A description of how crews will manage situations where the patient or family request is not in keeping with the agency’s transport policy.

Regional Patient Care Guidelines

Documents

Transcript of Regional Patient Care Guidelines